ThePrinciplesandPracticeofToothExtractionandLocalAnesthesiaoftheMaxillae 10031932

Th e
Pr i n c i p le s a n d Pr a c ti c e
of T o o th Ex tr a c ti o n
L o cal A n e s the s i a o f t he M a x i lla e

By
WI L L I AM J L EDER ER .
, DD S
. a .
D t l C
en a u lt n t t th G rm H
o ns a o e e an o spi ta l i n th e
C i ty f N w Y rk
o e o
I ll ustr a te d w it h 1 20 T e xt ual F i g ure s an d 8
NEW YO R K
1 4 1 - 1 45 W ES T 3 67 14
. S T R EET
A U T H OR S ’
NOTE
IN O FF E R I N G th i s little v olume th e auth or doe s no t

pre s ume to h ave fully e xh austed h is subj ect s ; h e
present s these in compend form to aid b oth th e ,
Dental S tudent and P ractitio n er and recall to

thei r minds th at Tooth E xtraction i s a S ur gi c al
P ro c edure and must be c a r ried o ut acco r dingly .
T h e ch apters o n CO ND U C T IVE A N E S T H ES I A
s h ould emphasi z e t h e g reat value o f this m ethod
in performing painless operations about th e teeth
and j aw s PA I N LE S S DE N T I S TR Y is n o t a d r eam any
.
more ; to day it has become a r eality th a nks to

-
,
B raun and Fisch e r .
F o r ca r eful s tudy t h e suc c eedi n g s teps o f th e

M an dibular I nj ect i on h a ve been assembled sep a
r a tel y o n four P lates Figures 1 06 1 1 2 ,
-
.
T h e auth or expresses h is sincer e t h ank s to t h e

Dent i sts S upply C ompan y T h e S S W hit e De n ,
. .
ta l M fg C o as well as to th e K n y S ch ere r C o
. .
,
-
.
fo r th e loan o f electrotypes and also to th e R e b ,
man 0 0 for t h e interest s h own and valuable a s

.
s i s tan c e given in th e publi c ation o f t h i s b oo k .
W ILLIAM J L E DER ER
. .
1 50 E as t Se v enty f u r th S tr ee t
-
o , Ne w Y rk o .
C O NT ENT S
PA R T I
DE N TAL A N D O RAL O PERAT IO NS IN T H E IR

T R U E ASPE C T
S TE RILI Z AT I O N
C L EANLIN ESS AND AS E PSIS
C AR E O F T H E O P E RAT O R S HANDS
’
C A R E O F I N S T R U M E N TS
TH E RE LA T I O N O F T H E O P ERATOR T O W A RD
T H E E xA PAT IE N T
M I N A TI O N O E T H E
TH E PR E PARA T I O N O F T H E P A T I E N T
I NDICA T I O NS F O R T OOT H E xT RA C T I O N
T H E O P ER A TO R S ARMAM E N T ARIU M :
’
I NS T R U M E N T S D R U G S AND D R ES S I N G S
,
C LAS S I FICA T I O N O F C AS ES
IX . T H E TE CHNI " U E O F NO RMAL E xT R A C
T I O NS
ROOT E X T RAC T I O N S
I MPAC TE D T E ET H
U N ER U P TE D T EET H
PO S T EX T RAC T I VE T R EA T M E N T
THE T R E A T M EN T O F C O MPLICA T I O N S
v
CO N TE N T S
PA R T I I
PA G E
I . A N A ES T H E SIA
G E N E RAL , LO CAL ,
CO ND U C T I VE ,
RE
G IO NAL
S OLU T I O NS F O R LO CAL A N E S T H E SIA : T H E
S O L VE N T M E DI U M
T H E ARMAM E N TARI U M
CO CAIN E NO VO CAIN ADR E NALIN
, ,
T H E T E CHNI " U E O F LO CAL (I N F ILT RA

T I O N ) A N ZE S T H ES I A
A NATO MICAL CO NSID E RAT I O NS
T H E T E CHNI " U E O F CO ND U C T IV E A N E S
T H ES I A
VIII . I NDICA T I O NS AND CO N T RAINDICA T I O NS

F O R LO CAL AND CO ND U C T I VE (RE
GI O NAL ) A N E S T H E SIA
I NHALA T I O N A N E S T H E SIA V E RS U S RE
GI O NAL A N JES T H ES I A
S H O C K IN O RAL S U R G ER Y
RE C ORDS O F CO ND U C T IV E A N JES T H ES I A S
IN —
O RAL S U RG E RY RE C ORDS O F
CO N D U C T IV E A N JES T H E S IA S IN O P
E R A T I V E DE N T IS T R Y
US E F U L F O R M U L JE AND P R E SCRIP T I O NS
POIS O NS A N D T H E IR A N T ID OTE S
T H E T R EA T M E N T O F EM ER G E N CIE S
G L O SSAR Y
I ND E X
DE N T AL A ND O RAL O PERAT I O N S IN T H E IR T R U E
AS P E CT
TH E prin c ipl e s of surge r y are al w a y s th e same no ,
m atter to w h at part of th e body they are applied .
Di fl e r en t localities o f th e b ody vary in degree o f

’
s uscepti b il ity to infect i o n T hu s the openin g o f

.
th e a b dominal cavi ty or t h e explora tion of th e

kn ee j oint is attended by more appreh ension th an
t h e in c i s ion o f a su p erfi cial ab s ces s o r the extrac
tion of a tooth ; ne verth ele s s th e latte r p r o c edu r e s
,
are s urgical operations just as th e fo rmer and ,
th e same ru l e s m us t b e Ob s er ved .
T h e l ate W D M iller in h is work o n T h e M i

. .
,
“
c r o Or gan i sm s of th e Human Mouth

”
collected a ,
list O f 1 65 cases of severe i nfections following den

tal and buccal lesions of w h ich more than 60
,
term i nated fatally S ome s uccumb ed to h eart l e

.
sion s Oth er s de veloped pulmona ry in fections

, ,
oth ers m eni n gitis cerebra l a b scesse s pyemia

, , ,
septicemia L u d wi g s angina frontal s inusiti s

,
’
, ,
t h rombo s i s et c Th os e wh o d id not die c arried

, .
,
o ff s yph i litic infe c tio n s and t h ose w h o fi nally t

, ge
wel l went th rough lo n g su ffering and a tryi n g

convale s cence T h ese c ases w ere repo rted b y me n
.
3
4 T OOT H E X T RAC T I O N
like K irk J ack W ilson Darby Truman Mars h all
, , , , ,
and o thers of like quality .
—
V on M o s e ti g M oorhof the eminent V iennese ,
surgeon reports two cases in which extraction o f

,
th e second right and left lower molars re ,
s p ec ti v e l y was at tempted ; the fi rst case devel

,
oped gangrene O f the soft tissues phlebitis , ,
myeli tis oedema of the lungs and died The sec

, ,
.
o n d patient contracted an osteitis followed by
p h lebi tis and pyemia and also terminated fatally

,
.
I n both instances the broken o ff roots had been -
extracted dr a inage established by deep incisions

, ,
but it was too late .
S c h wendt reports a case wherein the extraction

of teeth was followed by infection o f the orbi ts ,
r e s ulting i n blindness Baume S pe ak s of a

.
case of an attempted extrac tion of a S i x year -
molar follo wed by periostitis necrosis pyemia , , ,
pleuro broncho pneumonia and death after tw o

- -
,
weeks .
M any a death certi fi cate reads myocarditis ,
nephritis o r pneumonia the patient is laid at rest

, , ,
and the fact th a t his death is the result o f a tooth

lesion is not known either to his physician o r h is
dentist The certi fi cate really S hould read S e p
.
“
tic endocarditis produced by streptococci which

”
h ailed from an alveolar abscess .
H o w can such severe conditions result from a

”
localized absces s P athology teaches us that
I N F E C T I O NS F O LLO W IN G DE NTAL O P E RAT I O N S 5
wh en pyogenic organisms reach the walls of bloo d

vessels they may set up a phlebitis (inflammatio n
of a vein ) The endothelial lining Of the vesse l
.
i s broken up l eu co cytes collect at these points a n d

, ,
”
a mass is formed known as a white thrombus “
.
T h i s thrombus b e c o me s infected w i t h bacteri a and ,
i s b roken u p loos ens , and thus becomes an em

,
b o l i s m or a n umber of emboli T h ese masse s are

.
carried along i n th e bl ood s tream a n d may pro

d uce meta s tatic abscesse s or i nfect oth e r s tru e
ture s ; thu s reach ing th e right heart a n en d o c a r ,
d i ti s or a m yoc a rditi s may result ; or th e s epti c

mas ses e n ter th e p ulmonary sys tem and produce
lung lesions or they enter the g en e r a l circula
,
tion by th e left h eart a n d infect other r emote

s truc ture s .
T h e re s ear ch es of Bil lings an d R o s eno w o f ,
C h icago and H art z el l of M inneapoli s h av e

, , ,
pro ven beyond a S hadow of a dou b t that pyogeni c

foci i n and a b o ut th e mouth m a y produce distal
lesions H en r y H e m s te d in th e L ondo n L a n c e t of
.
,
J anuar y 4 1 91 3 d e s cri b es a ca s e of strepto c occ us

, ,
endocarditis w h i ch h e positi vel y traces to a n ab

s c e s s e d t o oth .
S uc h t h i n g s b e i n g pos s i ble dental a n d ora l ,
operation s s h ould be vie w ed in t h eir true l igh t ,
n amely as s u r gic al ope r a tion s and be carried out

, ,
accor d in gly ; and th e d ental a n d buc c a l S pecialist ,
w h et h e r h e call s h i m s elf d ent al S ur geon s tom a ,

6 T OOT H EX T RAC T I O N
to l o gi s t, o r a l s urgeon o r dentist mu s t a cc e p t a n d
, ,
a pp l v the p r inciples of g eneral surge r y .
S urge ry i s de fi ned as that branc h o f medi c ine

dea l ing with di s ease requi r ing ope r ative p r o
c e d ur e s ; the r efo r e any ope r a tive p ro c edure in the
,
mouth i s mout h s urge ry I n fa c t all o p e r ation s

.
,
in the mouth are s urgi c a l procedu r e s exceptin g ,
th e inse r tion Of a r ti fi cia l teeth and the i n tr o d uc

tion of appliance s requi s ite for the c orre c tio n Of
defo rmitie s Of the teeth and j aws The in s ertio n
.
of a filling i s pla s tic dental s urgery and c alls fo r

antiseptic precaution a p r inciple o f s urgery ; th e
,
ext r action o f teeth is c e r tain ly a s ur g ical Opera

tion and r equi re s th e O bs e rvatio n Of s u rg ic a l
p r in c ipl e s .
S TERILIZ AT I O N
1 .
—
C l ea n li n es s A s ep s i s
TH E fi r s t p r inciple O f succe ss ful surge ry is th e
cr e a tion and maintenance Of a s ep s i s a s fa r as po s
s i b le A good deal h as been w r itte n about sterili
.
z a ti o n and a s ep s i s H owe ve r the au th o r fi nd s

.
,
that many men hav e not lea rned t h eir lesson well ,
for h e frequently notes a l a ck Of understandin g

Of th e b asa l p r incip l e s Of asep s is among dentist s .
He h a s seen good Oper a tor s sterilize a pair Of fo r

ceps prio r to extra c tion and then pausing to r e
,
examine the toot h to b e r emoved del ib e r ately ,
place the s terile instrument into their operati n g

coat pock et whence they had drawn a pen c il o r
,
pad a few moments previously .
S ome dry a sterile instrument on a previously

used towel I n S pite Of knowing the meaning of
.
a s epsis and s epsis they lack what Dr M ar s hall

,
.
”
calls the sense Of asep s i s
“
A n Operato r mu s t
.
n o t only know the meaning Of the word a s ep s i s ,
h e must feel it ; it must become p a rt o f h is phy s i c al

m ak e up-
. S urgi ca l cleanl ines s S pells ab s o l ut e
asepsis (as far as it is pos sible ) as the re s ult Of ,
any operation depends in a large measure upo n th e

d e gr ee of a s ep s i s unde r w h i ch it i s exe cute d .
7
8 T OOT H E X T RAC T I O N
A sepsis for the mouth specialist means aseptic
hands aseptic instrumen ts aseptic i ns trument ta
, ,
b le asep tic fi eld of Opera tion

,
There are den tists .
who will s terilize their ins truments but fail to ,
properly cleanse their hands and the r e are men ,
who ca r efully Observe p ersona l cleanliness boil ,
their instr uments but fail to sterilize their i m

,
pression cups M any keep s terile instrument s in

.
fi lthy d ental cabinets ; by fil th v cabinets I mean

highly polished pieces of f urni ture with felt lined -
d raw e rs full of dus t gold scrap drugs sand from

, , , ,
polishing discs in short fi lthy d r awers an d com

, ,
p a r tm e n ts w hich
,
become the receptacles for
sterile instruments T h ese instruments un avo i d
.
ably become tainted .
I n how m any O ffices are instruments boiled b e

fore using ? Dipping into carbolic acid b efore
using is not prac tical ; in fact all dipping is bad ,
steriliza tion unless tr iodine is used a n d th is is

, .
,
hard upo n in s trumen ts A ll partial methods of .
s terilization are b a d ; they are a little b etter than

no attempt but they are unscientifi c and directly
,
crimin a l tow a r d the patient .
The new depar ture of instrument houses to con

struct denta l furni ture o n th e li n e s of surgical fur
mit a re is an innov a tion in th e right direction De n .
ta l and buccal ope ratio n s m ust be viewed as s urgi

cal proced ures and carried out accordingly The .
wh ite enamel O ffi ce is unq uestionably the dental O f

-
A S EPSIS 9
fic e of the future ; i t must be k e p t clean and the ,
clea n er an operatin g room th e more aseptic The .
following is the plan of s terilization pursued by

th e writer .
O H a n ds
’
2 Ca r e
. o f th e p e r a to r s
In s urgical cases the han d s and arms are

b rushed thoroughly with h o t water and tr Of .
green soap P ar ticular atten tion is given to the

.
n a ils which are pared and cleansed with nail fi l e

,
and orange wood stick The h ands are then rin sed
-
.
in s teri l e water bathed in alcohol and immersed

, ,
for some time in a s ublim a te solution I f rubber .
gloves a r e worn th e h a nds are dried i n a s terile

,
towel and powdered w i th sterile talcum p owder

a n d then sterile gloves put on I f there are any
.
cuts o r abrasions upon th e fi ngers these are ,
pain ted with a coat of collodio n I n d aily dental .
prac tice (ordinary cases ) the thorough brushing

of the hands and fi ngers wi th a good soap and h o t
wa ter is su ffi cient I f an operator is treating a
.
s yphilitic pat i ent a n d S ho uld injure the S kin the ,
immediate and very thorough massage of the

wound wi th 33 per cent calomel Ointment is
.
a prophylactic meas ure against infection The .
h ands must always be very thoroughly d r ied b e

fore going O ut to prevent cha pp ing .
10 T OOT H EX T RA C TIO N
3 Ca r e
. o fI n s tr um en ts
A ll inst rument s a r e b oiled i n wa te r to wh i ch a

l ittle wa s hin g s od a h a s b een added A ft er use .
they a r e b ru s hed to r emo ve blood pu s and ti ss ue , ,
r e s idue a n d then b oiled d r ied in a s terile towel

, ,
and placed in a c ab inet Knive s after b ru s hin g

.
a r e p l aced in ly s o l wa s hed in alco h ol

, and put ,
away Before u s in g a knife it is pla c ed i n ly s ol

.
, ,
w a s hed in al c oho l b ut n o t d ried T h e autho r

, .
keep s a te s t tu b e half filled with ly s ol w h erein a ,
k nife is p laced pe r manent ly a l ways r eady fo r use

,
.
H ypodermic s yrin ge s are wa sh ed o ut wi th s terile

water and then kept in 70 pe r cent alcohol Hy . .
p o d e r m i c needle s a r e cl ean s e d b y atta c hing to t h e

s y r inge passin g water th rou gh then d et a ching
, ,
them d r awin g a w ire th rou gh t h e c annula an d

, ,
b oilin g A fter boiling they a r e pl a ce d in pure

.
lysol and kept there until used Before using a ll

.
,
traces Of lysol must b e remove d by wa s h i n g fir s t

i n al co h ol and then in s te r ile water .
M irrors are brushed and b oile d I t i s b ett e r to .
i ncrea se the mirror b ill than to r un chan c e s Of i m

perfect s te r i lization A ll ins trument s a r e h an dled
.
with forceps a n d pl a ced upon a s terile gl a s s tra y .
A fter us e they are pl a ced u p on a m e ta l tray which ,
is thrown i n to th e sterilizer with th e instru m ent s .
T h e as s istant never touch e s th e unu s ed i n s trument

wit h her hands alwa y s us in g fo rceps This
, .
m etho d O f s te r il i z atio n i s s impl e pra c tica l and e f

,
III
TH E RE LA T I O N OF T H E O P E RATO R T O W ARD HI S
PAT I E N T
T OOT H extr a c tion appears to b e a s imple p r o
c e d ur e
,
demanding lit tle S kill I f the operator
.
pro c eed s in th i s s pirit he will s oon learn t h at s u c

”
c e s s ful extracting is not merely tooth pulling
“
,
but th at c o n siderable S kill and jud gment are r e

quired I t i s i m p o s s i b l e for any intelligent p r ac
.
‘
ti ti o n e r to adhere to any fi xed set Of rules as ,
eve r y new case di ffers from its pre d e c e ss or and

patients vary in physical and mental make up and -
teeth and j aws di ffer anatomically .
Befo r e discus sing the actual modus Ope r andi ,
th e w r iter desires to S pea k Of a very important

fa ctor n amely the attitude o f the operator to
, ,
w a rd h is patient The fi rst e s sential for the opera

.
to r is absolute c almness fo r self control and pre

,
-
c i s i o n O f a c tio n will inspire confi dence Neve r .
hur ry ; y o u c annot extract teet h s uccessfully by

th e clock T h e patient mus t always feel that th e
.
operator i s th e maste r Of the situation S ome .
time s t h e operator i s c onf r onted by a di ffi cul t

problem and may be at a loss w h i ch cou rs e to
pur s ue ; let h im ca r efully weigh the s everal po s
s i b i l i ti e s and t h en proceed T h e operator m us t
.
12
ATT I T U D E OF O P E RATO R 13
never exhibit stage fright or appear o verwh elmed

b y the S i tuation A kind gentle word e s p ec i al lv
.
, ,
to women and children will do more to quiet the

,
patient than th e p o m p o us ult r a professional air

.
,
-
assumed by some K ind but fi r m never rough o r

.
,
impatient S h ould b e the attitude O f th e ope r ato r

,
.
M en s s uccesses can more Often be traced to t h eir

’
attitude toward their patients than to exceptional

S kill or ability . I n treating children or ex tremel y
nervous patients some men have recourse to a
,
falseh ood assurin g them that thi s o r that will n o t

,
hurt thus ga i n i ng their con fi dence and they per

, ,
form some painful operation as the extraction of ,
a tooth or th e removal Of a pulp T h is the w r iter .
abs olutely condemn s Never tell a patient a lie

. .
DO the lea s t painful work fi r s t gain the patient s ,

’
c onfi d ence an d then he will submit ev en to nece s

,
s a r ily painful operation s .

TH E EXAMINA T I O N OF T H E PA T I E N T
TH E examination of the patien t S hould begin
the moment he enters th e O ffi ce a s many Objective ,
symptoms valuable to th e Operato r can be elicited

, ,
by careful Observ a tion .
C ommon sense will forb id a long painful ses ,
S ion wit h a nervous ly agitated subj ect th e dange r ,
from S hock being greater here than i n the case

O f a robust indivi dua l A strong person will with
.
s ta n d the extraction O f a number of tee th without

an anae sthetic w hile a delicate patien t may not
,
bear a superfi cial scali n g A stout as thma tic is .
as unfi t fo r a long sessio n as a neuras thenic whose ,
confi dence can o n ly be gained by short S ittings and

the leas t painful methods A heart le s io n can fr e .
q u e n tl v be noted b y the congested a ppeara n ce O f

the mucous membrane club S haped fi ngers v e , ,
n O S i ty of the nails indicating an obstructed cir

,
culation E xtreme pallor may indicate anaemi a or

.
a weak ine ffi cient heart P rominent temporal ar

,
.
te r i e s standi n g out like whipcords indicate a

, ,
hardened condition Of th e blood ves sels and the

radial pulse S hould be tested as to the compres si ,
b i li ty of the vessels I n these cases it is a wise

.
precaution to determine the blood pressure by

14
EXAMINAT I O N 15
me a ns O f th e S p h ygn o m a n o m e te r particu l arly if ,
ni trous oxide is to be administe r ed The author .
would refuse th e administration o f N 0 if th e 2
b lood pressure is above 1 80 mm Hg . .
Tuberculosis is Ofte n written upon a patient s ’
face and if pulmonary the breathing may b e the

, ,
tell tale The respiration S hould be noted ; a p a

-
.
tient who is coughing is a poor subj ect for a n ae s

th e s i a The diabetic c a n Ofte n be recognized by
.
the odor of his br e a th .
The S hort j erk y movements and snappy s peech

,
of the neurotic are easily di fferen tiated from the

S lo w motions of the plethoric By carefully O b .
s erving a swollen face one c a n Often tell the O f

fe n di n g tooth ; a necrosis can frequently be de
tec te d by its Odor The di fferent types of physi
.
cal make up will not obviate a necessary ope r ation

-
,
but will modify our methods in some cases A n .
h ysterical patient i s be tter fi t for a general than

for a local anaesth etic A keen diagnostician
.
S hould always use all his senses be he a physician , ,
a surgeon or a dentist E verything S hould be .
noted about our patien ts : their appearance wal k , ,
mannerisms speech motions every little detail ;

, , ,
this is important in surgical practice as surgical ,
S hock plays a decided r Ol e in th e ultimate success
and may prove an impor tant factor in the extrac

tio n O f teeth especially as some extractions a r e
,
S evere surgic a l procedures .

16 T OOT H EX T RAC T IO N
In female patie n ts who are pre gnant the a d
vi s a b i l i ty of tooth extraction i s frequently que s
ti o n e d . T h e autho r sums up this muc h moote d -
question a s follows : P regnancy should n eve r

stand in the w a y of a n e c es s a r y tooth extraction .
I t i s far be tter for the patient to be promptly r e

l i e ve d of su ffering than to s ubj ect her to constant
pain wh ich is a muc h greate r S hoc k a s it i s con
, ,
ti n uo us and t h erefore accumulative

,
The care .
ful extraction O f th e diseased toot h can be done

with comparatively little shock especially if the ,
patient is given an anaes thetic preceded by a ,
sedative The author has performed tooth ext r ac

.
tion upon women in all stages Of pre gnan cy and

ha s no i ll results to report .
This close observation O f the patient enables the

dentist to better appreciate the phy s ical state Of
his charge to co operate with the ph ysician if
, ,
necessary and to better j udge th e u s e O f anaas

,
t h etics .
I t i s wrong to make up your mind to e x amine a

S ingle tooth First study the mouth a s a whole ;
.
note all the teeth and the articulation Ex ami n e .
the muco us membrane as to color and th e pre s ,
ence Of any lesion upon th e lip s the ch ee ks o r ,
ton gue Be o n th e loo k out for any S O called

.
-
“
fever s o r es-
”
M ake it your b usines s to become
.
acquainted with a typical ch ancre L oo k b eh ind .
the third mo l ar and take notice Of the ph a ryn x

,
EXAMINA T I O N 17
an d th e ton s ils ; s tudy th e ch aracte r Of th e alveo

la r p ro c e ss and t h en la s tly e x a m ine th e tooth to
, , ,
b e ext r a c ted.
FI G . 1
a inin g
Ex m th e S ub m a i ll ry
x a and S u bl in gua l G l a nd s
I f th ere is swell i ng or suppuration present ex ,
ami n e th e adj acent glands (Fig . .
A void placin g t h e fi n gers into the patient s ’
mout h as m uch a s po s s ible ; it is pleasanter fo r

t h e patien t and b ett e r protection fo r t h e operato r
to us e r e tractors (Fi g 2 ) o r wooden ton gue de
.
pres s or s (Fi g. T h e s e a r e th e cl eanest a s , th e v
are ch e a p en ou gh to be di sc arded afte r us e .
FI G . 2
a in ati n O f
Ex m o th e M o uth w ith R e tr ac to r s
If a s welling is present always examine t h e

,
contour Of the j aws by s tan ding behind the p a

,
tient and passing th e fi ngers al ong the border Of

the j aw from the symphysis toward the angle and
toot h may n o t give suffi cient drainage and t h e .
knife will b e requ i red .
The fever th e rmometer and th e frequency of the

pul s e w i ll h el p to g ive th e O p e r ator an idea to wh at
FI G . 4
a i n i ng th C nt u r O f th L
Ex m e o o e o we rJ aw
extent th e or ga nism i s taxed in fi gh ting an i n fec

tion I f s e p tic materi a l i s ab s o rbed th e p atient s
.
,
’
fa c e a ss ume s a g rayis h p asty a pp earance and h e

, ,
u s ually complain s Of h aving h ad ch ills Th e ex .
t r action O f th e guilty tooth i s then only part of

th e t rea tment and b e side s the es tablis h ment O f
,
PR E VI OU S H IS TORY 21
th orough drainage the elimination o f septic ma

,
te r i a l must be accomplished by means Of cath ar

tics and the free imbibing o f water .
Before operating the patient s previous history

,
’
as to hemorrhage S hould be elicited to bring o ut

the possible pre s ence Of hemophilia .
I f a number Of teet h o r roots are to be extracted

,
it is a lways best to fi rst make a chart o f these ,
to be certain that nothing is overlooked o r fo r

gotten .
V
PR E PARAT I O N OF TH E P AT IE N T
TH E succes s ful ou tcome Of any operation depends
to a large exten t upon the physical and mental
state Of th e patient NO Operation fi lls the p a
.
ti e n ts with more apprehension than the extraction

O f teeth. O n e reason for this is th e fact that the
patient is n o t able to see what is going o n The .
gre a ter th e fear felt b y th e pa tient th e greater the

S hock to th e nervous system The extent of shock
.
attending denta l opera tions is very much under

rated and is only visible to the careful Observer .
The sudden b lanching of th e p a tient the frequen t ,
and thready pulse m uscular spasms and vomiting

,
are all symp toms of profound S hock M any p a .
ti en ts are sent h ome from the dental O ffice who

are really n o t fi t to leave it A good dea l can be .
d one to alleviate S hock .
The pa tien t S hould be in a comfo rtable semi

reclining position ; tight clothing S hould b e
loosened whether an an aes thetic is used o r n o t ;
,
the head should be well su pported and c o m fo r ta

ble so that the muscles Of the neck are not
,
strained The a ttendant S hould always direc t th e

.
pa tient to the toilet as invo lun tary micturi ti on i s

,
not only very embarrass ing but may prove harm ,
22
PR E PARA T I O N OF P AT I E N T 23
ful to the patient p arti cularl y i n co ld weath e r

, ,
fo r su d den ch illing o f th e pelvis as the re s ult of

wet clo th i ng may b e the cause Of sever e i lln ess .
M any patient s are s o agita ted as to b ecome hy s

te r i c a l
. They tremble an d their muscles twitch .
This type c a n be great ly bene fi ted by the a dm i n i s

tr a ti o n Of seda tives in th e S hape o f bromides o r
,
valerian half a n hou r b efore operating The a u .
thor has been h aving v ery sa tisfac tor y re s ults by

th e administr a tion o f B r o m ur a l in ten grain dose s
-
.
I n extreme cases Opi a tes will b e Of great bene fi t .
The latter S hould o f course onl y b e re s orted to

, ,
in ex treme cases .
There should be as little preparat i on as po s si

ble while th e patient i s in the room ; e verything
s hould be ready when he enters the cha i r .
T O prepare the mou th fo r any operation it

would be wise to have the patient c a refully brush
the teeth and use an antiseptic wash but this will ,
not be carrie d out even under ideal conditions .
The writer applies the O fficial Tr I odine full .
strength to th e too th and s urrounding structures

before applying the forceps I t is true th e buccal
.
tis sues cannot be sterilize d and they a r e not as

,
susceptible to infection as other structures but ,
we must remember that by extracting we create

an Open wound which may become an avenue fo r
,
i nfection .
VI
I NDICA T I O NS FOR T OOT H EX T RA C T I O N
1 Teeth resisting medicinal o r surgi cal treatmen t
. .
2 T eeth causing infection where the s ep tic focus

.
,
must be removed ha s tily .
3 Teeth which h ave lost their function .
a Teeth which inte rfer e with p roper a r ti c u

.
latio n ;
b Teeth wh i ch cannot be re stored by fil l
.
ings inlays or crowns ;

,
c Teeth which interfere wit h the i n tr o d uc

.
tion o f bridges o r dentures .
4 Teeth which are impacted and are the source Of

.
trouble .
5 S upernumerary tee th
. .
6 Teeth which erupt before o r S hortly after bir th

. .
7 Temporary tee th which are retaine d be y ond

.
t h e i r proper time Of exfoliation .
8 S ingle teeth in th e upper jaw

. .
M a lp o s e d te e th s h o ul d n eve r b e ex tr a c ted fo r
th e c o r r e c ti o n o f a d ef o r m i ty un l es s a n o r th o
,
d en ti s t h a s b een c o n s ul ted e ven i f th e p a ti en t ex

,
p r es s es s uc h a d es i r e .
Broken down temporary teeth s h ould n o t be ex

tracted unless th e seat o f infection and beyond
,
t r eatment I t is Often advisable to retain tem

.
p o r a r y roots in p osition until the permanent teeth

24
EXAMINAT I O N OF T OOT H 25
are d ue eve n if they cannot be fi lled lege artis ;

“
,
the fact m ust be borne i n mind that such roots

are not absorbed .
TO O much stress cannot be laid upon these ex

trac tion as many irregularitie s of th e
permanent teeth are the re s ult O f u n ti mely r e
moval o f their temporary predecessors .
O n c e i t h a s b een decided upon th at a toot h be

extracted th e operator shoul d carefully exa m ine
,
th e dise a sed orga n and note its surroundings no te ,
t h e th icknes s of t h e alveolus t h e po s s i ble d i rc e ,
tion of th e roots , the degree of attachmen t th e ,
po s ition of the neighbor in g teeth Note wh eth er .
o r not th e o ffending organ is fi lle d an d h ow I f .
th e re i s a cot ton dressing in th e too th remove ,
s ame to note w h ether or not the p ulp chamber i s

Open or perforated al s o i f the tooth i s S plit , a
, ,
fact wh i c h m ay e s ca p e notice durin g a c asual ex

amination .
I n r oot e x traction s the gingi val b or d e r sh ou l d

b e care fully examined and it S hould be noted if ,
th e gum tis sues co ver or gro w i n to t h e s ame .
S uc h g r o wth s S h ould b e removed before extract

ing T h e resulting hemorrh age can b e controlled
.
by Tr I odine or T richlora c etic a c id The co us i s

. .
teney of th e root wh eth er it i s soft and m ushy or

,
h ard s h ould b e note d

,
M ost fail ures in e x tract
.
i n g a r e due to l ack of thoro ugh e x am i nation b e

.
fore applying the forcep s .

VII
TH E ARMAM E N T ARI UM
O N E o f the errors committed b y many young p ra e
ti ti o n e r s is the purch a sing o f to o ma n y forceps ;
ma n y a pair o f these after an idle life in t h e cabi
net fi nds a more active s phere i n the laboratory
loosening flask bolts o r doing some oth er n o n
-
“
”
surgical duty T h ere are many types Of forceps
.
for di fferent teeth but the fewer fo rceps an opera

,
to r gets along with the better There are indi

.
vidual forceps made fo r nearly every tooth and ,
almost all manufacture r s have di fferently S haped

instruments S O that there exist s really an em
,
“
barasse de richesse which to say the least to

, , ,
t h e inexperienced operator is confusing The.
writer us es comp a r a tively fe w instruments em ,
ploying the following forceps made by th e S S

,
. .
W hite Dental M fg C O (Figs 5 1 2 )

. . .
-
FIG 7 .
Forcep s used fo r all lower tee th e x cep t for ,
molars whose pulpal floor is in tact ; if roots are

se p arated then th e se force p s a r e to be used S ome
,
.
Operators use t h ese forceps for a ll lower molars ,
but th e writer prefers the NO 1 5 if the pulpal floor

.
is i ntact as it give s a bet ter hol d on the tooth

, .
Forceps used for the extractions Of lower ch il

d ren s teeth NO 1 01
’
. .
,
F IG 8. .
F o r the removal of upper narro w roots par ,
ti c ul a r ly S lender lateral roots NO 65 , . .
FI G . 9
AR M A M E N T ARI U M 29
The root forceps d evised by P rof C ry er NO .

,
.
1 50 and NO 1 51 Figs 1 0 a n d 1 1 prove useful ;

.
,
.
,
No 1 50 originally designed for up p er roo ts fr e

.
, ,
quen tly is th e i n strumen t of choice for the r e

moval of thir d molars in e i th e r j a w .
C ryer s forceps have to be used with care as

’
,
th ey a r e ver y S h a rp a n d if a pplied wi th to o muc h

,
force they are a p t to frac ture th e crow n .
No 150
FI G 10
f r Cry r
.
Upp r e Roo t F rc p
o e s A te e
F IG 11
yr
.
L o we r Roo t Fo rc p e s A ft er (
‘
r e
On e ad v antage of the lower C ryer forceps is th e

S harp angle of the be a ks .
A pair of universal root forceps applicable in
F IG . 12
both uppe r and lower j aw al s o ve ry h a n dy fo r the ,
removal Of th i rd molars are the N O 63 , . .
Besi d es th e aforeme n tioned th e following i n ,
s tr um e n ts are required
M outh mirrors these S h oul d be b oilable

,
“
.
E xplorers and pro b es .
G ood medium S ized s c a lpels to incise ab s c e s se s

-
( Fi g .
F IG 1 3 .
A knife to p re p are gum flaps .
F IG 14
Le d r r Fl ap
.
e e
’
s K nif e *
FIG .
S h ears both s trai ght and

, curved ,
div ide
tissue (F i g . .
A good water syringe .
“
O btaina bl at e an y D nta l
e De p t o .
A R M A M EN TAR I U M 31
M o uth P r o p s Of
various S i z e O f met a l rubber
, ,
o r wood . A large v ariety c a n be easily cast in

lead o r tin E ach prop S h ould be att a ched to a
.
heavy S ilk or cotto n s tring a n d t i ed to a se c ond

prop S O that i t c a n be withdra w n fro m the m o n th
,
if it S hould become loo s ened a n d that there i s n o

,
danger Of the pro p entering the pharynx The .
write r' h as two mouth prop s connect e d by metal

chains (Fig .
S everal pair O f anatomical forceps for graspi ng

soft tissue (Fig
. .
32 T OOT H EX T R A C T IO N
A mouth gag and oral screw S hould always be
handy to enable the operator to open the patient s
,
’
mouth while under an anaesthetic .
The Denhart pattern of mo uth ga g is very us e

ful and is handy to keep the mouths Of children
O p en if th e li ttle p a tients are inclined to resi s t .
FI G . 18
De n h ar t u
M o th G a g
C hildren are apt to give the de n tist a good deal

of trouble A fter coaxing begging a n d promising
.
,
the ful fi lment of their most coveted wishes or by ,
threat or force the little su fferer is m ade to S i t

,
i n the opera ting chair The doc tor by coaxing

.
locates the guilty organ and takes up his forceps

to e x tract but qu i ck as a flash the little fellow
, , ,
S hu ts his mou th and refuses to par t his lips This .
is a most trying moment for both opera tor and

parents . I n these ins tances the Denhart gag
proves I n v aluable By closing the li ttle patient s
.
’
nostrils air is cut O ff and he is forced to Ope n

,
his fm o uth a bit I f the Denhart gag is now

.
quickly brought between the teeth pressure upon ,

AR MAM E N TA R I U M 33
th e handles o f the instrument w i ll pry th e j aws

apart and nolen s volens the forceps can be a p
, , ,
plied G reat care mu s t be e x e rci s ed th at th e i n

.
s trument i s n o t Opened to o wide fo r ch ildren a n d ,
that the soft part s o f the mouth are not inj ured ;
th e instrument should never be opened unless i t i s
placed between the upper and lower teeth a s ,
otherwise th e soft tissues will be traumati z e d .
A not h er instrument very useful in treati n g

ch ildren i s a metal fi nger protector wh i ch S lide s ,
over the o p erator s left inde x fi nger and i s placed

’
i nto t h e p atient s mouth

’
I t protects the o pe r a
.
to r a gainst be i ng b i tten by th e little o n e a n d ,
being Of metal it keeps th e j aws apart

, .
FI G . 19
M eta l F in g r Pr t c t r
e o e o
FIG . 20. OR A L S C R EW
A pair Of ton gue forceps in ca se the ton gue
should fall b a ck .
FIG . 21 . TO N G U E FO R CEP S
C hisels fo r cutting bone as well as a mallet and ,
a set of retractors for retracting the lips cheeks ,
and tissue flaps P eriosteal elevators to raise soft

.
ti s sues and per i osteum (Fi gs 22 . .
F IG . 22
Re t r a c to r l
s . 2 3 4 7 8 fo r
. . . . . L ip a n d Ch ks
s ee .
36 T O OT H EX T RAC T IO N
FI G 2 5
. . HEA DL IGHT
A caute r y o p e r ate d b y ele c t r i c i ty or b e n z ine .
ARMA M E N TARI U M 37
FI G . 26
A pair O f b one cutting forceps (R ongeur ) to cut

-
away S harp edges O f b one (Fig . .
FI G . 27
A good double en d curette to r emove granula

-
tions and soft b one ti s sue (Fig . .
M astoi d cu r ettes a r e also quite u s eful .
D R E SSIN G S
I odoform gauze in strips o n e half and one inch -
w id e fo r packing .
Plain s terile gauze .
G auze b andages two and one half inches wide -

.
R u bb er tissue .
C otton swab s .
These are b est made by winding a little cotton

around one end O f a toothpick .
A dhesive pla s ter S trips o n e half to one inch -
wide .
C heese cloth S ponges ; these can b e made at

-
h ome as shown in Fig 28

, . .
38 T OOT H EX T RA C T IO N
FI G . 28
T h ey are made b y cutting cheese clot h into

p ie c es one and one half inches S quare and fold
-
,
ing ove r th e four corners ; th e r esulting corners

a r e folded ove r again and the new corners formed
,
are drawn together by a strong thread ,
the tampo n thus forming a b all A number O f .
these are made o n one thread and then cut a p art .
The following d rugs should be h and y

Hy podermic tablets .
S trychnine S ulphate gr , .
M orphine S ulphate gr ,
.
M orphine S ulphate gr , an d A tropine S ul

.
phate gr
, .
A romatic S pirits O f A mmonia (A romatic A m

moni a Va p a r o l e Bur r ows Welcome )
, , .
DRUG S 39
A m yl n i tr i te
in globules (gla s s pe a rl s h ol d in g 3
and 5 minims , whic h are br oken in a napkin and
inhaled b y th e patient ) .
Bromides B r o m ur a l (Knoll
. fiv e gr a in -
tablets .
A drenalin c hloride 1 : 1 000 .
I odoform p owder .
O r th o fo r m .
No v o c a i n .
Thiersc h S olution .
S aline S olution .
Burrow s S olution .
Boric A cid S olution 2 p er cent , .
I odine .
A lcohol .
Bicarbonate O f S oda .
Hydrogen P eroxide .
Nitrate of S ilver in 5 pe r cent S olut i on . .
Nitra te of S ilver in C rystal s .
C arbolic A cid .
I J YS O I .
A tube O f E thyl C hloride .
A j ar O f pe r cent C alomel O intment .
A j ar O f 5per cent I chthyol O intmen t . .
A j ar of 1 0 per cent I chthyol O intment . .
A j ar Of V aseline .
C LASSI F ICA T I O N OF CAS E S
T OOT H extractions can be divided into
1 Normal e x tractions
. .
2 The removal O f roots

. .
3 The removal of impacted teeth

. .
4 The removal O f unerupted teeth

. .
A normal extraction is one performed upon a

tooth which has su fficient crown struc ture present
to ena ble th e operator to grasp th e tooth wi th for
ceps and remove it wi thout di ffi culty .
R o o t E x tr a c ti o n s are subdivided into

Normal and surgical .
A normal root extrac tion is one performed upon

a root which can be grasped by forceps (or luxate d
by an elevator ) and removed without di fficul ty .
A surgical root extrac tion is an opera tion in

which th e knife chisel or bu rr must be employed
,
to remove overlying tissue when extracting a

roo t ; these are distinctly surgical procedures and
must be carried out accordingly Observing st rict
,
asepsis and subsequent proper after treatment O f -
the w ound .
I m p a c te d tee th are designated as such when e n ~
gaged or incarcer a ted by adj oining teeth or c o n

40
T YPE S OF C AS E S 4]
ti guo us s tructures as the ramus of the mandible

,
o r the tubero s i ty of the upper j aw .
Un e r up te d te e th are suc h w h en covered by soft

o r hard tissue or b oth .
These d i fi e r e n t types O f operations demand a

varying tech n ique ; neverth eless all extractions ,
are governed by prin c iples b ase d u p on ph ysi c al ,
law s w hich demand O b servation

, .
FIG . 29
I ll u t r ating th Va r i u Ty p O f Ex t r a cti n Diagr m m ati call y

s e o s es
— N r m a l E x t ra c t i n ; b N r m a l R t ;
o a
a, o o o Fr a c tu r ed R t ; d
oo 0, oo
I m pac t d T th ; Un r upt d T th
,
e oo e, e e oo .
IX
TH E T E CHN I" U E OF NO RMAL T OOT H EX T RAC TIO N
F OR convenie n ce in teaching the writer d ivi d e s ,
the operation o f tooth extrac tion into fou r stage s

1 The grasping of th e forceps
. .
2 The application O f the ins trument

. .
3 The closing of th e instrument about th e toot h

. .
4 The actua l remov a l of the toot h o r root

. .
I t is important for th e stu d ent to carefully m a s

ter these di fferent steps and though no rigid rule s
,
can be laid down for the extrac tion O f teeth the ,
variou s steps mus t be executed correctly as they ,
depend upon p hy s i c a l la w s and these must be O b

,
served i f succes s is to be att a ined .
Th e for c e p s S h ould b e g r a s p ed and pla c e d
F IG 30
and
.
P l ing th
ac e Fo rc p L
e s o o se ly Acr o ss th e H
42
44 T OOT H EX TR A C TIO N
FIG 32 .
App l i c a ti Of Be ak s t T th Th a t
on o oo th e D i stal P ar t Of I n str u
m en ts P o i n t s Aw ay fr o m M d ian L i ne
e .
FI G 33
App l i c ati n O f Fo rc p Of T th
.
o e s to Cr o wn oo
APPLICA T I O N OF F O RC E PS 45
FI G 34
Cl i ng F rc p A b ut T t h Th I n d x F in g r
.
'
os o e s o oo . e e e H a s B ee n
W ith d w n f r m B tw n th F c p H dl an d
ra o e ee e or e s an es H a s B ee n
C u rv d A b ut th I n t r u m nt
e o e s e .
The forceps are so adjusted that the l o n g a xi s

o f th e b e a ks r un s p a r a l l el w i th th e l o n g a x i s o f
th e ro o t
.
This constitutes the second stage O f th e O pera

tion and is one O f the steps important to b e O b
s erved I f the forceps are applied incorrectly the
.
,
force used fi rst in driving the forceps home and

then in extractin g the tooth will travel in a wrong
direction and fr e q ue n tlv cause th e tooth to frac
ture or produce unnecessary mutilations or bot h .
F i g 35 represents a pair of for c eps c o r r ec tly

.
a pp lied to a L eft U pper C anine .

46 T O OT H EX T RAC T I O N
FI G . 35
i n dicates
th e long axis of both the tooth
the fo rcep s beaks ; it also shows the path in which
-
th e for c e requisite to dr i ve th e instrument home

,
and to extract the tooth will travel ,

.
is a rectangle which r epresents d ia

grammatically th e area o r amount O f re s istance
O ffered to the operator .
2 r epresents th e s ame forceps applied i n c o r

.
r e c tly .
c d repre s ents the long axis O f the toot h

. . .
H G represen ts the long axi s O f the forceps

. .
beak s (not parallel to H G also s h ow s t h e .
path along wh ich the applied force w ill travel .
repre s ents th e area o r amount o f r e

APPLI C AT I O N OF F O RC E P S 47
s i s ta n c e be ove r come wh ich is ab out thr ee to

to ,
four time s greater th an in the precedin g illu s t r a

tion .
The a r ea Of r esistance is O b tained by ma rk

“
ing the widest cervi cal portion O f toot h emb e dd ed

in bone B D then drawing a line markin g th e
. .
,
lon g axis O f the toot h E F and a tange nt to th e . .
apex O f th e r oot A O parallel to R D Now lin e s . .

, .
are erected at B and D parallel to E F and e x . . . .
tended upward till they intersect the tan g ent

A C this gives us
. .
(shaded p o r tion ) a n d
expresses diagrammatically the area O f r esistance
to be overcome in extr a cting the toot h I .
That the forceps beaks are incorrectly a pplied -
to C anine 2 is shown by the fact th at t h e long

axis O f the beaks H G does no t run parallel with . .
c d th e long axi s O f the tooth ; we therefore get

. .
, ,
a much greater area Of resistance (shaded po r “
tion ) and the tooth is apt to fracture at M N o r

,
. .
,
in exerting su fficient force to ove rc ome th e r e

s i s ta n c e Ofi er ed b y the solid b lock O f ti s su e
t h e alveolus will S plinter or other inju r y
result without (in many cases ) the tooth leavin g
,
th e socket .
T h e area O f resistance may appear r ath e r

“
theoret i cal ; the w riter however has seen th i s

”
, ,
theory demonstrated as a fact in th e mo uth i n , ,
numerable times ; b oth in the lower and upper

j aws I ts Object
. i s to impress the student wit h
th e importance O f correct forceps applicatio n .

A fter the forceps h ave been applied correctly th e ,
index fi nge r is w ithdrawn from between the

handles and place d on top of th e middle fi nger th e ,
th umb is brought around th e handles and th e

beaks closed about the too th (Fig Thi s . .
terminate s the third S tage O f the o p er a tion .
FIG . 36
ft r
A e th e o F rc
e p s A i e l r O pe I
’
pp l i d d th Ind x F in g r
Iy A e an e e e
ls P el ac d
o n T o p o f th e M i ddl F in g r th Th u m b I B r ugh t
e e ,
e S o
A o r un
d th e H an dl an d
e th e B e ak Cl d s o se .
C L O SIN G OF F O RC E PS 49
In clo sing the forceps too much force S h ould not

be exerted as the tooth will then be fractured by
,
th e sharp beaks Th e forceps should b e closed

.
just tight enough to j oin tooth and forceps I n .
fact we must look upon forceps as elongations of

,
our fi ngers H and forceps and tooth must b e

.
,
come one O bjec t .
The fourth stage O f the operation the actual ,
r emoval Of the tooth from its socket is neither a ,
j erking n o r pulling process but rather fi rst the

, , ,
determination of th e direction o f least resistance

by luxation and then a teasing O f the tooth out of
,
its socket b y an inward and outward motion

,
.
I n removing a tooth from its alveolus there a r e

two force s to be overcome
.1 The pericemental a ttach ment .
.2 The mechanical insertion O f the toot h i n its

socket The latter is particularly marked in multi
.
rooted teeth and is w ell ill ustrated in old S kulls ,
wherein the pericementum is dried up and plays

no part in the retention of the teeth ; still th ey are
re tained by the S hape of their roots as a peg i s ,
—
held in a board b y adhesion Bearing t h ese two .
”
retentive factors in mind w e formulate the ,
actual extraction accordingly .
The pericemental attachment is broken up by

driving t h e root into the socket then luxating the ,
same inward and outward and then continuing

thi s rocking motion till tactile sense indicates the
d i re c t i o n Of
l ea s t resi s tance and a c tuall y tea s e s
th e toot h o ut of it s s oc k et .
A s w e u s e b ayonet fo rc eps fo r all upper teeth ,
t h i s tech nique applie s to all teeth in th e uppe r j aw .
FI G 37
S h o w s Ap p l i cati n Of Fo rc p t R i gh t U p p r T h i r d M o la r ;
.
o e s o e
N o t L eft T h u m b an d In d x F i n g r P r t c tin g S f t P a r t s
e e e o e o .
52 T OO T H EX T RA C TIO N
FIG 39
S h o w s App l i c ati n O f F rc p t L ft U pp r T h i rd
.
o o e s o e e M o l a r ; No t e
L ft T h u m b d I n d x F ing r P r t t i n g S ft P r t
e an e e o ec o a s .
In extracting lower teeth the forceps a r e ,
grasped and also placed loosely a cros s the palm

of the hand (Fig 40) the index fi nger is then i n
.
tr o d uc e d be tween the handles (Fig the other .
fi ngers being placed abou t th e handle The thumb .
is now ex tended along the S hank O f the i n s tr u

ment (Fig 42 ) the beaks are then applied to th e
.
crown of the tooth by tilting the beaks downw a rd

,
so as to bring them in a parallel position with the

long axis of the tooth (Fig The index fi nger .
is withdrawn from between th e h a ndles placed ,
above the middle fi nge r, and the thumb i s kept

HO LDI N G LO W ER F O RC E PS 53
ex ten d ed t h e forcep s are clo s ed (Fig

,
. and
the toot h lu x ated and withd rawn .
F IG 40
l ac in g In s t ru m nt L s ly
.
H ld in g L w r F rc p
o o e F i r t S tag
o e s, s e, P e oo e
Acr o Pa l m f Han d
ss o .
F IG . 41
I tr d uc i n g I n d x Fing r
n o e e t
B e w ee n Ha n dl s
e to O p n F rcep s
e o
54 T OO T H E X T RA CT I O N
ing P iti n O f L wer F rc p as Th y A e B ing App l ied

S ho w os o o o e s e r e
t T th
o oo Th In d F ing r I S t i ll B tw n th H an dl th
e ex e s e ee e es , e
Th u mb Ext n d d A l n g th S h an k O f th I n t r u m n t
.
e e o e e s e .
APPL ICAT IO N OF F O RC E P S 55
F IG 43 .
S h w th e
o s pp l i c at i n f F rc p t a L w r B i cu pi d Th e
a o o o e s o o e s .
Ind x F i ng r H B n W i th dr w n P l c d A b v th M i ddl F in
e e as ee a a e o e e e
T
,
g d
er , an t h h u m b
e E t n d d A
x el n g teh S h an k o f th In tr u ment o e s e .
N t
o th
e Pa r l l l A pp l i c a t i n O f t h
e a e B ak
o t th L ng A x i
e e s o e o s
Of T th oo .
F I G 44 .
S h w L a t S t a g O f A pp l i c a t i n O f L w r F r p
o s s e th In d x o o e o ce s, e e
F ing r H B n W i thdra w n fr m B t w n th Handl th
e as ee o e ee e es , e
T h u m b I Ext n d d A l ng th e S han k th B ak A C l d A b ut
s e e o e e s re o se o
f th T t h
,
th Cr w n
e o o e oo .
IVi th lower forceps where the handles a n d ,
beaks form an angle the h an d le must be raised ,
su ffi cien tly high that the beaks become a continua,
tion O f the roots (or that the long axis of the be aks
runs as n early parallel to the long axis O f the
tooth as possible ) not Observing this accounts for
many failures .
L ower molar forceps should be so applied that

the pointed portion O f the blade s strikes the bifur
c a tion of th e roots as nearly as possible .
The curved blades of the lower molar forceps

should enclose the bifurcation O f the root and n u ,
les s there exists an ankylosis the roots are badly ,

A PPLICAT I O N OF F O R C EPS 57
curved on diverging ; there is little ch ance fo r fail

ure if the tooth is properly luxated (Fig .
The applic a tion O f sudden force by j erky move

ment s o r pulling will s n ap O ff the crown o r tire
the operator rapidly cause a sore hand and fail
,
to dislodge the toot h .
FI G 45
.
Fo rc p C rr c t l y
e s o e and I n c rr t l y A pp l i d
o ec e to L o we r T th
ee
58 T OO T H EX T RAC T IO N
F I G 46
S h w App l i c ati n O f F rc p t L w r Ant r i r T e th ; N t e
.
o s o o e s o o e e o e o
L ft T h u m b S upp r ti g M a n d i bl
e o n an d Ind x a n d S ec n d F inger s
e, e o
P r t c tin g S ft P a r t
o e o s.
FI G 47 .
s App l i cati n Of F rc p t L ft L wer M lar ; N te D i

Sho w o o e s o e o o o
r ct i n O f B
e o k Pa r a ll l t T th F in g r O f L ft Ha n d S up
ea s, e o oo e s e
p rting M a n d i bl an d Pr t t ing S ft P rt
,
o e o ec o a s .
S O, a fter all if all points necessary fo r s ucces s
,
ful tooth extrac tion are considered th e operation ,
i s n o t merely pulling b ut a co m plex procedure ,

.
TO recapitulate one has to bear in mind

1 G raspi n g o f the force p s n o t tigh tly but
.
, ,
l oosely .
2 C orrect ap plication of th e forceps beak s to

.
-
the tooth L ong axis Of b eaks parallel to long

.
,
axis of the root .
3 C losing O f forceps not to o ti ghtly ; j oin h and

.
, ,
forceps and tooth into one .
4 C orrect application of for c e upward or down

.
ward then in and o utward to break up perice

, , ,
men tal fi bres and thus loosen the roots in their

al veoli and then con tinue th e in and outward mo
,
tion gaining th e direc tion o fleast resist a nce

,
— then
removing th e too th never losing control o ver th e
,
instrument .
H a vi n g consi d ered the general principle s of

Normal E xt r actions a few words regarding t h e,
posi tion O f the Operator wil l be in orde r .
Di fferent operators assume vario us p ositions

wh ile extractin g .
P OS ITIO N OF O PERATOR 61
F IG 49
s iti o n Of Operat o r Wh i l e Ext r ac ting U pper Le ft Anter i r T eth
.
Po o e
FI G 50
t U pp r P t r i r T
.
Po s iti n
o o fO p r at r Wh i l
e o e E xtra ct n i g R i gh e os e o ee t h
The wri ter usually s tands at th e r i ght S ide ,
facin g h is pa tient except while r emoving tee th

,
from th e left S ide b o th upper a n d lowe r j aws

, ,
w h en re m a i ning a t the sa m e S ide h e will turn

a round so as to stand parallel to th e patient
,
.
(Figures 4 9 54 i llustrate this bet ter than wor d s )

-
.
PO SI T I O N OF O P ERATO R 63
The w ri ter never s tan d s b ehind th e p at i ent a s ,
i t i s ea s ier to remove tee th from the alveoli facing

t h e patien t The teeth forming an arch in the
.
j aw s Figures 56 and 57 will demonstrate th at i t

, ,
w i ll require les s force and e ffort o n the part Of the

Operator to dislodge a tooth labially o r buccally
s tanding in front (F i g 57 ) th an stand i ng behind
.
the patient (Fig a s th e operato r ha s to use

.
h i s wrist elbow and s h oulder j oints a n d i s work

,
ing overh and o r indirec tly w h ile w h en h e faces

,
the patient he w orks directly and only us e s hi s

wri s t and elbow .
F I G 51
r P t r i r T th
.
Po s iti n Of Ope r at r Wh i l Extr a c ting R i gh t L

o o e o we os e o ee
T OO T H EX TR A C TIO N
FI G 52
Po s iti o n O f O per a to r xt racti ng Lo wer Ant r i r T eth
.
il
Wh e E e o e
P O S ITI O N OF O PE RAT OR
FIG 53
.
Po s iti n Of O p ra t o r Extrac ting L ft U pp r P st er i r Teeth

o e e e o o
66 T OO T H EX T RA C TI O N
F I G 54
P o iti n f O p r t r Ex t rac tin g L eft Lo we r T eeth
.
s o o e a o (S o me ti me s
th e W r it r W i ll S tan d as in F i g
e .
FI G 55
ta nd ing in d atien t
.
S Be h th e P
X
TH E EX T RAC T I O N OF RO O T S
NO CLA SS f
conditions will test the skill Of th e
o
operator more s everely than the successful e x

traction O f roots Those roots wh ich can easily b e
.
reached b v forceps or elevato r will not prove dif

fi cul t but roots fractured below the level of t h e
, ,
a lveolar proces s roots malposed or curved may

, ,
at times ta x t h e utmost S kill O f the most ex p e r i

en c e d Operator and their succes sful re m oval fr e
,
quen tly proves to be more d i fli c ul t operations than

many maj or surgic a l pro c e dures .
For the extr a ction of upper single roots bayo ,
nets NO 32 and NO 65 will usually su ffice ; in some

. .
instances NO 1 50 will be valuable For the mandi

. .
ble NO 85 and NO 1 51 answer the purpose U p

. . .
per molar roots united by pulpal floor the writer ,
attempts to remove in one operation by driving

th e NO 1 0 forcep s betwe e n gum and bone as high
.
as pos sible .
I f necessary th e gum is separated from th e

,
alveolar process by making a flap on the facial a n d

palatine aspects (Fig .
I f th e roots are separated they are treated as

s ingle roots and removed with th e narro w bayo
net individually For lo w e r molar roots wh ich
.
68
C AR E OF GU M T ISS U E 69
are not divided the NO 1 5 lowe r mol ar for c eps

, .
a r e emplo y ed ; if divided NO 85 and NO 1 51 prove ,

. .
useful ; a fi x ed rule cannot be laid down however ,
and th e individual case m ust dec i de the b est i n

strument in a given case .
‘t d;
-
l u
‘ ( d tu
FIG . 58
If a root is decayed or fractured below the level

o f the alveolar border it is the writer s practice to
’
,
incise the gum parallel to the root facially and

lingually and then force th e instrument bet w een
,
the gum and the b o n e c utti n g through the alveolar

‘
proces s if necess ary When grasping the root

,
.
n e ve r i n c l ud e th e s o f t ti s s ues within the beaks o f
the forceps .
To c ut s o ft ti s s ues w i th th e f o r c ep s i s b r uta l ,
un s c i en ti fic , un s ur gi c a l , un n e c e s s a r y an d h a r m ful
to th e p a ti en t, f or it is no t c utti n g , b ut te a r i n g
ti s s ue.
I t i s an e s tab l i sh ed fact t h at incised wounds h eal

b y fi r s t intention O r pri m ary union wh ile la c erated ,
wound s heal by granulation which is a longer ,
pro c e s s ; besides a lacerated wound become s i n ,
fe c te d more Often than an inci s ed lesion I t is .
import a nt to remember in the extraction Of roots

th at gum tis s ue S hould n ev e r be torn but alway s ,
incised by means Of a knife o r s ci s sors .
Fig 59 illustr a tes the c orrect and in c or r ect p r o

.
c e dur e in these ca s es .
FI G . 59
I S h w s th F i rst B i c u pi d R o t i th A lv l u s 1 1 S h w s th
o e s o n e eo o e
Of th T i u A ft r
. .
.
G um In c i d III Sh w se . th A pp a r an c
. o s e e e e ss es e
Ex tr c ti n F ll w i n g P r p r In c i i n
a o o o I V S h w th e A pp a r an c
o e s o . . o s e e
O f th P a rt A f t r th E x tr ac ti n i f th O p r at r D N t I
e s e e o e e o oes o n
c i th G um F i r t b u t In cl ud t h S ft T i u W i th in th
,
se e s es e o ss es e
B lad
,
Of th F rc p
es e o e s .
I f the
root is a mol a r root two parallel incisions
c an be made and thus a flap prepared wh ich is
, ,
loosened with the lower end of the flap knife or

periosteal elevator and the forceps are then ,
driven well below the gum F o r cutting gum tis .

ELEVA TORS 71
s ue the aut h or devised a knife shaped like a ch i s el ,
which will not nick when brought to bear upon

bone The lower end is shaped like a periosteal
.
elevator wit h which the gum flap i s separated

from the bone Fig 1 4 The knife can be sh ar p . . .
ened o n an A rkansas stone .
E levators wh ich are really but o n e be a ked ,
S ingle handled for c eps or gouges prove very use

-
,
ful at times but must be employed very cau ,
ti o us l y as a S lipping elevator can do a great deal

,
o f harm The inst r ument is held in the right hand

.
a n d grasped as s h o r t as possible ; the left hand
should always protect th e surrounding tis sues S O ,
as to avoid s lipping .
F I G 60
El v a t r U d b y th A uth r Th R i gh t a n d L ft I n s t r um ent
.
e o s se e o . e e s
A re N O 1 3 an d N
. 1 4 S S Wh i t Th O th r Th r
O Eu r p an
.
,
. . e . e e e e, o e
In tr u m nt T h O at th Ex tr m R i gh t I P t h E l v at r
s e s e ne e e e s ar sc
’
s e o
P a r t i c u l a rl y A d apt d f
. ,
R m v al f L w r R t Th O N x t
e or e o o o e oo s e ne e
t Th i I L
.
E l v at r an d th O in th C nt r B t n ’
lu
’
o s s ec se s e o , e ne e e e et e s
El va t r
e o .
72 T OOT H EX TRAC T I O N
The blade of the instrument is then forced b e
tween root and alveolus s o as to force the root ,
o ut Of its socket There are many types Of eleva

.
tors and it makes really no di fference wh i ch one

,
is employed as long as the desired end is a c c o m

,
p l i s h e d i e t h e removal
,
. o.f the
,
root wit h n o dam
a g e to adjacent tis sues The writer uses th e i n .
s tr um e n ts S h own in Fig 60 Figs 61 65 demon . . .

-
strate the use Of elevator s .
FI G . 61
S h o w s th e Mann r O f in an l v t r in th Upp r J w Th
e Us g E e a o e e a e
p t y lv l u t D m n tr at I t
.
In t ru nt
s me ls A pp l d an
i e to Em A eo s o e o s e s
U se .t t n
No e th e P o s i i o o f th e T u b O f th R i gh t H an d ; th
h m e e
tn p n
S a m e I s R es i g U o a l t t i S t a d i th H a d d
th e P a e ; h s e es e n an
P r v nt S l i pp i n g f t h I n tr u m nt
e e s O Th L ft H an d i E m p l y d
e s e e e s o e
L ip an d C h k Th I n t ru m n t I H ld V ry
.
t R t r ac t th
o e e s ee . e s e S e e
sh r t
o .
US E OF EL E VA TORS 73
F IG . 62
E l v at r App l i d
e o e to T oo th , R ghi t S id e L o we r Jaw
In using eleva tors it must be borne i n mind that

these instruments a r e used as levers and c o n s i d ,
c rable force is required to dislodge a root ; if such
an ins trument S lips it is apt to do considerable

,
da m age to the patient as perforating the c h e c k

,
or the palate A n el eva to r s h o ul d n e ve r b e r es te d

.
up o n o r a g a i n s t a n a dj o i n i n g to o th I t therefore
'
.
, ,
is necessary to have full control over the i n s tr u

m ents . S oft parts S hould always be drawn out o f
the w a v .
C ases often present instances where the frac

FI G 6 3
Em p l y in g E l v at r t G u g Out T th —L e ft L we r To th
.
o e o O o e oo o o
N t T h u m b f R i gh t H n d L ft H and
.
o e O a S h an k O f I n t r u m nt
o n s e e
P r t c t T ngu T h at S i d
.
o e s o L i p an d C h k
e, ee On e .
tur e d root lies so deeply embedded in bone that it

is impo s sible to reach it with forceps o r elevator ;
in t h ese ca s es the gum and periosteum are incised ,
S O a s to form a flap which is separated from the

,
bone by a p eriosteal elev a tor and held by a r e

tractor o r tenaculum thu s exposing t h e bone , .
T h e bone is then removed wi th engine bur

o r chisel until the root is su f ficiently ex posed
to enable the operator to remove it wit h
elevator o r forceps I f a chisel is used it i s a d
.
,
76 T OOT H EX T RA C T IO N
FIG . 65
U i g El va t o r to G ug
s n e o e i t Upp r R t N t P iti o n
O ut R gh e oo . o e os
o f R i gh t In d x F in g r a n d
e e i n O f L ft H n d an d F ing rs
P o s ti o e a e .
novocain and adrenalin the va s oconstric tor prop

,
e r ty o f the last named dru g serve s to good pu r

-
p os e Thi s however is n o t su ffi cient to d o away

.
, ,
w ith all the annoyance Of bleeding ; constan t S wab

b ing by an a ss i s tant with sterile gauze spon ge s
i s essential to k eep the fi eld o f operation s uffi
EX T RAC T I O N OF ROOT S 77
c i e n tl yfree from blood so t h at the operator can

p roceed with any degree o f certainty These gauze .
s ponges must be prep a red in advan c e and s ev ,
eral hundre d shoul d always be o n hand r e a d v

fo r u s e A few illustra tions will S how the most
.
common root extractions and th e methods em

ployed Fig 66 shows a case wherein a root is so
. .
crowded i n the alveolus that it proved imposs ible

to remove it The cause of its resistance to ordi
.
n ary method s was brought out by the radiograph .
W it h th e X ray in possession a flap operation

-
,
was decided upon and after burring away the a n

,
te r i o r alveolar wall the m olar root was easily r e

moved C ase s O f this type indicate th e extreme
.
FI G . 66
v alue Of th e X ray T h e writer mak e s it routin e
-
.
pra c tice to demand an X ray if a toot h o r root O f

-
fers resi s tance to ordinary method s .
The steps of such an operation a r e

1 S terilization by Tr I odin e
. . .
2 I nduction O f a n a s th e s i a
.
=
.
3 I ncision A B
.
-
.
I ncision C D
-
.
I ncision B D
-
.
4 L oosen flap wit h raspatory

. .
5 R etract flap Of gum and periosteum F b y

. .
means o f retractor .
6 Bur away alveolar process at G until low e r

. .
portion Of root is exposed .
7 E xtract root by means of suitable for c ep s

. .
8 W a sh out wound with boric acid a n d b e sure

.
,
to remove all loose spicules of bone .
9 Blow powdered iodoform into woun d

. .
1 0 R eplace periosteal and gum flap

. .
1 1 S uture into position if neces s a ry o r p ack

.
, ,
wound .
T h e removal Of p i ece s o f molar roots in th e

mandib le m a y prove a very delicate Operation ,
a s in the case sho w n in Fig 67 ; h ere the ab .
s c e s s e d area wa s S ituated directly above th e i n fe
rior dental canal ; t h e W hole mandible wa s c o n

structed along delicate lines and t h e brutal ,
meth od Of c rus h ing o ut t h e root migh t h av e r e

s ul te d in :
EX T RAC T I O N OF ROOTS 79
1 . infe c t i o n Of the mandibul a r c a n al

A n .
2 A n injury Of the I nferior Dental Ne rve c au s

.
,
i ng neural gia I t al s o had to be bo rne in min d

.
th at the ma n dib le i n this region i s very t h ick an d ,
t h e attempt to cru s h o ut a root mu s t neces sarily

result in con s ide r ab le bone injury which in turn ,
can be produ ct ive o f a periostiti s o f th e j aw o r , ,
w h at is wo r se osteomyelitis T h e s lower method

,
.
of dissectin g the s oft tis s ues away elevating the ,
periosteum ex p osin g the bone and th en c arefully

,
removing th e ov erlyi ng os s eou s tissue till th e

roots are exposed i s th e more co n s erv ative s a f e r
, ,
and s urer met h o d .
FI G . 67 FI G . 68
Fig . h ow s another class of c a s es met wit h

68 S
n o t i n fr e q ue n tl v ; t h e technique is al s o the prep a
ration O f a ma c e periosteal fla p expo s ing th e-

,
bone and th e n remov i ng suffi cient Of the anterior

alveolar wall to ena b le the oper a tor to r emove the
r oot .
XI
TH E RE M O VA L OF I MPAC TE D T EET H
T EET H are designated as impacted wh en engaged
o r incarcerated by adj oining teeth or contiguous
structures as th e ramus O f t h e mandi ble o r th e

,
tub ero s ity Of the u pp er j aw .

I MPAC TE D T EET H 81
The successful termination O f these cases r e

quires a good de a l O f judgment as each case d e ,
mands individual treatment and there are m a ny,
types and degrees O f impactions I t is impossible .
to cla s sify a l l impactions but we can divide them

,
primarily into tw o groups

1 Those teeth whose crowns alone are engaged
.
o r inc a rcerated.
2 Those teeth w hose crowns and roots are e n

.
gaged o r incarcerated .
The fi rst class Of conditions is usually due to

rotation Of teeth in their sockets (Fig 69 C ) . .
The second type is usually caused by tilting Of

teeth o r faulty eruptions (Fig 69B ) . .
I t is evident that the fi rst clas s O f condit i ons is

more easily coped with than the s e c ond division .
FIG . 70
For example take Fig 690 L e t us suppose

, . .
that t h e second bicuspid were to b e removed This .
would prove a di ffi cult extraction as the teeth ,
are crowded and th e tooth is S li ghtly rotated in its

s ocket I f v iewed from the morsal aspe c t the
.
cr o wn s would appear as in Fig 70 . .

T h e fo rcep s applied in the usual fas h ion and fo rc e
e xerted in the accepted manner palatally and bu c
,
c ally indi c ated by arrows (a ) and (

, b ) b oth a d ,
j oining teeth 1 B and 1 M would O ffe r r e s i s tanc e ,
the molar toward the palate the fi r s t bicuspid fa

,
c i a lly. S u ffi cient force employed to l oosen th e

s econd bicuspid would also luxate th e molar and
fi rst bicuspid . TO extract the second b i cuspi d

s u cc e s s fully would neces sitate the loosening O f th e
food / W W
FIG . 71
84 T OO T H EX T RAC T IO N
6 Ch i s e l
. or b ur s uffi cient bo ne a w ay to ex po s e
en ough tooth S O t h at it c an b e rem ove d with fo r
ce p s o r elev ato r .
7 C ut aw a y all rough ed g e s Of b one

. .
8 W as h o ut bon e cavity wit h b ori c a c id solu

.
-
tion to remo v e all S piculae O f bone .
9 Blow iodoform into bone c a vity ; pack with

.
iodoform g au z e .
The bleedin g wh ich prove s very Obj ectionabl e

, ,
i s c ontrolled by th e suprarenin which is c o m ,
binded with th e local anaesth etic alw ays use d i n

th ese ca s e s and th e constant swabbing w it h ste r ile
tampons Fig 69b illustrates another type Of i m
. .
paction wh ich in reality come s under th e head

,
ing of unerupted teeth and will be c onsider e d i n ,
due time .
The most frequently occurring impaction is that

Of third molars the lower teet h ex c eeding the up
,
per i n frequency .
T h e impacted lower th ird molar occurs i n al l

”—
shadings from being slightly engaged by t h e
second molar to complete incarceration b y b oth
an terior tooth and r a mus O f m an d ible Fig 7 2 . . .
The technique Of operation in its removal

varies with each c a se O n e facto r h owever should.
, ,
n e ve r be overloo k ed a n d that i s the radiogr a ph

, .
By the X ray alone we can d etermine with any

-
degree Of accuracy what condition confront s us ,
and a ca s e which may appear very di ffi cult will

I MPAC T E D T EE T H 85
FIG . 72
pr ove to b e rat h er easy while a, v e r y i n nocent

looking impa c tio n will reveal its real character by
S kiagram only .
S ome operator s advise the removal Of the

tw e lve year molar in lieu of doing a di ffi cult third
-
mol a r extra c tion T h i s the writer i s n o t i n favor

.
o f fo r the following reasons

,
1 W e never know if the relea s ed t h ir d molar

.
will advance into proper posi tion .
2 The Opposing twelve year molar i s r o bb ed Of

.
-
its properly articulating opponent .
3 I n many case s th e third molar i s di s eased

.
,
and thus a h e al thv useful too th i s sa c rifi ced fo r

a dis eased organ .
4 The articulat i on is spoiled

. .
S ome operator s remove b oth th e tw elve year -
m olar and the wi s dom tooth ; thi s the w rite r con

s ider s malpra c ti c e .The only indicatio n to a s a cri
fice Of t h e twelve year molar fo r a th i rd mola r i s
-
pre s ent in patients who are in very delicate heal th

an d S O d e b i l i ta te d that a S hort operation i s i m
'
p e r a ti v e ; al so where the third molar is in goo d

c o n d ition wh il e the s e c on d mol a r i s d i s e a s e d
, .
FIG . 73
The operation fo r removal Of the impacte d

tooth S hown in Fig 7 3 is o n e Of the mos t di ffi cult
.
imp a ctions which the oral surgeon is confronte d

by The technique is that O f the open fla p opera
.
-
I M P AC TED T EET H 87
tion aided b y remov i ng th e overh an gin g port i on s

,
o f ramus b y me an s O f b ur or c h i s e l .
c . s ha ded po r ti o n bo ne r emo ved
b . ex po sed bo ne
(1 . m uco us fla p turned bac k
s ho ws ac tua l bo ne ca vi ty
FI G . 75
Fi g 74 S h o w s th e method Of O per a tio n

. .
Fig 75 th e a c tual loss Of bone ti ssue

.
,
i s le ss in e x tent th an if an attempt i s made to

”
crus h o ut a toot h Of thi s type o r r emove it b y
b ruta l force .
S ome operator s Obj ect to t h e O pen fla p meth od -
b ecau s e they claim that th e remova l o f bone b y

drill o r chi s el endangers th e integrity Of th e se c
o n d mo l ar T h e writer cla im s that th e open fla p
.
-
metho d is the only reasonable method to employ,

a s t h e Operato r s ee s what he i s doing T h e Opera .
tion i s not an a rtistic performan c e o n pape r

“
alone but if carefully and slowly done a practi c a l

, ,
procedure if carried o ut along sur g i c al lines I t

,
.
is a delicate operation b ut if a catara c t c an be r e

,
moved without injury to th e eye w h y S hould a ,
tooth n o t be freed from im p action ? The write r

al way s follow s th i s meth od wi th gratifying r e
s ul ts .
T h e next teeth in frequency Of i mpaction are

th e b icuspids .
A ll impaction s can b e o v ercome by employing

thi s meth od i e by di ss ecting away overlying
, . .
,
gum ti s sue in sh ape of a flap wh ich serve s a

, ,
double purp o s e First it con s erves the integrity

.
,
Of th e soft parts creating an incised wound ; a n d

, ,
secondly the flap acts as a protection to th e bon e

,
ca vity af ter operation T h e incisions may vary .

,
the flap may be differently shaped but the me th o d ,
Of p rocedure i s always the s ame where th e root s

Of a tooth are engaged .
S ome teeth are impacted to such extent th at

I MPAC TE D T EET H 89
their roots actually are situated between those Of

their neighb ors The writer once Operated fo r
.
an impacted canine erupting lingually in the

,
upper j aw T h e cro w n was freed by drilling the

.
palate away around its circumference and grasped

with forceps NO amount Of reasonable traction
.
and manipulation would free the tooth b ut the ,
b icuspid showed S ligh t motion .
T h e buccal wall was th en opened by a flap and

the canine root was seen to be engaged by the
bicuspid The impacted portion Of the canine root
.
T OOT H EX TRAC T IO N
w as cut O ff with a fi s s ure b u r an d th e toot h w as
then easily removed from the pal a te T h us there .
was a canal from the facial aspect Of th e alveolus

right through the palate The c a nal o r wound
.
wa s carefully washed o ut iodoform blown into it

, ,
and t h e facial flap w a s sutured into position T h e .
palatal O pening wa s packed with gauze The fi nal .
result wa s perfect A n y other me thod emplo y ed

.
woul d have resulted disastrously a s fa r as the

b icuspid was concerned .
Fig 76A s hows a right lower second b icuspid

.
,
impacted and eruptin g lin gually Fig 76B show s . .
t h e root impaction . Fig 76C illustrates th e

.
lingual flap The overlying process o r b one wa s

.
cut a way with a b ur until the tooth could b e lux

ated ; in this case upward inwar d an d outwar d
, , ,
a n d then removed fro m its so c ket .

92 T OOT H EX T R A C T I O N
r emov e the overlying tis sue wit h knife anatomical ,
forcep s and curved shears T h e simplest method .
to r emove such gum tis s ue is after painting th e ,
p a rt wit h Tr I odine to make a flap loo s en it with

.
, ,
a per i o s teal elevator g ra s p it with an a tomical fo r

,
c ep s and then cut O ff t h e flap with curved s he a rs

,
o r a s tro k e o f the k nife (S e e F

. i g .
TO re a ch a tooth th a t is cov e red wit h bone i s

‘
m o r e d i fli c ul t as t h e overlying os s eou s ti ss ue mu s t
,
be r emoved . T h e deeper t h e tooth i s bu r ie d in

b on e th e more di fficult t h e Oper a tion A p r o
,
.
c e dur e o f this k ind s h ould never b e attempte d
with out a ra dio g raph wh ich determines th e ex a c t

,
position o f the to o th and its relation to surroun d

,
ing st ruc ture s a s the inferior dental canal and

.
mental foramen in th e m andible and th e ant rum

Of High more and na s al cavity in the upper j aw .
I t h elp s to gauge the severity Of th e operation ,
it s proba b le length Of time an d possible complica

tion s A lower th ird molar may b e lo d ged s o near
.
t h e i nferio r b order o f the mandible t h at i t may

prove a much easier operation to make an ex
ternal inci s ion well under th e bo rder O f the jaw
than to a ttempt to remove th e tooth i n tr a b uc c ally .
This i s a rare occurrence but it may h appen T h e

, .
writer alway s insists upon an X ray before Oper -
atin g .
Th e s te p s fo r re m oval Of a n uneru p ted tooth

U N E R U PTE D T EET H 93
( b uried in bone ) which operation

,
can b e termed
”
“
O dontectomy (cuttin g o ut a tooth ) are ,
1 S terilization Of fi eld Of operation

. .
a Thoroughly brushing teeth and washing the

.
mouth .
b P aintin g the part to be opened wi th Tr

. .
I odine .
2 I nduction Of anaesthesia
. .
3 R etraction o r removal Of overlying soft

.
tis s ue s .
4 R emoval Of bone cove r ing t h e tooth with

.
,
burs chisel s o r bone forceps

,
.
5 R emoval o f tooth
. .
6 W as h in g Of wound with b oric acid solution

.
to r emove spiculae Of bone .
7 P ackin g or closing Of wo und

. .
T h e m ethod Of procedure o n th e whole is the , ,
s ame as followed for th e removal Of impacted

teeth exceptin g that in freeing a tooth completely
,
embedded in bone more o ss eous tissue must be

removed .
S ome teeth are c overed b y a t h in S h ell Of b one ,
which is easily removed with a b ur as the case ,
S h own in Fig 78 wh ere after dissecting the

.
, ,
gum a w ay flap fashion th e ov erlying bone was

, ,
removed w i th a fi ssure b ur a n d a groove cut poste

rior to t h e tooth as indicated by dotted lines
,
.
T h e Oper a to r was then able to lift the tooth out

O f i t s s o ck et quite readi ly (Fig .
94 T OOT H EX TRAC T I O N
F IG . 78
I n other c a ses the procedure is more compli

c a te d . Fig hows a supernumerary tooth b e
. 79 S
tween tw o upper centr a ls o n e O f which was r o

,
ta te d due to the presence O f supernumerary

,
In .
thi s ca s e tw o incisions a b and c d we r e ma d e ;

,
. . .
,
po s ition and tack ed down with a s in gl e silk s u
ture A fter fi ve day s thi s wa s r emove d an d th e re
.
,
wa s n o trace Of any o p erati on Th e tw o centrals .
w e r e n o t disturbed .
A fter the cavity will b e c ompl e tely fill e d w ith

o s seous tissue orth odontic trea tment will be r e
,
s orted to to bring th e ro tated central into normal

,
p ositi on .
Fig 80 illustrates o n e Of th e most inte r e s ting

.
and rare c ases th e writer ha s met wi th in hi s ex

p e r i e n c e The pa tien
. t was a y oung woman w h o
had su ffered fro m neuralgia and had developed

a swollen face producing trismus S h e consulted
,
.
a dentist w h o referred her to a physician w h o

, ,
a dv i sed h o t poultice s and gave sedatives and coal

ta r preparations to allay her pai n A fter s u ffer .
ing ten days and consulting s everal dentist s and

physicians the wri ter was asked to s ee the p a
,
tient with o n e Of the medical men

,
The pati ent .
at th at time was exhausted and near coll apse .
H e r face was swollen there was trismus s h e had , ,
a temperature Of 1 03 w i th a rapid irre gular , ,
pulse 1 20 F ractured tooth necrosis Of j aw b e

,
.
, ,
ginni n g erysipelas were the varying diagnoses ,

.
There was n o fluctuation discernible o n the face .
S h e could not open her mou th but the buccal ti s ,
sues in th e lower molar region were swolle n an d

hard as a bri ck The writer after administe r ing.
,
an anaes thetic made sweeping ex p lorato ry i n c i

,
U N ER U P TE D T EET H 97
sions along the l ower j aw where the s w elling wa s

fou n d but could n o t reach any pus
,
.
The patient was given Opiates an d an i mm e d i

ate X r ay demanded which cleared up the diag
-
,
nosis A n unerupted lower molar had produce d

.
an Odontoma The dark mass occupying the

.
whole molar region and reaching almost fro m the

b order up to the gingiv a proved a tooth substance -
tumor Odon toma The pa tient was removed to

, .
the hospital and tooth and tumo r removed

,
.
The operation was o n e O f the s everest the w ri ter

ev er had o c casion to a ttend and lasted nearly
th ree hou rs O n e Of the dangers attending was
.
th e fra c tu r e Of th e mandible which S howed b ut

,
a v ery thin strip Of heal thy bone at the l ower
b or d er ; but good fortune attended th e case an d ,
the tumor plus tooth were shelled o ut without frac

tu ring the j aw The patient ma d e a complete r e
.
c o ve r y and a r adiograph taken su b sequently

,
S howed a gradua l regenera tion O f the j a w There .
are very fe w case s Of Odontoma o n record I f the .
molar tooth were situated S O low in the j aw an d

th ere wa s n o other complication pre s ent if it had ,
to be removed th e remo val Of the tooth could be

,
accomplished by d i s secting the cheek away from

the mandible and b urring and chiseling away the
fa c ial wal l In doing thi s the facial artery would
.
very l ik ely b e cut and would have to be liga ted o r ,
a n e x te r na l i ncision below and behind the inferio r
b o r d er Of th e j aw might accomplis h th e de s ire d

FIG . 80
end easie r I f th e incision is located properly a

.
,
scar wi ll not be visible .
Fi g 81 S hows an unerup ted lower permanent

.
canine tooth The radiograp h was taken because

.
the patient still had a perfec tly tight temporary

canine toot h in S itu and b eing referred to the
,
writer for an Opinion w he ther or n o t thi s baby “
tooth should be removed particularly as she

”
,
wan ted a bridge put into the space S hown T h e .
author advised a radiograph and the retention Of ,
the temporary too th as it has its root completely

,
.
W ere it necessary to ever remove the unerupted

tooth the au th or would dis s ect th e soft tissue
,
1 00 T OOT H EX T RAC T I O N
M or e Often in the upper than the l ower j aw .
A g ood deal more could be written about th e

r emo va l o f unerupted teeth many more c a s e s ,
c ould be c ited but it would s p ell r epetition of p r e

,
v i o us l y ment i on e d matter T h e most imp ortant

.
featu r e s are :
1 The corre c t d ia gnos i s wh ich can in al l case s
.
,
b e made by m eans Of the radiogr a ph .
2 The skilful removal o f the too th

. .
T h is means in all ca s es the dissection of soft

tissues and the r emoval Of b one until the tooth is
reach e d There is n o fix ed rule h o w to O b tain this
.
end ; th e w riter ha s attempted by S howing pra e ,
tical c ase s to illu s trate the general principles

,
.
W hat must be borne in mind are : A sepsis and ,
ni cety Of pro c edure ; by that I mean exactness Of
ex ecution I n other words do n o t hurry ; think

.
,
w hile you w o rk ; S peed will come by itself .
A nother point to be b orne in mind is never to

attempt to Operate in th e dark ; d o n o t feel you r
way along ; s ee what y o u are doing Dissect away .
a s mu c h tis s ue a s poss ible ; remove all bone i n c a r

cerating th e tooth o r r oot to be extra c ted A n .
aseptic Operation favor s healing by p r i m a r v

un i on or granulation DO n o t spare iodine the
,
.
,
knife o r ch i s el I t i s better to cut a little more tis

.
sue away and pro c eed than to do damage cause , ,
infect i on and let the general surgeon do a r adical

,
o p eratio n fo r perio s titis o r o s teomyelitis .

P O ST EX T RAC T I VE T R E AT M E N T
TH E t r eatment Of alveola r s ocket s followin g e x
traction s is a mu ch neglected su b je c t and m a n v ,
ope r ators after removing a diseased toot h c o n

sider th e c a s e ready for dismissal .
This is wrong acco r ding to s u rgical p ractice ;

no surgeon would think Of creating an open wound
and dismi s s hi s p atient tru s tin g to lu ck that all
,
will remain well .
Th e trea tment Of the maxillary alveo l i afte r

tooth e x traction i s that Of Open wound s a n d v arie s ,
w i th th e type Of case presen te d .
A fter norma l extrac tions without c omplica,
tion s th e au thor s imply applie s T r I o d ine into

,
.
the s o cket and leave s the case alone I t i s essen .
tial how ever to i n s p ec t th e s o c ke t th e n ex t d ay

, ,
to make cer tain th at n o t r ouble is arising an d

th at there i s n o tenden cy fo r the c olle c tion Of food
i n th e so ck et .
The accumulation o f foo d et c may lead to i n

,
.
,
fec ti o n and s h oul d be guarded against

,
.
T h e bleed ing in th e socket usually stops spon

ta n e o us ly due to clot formation and clot and
, ,
alveolus gr adually become ab s o rb ed .
I f drillin g o r chiseling Of bone is nece s sary th at ,
1 01
1 02 T OOT H EX T RAC T IO N
a la r ger wound is created the part i s irrigate d ,
wit h 2 per cent boric acid or normal saline solu

.
t i on to remove spiculae Of bone and powdered ,
o r th o fo r m to which a li ttle powdered p l a i n novo

,
cain is added is blown into the w ound by means

,
of a powder blower and a small s trip Of 5 per

-
,
cent iodoform gauze is inserted to prevent food

.
from entering I f the wound is not very d eep the

.
,
gauze can be omi tted after a fe w days but irriga ,
tion S hould be continued fi rst daily t h en every

, ,
oth er day and fi nally a bout t w i c e a wee k until

,
the w ound is closed .
I f the wound is sterile it c an b e cl o s ed a t once

by s il k sutures w h ich are remo ved af ter about
,
fi v e d ay s in whic h ca s e th e blood fi lling th e c av

,
ity clo ts and becomes organized .
I f a chronically abscessed tooth i s ex tracted it ,
i s essential to curette th e socket to remove gr an u

l a ti o n s and d ébris occupying the apical space The .
reaso n for curetting here is due to the fact that

when a tooth b ecomes abscessed nature in order ,
to protect the surrounding tissues and the organ

i s m a t la r ge again s t further infection throw s u p ,
a wall of connective tissue to localize the absces s .
I f the tooth cau s ing the infection i s extra c ted t h e ,
original cause i s removed but the pyogenic focu s ,
h aving involved the apical space i s not completely

extirpated and the gr a nulations (which contain
,
pyogenic organisms ) remaining behin d may act

1 04 T O O T H EX T RAC T I O N
T h e treatment i s self evident F i rst clea r th e
-
.
sock et Of piece s of root s p i c ules o f alveolu s o r

,
products O f suppuration wash it o ut carefully ,
with a w a r m non irritating solution (bori c a c id o r

-
normal saline solution ) and make a pa s te O f ,
o r th o fo r m ,
to which a lit tle plain novocain is
added with glycerine o r p ack o r th o fo r m and novo
, ,
cain powder into the socket This i s b est a ecom .
p l i s h e d by placing a tampon into t h e socket h a v ,
ing t h e powder scooped up upon a bone spatula ,
an d quickly withdrawing the tampon and then

dropping the powder into the s ocket T h e pow d e r .
is gently pressed down by another tampon whic h ,
is wit h drawn again and more powder placed u p on

,
the fi r s t batch This is repea ted until the sock et

.
i s fi lled The O bj ect of th e tampon is to prevent

.
t h e s ocket from fi lling with blood w hich i f pre s , ,
ent makes it di ffi cult to pack the alveolus with

,
p owder The packing O f th e alveolus w it h powder

.
usually terminates all discomfort I n the upper .
j aw the powder can be introduced with the p o w

der blower I f the powder blower i s used the
-
.
-
,
operator should n o t permit the bulb to fi ll up with

air w hile the pointed end is wit h in the alveolu s ,
as blood is ea s ily drawn into t h e tip and the appa

ratu s thus clogged .
A fter using the powder b lower the tip shou l d -

,
be un s crewed sterilized and dried I n V iew Of

,
.
th e fa c t th at th e ti p i s ma d e of rubb er it i s b e s t ,
P AIN AF TER EX T RA C T I N G 1 05
s ter il iz ed b y was h in g in and blowin g al co h ol

t h rough t h en thoroughly d rying and r eplacin g
,
upon bulb .
The appli cation of dry heat will Often give r e

lief Thi s can be ap plied by making a meal b a g
.
-
an d heating in s to ve o r w rapping a conne c ted elec

,
tri c bulb into a piece o f flannel an d h o ld ing to th e

face .
M oist heat s houl d n o t be applie d exte rnally a s ,
i t favor s s uppuration A n oth er useful a djuvant

.
to redu c e local h yp e r ai m i a i s a hot footbath .
The hot footbat h must be pre s cr ib ed as foll ows

-
A tu b is partly fi lled with fai r ly warm w ater
and the feet immersed H otte r water is ad d e d to
.
r aise the temperature O f the bath to the greatest

d egree Of tolerance The feet are k ept in th is hot
.
water fo r 5 to 1 0 minutes k eeping up th e degree Of ,
heat This causes a dilatation Of the b l o o dve s s el s

.
in th e lower ex tremitie s reduci ng the blood pre s

,
sure i n the head and upper part Of th e b ody This .
ac c omplishe d the feet a r e tho r ou ghly d rie d and

,
the patient is put to b e d I t i s es sent i al not to .
walk with b are feet and thu s cause a ch ill as ,
anaemia o f the feet and hy p er aemi a O f the upper

part Of the b ody will cause the pain to r etu rn .
S ometimes we ha v e to r e s ort to inte rnal me d i

cation P henacetine and a s pirine in dose s Of g r
.
.
V each to be repeated after thr e e h our s i f n ec e s

,
s a r y, o r tr i ge m i n , V py ra m i d on
gr ,
o r .
, g
r fi s s , .
w i ll p ro ve o f value T h e fi r s t e ss ent i al h o w
.
,
ever i s the clearing O f the s ock et Of all déb ri s

,
.
A fter a di ffi cult extract i on s omet ime s patient s

de velop an o s teitis o r per i ostitis c aus e d b y me
c h a n i c a l injury to the bone The symptoms are .
pai n and marked tenderne ss to tou ch if the p er i ,
o s te um is involved attended by more o r le s s sw ell

,
ing T h e treatment c ons i st s o f the a pp l i c a tion Of

.
d r y heat o r a wet dressing to th e face o r th e ex ,
tern a l application of 5 1 0 per cent ich th yo l Oint

-
.
m ent coupled wit h the administration Of a s pir ine

,
and p h enacetine unt i l relief i s Obt ain ed

, .
P O S T E X T RAC T IVE HE M O RRHA G E

T h e h emorrh a ge follo w i n g tooth extraction us u
a lly ceases spontaneou s ly I f c ontinuin g unduly
.
,
it must b e checked .
H emorrhage occu r ring d i r ectly afte r an injury

or operation i s designated a s p r i m a r y and the ,
flo w of blood occurring some time af ter trauma

ti s m is kn o w n as s ec o n d a r y I n o the r words a
.
,
s econd flo w Of blood after i t has once s top p ed is

actually s e c o n d a r y h em o r r h ag e .
H emorr h age can al s o be cla ss ifi ed a c c ording to

i t s etiology Namely as caused by
.
,
1 T r au m atism
. .
2 L oo s enin g o r di s integration Of the p r im a ry

.
clot .
The socket i s t h en tigh tly plugged with io d ofo r m
gau z e upon wh ic h pre ss ure is exerted
,
.
I t i s e ss ential to p a ck th e ga uze to the v e r v

b ottom Of the alveolu s and pa ck it t i gh tly i n lay
e rs T h e pres sure is b e s t ex erted by means Of a
.
p a i r Of pliers w i th cotton wound a r oun d them .
I f the pres sure must be con tinue d a w a d of tightly ,
r olled cotton c a n be pla c e d between the j aws and

t h e patient as k ed to bite upon th e same I f n e c e s .
s ary a bandage can be applied to keep the jaw s

,
togethe r The gauze tampon i s removed afte r two

.
to th r e e days very carefully and to facilitate i ts ,
r emo v al a little peroxide Of hy dr ogen is dro p ped

upon t h e dressing .
I f pres s ure fail s to stop b leeding a cl ot c an b e ,
forme d by e sc a r i z a ti o n of t h e v e ss el s with th e
thermo O r galvano cautery
- - -
.
S typtic s and astringents occupy a rat h er O h

scure place in the writer s a rmamentarium a s he ’
,
has had prac tically no use fo r them in over thir

teen y ears O f a c t iv e private d is p ensary and ho s p i ,
tal pr acti c e .
A lum tannic acid galli c acid fe r r o p y r i n e

, , , ,
a d renalin are all r ecommended The writer feel s .
that if a c tua l d i r ec t pressure i s applied to the

,
bleeding surf a c e the hemorrhage is b o un d to

,
cease unle ss an abnormal condi tion Of the blood

, ,
r etarding coa gula tion is pre s ent ; s u ch being the ,
c a s e this has to be corrected

,
.
HE M ORRHAG E 1 09
Text b oo ks tell us that bleeding c an b e c o n

-
trolle d by the internal administration of ergot o r

tannic acid ; t h is is true i n u terine hemorrhages ;
the aut h or however has doubts whe th er an al veo
, ,
lar hemorrhage can thus be controlled A s an a d .
j uv a n t to other trea tment (pressure ) i t may have

its value but the wri ter has never failed to con
,
trol any hemorrh age if no systemic factor was

at the bo ttom I f internal medication is to be r e
.
sorte d to the administration of calcium l actate is

,
more certain in action (raising the coagulative

power Of the blood ) than giving s typ tic s i n
te r n al ly .
The writer would wa rn against the use Of

M o n s el s solution as the clot formed by se s qui
’
,
ch loride of iron comes away easily and bleeding is

s tarted again .
A patient su ffering from severe bleeding after ,
having th e socket packed and thi s is a lway s th e ,
fi r s t c o n s i d e r a ti o n S hould be placed
,
at perfect
r est s i tti n g up in a comfortable cha i r in a cool
, ,
r oom C old application s to the j aw wherever th e

.
bleeding ta k es place have a tendency to constric t

th e b lood ves sels .
S Y S TE MIC CO NDI T I O N S
G enera l systemic conditions of interest to th e
dentist in t h e treatmen t of post extracti v e h e m o r
r h a ge are mainly : A n a
em i a and hemophilia .
If the o p erator i s careful and closely o b serves
h i s patient before Opera ting he w i ll frequently
,
note the pallid appearance Of his patient though , ,
Of cour s e not all a n aem i c s look pale H owever

, .
,
the Operator should note all little details about

his patient and make good use O f his fi ndings b e
fo r e he meets wi th alarming symptom s Th e i m .
portant fact to bear in mind is that just a s the

amount Of blood in an organis m is reduced so the ,
coagula b ility of th e remaining liquid is les s ened ;

therefore an anaemic individual should be treated
,
with care I f a large number of teeth are to be

.
e x tracted and the pa tient appears very anaemic ,
i t is better to consult th e physician or if that is ,
not practicable why make an appro x imate

, ,
hemoglobin estimate with T a lq ui s t hemoglobin

scale I t will give a fairly accurate idea o f the
.
hemoglobin status of th e patient and if it is l o w

,
( 6 0 or less ) it is s afer to consult with the med i cal

adviser .
I t i s better to err on the s afe side a good many

times t h an to fail to reco gnize one case which will
cause trou ble The Operator may not have auv
.
trouble but once in a lifetime ; the careful operator

should however n e ve r meet with an accident
, ,
which is avoidable and be a lw a y s o n t h e loo k

,
o ut
.
I f th e
teeth are the cause of infection of cour s e , ,
the septic focus mu st be removed at all time s but ,

1 12 T OOT H EX T RA C TIO N
ad r enal in gauze T h is did not h av e th e de s i re d
.
e ffect t h e bleeding continued and the patient b e

, ,
gan to S h ow S igns O f weakness fi nally fainting ,

.
T h e w riter wa s called in consultation at tw o A M . .
T h e patient looked ve r v very pale and w a s to o , ,
wea k to stand H e r pulse was rapid and very thin

. .
T h e writer fi rst cleared out the socket bro k e up ,
th e alveolar septum curetted o ut piece s Of clot

, ,
and t h en packed the socket very tightly wit h io d o

form gauze placed a roll Of cotton betw een t h e
,
j aw s and applied a bandage .
T h e p atient was put to be d an d given morphine

and atropine hypodermically al s o twenty grains ,
Of calcium lactate were administered R a w eggs .
in milk were ordered every three h ours The cal .
c i um lactate was ordered in twenty grain do s es -
every four hours fo r tw o d ays ; also the inge s tio n

Of lots Of water P atient remained in b e d ten
.
day s A tonic containing iron and s trych n ine was

.
—
given and plen ty Of nouri s hing food milk broth , ,
,
eggs There was a slight recurrence Of h em o r

.
r h a ge o n the fi f th day when the packing was r e

,
moved C alcium lacta te wa s administered again

.
for thirty six hours

-
.
A year later the same patient h ad to h ave an

other tooth removed S h e consulted the writer . .
S h e was given calcium lac tate and egg albumen

for thirty hours prior to extraction and t h ere w as ,
n o a b n o r m a l hemorrhage .
HE M O PHILIA 113
T h e ot h er c ases wh ich th e writer s aw w e r e c a s e s

”
sent to h im as hemophiliacs fo r ex tra ction
“
.
T h ey all re c eived calcium lactate in fi fte en grain -
do s e s every four h ours until fi ve o r six doses w ere

tak en also albumen in t h e sh ape Of raw eggs an d
, ,
they all did well .
T h e fo l lowing case is Of intere s t s h o wi n g th e ,
value Of treatment before ex tr a ction in a negat ive

way
M r s E A age 33 married hemop h iliac w a s
. . .
, , , ,
referred by h er dentist fo r t h e ex traction Of tw o

small roots The patient requested to have h er
.
physici an present The physician upon arrivin g

.
,
at the writer s O ffice sent t h e patient from the

’
,
room and told the writer No w Doctor I d o n o t

“
, ,
believe in th is calcium treatment ; th ere will be

no trouble in thi s ca s e at all ; y o u just extra c t
”
the s e r oot s . The writer c alle d th e phy s i c ian s ’
attention to the fact that t h e patient h ad h a d a

great deal Of trouble only a ye a r previous afte r
having a toot h extracted by anoth er spe ciali s t .
T h e phy s i cian insisted upon h aving the root s out

with out p r el i m i n a m treatment t aking as family
7
, ,
p hy s i c ian all re s ponsibilities upo n h imself Un

,
.
de r t h o s e c ircumstance s t h e writer yielded and,
e x t r a cted the roo ts Three day s l ater the writer

.
w a s s ummoned la te at night by the physician to “
d o s omething to s top t h e bl eedin g

”
T h e h em o r .
r h a ge w a s fi n ally stoppe d a ft e r most s trenuou s

treatment us ing
,
t h e th ermo c aute ry th r ee-
times and giving s everal i nj ections Of h or s e

serum T h e patient was in bed for t h ree w eeks
.
,
un til s h e was strong enough to leave the c i ty fo r

a s tay in the coun try .
T h e damage in h emophiliacs S h ould be avoided ,
by treatment before t h e extracting .
T h e treatment if a case is a bleeder con s ists

“
,
fi r s t in cleaning up the bleeding alveolu s pack

,
“ ’
,
ing it and administering

C alcium lactate and egg albumen as indicated ,
above .
R est in bed and the general improvement and

building up O f the system .
The inj ection Of horse or human serum to raise

the coagulabil i ty O f the blood .
I f human or pl a in horse serum is not available ,
a n ti d i p h th e r e ti c serum from any Board O f H ealth
S tation will answer the purpo s e .
The local application Of hor s e serum upon gauze

r ight into t h e bleeding socket h as also proven
valuable .
I f a great deal of blood has been lo s t the i n ,
tr av e n o us inj ection of normal s aline or R inger s

’
solution i s indicated .
Blood transfusion may h ave to be resorted to .
C ases of this type are distinctly h ospital ca s es ,
as th e v need constant watching and treatment

w h ich cannot be given at h ome .
1 16 T OOT H E X T RAC T I O N
in terproximal spaces S O that t h e lips ar e n o t trau
,
m a ti ze d The y must not extend to o far lin gually

.
,
o r they will injure the tongue This is practically .
a H ammond splint A few d ays immobilizatio n

.
’
S ho w in g t he M ann r Of Ty ing W i r
e e S p l in t
w ill usually restore these teet h to normal healt h ,
unle ss the pulp is a ffected and then th e treatment

, ,
O f course is devitalization
, .
2 A c c i d e n ta l ly E x tr a c te d T e e th
ca n s ometimes be implanted I f a tooth be .
removed accidentally it is washed in lukewarm

,
s terile saline solution grasped with sterile gauze

, ,
opened pulp removed pulp chamber and roo t

, ,
CO MPLICAT I O N S 117
canal th oroughly cleansed and fi lled th e toot h ,
fi lled and again washed in saline and reintroduced

into its socket and ligated to its adj oining fellows .
I t i s evident t h e tooth h as to be h andled carefully

and strict asepsis must be Ob s erved I t is essen .
tial to avoid inju ry to the pericementum S O that ,
th e reimplantation be a physiologic implantation .
I f the peridental membrane is destroyed t h e r e ,
implantation will be a mechanical implantation ,
just as a porcelain roo t would be A physiologic .
implantation has a better ch ance O f permanency ,
as K auffe r Of New Y ork has s h o wn

, , .
The writer has seen a few (three or four ) s uch

reimplanted tee th h aving given sa tisfactory ser
,
vice for several years ; however he is very s ke p ti,
cal a s to the fi nal outcome I t is a risky thing to

.
promise a patient a good resul t with certainty .
I t i s wort h trying if all s teps are carried o ut

,
under absolute asepsis .
3 F r a c tur e
. o f A d j o i n i n g T ee th
T h e treatment is Of course the restoration O f

, ,
t h e lost s tructure by fi lling inlay or ar tifi cial

,
crown according to the amount O f tissue lost

,
.
The writer suggests to wait a few days until a

restoration b y fi lling or inlay is a ttempted to have
an opportunity to learn whe ther or n o t the pulp
ha s been a ffected b y trauma tic s h ock I t i s awk .
ward to p e rform a restoration and then be forced
to open into the tooth a little later O f course we .
,
have to b ear in mind that a toot h may not S how

s igns O f devitali z ation for a long time sometimes ,
n o t for mont h s or years .
4 F r a c tur e
. o f A l v e o lus
If th ere Ob tains a comminuted fra cture the Of
process and t h ere are small loose pie c es di s cern i

ble these shoul d be removed ; o th erwise the alveo
,
”
lus is gently pressed into place i e restored
“
, . .
,
to its origin a l posi tion a n d left alone I n a few .
days union will usually occur .
5 F r a c tur e
. o f th e J a w
A ery rare complication unless there exists

v ,
necrosis so that only a narrow strip of heal thy

,
bone remains The treatment O f frac tures is so

.
well known that I shall not ente r into its discus

sion A radiograph however S hould be taken in
.
, ,
all cases of fractures O f the teeth alveoli or j aw , ,
as the X ray will bring out complication s w h ich

-
may not b e suspected .
6 . Op en i n g o f th e A n tr um o H
f gi h m o r e
T h e accidental opening O f the A ntrum Of H igh

more may occur during the extraction of upper
teeth T h e treatmen t of this mishap varies with
.
di fferent attending conditio n s I f the root Of t h e .

wit h a natomical forceps A small root slipping .
into t h e antrum through a s mall opening O ffer s

more difficulty for it s removal The proper p r o .
c e d ur e i s to make an opening large enough to t e
move i t as a maxillary S inusitis will most likely

,
result if th e root is left in si tu A radiograph will .
facilitate the localization O f the root if it cannot ,
be reached readily The opening should be made

.
by preparing a mucoperiosteal fla p i e to dis sect , . .

,
mucous membran e and periosteum away from the

‘
bone cut away s ufii c i en t bone to be able to remove
,
the root and then suture the mucoperiosteal flap

,
to close the opening I f the antrum i s in a h e al th v

.
state nothing S hould be introduced into t h e s ame

,
but normal s aline or 2 per cent bori c a c id solu .
tion then the cavi ty closed

,
.
I f while extracting the operator enters a c av

ity he should not take it for granted that he i s
,
”
“
in th e antrum but be a r in mind the possibility
,
O f the presence of a cyst The di fferential diag

.
nosis depends upon the following points :

1 A cyst contains liquid or semi liquid mate
.
-
rial I t is a good plan to was h out the cavity with

.
sterile saline and note th e appearance of the liquid

returned .
2 A cy s t unle ss it h as invol v ed th e antrum will

.
, ,
n o t permit passage of air from the nose into the
antrum and thence into the mouth .
3 I f there exi s ts a normal ostium m ax i ll a r e an d

.
CO MPLICA T I O NS 1 21
l i qui d i s for c ed into t h e antrum the s ame w ill flo w ,
from the n ose .
.4 T h e r adiograph .
I f th e cavity entere d proves to be a cy s t th i s , ,
Of c ourse mu s t be treated accordingly

,
.
8 F r a c tur e
. o f th e T o o th Wh i l e E x tr a c ti n g
The questio n whether o r not a tooth which fra c

tures w hile being ex trac ted should be permit ted
to remain h a s be e n brought up from time to time ,
and well kn own spe c ialists di ffer in th ei r fin al

-
Opinion .
P rimari l y t h e write r w ou l d s ay th a t a b r o k e n
Of f r oo t S h ould alway s be removed ; o n the other
hand he would not deem it wise to subj ect a p a
,
tient w h o i s already s u ffering from s h o ck to a

, ,
long s earch in g operation w h i ch i n th e en d i s n o t ,
completed .
I f a root fractures the writer procee ds a s fo l ,
l ows : E very reasonable attemp t i s ma d e to r e

move i t by means O f fi n e forceps and elevators .
These means may prove fat al fo r tw o r ea s ons

1 Incessant hemorrh age
. .
2 Th e fra c tured p ie c e may be s o sma l l th at it

.
cann ot be reach e d i e the alv eolar sock et i s s o

, . .
,
deep t h at t h e r oot c annot be gra s p ed o r eu

c r o a c h e d upon .
I f th e h emorrhage i nterfe r es with th e o p era

ti o n the writer pa ck s the sock et with iodoform
,
gauze and di s misse s the patient A t th e n ext vi s it .
the patient is given b r o m ur al gr x and the s ite , .

,
injected with novocain and supra r eni n the tam ,
pon carefully removed and the root taken o ut b v

cutting a way the o verlying tissue w ith knife and
chi s el o r bu r doing a flap operation
,
.
I f the root escapes all at tempts Of remo val t h e ,
patient is radiographed to ascertain its e x act p o

s itio u its S hape (s ometimes crooks o r h yp e r c e
,
m e n to s i s i ncarcerate it ) and th e surrounding

structures fo r o n e has to consi d er the inferior
,
dental canal and mental fo r amen in the mandi

,
b l e and the antrum and nasal c a v i ty in t h e uppe r

,
j aw A fter the root is located it is r emo ve d by

.
the open fla p operation

-
.
9 . T r i s m us (L o c ke d J aw )
S well ing about the face producing locke d “
j aw may prove a diffi cult complication Of tooth

extr a ction .
The infi ltrat i on Of t h e mus cle s Of mast i catio n

caused by ab s ces sed o r impacte d lower molar s
particularly engage s o ur attention T h is i n filtr a .
”
tion pro duce s that swellin g har d a s a board “
,
l ock ing the j aw s completely prevent i ng e v en th e ,
in troductio n Of a t h i n c ardbo a rd betw een t h e

teeth ; o r th e patient may be abl e to open the j aws
more or l e s s but not s u fficiently to apply for c eps
,
to t h e guilty tooth T h e amount Of tri s mus de

.
c ations cau s ing permanent damage may r e s ult
, ,
(stretching O f ligament tearing Of mu s cles ) ,

.
There is danger Of producing s eve r e shoc k if a

muscle is stretched forcibly .
I n th e s e cases it i s advisable to admini s ter se d a

—
ti v es b r o m ur a l , (gr X ) o r Opiates morp h ine
.
,
sulphate , (gr — to . re d uce shock and

sensibility and then applying hot application s to
,
the swelling for fi v e minutes then introducing an ,
oval screw between the teeth and gradually pro

duce relaxation of th e in fi ltrate d muscle s Th e .
stretching must be done gradually and it is sur ,
prising what can be accomplis h ed with a l ittle

p atience .
The opening Of th e j aws may require from ten

minutes to an hou r .
A fter the j aws have been Opened su fficiently the ,
tooth giving trouble is ex tracted .
The most diffi cult cases to treat are O f course , ,
those of the third degree The method Of p r o .
c e d ur e i s the same as outlined for treatment Of
the second degree The pa tient is given an opiate

.
and the teeth pried apart gradually with any fi n e

instrument s o as to enable the Operator to intro
,
duce the small end of th e screw gag This i n s tr u .
ment is then very S lowly turned to gradually force

the j aws apart I n s o me cases it is impossible
.
to get su fficient relaxation to extract but we c an ,
o p en the j aws far enough to be able to palpate the

CO MPLICA T I O N S 125
s welling i n tr ab uc c ally and inci s e where pu s i s felt

o r suspected . A fter drainage has been e s tab
l i s h e d the swelling wil l begin to go down
,
The .
treatment after incision consis ts in

.1 T h e administration O f a laxative .
.2 T h e l oc a l application Of wet dressings O f

eith er Thiersch s s olution L i q A la mini A c e ta ti s
’
,
.
,
o r a saturated solution Of E psom s alt s diluted ,
w i t h four parts Of water .
T h ese cold application s ca n be made fo r o n e

h our at a time three times a day or a wet d r e s s
, ,
ing c an be put on and kept there in s itu by a

b andage A mouth was h i s to be u s ed frequently
.
-
to reduce ora l s ep s i s .
I n concl usion the author again empha s izes th e

,
fact that tooth ex traction s a r e s urgical procedure s

and must be c arried out according to surgical
principle s C a reful examination and deliberation
.
are essential before extracting pos t ex tracti ve i n ,
s p ec ti o n a n d treatment are required sub s equently .
Toot h e x tra c tio n s a r e divided into

.1 Normal e x tractions .
Normal ,
2 R oot extr a c tions
S ur gi cal
,
.
.3 R emo val Of impa c ted teet h .
.4 R emov a l O f unerup te d teet h .
S urgica l root e xtract i ons as well a s th e r e ,
mo val O f imp ac te d a n d unerupted teeth are b e s t ,

c arrie d o ut by the preparation Of a ti ss ue fla p

and the free removal of overlying b one ti ss ue .
The techni q ue in all cases is :

1 S terilization
. .
2 I nduction O f anaesthesia
. .
3 P reparation of soft tissue flap

. .
4 R etraction of flap
. .
5 R emoval O f overlying bone tissue

. .
6 R emoval of root or tooth

. .
7 R emova l Of all gr a nul a tion s o r b ro k en d own

.
-
tis sue .
8 I rri gation Of wound with non irritating s o lu

.
-
tion .
9 P acking or closing up o f woun d

. .
1 0 S ubsequent inspection or repack ing o r irri

.
g a ti o n of wound a s case
,
demands .
I
A N IES T H ES IA
— — —
G en er a l L o c a l C o n duc ti ve R egi o n a l
A N E ST H ES IA is th e loss Of s en s ation produced by
th e a ction Of agents k nown as anae sth etic s .
G en e ral anaest h esia is i n duced by t h e i n tr o d uc

tion o f s uch agent s into t h e cir culation which act ,
ing upon c ertai n c e reb ra l ce nt e r s produ c e a ncon

,
s c i o us n e s s a cc o m p an i e d b y c o m plete lo ss Of s en
s at i o n .
G e n e r al a naes t h e t i cs a r e i n t r o duced by i nh al a
t i on thr o ugh th e lun gs a n d by intrav enou s o r rec
tal infu s ion T h ey are a bs o rb e d b y th e bl ood and
.
,
t hus c arr ied to t h e br a in .
L o c al anaest h e s i a i s th e r egi o n al l o ss O f s en s a
tio n p r o d u c ed by th e actio n O f certain agen ts up on
s e n s ory nerv e s A gent s producing lo c al los s O f
.
s en s ation are kn o w n as lo c al anaesthet i cs L o c al .
anae s t h e s ia ha s displa c ed gen e r al a naes t h e s i a to a

l a r ge e x tent in dental a n d o r al O p eratio n s .
L ocal anaes t h e s i a c a n b e p r oduce d b y p h y s i c al

mea n s a s c ol d an d p r e ssure an d by th e us e Of
, ,
drugs a s cocaine euca in e alyp ine n ov o c a in etc

, , , , ,
.
P hy s ical agents s hall n o t b e cons i d ere d b ut t h e

,
1 29
1 30 LO CAL A N ZES T H E S I A
write r s h all co nfi ne h imself s trictly to th e p roduc
tion Of local anaest h e s i a by th e use O f drugs .
L o c al anaes thesia ca n b e produced by t h ree met h

o d s : Direct application infi ltratio n and nerve
“
,
blo ck ing (conductive anaes thesia )

’
A naest h esia by direct application i s Ob taine d by

painting the part with a s olution o f t h e anae sthetic
o r t h e application o f a tampon dippe d into s uch
s olution For e x ample a tampon dipped into t h e

.
,
anaes th eti c and in s erted into the nares w ill c au s e

a naest h e s ia in the anterior part o f the u p per j aw .
Infi ltration a n ws th e s i a is produced by the hypo

dermi c inj e c tio n o f the a naes t h etic into t h e fi eld Of
operation .
C onductiv e anae s t h e s ia is Obtaine d b y inj e c ting

the anaest h eti c into o r about a nerv e trunk p r o ,
da cing anaes th e s ia in t h e whole area of d i s tr i b u

tio n Of t h at particular nerv e ; prohibiting a fferent
impul s e s traveling along this nerve and it s
branch es and thus pre vent i n g their reaching t h e
,
b rain .
T h e followi ng e x ample w ill illustrate b oth meth

o ds. S uppo s e a l owe r s i x year molar is to be e x
-
tracte d
Infiltratio n anae s t h e s ia would b e produced by i n
j e c ti n g the buccal and lingual aspects of th e al v eo
lar pro c es s which would cause a loss O f sensation
,
in and a b ou t that too th .
C on duc t iv e anaest h esia would be induced by i n

II
S OLU T I O N F OR LO CA L A N JES TH ES IA
IN VI E W Of t h e fact th at l o c al anae st h esia i s p r o
d uc e d by hypodermi c o r h yp o m uc o us injection o f
t h e anaes th e tic agent i n s olution and th is s olutio n
,
is b ro ught in direct o r indirect contact with nerve

an d o t h er tissues it is Of great importance th at
,
t h e agent a s w ell a s i ts s olvent medium be tol

, ,
c rated by t h e ti ss ue s wit h o ut in j ury to the c ell ular
element s .
Wh at ar e th e r equi s ites dem an d e d o f a s olution

emplo y e d to p ro duce l o c al a n ws th e s i a ?
1 I t mu s t b e n o n i r r i ta ti n g to th e tis s ues
.
a
.
2 I t must b e readily absorbable

. .
3 I t sh ould b e a s devoi d o f to x i c e ffects a s p o s

.
s ib le .
In s tudying th e e ffect s o f a gents employe d to

p rodu c e regional a n ws th e s i a we have to con s i de r :
1 T h e s ol utio n us e d a s a s olvent fo r t h e a naes
.
t h et i c a gent an d it s e ffect s upon th e ti s sue s .
2 T h e ph y s io l ogi c e ffe c t s O f th e an ae st h eti c upo n

.
th e s enso ry ne rv es .
3 T h e p h y s iolog i c e ffe cts O f t h e a naest h e t i c up o n

.
th e or g anis m a s a wh ole o r , in othe r w o rds , i t s

,
d e gr ee O f to x ity .
S O LUT I O N S 1 33
Th e S o lven t M e di um
If s t e r il e w ate r i s i nj ecte d hypodermicall y a ,
w h e al i s fo rme d fo ll o w ed b y o s motic a c tion b e

t w een t h e inje cte d l iqui d a n d th e c on tent s O f th e
ti ss ue c ell s.
Th e ti ss ue c ell s by en d o s m o s i s t ak e up w ater ,
s w ell up an d a t th e s am e time b y e x osmo s i s th ey

, ,
give up some Of th ei r s alt elem ents W ater a s .
H O alone does n o t e x is t i n t h e b ody water al

z ,
ways b ein g th e s olvent o r suspending me dium O f

organ i c o r inorgani c s ub stance s .
T h e s welling of t h e tissue s produces a c ertain

amount O f anaesth esia due to pre s sure upon the
,
terminal nerve s o n o n e hand ; and o n th e oth er

, ,
t h e s ensib ility Of t h e part is al s o reduced b y th e

phy s ical o r mayb e even chemi c al ch ange s tak ing
, ,
pla c e in th e nerve c ell s due to th e inj ectio n The

,
.
re s ulting anaest h e s ia i s alway s preceded by pain ,
is Of s h ort duration very un s ati s fa c tory and a t

,
tende d by d i s turb an c e o r rath e r i rr itation O f th e

, ,
tis s ue cell s wh ich frequently leads to necros i s

, .
I f a little s alt (so dium ch lor i de ) i s a dd ed to t h e

w ater and t h is solution is inj ected the pain is
, ,
s om ewh at les s an d w ill d ecrea s e a s the salt c o n ,
te n t Of t h e solutio n i s increa s e d until i s otonicity

to t h e b lood i s reac h e d .
T h en t h ere i s absolutely n o d iscomfort felt but

n o a n ws th e s i a . I f th e salt i s increased beyond
pe r cent , p ain reappear s an aesthesi a follow s
.
,
1 34 LO CA L A N E ST H ES IA
an d th e tis s ue c ell s s uffer T h e s e ph enomen a i n
.
crease pro p ortionately a s more s al t i s added I t i s .
impo s sible to bear t h e pain attending a n inj ection

Of a saline s olution c ontai n in g more t h an 1 0 p er
cent s odium chloride
. .
T h e foregoing (experiment s m a d e b y Braun

an d H e in z e ) s how s that saline solution s fo r h yp o
d erm i c inj ections to b e n o n irrit a ting mu s t c o n

-
tain a definite amount o f s alt The con c entration .
Of t h i s s olution mu s t c orrespon d to th e c oncentra

tion o f th e bl ood I n ot h e r w o r ds it must be i s o
.
,
toni c T h e Obj ect O f th e s olution i s simply to act

.
as a diluent an d carrie r fo r th e anaest h eti c T h e .
saline s olution does n o t produce in fact s h oul d not

,
produce an ws th e s i a ; th e p a i n abolis h er i s th e
,
anae stheti c an d the saline solution is simply the

,
mean s o f tran s porting the drug into th e n erv e .
A s olutio n Of sodium ch lori d e per cent

p er cent in water i s d e s i gn at e d a s phy s i olo gi c o r
.
normal salt solution .
I f th e inj ecte d s olution i s hyp oton i c (l e s s c o n

c en tr a te d th a n t h e b lood pla s ma ) t h e cellul a r ele
,
ments will ta k e u p water from the solution and

swell up ; in the ca s e o f red bloo d cells a c tual
h emolysis may re s ult .
I f t h e inj ected solution i s h yp ertonic (more c o n

c en tr a te d t h an the b lood plasma ) t h e ti ss ue and
,
bloo d cell s will give up part Of th eir aqueou s c o n

tent s an d s h r ink I f the s olution i s isotonic to t h e
.
1 36 L O CA L A N JE S T H ES IA
b ro k e n O ff th e n eedl e in s erted an d t h e c ontents
,
d r a wn into the s y r in ge ; it d oes away w ith k eeping

Of sto ck s aline o r R inge r s s olut i on s and the boil
’
,
i ng O f t h e ta b let T h e write r i s still preparing

.
h i s o wn a nae s t h eti c solut i o n a s d e sc rib ed h erein

,
.
T h e w r i ter w ould h o ld an y o p e r ato r d i r e c tly re

spon s ib le fo r un p lea s ant aft e r e ffe ct s from hypo -
de rmi c inj ection s i f t h e o p erato r d oe s n o t know

th e e xa c t in gre d ie n ts O f a so l utio n em pl oyed It .
i s th e writer s opinio n t h at c a rb oli c a c i d p o ta s

’
,
s ium i o di d e iodine b aptisia h amamelis and the

, , ,
h undred and o n e ot h er dru gs a s ingredients i n

l o c a l a nae sth etic s p la c e d upo n t h e mark et h av e ab
s o lutel y n o pla c e i n such pre p a ration s and t h ey ,
can o nly exist and enj oy a s ale due to th e i gn o

ran c e O f th e profe ss ion at l ar ge .
T h e important feature a b out a lo c al a n ai sth eti c

i s not th e anaes th e s i a alone wh ich i s Obtaine d with
,
many preparation s o n the ma rk et but a v ery i m ,
portant fa c tor i s th at th e ti s sues aft e r an aes th e ,
s i a h a s passe d O ff b e left unh armed T h i s s tate

,
.
ca n only b e O b taine d by a n o n i rr i tat in g i s oto ni c -
s olution .
P o s tan aes th eti c p a in oed em a g an gren e ne c ro

, , ,
s is emb olism ecch ymosi s an d oth er un d e s irabl e

, ,
and harmful result s after loca l anae sth esia a r e

caused by lack Of a s epsi s fo r w hich th e operato r
,
is re s ponsible or t h e inj ection Of media wh i ch

,
cause the deat h Of ti s sue c ells .
The a c tion Of th e an ae st h et i c s h oul d s imply b e

S O LUT I O N S 1 37
a temp orary inhi b ition of impulse transmi s sion

w i th o ut d es tr o y i n g tissue cells I t therefore is.
, ,
apparent th at the proper solvent medium fo r p r o

d uc i n g local an azs th e s i a is important and in t h e ,
ligh t O f modern sc ience not a que s tion Of choi c e

,
O nly normal sali n e o r R in g er s solution c a n b e

’
c on s idered .
P r ep a r a ti o n o f th e S o l ven t M e di um
C h emically pure sodium chloride tablet s fo r
ma k ing normal salt solution can be purchased
from any Of the well known drug houses These
-
.
tablets in well cork ed colored b ottles will k eep

,
-
,
a long time On e ta blet according to wei ght is

.
, ,
dissolve d in th e proper amount o f p r evi o us ly

b o i l e d s te r i l e w a te r (th i s d o e s n o t m ea n ta p w a te r -
w hi c h h a s b een b o i l e d , b ut d i s ti l l e d w a te r w hi c h
h as b een s te r i l i z e d
) that a ,
per
so cent s odium .
ch loride solut i on is Obtained I f a tablet weigh s .
2 g ri n . three tablets di s solved in o n e

litre will give the proper s olution R inger s olu .
tion tablet s (Farbwerk e H oechst dis s olv ed

,
according to directions (one tablet in 10 ccm Of .
w ater ) will give R i nger s solution

’
.
,
These solutions can be k ept in alkal i free s to ck -
b ottles but they must be well stopper e d Th e

, .
a ut h or uses a ground gla s s sto p pered b ottle ove r

-
,
w h ich a ground glas s cap is placed (Fig

-
.
T h ree o r four ou n ce s (90 1 20 ccm ) a r e prepare d -

.
,
wh ich lasts fo r several days The lea s t cl oud in e ss .
O f t h e s olution ma k e s it unfi t fo r us e .
TH E A R MAM E N TA RI U M
Th e S y r i n g e
TH E syringe s h ould be a good all metal an d glas s -
syringe holdin g 40 min o r o n e having a ti gh t

, .
,
fi tti n g ,
interch angea ble asbe s to s plunger A .
syrin g e w ith leather was h ers o r plunger s is n o t

fi t fo r thi s wor k a s t h e leath er i s a fi e c te d b y b oil
,
in g a n d al c o h ol .
The author u s es a Freienstein syringe ma d e of

g las s and metal e xc
,
eptin g t h e plunger w h ic h is a ,
pad o f a s bestos A ll part s are interch angeable

.
( Fig . P rof G uido Fische

. r employs an ih
strument Of th e same ma k e devised by h imself , ,
made entirely o f meta l and gla s s with a r evolving ,
h and rest
-
.
Th e writer fi n ds Fisch er s syringe a little ’
too h eavy ; but in th e end it makes little dif

ference which type o f syringe is employed a s lon g ,
as it i s capable Of sterilization and none O f its

p a rts injured by alcohol .
The s yringes are k ept in a j ar wh ich c ont a i n s ,
a metal stand holding several syringes (Fig .
T h e j ar i s filled with a mixture Of 70 per cent al c o .
h o l and 30 per cent glycerine and the s yr inge s r e

.
,
1 38
1 40 LO CA L A N E S T H E SIA
Ne edl es
T h e a uth or use s tw o types o f s teel needles : for
mandibular inj ection s th e NO 1 ,
mm in . .
diameter ) 40 mm long and fo r all other i n j e c

,
.
,
tions the NO 1 7 . mm in diameter ) 42 mm

.
,
.
long A ll needles fi t into a hub wh ich is screwed

.
,
upon th e syringe and drawn tight with a wren ch .
The needles are ma d e o f seamless tube ; t h e

mounting consist s Of a soft metal head and a thin
but strong hard metal casing T h e soft metal .
form s an abs olutely tigh t j oint with th e end o f the

syringe and the h ard metal prevent s the needle
,
from stick ing in the hub and also prevents the

,
soft metal from becoming distorted .
The s e needles O ffer decided advantages over th e

O l d fashioned threaded needle
-
wh ich is screwed ,
directly onto the syringe They are cleaner and.
form a closer joint with the syringe s o t h ere is ,
practically n o leakage The author uses the steel

.
needles with satisfactory results The P latinum .
I ridium needle O ffers the advantage that once ,
mounted upon the s yringe it need not b e removed

, ,
as it i s sterilized by burning it in the alco h ol flame .
T h e steel needle and hub o f course are removed

, ,
after being used once and ch anged fo r a new o n e

,
.
S ome men advocate the discarding o f t h e steel

needle after using it once ; the author w h o receive d ,
part Of hi s training in P rof W i l l i ge r s C lini c

.
’
,
still adheres to the method used ther e W illi ge r .

ARMAM E N TAR I U M 1 41
does n o t discard h i s needl es after us in g them but ,
ster i lizes them and employs them again H o w

‘
ever each n eedle i s carefully in s pected before b e

,
in g steril i zed a n d the slightest defect condemns

it to the scrap pail The author would sound a
-
.
note Of warning to e x ercise great care in the us e

Of steel needles : to c a r efully i n s p ec t them d ai ly
before s terilizin g s o as to note any defect and
,
discard th em at once if a flaw is di s covered .
A rusty needle means trouble and a broken ,
needle a l o t Of anxiety fo r as a rule only a

, , ,
surgeon can remove it .
I f a needle fractures at the h ub there is a chan c e ,
to g rasp it with anatomical forceps and withdraw

it but if it breaks distal to the hub w i thi n the ti s
,
s ue s it s removal can only be done by a surgeon

,
.
The possibility O f fracture caused a good

many Operators to use P latinum I ridium needles -
.
These h owever after h eating repeatedly get

, , ,
quite soft and make th e palp atio n o f the bone (in

mandibu l ar inj ections ) rather diffi cult .
There is les s chance for needle s to break in other

injections than i n mandibular anae sth esia .
The needles are washed out after usin g th e wire ,
is drawn through them they are the n boiled and

,
then pl aced in a closed vessel containin g the alco

hol and glycerine mixture o r in p ure lysol I f they
,
.
are kept i n lysol they have to be wash ed thor

,
oughly in sterile water to remove a ll tr a c es o f

,
1 44 LO CAL A N JES T H ES I A
NO alcoh o l lamp fo r b oiling s olution s and

.
to bur n O ff plati n um iridium needle -

.
NO 4 are gla ss s labs to cover the por c elain cru

. .
cible and the medici n e bl ocks s o that n o
dust contaminate s their co n ten ts .
T h e glass table is used fo r n othin g els e b ut th e

p rep aration O f anaestheti c s olutions .
S tep s o I
f jn e c ti o n
1 . Bo i l R ing er s solutio n i n cru c ib l e

’
.
2 Drop novo c ain supraren in tablets in cruci b le

.
-
an d br in g to boil in g p o int to di s solve tablets ; place

gla ss c over o n crucible .
3 R emove syrin g e from jar wa s h outside in

.
,
s te r i l e w ater an d dry in s te r i l e towel ; d o not r e
move c ap .
4 R emove needle and h u b from j ar w i th p liers

.
,
and wa sh with s terile water i n s p e c i al dish .
5 R emove cap from syringe attach n eedl e an d

.
,
h ub w it h p liers and w rench .
6 P a s s steril e wate r in an d o ut o f s yringe a

.
,
th ird s p ecial di s h .
7 F il l syringe with an ae s thetic

. .
8 I od i ze mucous memb rane

. .
9 Inject anaes t h e tic ; wipe needle w ith steril e

.
cotton .
10 R emove needle and h ub was h in s teri l e

.
,
water r e place wi r e into needle then s terilize b y

, ,
boil ing .
T E CH N I " U E 145
11 . W a sh s yringe by p as s in g fres h s terile water

in an d o ut, attach c ap wa s h out s ide Of syringe
, ,
d ry .
1 2 R e p lace
. into j ar .
I fP l a ti n um I r i d i um Ne ed l e I s Us ed
-
1 .Boil R inger s solution in crucible

’
.
2 Drop novocain suprarenin tablets into cruci

.
-
ble and bring to boiling point to dis s olve tablets ;

pl a ce glas s cover o n crucible .
3 R emove syringe from j ar w a sh outside in

.
,
s terile water and dry in sterile towel .
4 W as h o ut syringe s i n sterile water

. .
5 S terilize needle in alco h ol flame

. .
6 F ill s yringe w ith a nae sthetic

. .
7 Burn O ff needle
. .
8 I odize mucous membrane

. .
9 I nj ect anaes thetic w i p e n ee dle with s terile

.
,
cotton .
1 0 Burn O ff n ee dle
. .
1 1 W a s h o ut s yringe dry outside

.
, .
1 2 R e pl ac e sy r in ge an d n ee dle into j ar
. .
IV
CO CAIN E
LO CAL anaesthesia o n ly became an e s tablished fact
after the recogn ition O f cocaine a s an anaesthetic
agent P rior to this time compres sion o f nerve
.
trunks th e application Of cold by freezing mix

,
tures and th e s praying O f ether and other volatile

s ubstances were p ractised but all this w ith i n d i f
,
fe r en t and u n sati s factory r e sult s .
H i s to r y
P izarro , wh e n invading P eru in 1 532 d i s covere d ,
that th e inhabitants O f that coun try cultivated the

C oca plant (E rythroxylon C oca ) and chewed the
leaves to appease h unger and to overcome fatigue .
M essenger s running l ong distances carried a

s upply O f coc a leaves for a rti fi cial s tim ulation and
cu tting down rations and sleep I t was also kno wn
.
that th e exces sive use O f th e plant proved very

h armful The S panish govern ment pro h ibited the
.
general cultivation O f the coca plant fo r some

time ; later however permitted its growing but
, , ,
levied a ta x upon its production By this taxation

.
the S tate o f Bolivia during 1 850 according to ,
W endell netted a revenue o f three million dollars

, .
T h e fi rst to bring a large r q uantity O f coc a

leave s to E uro p e w a s S cherzer P art Of this sup
.
146
1 48 LO CAL A N JES T H ES I A
in s t i ll ation Of a cocaine solution into th e eye s o f

a n i m a ls aboli s hed ocular refle x e s and F auvel , ,
S a gli a and other s employed cocaine in the treat

ment O f p ainful a fi e c ti o n s Of the larynx and
p harynx .
H owever c o c a ine w a s n o t univer s a lly a c kn o w l

,
edged and accepted as an anae sthetic agent until

K a rl K oller o f V ienna (n o w Of New Y ork ) in
, ,
1 884 b efore t h e O phthalmological C ongres s at

,
H eid elberg demo n strated that the instilla tion O f a

,
2 per cent s olut i on O f cocaine into the eye per

.
i n i tte d th e performance Of oph th almological oper

a ti o n s without pain .
Ph ysicians all ov e r th e worl d began to use it ,
and scienti s ts took up th e study O f this new drug .
Th e re p ort Of K oller wa s soon corroborated by

A gnew M oore M inor K n app G rafe and oth ers
'
, , , , ,
and the co c ainization O f the eye and mucou s mem

brane became universal C ocaine soon established .
it s elf in laryngolo gy and rhinolo gy and was also ,
u s ed in genito urinary practice S oon surgery as

-
.
,
w ell a s den tistry made use O f th e wonderful prop

,
e r ti e s o f t h is dru g I n 1 885 C orning reported that

.
if th e circulation be cut O ff in the part to be anse s

th e ti z e d t h e action O f th e dru g became inten s ifi ed
, ,
and anaesthe s ia i s O btained with much wea k er S O

lutions th us red ucing th e toxic e ffect s TO pro
,
.
duce anae mia in th e part he employed E smar ch ,
bandage s This di s covery w a s the forerunner O f

.
CO CAIN E 1 49
o ur pre s ent dry method o f producin g local a n ae s

th e s i a co upled wit h anaemia (anae s thetic plus
adrenalin ) .C orning and G oldscheider demon
s tr a te d t h at the conductivi ty o f impulse s along the
nerve is inhibited by th e inj ection Of cocaine and ,
this in turn i s th e forerunner O f conductive

anae sthesia .
H o w rapidly t h e s e fi nding s were utilized wa s

demonstra ted by H al s te d t o f P hiladelph i a wh o
, ,
in 1 885inj ected th e i nferior denta l nerv e fo r tooth

extraction C ocaine was taken up all over th e
.
globe by all wh o practised the healin g art I t was .
used in 2 to 20 per c ent so lutions and n o s ooner

.
,
was it employed here a new use was found for i t

,
there but soon sever e c a se s O f poisonings and

,
fatalities be ga n to be re p orted The new gift O f .
fe r e d to h umanity proved a doub le edged sword -

.
By virtue Of its wonderful anae s th etic propertie s ,
undreamed O f advances w ere made in all spec i al

-
ties i n med i cine but its u se frequently p roved

,
dangerous and th e number O f cocain e fatalitie s i s

,
much greater than th o s e reported .
P hy s i o l o gi c A c ti o n o f C o c a i n e
T h e symptoms O f cocaine poi s oning v ary in dif

fe r en t i n dividuals I n m ost ca s es small quantities
.
produce some excitement pl easurable and di s ,
agre e able The patient is generally more garru

.
lous th an i n ordinary l ife O ften s o m ewhat a nx i ous

,
1 50 LO CAL A N zES T H E S I A
and confused V ery small doses produc e a calm

.
,
languorous state somewhat resembling that fol

,
lowed by taking small q uantities O f morphine but ,
di ffering from it in there being less tendency to

sleep Th e p uls e i s a c c el e r a ted th e r es p i r a ti o n
.
,
q u i c k a n d d e ep t
,
h e u
p p i l generally d i l a te d and ,
headache and dryness O f th e throat are frequently

complained of The reflexes may be a little ex a g
.
g er a ted and tremors or sli ght convulsive move

ments m a y occur L ater powerful tonic o r clonic
.
c onvulsion s s uperve n e th e heart becomes ex

,
tr e m e l y accelerated the breathing becomes rapid

,
and dyspnoeic and may finally be arres ted during

a c onvulsion . I n other cases the convulsive
seizures are almost entirely absent and fainti ng ,
and collapse occur The skin is cyanotic and cold

.
,
th e heart S low and weak ; th e respiration is very

much depressed and death follows from i ts grad
,
ual cessation V omiting is occasionally seen at

.
an early stage but is by no means common

, .
The general action o f cocaine seems to indicate

a stimulation Of th e central nervo us system Thu s .
the talk ativenes s s o Often produced by the drug

indicate s an increased activi ty of th e cerebrum ,
and t h e increased move m ent in lower animal s di s

ti n c tly p oint s to an a f ection O f this part O f the
f
brain for the movemen ts are perfectly c O Or d i

,
n a te d ,a n d in t h e early stage s resemble e x a c tl v
those p erform ed by the normal animal in a s tate

1 52 LO CAL A N E S T H ES IA
.
A ccording to H entze a young lady pre s ented at

,
a cli n ic and had a too th removed under local an aes

th e s i a . S h e showed s ymptoms o f cocaine i n to x i
catio n and h y steria ; however recovered very s oon ,
and returned to her home S oon thereafter o n e Of

.
the assistant s receiv ed letters from her Of amorou s

character thou gh she even did not know th e as
,
s i s ta n t s name The assistant paid n o attention

’
.
to these n otes and thr e e days later th e youn g

,
woman committed suicide after no tifyin g th e a s ,
s i s tan t Of her i ntention I t was determined th e

.
young woman w a s O f un reproachable ch aracte r

and engaged to be married H e r actions n o doubt .
, ,
were cau s ed by the reaction o f the co c aine p rodu c

ing erotic conditions O f the mind .
The author himself Observed several ca s es O f

marked sexua l excitement followed by orga s m ,
w hile th e patient was lying in the chair showin g ,
symptoms O f cocaine intoxication resulting upon ,
l oca l anaesthesia i nduced fo r t h e extra c tion O f

teeth .
R es p i r a ti o n after cocaine i s much ac c el erate d ,
o wing to central stimulation A t fi r s t th e depth .
i s n o t ch ange d but as the acceleration pro g re s ses

,
th e air inspired with each breath gradually b e

comes less During convulsions the respiration is
.
irregular or c ea s es but it recovers agai n in th e i n

,
fe r v a l s until after a very violent paroxysm it f a il s

,
to be reinstated I n other ca s e s the breat h ing b e

.
CO CA I N E 153
comes sl o we r and weaker after a time and even tu ,
a l ly stop s from paralysis Of the center .
Th e c i r c ul a ti o n i s al tered by cocaine o w ing to ,
it s action o n th e heart and on the vessels The .
h eart is much accelerated in mammals while in t h e ,
amp h ibian s this is le s s Often Ob served Th e q uick .
e n i n g has been ascribed to paralysi s O f t h e i n h i b
i to r y termination s but thi s seem s n o t to be th e

,
ca s e for stimulation O f th e vagu s s lo w s th e h eart

,
even late in th e poiso n ing T h e h ea r t i s ac .
c el e r a te d then eit h er by direct action Of t h e muscle

,
or by stimula tion O f the ac c el erator mechanism .
I t is Often s low b efore dea th but apparently n o t ,
invari a bly and t h i s is p ro b ably due to dire c t a c

,
tion o n the mus cle .
The v e s sel s are much contra cted in th e earl i er

stages O f p oisoning and this togeth er w i th th e
, ,
increased rate o f the heart leads to a very con ,
s i d e r ab l e rise i n the blood pre s sure The c o n s tr i c .
tion o f the ve s sels seems pa rtly due to stimulation

O f th e vaso constrictor center for s ection O f the ,
S planchnic nerves leads to direct fall in th e

arterial tension C ocaine s eems to act directly
.
upon the walls O f the blood vessels as i ts local a p ,
plication is followed by constriction Of the ves s els

and blanching of the m ucous membrane .
Th e e ffects on the peripheral n e r ves and m us c l es

are still disputed .
Th e ur i n e is sometimes said to be increas e d by

1 54 LO CAL A N E S T H E SIA
c ocaine whil e in ot h er instances i t s inj ection has
,
bee n followed by anuri a lasting s everal hours .
The other s e c retions seem rather reduced .
The tem p e r a tur e ri s es in c a ses Of p oisonin gs as

much as 35 C .
The elimination Of cocaine from the organism

is still a muted question I n dog s a portion is ex
.
c r e te d by the kidney s the greatest portion 95 per

, ,
cent being destroyed in the tissues I n the rabbit

.
,
.
it is co m pletely oxidized I n man the fi nal stat e

.
o f cocaine is n o t de fi nitely e s tablis h ed .
L o cal Eflee ts o f C o c a i n e
C ocaine app lied locally in mo s t parts O f the

body produces a los s O f s ensatio n by its p a r aly z
ing the te r m i n a ti o n s o fs o m e o fth e s en s o r y n e r ves ,
particularly those conveying impressions Of pain

and to uch I t is Often sta ted that the end organs
.
Of the nerve s concerning w h ich th e feeling Of heat

and cold are al s o disorga n i zed but the researches ,
o f K ieso w S how t h at thi s is i ncorrect and th at ,
heat and cold are recognized a s readily as in the

una ffected part s o f the body C ocaine a p plied to .
the to n gue remove s the taste Of bitter sub s tance s ,
while sweet and acid fluids lose their taste only

p artially and salt is recogn ized as easily as
,
usually .
A solutio n applied to the n as a l m uc o us m em

b r a n e paralyze s t h e s ense Of smell entirely .
1 56 LO CAL A N zES T H E S I A
over lar ge area s Of the body s ometime s over al ,
mo s t the whole body T h i s i s probably due to i ts

.
a cting o n t h e po s terior root s o f the cord I t mu s t .
b e note d that th e anae s t h e s ia i s only pro d uce d by

th e local applications o f th e dru g The intern al .
a dmini s tration only leads to a par tial los s Of s e n
s ation in th e th roat and s tomach and no anaes th e ,
s ia i s induced by its a c tion after it reaches the

b loo d ve ss el s The rea s on for t h i s evidently is
.
that i n order to paralyze th e s en sory fi bre s an d

,
termin ations a con s iderable a mount Of th e dru g

,
i s required but much le s s i s n e c essary to paralyz e

,
th e c entral nervou s s ystem wh en c o c ai n e i s a p

pl i ed to a mucou s membrane s urface ; it produ c e s ,
beside s loss O f sen s a tion a feelin g O f cons tri c tio n

,
a n d a distinct pallor a n d co n tra c tio n Of th e v e s
s el s which point s to a local actio n o n the ve ss el

,
w all s . The anaes th esia produced by c o c a ine i s

comparatively s hort b ut varies with th e stren gth
,
o f the s olution applied and wi th the va s cularity Of
th e part ; a s soo n as the coc a ine is absorb ed th e ,
l o ca l action di s appears an d s e n sation return s .
C ocai n e can be looked upon as a g en e r a l p r o to

p l a s m i c p o i s o n ; muscle s ner v es
,
and nerve end s
cea s e to c ontract or to conduct s timuli wh en ex
posed to ev en very dilute s olutions Of cocaine ; the
ciliated epith el i al cells leucocyt es and sperma
,
to z o a b e c ome motionles s ; the cortic a l nerve c ell s

l o s e th ei r ex citabil i ty and ma n y Of th e i nv erte
,
NO VO CAIN 1 57
b r a te s a r e k illed by even s hort ex p o s ure to c o

caine T h e movements o f protopla s m in plant s
.
a r e al s o retarded or entirely suppre ss ed an d p u ,
tr e fa c ti o n is delayed con s iderably I n s ome c a s e s .

,
notably in th e higher invertebrates th e fi nal de ,
pression is preceded by a stage of increa s e d move

ment I n other instances however c ocain e i n
.
, ,
duces on ly depression and paralysis .
F rom th e above we note th at th ough coc a in e ,
h as proven of inestimable value at the same time ,
it is a powerful poison and chemists an d investi ,
gators all Over the world have been tryin g to p r o

duce agents which posses s the anae sthetic pro p e r
tie s Of cocaine but are devoid o f its toxic qualities .
T h e substitute s O ffered fo r co c aine a s a n ws th e ti c

agents are many ; h owever all had th eir s h ort ,
comings : eith er their toxity was practi c ally equal

to that of cocaine o r if they were less poisonous
, ,
th e anaesth esia produced by these agents was n o t

sat i sfactory ; certainly it did not prove equal to
that Of th e c o c a leaf alkaloid .
N o vo c a i n
A fter many sub sti tutes for cocaine were
b rought out an d found wanti n g P rof E inhorn O f ,
.
,
Munich in 1 905 produced h ydro ch lorid o f

,
-
p
-
a m i n O b en
-
z o y l d i e th y l a m i n ceth a n O l w hic h r e,
c e i v e d t h e trade name Novocain“ ”

.
B I B L I OG R A P H Y :Cu h in g Ph a rm c l gy an d Th r ap uti c s
s a o o e e .
H a r P r a c ti c a l T h r ap uti c
,
B raun Di L ka l
, e o aes th e i
an s c . e, e e s .
1 58 LO CAL A N ZES T H E S I A
Dr . Biberfeld ex p er i mented w i th th e n ew
J .
d rug at t h e Ph armacological I nstitute O f th e Un i

ver s i ty O f Bre s lau whi ch experime n t s gav e the
,
following d a ta
No vo c a i n po ss esse s th e s ame a c t i on upon s en
sory nerves as cocaine ; a per c en t s olu tion .
s u ffice s to c ompletely anaes th etize even h eavy nerve

trunks s uch as the scia tic nerve in about ten min
, ,
ute s A pplied lo c ally i t cau s es n o i r r i ta ti o n even

.
,
if used in strong solu tions The au th or applies .
pure novocain powder to th e oral m u c ou s mem

brane b efore making a mandibular inj ec tion and ,
h a s not seen any ill results after us in g it in a b out

fiv e hundred mandibular injectio n s .
There appear s pra c tically no ill e ffe c t upon t h e

s y s tem after its ab s orption in doses w h ic h would
b e da n gerous i f c ocaine were used Neither th e .
c irculation respiration o r cardiac acti vity s eem

,
to s u ffer Two to three grains

. 02 gr ) Of -
.
novocain inj ected subcutaneously into a rabbit

h ardly s h owed a change in th e blood pressure or
th e respiratory curve Novocain does not produce .
mydriasis does not ch an ge th e i n tr o Oc c ul a r pres

,
s ure and does not a ffe c t periph eral v es sels as

, ,
c ocaine does .
T h e toxicity i s v ery low compared to c ocaine ,
an d was determined by comparing the leth al dose

Of novocain wi th th at of cocaine and s to va i n i n ,
anim a l ex p e r iments .
1 60 LO CAL A N E S T H E S I A
co ve r ed t h e l ocal anaes th etic I n spite Of all the ,
writer would wa rn again s t th e t h oughtle ss indi s

c riminate use of th e dru g but im p re ss th e re a der
,
that t h ough we ha ve an a gent th at i s a g re a t d eal

,
le s s toxic th a n co c aine w e s till h ave to study o ur

,
patien ts and u s e judgment an d never forget th e ,
mea n ing of th e word asep s i s .
No v ocain is manufa c tured in t h ree fo r m s

1 Basic novocain
. .
2 Novocain nitrate
. .
3 No v o c a i n h ydrochlorate
. .
T h e ba s ic form i s mai n ly used in otolo gy r h i n o l ,
ogy and laryngology in 1 0 per cent solutions in .
Oil fo r applications instilla tions and inhala tion

,
.
Th e ni trate is particularly O f value in urolo gical

pract i c e a s the nitra te o f novocain c an be c om
,
b i n e d wit h s ilv e r s alt s w hic h is not pos s ibl e w it h

,
the ch lorate th e latte r decomposin g and thus l o s

, ,
in g it s p ro p ertie s .
A d r en a li n
T h e fi ndi n gs o f C o m in g (1 885) th at c o c aine i n
j e c te d into an an aemic area will produ c e a naes th e
sia in weaker s olutions and le s sen th e to x i c e ffect s

due to a s maller amount being ab s o rbed into th e
general circulation becam e O f pra c ti c al us e w h en
, ,
in 1 901 Takamine and A ldrich inde p endent Of

, ,
e ach other produced th e extract of th e s upraren al

,
capsules known as adrenalin .

A DR E NALIN 1 61
T h e most characte rist i c action Of a d ren alin i s a

temporary raising o f th e blood pre s sure even if ,
administered in minute quantitie s A c c ordin g to .
M oore and Purrington gi ve n to dog s in

,
gm for each kilogr a m Of

.
bodywei gh t it s a c tion is dis c ernible

, .
T h e reason for this reac tion is due to direct c a r

diac s timulation and also to the contraction of
,
arterioles and capillaries .
The action O f novocain is en h anced b y adding a

small quantity of adrenalin or suprarenin synth .
The E novocain suprarenin tablets made by t h e

“
HOc h s t Farbwerke C O contain no vocain

. g ram
an d suprarenin gram an d a r e th e most
,
conven ient for dental practi c e .
W here l a rge quanti ties Of novo c ain are us e d it

is probably better to make up a o r 2 per ce n t .
solution O f novocain and th en add 1 drop Of s u p ra

renin for each ccm O f novo c ain solution
. .
A n y systemic symptoms wh ich m ay appe a r after

th e hypodermic inj ection of novocain suprareni n ,
namely th e bl anch ing O f the patient per s pir a tion

, ,
and sligh t n ausea are due to suprarenin an d not

, ,
to th e novo c ain I n O l d people with hardened ve s

.
sel s an d i n arteriosclerosis as well as wh ereve r

,
th ere is an abnormal high blood pressure it i s a d ,
v isa b le to reduce t h e amount Of suprarenin .

V
I N F IL T RA T I O N A N JES T H E S IA
I N F IL T RA T I O N is th e region a l l os s Of
an azs th e s i a
s ensation p r odu c ed by the action O f certain a gents

upon sensory nerve endin gs introduced by sub en
tan e o us or submucous inj ect i on .
H ow these agents act upon th e nerve ti ss ue di

r e c tly h as n o t been establis h ed ve t W e onl y know .
the result of s u ch action namely a d i s turb ed, ,
physiolo gic fun c tion wh ich in s ensory nerve ti s sue

,
is exhibited by los s Of sensation .
The auth or believes tha t w h en an agent l ik e c o

caine or a S imi l arly acting drug is brou gh t in
, ,
contac t with nerv e tissue th ere occurs a p r ec i p i

,
ta ti o n or coagulation Of s ome O f the cell contents

( albumins ) w,
h ich altered biologic state produ c es
t h e loss of function ; after th is precipitate i s c l imi
na fed by ab s orption or is redi s solved with in th e
cell body the normal funct i on is r eé s tab l i sh e d
,
with out ap p a r en t injury to th e nerve tis s ue a n d ,
sen s ation return s This will very likely a cc ount

.
fo r the transient ch aracter Of the drug e ffe c t .
I n employing local an ws th e s i a it is not onl y e s

s en ti a l to be acquain ted w it h th e lo c al and ph y s i o
l o gi c action O f th e drugs u s ed but a t h orough ,
kn owledge Of th e ana tom ic al and histo l ogi c al

1 62
1 64 L O CAL A N JES T H ES I A
stru c ture will be anaesthetized more s ati s factorily

than t h e solid areas .
Th e upper j aw is more porous in s tructure th an

th e mandible The lower maxilla bein g porous
.
only in t h e a nterior portion between th e can ine

,
teeth i n fi ltration anaesthesia will prove more e f

,
fe c ti v e here than in th e bicuspid and molar re

gion s wh ere the bone is denser in ch ara c ter
,
(Fig .
A nother point to bear in mind is t h e fact th at

the maxillary bones are more porous in early life ,
and wit h advancing years grow more compact and

denser ; thus it will be easier to induce anaesth esi a
wi th les s Of t h e drug in ch ildren than in adults .
L ocal o r infi ltra tion anae sthesia can be employed

upon single o r groups O f teet h in the anterior part
of th e mandible and in the upper j aw p ro vided ,
th ere is no infection present .
Th e T e c hn i q ue o I
f fin l tr a ti o n A n a e s th e s i a
S uccessful local anaesthesia depends upon t h ree

factor s : local asepsis the use of the proper solu
,
tion and correct techni q ue The second factor

,
.
has been discussed elsewhere .
L ocal asepsis is Obtained by applyi n g tr iodine .
to th e part to be inj ected This is best done wit h

.
an applicator m a de by tigh tly w inding some ah

,
sorbent cotton around o n e end O f a too th pick .

I N F IL TRA T I O N
Thi s method is s imple inexpen s i ve a n d clean a s

, ,
th e applicator is discarded afte r use .
Th e tech n ique o f lo c al a naesthe s i a require s th e

p p
r o e r i n tr o d uc ti o n o f th e n ee d l e th e c o r r e c,
t
m e th o d o f i n j e c ti n g th e anae sth etic and w a i ti n g a
,
su ffic ient length Of time until t h e anaes th eti c h a s

,
af fected t h e nerve s s up plying th e part to b e Op e r

ate d upon .
A fter th e an aesth etic h a s b een prepared t h e ,
s yringe is filled and th e needle attach ed A i r .
bubble s w ithin th e barrel are expelled by h old

ing th e syringe upward and th e air will then raise
,
to the top ; by slowly expres sing a fe w drops O f

solution t h rough t h e needle the advancing liquid ,
will force o ut th e air A i r inj ected in to the ti ss u e s

.
may produce pain I t i s better to fill a s yri n ge

.
b ef o r e a tta c hi n g t h e n eedle as if more anae sthetic

,
s olution is required th e Operator (once h aving ac

quired th e h abit ) is les s apt to place th e bloody
n eedle i n to the s olution and th us taint the in side
,
O f the syri n ge as some of the material adhering

,
to th e needle leaving th e tissues will b e s et free

, ,
in the solution I f a platinum needle is used h eat

.
,
in g it i n th e flame will sterilize it of course ,

.
I f a needle i s removed or attached to th e

syringe it s h ould b e h andled with fo rceps as the
, ,
fingers destroy its sterility .
H aving fi lled the syringe and expelled air bub

bles wh ich may b e present i t i s g r a s p e d li ke a p en
,
1 66 LO CAL A N E ST H ES IA
ho ld er ,and th e t i ssues h av ing b een iodi z ed t h e ,
needle i s thrus t in to the gum until bone is rea ch ed .
T h e flattened portion O f the needle should always

lie parallel to th e b one I f i n s erted otherwi s e , th e
.
needle is a p t to be n d a n d b r eak (Fig .
T h e needle s h ould not be in s erted at the gin gi v al

border b ut h igh er up toward th e apex of t h e r oot
,
( F i g .
F I G 86 .
S h o w in g P r u C h a rac t r O f U pp r J a w in P t r i r P o r ti o n
—S h w T ub r ity Of U pp r M ax i ll a—A l D m n tr at th
o s
o
e os
o s e
e
e ,
so
os e
e o s
o
es e
D n C h r ct r O f th M an d i bl in th P t r i r P r t i n O f th
e se a a e e e e os e o o o e
B dyo .
Wh en the bo n e i s reached the liquid s h ould b e

S lowly and evenly inj ec ted s ub p e r i o s ti a l ly and the ,
area then mas s aged W h eals should not be .
formed ; if such i s th e case th e liquid has n o t been ,
i n j ec ted deep enough and h a s s p r ead ju s t bel ow

1 68 LO CAL A N 1ES T H ESI A
to p r es s ur e , but indu c ed by th e s o l ution r each in g
the nerve endings t h rou gh ab s orption This mean s .
a bout three to fi v e m inu tes T h e e ffi ca cy of th e

.
anae s thesia c an be te s ted by p ri cking t h e infi ltrated

are a wit h t h e hypodermic needle A fte r th e s u .
'
p er fi c i a l area is an aes thetized we have to wait until

the solution traverses th e alveolar process to the
pericementum Fig 89 shows the proper method
. .
of inducing infi ltration anaest h e s ia I nfi ltration .
a n ai s th e s i a can be u sed wit h good success in t h ose
areas of the maxilla: which are spon gy and pre

sent many small foramina ; but in those lo c alitie s
w h ere the bone is dense as in th e molar and b i
,
F I G 89
ia i n An te r i o r P o r ti o n O f Upp er Jaw No te
.
In fi l t r ti o n An th e
a aes s .
Po iti n O f S y r in g
s o e .
I N F IL T RA T I O N 1 69
F I G 90
.
In fi l t rati n Anaesth e i a
o s on Lingua l A p c t O f Lo wer
s e Mo l a r R egi o n
cu s pid region of th e mandible th e i nfi ltration ,
meth od wil l n o t b e s uccessful and we have to r e,
s ort to th e condu c tiv e method A not h e r point to .
r emember i s t h at we may n o t in filtrate a n y i n

fe c te d a rea as s eptic material will b e fo r ced into
,
adjacent tis s ues and a very poor or no a n a3s th e

,
sia is Obtained The in filtration method has i ts

.
decided limitations and as con du c tive a n ws th e s i a

,
will do all that wh ich in fi ltration a n ws th es i a w i ll

a c complis h it is far s uperior in e ffi c a cy
, .
Th e advanta g e s a n d disadvanta g e s O f th e tw o
met h od s a r e :
1 70 LO CA L A N E S T H E SIA .
FI G 91
A n ws th e s i a by I n fi l t ra ti n o I n L Owe r J a w , C anin e io n
R eg
I n fil tr a ti o n C o n d uc ti ve
L ast s a S h ort time . L asts longe r .
A naes thesia c onfi ne d A n ws th e s i aextends

to inj ected a r e a . throughout wh ole
area O f nerve sup
ply .
3 I nfected
. ti ss ue can By blocking O ff the
not be anaest h etized . nerve at its foram i
nal exit distal i n
,
fe c te d a r ea s a r e an
aes th e ti z e d .
4 M ore
. frequent i n j e c 4 . Fewer injection s r e
tion s required . quired .
VI
A NAT O MICAL CO N S IDERATIO N S
TH E anatomical considerations in t h i s ch apt e r
should merely serve to recall to the re a der s mi n d ’
the most important landmark s essen tial fo r th e

practice Of local anaesthesia ; fo r more c a re ful
study which is essen tial the s tudent is r efer r ed to
, ,
special works o n ana tomy The upper j aw i s s up

.
plied by the s uperior maxillary nerv e th e s e con d ,
division O f the trigeminus and the up pe r te e th

,
can be divided in to three groups accordin g to ,
the i r ne rve supply .
The c en tr a l a n d l a te r a l i n c i s o r an d c a n i n e te e th
are supplied by the a n te r i o r s up e r i o r d en ta l
b r a n c h ; the b i c us p i d s by the m i d d l e s up e r i o r d en
,
ta l b r a n c h es and the m o l a r s by th e p o s te r i o r s u
,
p e r i o r d en ta l b r a n c h e s o n each side.
The middle superior branches communic a te

with the posterior superior denta l branches by a
thickening called th e ganglion of V alentine and ,
with the anterior s uperior dental branches by an

enlargement ca lled the ganglion of Boch dalek .
The a n te r i o r s up e r i o r d en ta l b r an c h is given
O ff from the superior maxillary nerv e ju s t b efo r e
i t s e x it f r om the infraorbital fora m e n .
1 72
A NAT O M Y 1 73
The m i d d l e s up e r i o r d en ta l b r a n c h i s given O ff
from the s ame nerve in the back part Of the infra
orbital canal and runs downward and forw a rd in
,
a canal i n t h e oute r wall Of t h e ant rum .
The p o s te r i o r s up e r i o r d en ta l b r an c h es a r i s e
fro m the trunk of th e s uperior m ax illary nerve
ju s t as it enters the inf r ao rb i tal canal running ,
downward o n th e tuberosity O f the upper m a x illa ,
entering the p o s te r i o r d en ta l c an a ls o n th e zy g o
matic surface o f t h e bone .
I n order to anaestheti z e the s e va r io us br an ch e s

w e h ave to block the m a s they ente r o r leav e their
b ony forami na Thus to rea ch th e an ter i o r s up e
.
r i o r d en ta l b r a n c h we have to make an i n j ection

.
at the i n fr a o r b i ta l fo r a m en ; t h i s will an aestheti z e

the cen tral l ateral and c anine teeth and by osmo
, ,
s is vi a the ganglion O f B o c h d a l ek a fi e c t s en s ation

in the m i d d l e s up e r i o r d en ta l b r a n c h and there
,
fore a n ws th e ti z e the b i s c up i d s m o re or les s .
I f t h e m o l a r s are to be anaesthetized the p o s te

,
r i o r s up e r i o r d en ta l b r a n c h must be injected at
the tu b erosity blocking O ff the nerves a s they

,
enter the p o s te r i o r d en ta l c a n a ls I f this i s done

.
,
in th e maj ority Of case s the middle b ranch is also

a ffected b y o sm osi s through the ganglion Of V al
e n ti n e t h u s also a n ai s th e ti z i n g the b i c us p i d s
,
.
A s the s uperior M iddle Dental Branc h e s sup ,
plyin g the b i cu s pids anastomose w ith both the

,
po s ter i or and anteri or dental nerve s the a n ae s ,

1 74 LO CAL A N E S T H E SIA
50 0( \ 0 (
N
k yd a flo u
p fi e
A nl r um
‘ ‘
.
“ (w e
FI GU R ES 92 A N D 93
S h w in g th N rv S upp l y O f th V a r i u s G r o up s O f T ee th Th
o e e e e o e
P t r i r S up r i r D nta l N r v S upp l y in g t h M lar
.
os e o e o e e th A nt
e e o s, e e
r i r S up r i r D nta l N rv S upp ly i ng th C ntr al an d L at r a l
o e o e e e e e e , as
W ll
e th C anin
as ean d th M i ddl S up r i r D nta l N rv S up
e e e e o e e e
p ly in g th B i c u pids A l o sh w s th A st m s s B t w
e s . s o th e na e o e e een e
D i ff r nt B r a c h
e e n es .
1 76 LO CAL A N ZES T H ES I A
or m ay b e a ffect e d I t therefore may b e n e c e s
no t .
s ary to in j ect t h e tubero s ity po s t e rior dent al ,
c a n al and infr a orb i tal fo r a me n to pro duce th e
re qui r ed r e s ult I n prefe r en c e to suc h c ompl i

.
c a te d inj ection t h e infi ltrat i o n Of b ot h b ic us p id s

,
b ot h o n the palatin e a n d fa c ia l a s p e c t w il l b e th e
si mpler method .
T h e h ard palate i s s uppl i e d by two n e rve s : th e

n a s o p a l a ti n e o n e O f the inte r n a l b ranch e s O f th e
-
,
sphen o p al a t i n e ganglio n w hich n e rve aft e r sup

-
, ,
plyin g p a rt O f th e na s al fo ssae pa ss e s d o wnw a rd ,
a n d for w ar d e n teri n g th e mout h t h rough th e o u

,
te r i o r p a la ti n e c a n a l s upplying th e muc ou s m em
,
bran e behin d th e i ncisor teeth .
T h e po s terio r portion Of th e pa l at e i s s uppl ie d

by t h e an ter i o r p a l a ti n e n e r ve o n e Of the de s cen d ,
ing b ran ch e s O f t h e S p h eno pal atine gan glion de -

,
s cen ding through the p o s ter i o r p a la ti n e c a n al an d

eme r ging upo n t h e h ard pal ate through the a nt e
ri o r p alati n e fo r am en oppo s i te the last mola r
toot h s upplying the palate as far a s the canine
,
t e eth th e gum s mucou s membrane and gland s

, ,
Of th e p alat e an a s tomo s in g w i th th e n as o p ala ti n e -
n e r ve .
TO anaesth eti z e th e a n ter i o r p art Of the p al ate

the n a s o p a la ti n e n e r ve i s r e a c h ed a s i t l ea ves
-
s carpa s foramina b y injecting the an te r i o r p a l a

,
ti n e c a n a l ; and to anaes t h eti z e t h e p o s te r i o r p o r

tion Of th e pal ate the p o s te r i o r p a l a ti n e c a n a l is
,
AN A TO M Y 1 77
inje ct e d op p o s i te t h e la s t m o l a r toot h wh i ch will

, ,
a naes the ti z e t h e a n te r i o r p a l a ti n e n e r ve (Fi g

.
The a n ter i or superior dental bran ch give s O ff a

n a s al br anc h s up plyin g the m ucous membr an e O f
th e forepart O f t h e inferio r meatus and the floo r

Of the no s e c o mmunicating w ith th e n a s al
,
b ran ch es fro m th e spheno palatine gan glion

-
.
F o r t h i s r ea s o n a more compl ete a nae s t h e s i a i n

th e a nterior p a rt Of t h e j a w c an b e O bta in e d by
pla c in g a tampo n s aturated wit h t h e anaes th eti c
s oluti on into th e anterior nare s I n inje cting
.
about th e infr a orb ital foramen besides produ cing

,
anae s th e s ia i n th e anterior superior de nt a l

branche s othe r branches Of the superior m a xi l
,
lary nerve a r e reached thus a fi e c ti n g t h e n a s al

,
and l abial branches producing an anaes t h e s i a in

,
the upper lip an d sometim e s ex tendin g to th e s i d e

Of t h e no s e .
The lower j aw o r mandible i s s u p plie d b y th e

inferio r maxillary o r mandibula r nerv e th e t h i rd ,
branch O f t h e tri geminu s .
I t d i stribute s branche s to the teet h and gum s Of

t h e lower j aw the lower p art O f the face and lip
, ,
th e mu s cl e s of mastication the inte gume nt of the

,
temple and external ear as well as the ton gue

,
.
I t s l a r g est branch th e inferior d ental nerve is

, ,
Of gr eatest intere s t to the denti s t a s thi s branch

,
supp li e s all l ower teet h with sen s ation I t pa s ses

.
do wn war d wi th th e i n fe r ior dental artery b ene ath

1 78 LO CAL A N JES T H E S I A
the ex tern al pterygo i d mus cle and th e n b etwe en

th e internal la teral (spheno mandibular ) l iga
- -
men t and the ramus Of the j aw to t h e dental fora

men I t then en ter s the mandibular can a l lying
.
beneat h t h e teet h as fa r a s the mental foramen ,
wh ere i t divide s into the incisor and mental

bra nch es the form er supplying the canine and i n
,
c i s o r t e eth the latter the s kin O f th e c h in a n d m u

,
cous membrane O f the lower lip These branch e s .
arbo r ize with th e facial nerve and for th a t reason

,
w e frequen tly note a drooping o f t h e facial

muscle s afte r mandibular inj ections .
Th e mo l ar s and bicu s pids a r e supplied by

branches given O ff from th e m andibular canal .
T h e li n gua l n e r ve s upplie s th e papillae and m u

cou s m embrane of the a nterior tw o third s Of the -
tongue and lie s benea th the ex ternal pterygoid

,
mu s cl e very near and o n the inner s ide O f the

,
inferio r dental nerve ; in fact it so m etimes is ,
j oine d to i t by a branch I t communicate s wit h

.
the inferior dental and hypoglossal nerves the ,
submaxillary ganglion a n d w it h the facial n e rve

th r ough the chorda .
T h e proximity o f the lingual nerve to th e i n fe

rio r dental nerve explains w h y in inj ecting the
mandibular nerve an a s th e s i a of one half O f the -
ton gue is Ob tained and also th e r eason fo r not

,
getting anae sthesia o n the lin gual aspect O f the

alveolu s wh en t h e lips and facial as p ec t m ay be
,
VI I
TH E TE C H N I " U E or CO ND U C T IVE A N ZES T H E S I A
Th e M a n d i bul a r I n j e c ti o n
IN OR DER to p r actice conductive anaes th esia o r ,
nerve blo ck in g it is essential to remember those

,
landmark s w h i ch will enable the operato r to l o
FI G 96
a C r n o i d P ro c ss ; b C n dy l i d Pr o c ess ; c S igm i d No t ch ;
.
o o e o o o
j B dy f M a n d i bl ; k R am u ; 1 A n gl ; e M nta l F r am n ;
. . .
o o e s e e o e
M y l h y i d R idg T r m i nat i n g a s My l h y i d
. . . .
o -
o e, e In t r na l o -
o or e
O bl i qu L in ; d Ex t r na l O bl iqu L i n ; 1 T r i g nu m R tr m l a r
e e e e e 1 o e o o e,
f rm d by th Ex t r na l d In t r na l Obl iqu Lin s an d th Di ta l
. .
o e e e an e e e e s
S u r fa c f th L a s t M l a r T th ; m L ingu la th B n y S pin
e o e o oo , e o e
d i r t ly ab v th Inf r i r D n ta l F ram n f t h w th
ec o e e e o e o e o s o e
F ram n an d L in gula to b tt r a dv ant ag th e L ingu l a h s b n
.
o e e e e, a ee
sh a d d w i th in k
e .
MA N DI B U LA R I N J E C T I O N 1 81
cate t h e foramina trans m ittin g th e nerve s to be

a na s th e ti z e d
. In the mandible o r lower j aw we
h ave to bear in mind the infe r ior den tal forame n
F
( g i . and t h e m ental foramen ( g
F i . T h e
i nferio r dental foramen is found b y plac i n g t h e
inde x fi nger o n the facial aspect of the alveol a r
proces s and pal p atin g fo r th e externa l ob li q ue
line (Fi g . H av in g l o c a te d th i s the fi n ge r i s
,
FI G . 97
slowly p a s sed ba ck ward an d upward along the ex

terna l o b lique line until the anterior border o f th e
ramus i s plainly felt The patient is then dire cte d
.
to rela x t h e muscles by slowly s h utting his mo uth

1 82 L O CA L A N E S T H ES A I
FI G . 98
in in r T ip P l ac d
S h o w g F ge - e i n th e R gh i t Re tr o mo l a r T r i a n gl e
l i t ly T i l t d
.
Th e F in r
ge l s S gh e .
half wa y T h e Object o f this relaxa tion is to be

.
certain that the operator is actually following the

b one and not palpating the internal lateral liga
ment which in some cases when put o n the stretch
, ,
when the mouth is open may be mistaken ,
fo r the bone When the muscles are r e

.
l a x e d in shu tting the mou th th e ligament also

,
relaxes and is pushed out o f the way A fter the .
finger has followed the ex ternal Oblique line the ,
tip is placed behind the last molar and the mylo ,
hyoid ridge is palpated The fi n ge r tip is then

.
-
slightly til ted lingually and placed in the tr i a n gu

,
lar S pace formed by the external and internal

Oblique lines and the distal surface o f the last
,
1 84 L O CA L A N zE S T H ES I A
FI G . 1 00
ing P iti n f I n d x F ing r in R t r m o lar T r iangl R i gh t

S ho w os o o e e e o e,
H an d H ld in g S y r in g ; th In tr u m nt I H ld L i k a P
o e e h ld r
s e s e e en -
o e
an d Pl a d D iag na ll y A cr th D nta l A rc h O E d Cr ing
ce o o ss e e ne n o ss
th B i c u pi d R gi n th N dl A b ut t P i rc th M u c u M m
,
e s e o e ee e o o e e e o s e
br an 1 m Ab v th M r a l S u r fa c f th e M l a r T th R t
,
e c o e e o s e o o ee es
t h N ai l o f th L ft In d x F inge r
.
,
i g
n on e e e e .
a level just about 1 cm abo v e th e morsal surface .
o f the molar teeth (Fig .
The syringe i s now rotated toward th e side to ,
be anae st h etized the needle point n ev er losing it s

,
cont a ct w ith th e ramus (Fi g .

MA N DI B U LA R I N J EC TI O N 1 85
FI G . 1 01
S h o w s Po s iti n f S y r ing Aft r M u c u

o o e, e o s M em b ra n
e H a s B een
P i erc d a n d In d x F in g r W it h d ra w n
e e e .
1 86 L O CA L A N zES T H ES I A
FI G . 1 02
S h o w s Po s i o ti n f S y r in g A ft r I t H B n R tat d T w a rd
o e e as ee o e o
d
th e S i e to B e A n th t i d J u t P r i r t Th ru ting th N dl
aes e ze , s o o s e ee e
l n
A o g th e L in ua l A p c t f th R a m u
g s e o e s .
In bringing the syringe a roun d from the lef t

towards the right side the instrument describes ,
an ar c as shown in Fig 1 03
,
. .
FI G
1 03
yr n dl I
.
A B In d i c at t n
e s th e P o s i i o o f th e S i ge a s th e N e e e s
T ru t T r u
. .
h s h o gh th e M uc u
o s Me m br an tr i k in
e, S g th e a u C D
R m s
yr ady
. .
S h o w s th e Po s i i o t no f th e S i n ge W n he p r at r
th e O e o Is R e
ld dl l n
to S i e th e N ee e A o g th e R m s to E e a u nt r patiu m
th e S
Pte r ygo -M an d i bu l a . . cr i b d by D i ta l
t e , D B A r c De s e s yr in g
En d o f S e .
1 88 L OCA L A N JES T H E S I A
W hen the needle pas s es the lingula mandibul ae

the contact o f bone is lost and we h av e entered
,
th e s patium p te r n m a n d i b ul a r e
-
.
O ur needle has disappeared almost entirely .
The writer n o w employs a slight lateral mo ve

ment attempt i ng to palpate th e lingula and then
, ,
slowly and evenly empties the contents o f the

syringe drawing th e needle s lightly in and o ut
,
.
By the lateral and in and outward motion the

lingual nerve i s usually anae s th eti z ed .
On th e left side the s ame tech ni q ue i s employed ,
palpating with th e right and holding the syringe

in the left hand The inj ection can also be made
.
with the right hand but then th e thumb o f th e left

,
hand is used instead o f th e index fi nger and ,
placed in the trigonum retromolare the operator ,
standing at the s ide o r behind the patient (Fi gs .
1 12 ,
otherwise th e technique is id enti c ally
the s ame a s e x e cuted o n the ri gh t s i d e .
Tub e r o s i ty I n j e c ti o n
The tuberosity o f the upper maxilla i s reached

by thrusting th e needle in to the buccal fold oppo
site the disto buccal root o f the s econd upper m o
-
1 89 PL A TE I
FI G . 1 06
P a l p a ting Fa c ia l A p c t
s e o fA lv la r P r c
eo o es s
FI G . 1 07
Pla ing I ndex Fi
c nge r in Re tr o mo la r Tr i angl e
191 PL A TE III
B r inging S yr ing T w a rd S i d
e o e to B e A n th ti ze d
aes e
FI G . l ll
Ent r in g S patium
e P te r ygo M a n d i b ul a r e
-
an d Em ptying S yr ing
e
T U B ER O S I T Y I N J E C TI O N 1 93
lar and passing it upward and backward (Fi g

,
.
The needle s hould keep in contact with the

b one .
FI G . 1 14
Ma ki ng T ub r s ity I nj c ti n
e o e o
P o s te r i o r P a l a ti n e I n j e c ti o n
The posterior palatine canal which terminates ,
upon the palate opposite the third molar as the

an terior palatine foramen giving exit to the an ,
te r i o r palatine nerve i s reached by thru s ting th e

,
needle into th e palatine mucous membrane about

cm inside (toward the median line ) o f the
.
third molar I n many subj ects there appears a

.
tiny depression in the mucous membrane at this

s it e .
194 L OCA L A N ZES T H E S IA
FI G . 1 15
Inj c ting
e th e P o s t ri r
e o Pa latin e Ca na l
By i n j e c t m g the tuberosity and blockin g O ff the

anterior palatine nerve th e th ree molars are c o m
,
p l e te l y an ae s t h etized The
. palatine surfa c e loses
s ensa tion up to th e canine tooth I n many i n .
stances the second bicuspid also b ecomes a n ae s th e

ti z e d by the tuberosity inj e c tion .
A n te r i o r P a l a ti n e I n j e c ti o n
To block O ff the naso palatine nerve b y nj e c t

- i
,
ing the anterior palatine canal the needle i s thrust ,
into th e poste r ior aspect o f the incisive papilla ,
w h i ch is situated abou t cm posterior to the .
c entral incisors The needle is directed upward

.
a n d b ackward (Fig . A bout se ven drops a r e

‘
1 96 L OCA L A N JE S T H ES I A
FI G . 1 17
Inj c ting Inf r a rb ita l F ram n
e o o e o n S kull No t D i r c ti n
e e o o f
N dl an d S y r i n g
.
ee e e .
F IG 1 18
L ft Ha d
.
M ak in g I n fr a rb ita l Inj c ti n
o e o . No t e Po s iti n
o o f e n
ME N TA L I N J E C T I O N 197
ab out a b ove the c anine tooth I nje c t dr o p b y dr o p .

,
as y o u go along until y o u feel the fo r amen with

,
the needle depositing about 1 c cm at t h e Opening

,
.
o f t h e c anal A little massa g e will d r ive t h e a n ms

.
thetic into the foramen (S e e C as es 72 80 89 92

.
, , , ,
in A naesthesia R eports ) (Figs 1 1 7 . .
M en ta l I n j ec ti o n
T h e mental foramen is reach e d by dr awing the
lip d own wit h t humb and index fi n ger an d thrus t
FI G . 1 19
in
S ho w g Me nta l Inj c ti n
e o on S k u ll . No t L c ti n
e o a o o f Fo ram ne
an d i r c ti n
D e o o f Ne e dl e .
1 98 L OCA L A N E S T H ES I A
FI G 1 2 0
.
Inj tin
ec
g th e Me nta l F ram n
o e
ing the needle through t h e man d ibular mucou s

membrane fold between the tw o bicuspids ; sli ghtly
advancing the needle point toward the fi rst bicus
pid will cause it to enter the men tal foramen (Fig .
A bout 1 ccm o f solution should be inj ected

. .
A bout c o m injected o n the lingual aspect will

.
anaesthetize the mucous membrane an d p e r i o s

teum This will an ze s th e ti z e th e tw o bicuspids and
.
canine I f this inje c tion is made on bot h sides the

.
,
si x anterior teeth are completely anae sthetiz ed .
(S e e C a s e 4 7 in A n ai s th e s i a R e p o r t s ).
200 L O CA L A NE S T H ES I A
th e s ele c tion o f th e anaesthesi a re s t s w i th t h e
Operator S ome o f t h e writer s most e nth u s ia s tic
.
’
patient s are t h o s e w h o at fi r s t obj e c ted to i n j ec

tions .
P a tie nt s w h o c annot tolerate c oca ine are n o t

ne c e s sarily unsuitable fo r novo c ain a nae s th e s i a ;
we must remembe r that novo c ain is a gr eat deal
le s s toxic than cocaine I n employ i ng novocain
‘
supr a renin anaesth es ia t h e operato r mu s t bea r in

mind that alth ough novocain itself d oe s n o t a f
,
fe c t t h e c ar d i a c fun c tion o r c i r culation in gene r al ,
o r th e respiratory fun c tion s upr a renin raise s the ,
bloo d pressure I n Ol d p eo ple an d patient s wh ose

.
blood pres s ure i s h igh as t h o s e s u ffering from

,
arterio sc leros i s i t i s wise to employ le ss s u p ra

,
renin .
H owever we mu s t n o t b e b lind to the fa c t that

,
t h ere are indivi d uals w h o possess idiosyn c rasies

a gainst certain d r ugs and undou b tedly cases will
,
present w h o react abnormally to novo cain in s pite

of its l o w toxicity There are person s w h o c an t
.
’
eat strawberries and others wh o can t p artak e o f

,
’
certain fi s h although both are arti cles o f food

,
considered benefi cial and nourishing We s imply .
have to w atch our patients c arefully an d if a n y ,
untoward sym ptoms present th e furth er use o f ,
the dr ug is contraindi c ate d T h e w r iter w h o h a s .

,
used novo c ain in several thousan d case s h a s n o t ,
met with any direct idiosyncrasy against novo ca in ,

C O N T R A I N DI C A T I O N s 201
b ut h e recalls tw o ca s es w h o su ffered f r om s l i ght

symptoms o f poi s onin g after but normal i n j ec
tions .
Ch il d ren whose c ooperation i s difficu l t to o b t a i n

,
at times prove unsuitable subj ects F o r extra c

, .
tions n o anaesthetic at all o r a short g eneral anec s

,
th e s i a will b e the methods o f choi c e i n s uch i n

,
stan c es .
3 A not h er contraindi c ation fo r lo c al anaest h esia

.
i s the presence o f infection in the area wh ere the

inj e ction is m a de ; th i s do e s n o t imply th e
fi eld o f operation but t h e are a whi ch the n e edle
,
t r averses Thus we can induce mandibular a n aaS

.
a
th e s i a in all cases excep t w h ere t h ere is i n fe c

,
tion in th e third molar re g ion as infected mate ,
rial may be carried into the spat i um p te r i go m an

d i b ul a r i s and thu s serious infe c tion neuritis
, , ,
a rteritis o r phlebitis in the mandibular area or ,
even infection o f the deeper structure s may be ,
produced I n o ther words mandibular a n aes th e

.
,
sia can b e induced fo r all case s in the l ower j aw

exceptin g wh en t h e third molar i s ab sc essed o r ,
when a complete tri s mus is present p reventin g ,
th e lo c ation of the inferior dental foramen A n al .
o go us conditions exist in t h e upper j a w .
From this we learn that even c on du c tiv e a nses

th e s i a h as its limitations and any o p erato r who
,
would s ay that h e has no use fo r in h a lation a nae s

th e s i a at all is eith er limiting his work to suit a bl e
202 L O CA L A N JE S T H E S I A
cases o r he is to say the least nar r ow minde d ,

-
.
TO perfectly master any method means not only

”
h o w to use it ,
but also to know wh en not to “
”
use it There is no infl exible rule in medicine
.
a s we are working on vital tissues and organs ,
w hich are controlled by a nervo us system w h o s e ,
condi tion is never alike in tw o in d ividuals .
L ocal a n a s th e s i a proves one of the greatest

blessings ever given to m e dicine and dentistry but ,
we m ust know how to use this gift .
What more c an we demand of any method of

an ae sthesi a th at insures us in the maj ority o f
cases
1 P ainle s s cavity preparation
. .
2 P ainles s pulp removal

. .
3 P ainless tooth extraction

. .
4 P ainless oral s urgery

. .
Th e w riter who limits his p ractice to the last

,
two has been able to cut down his hospital cases

,
to a small percent a ge Operati n g most cases in his

,
o ffice under conductive a n ms th e s i a .

204 L O CA L A N E S T H ES I A
s i a i s frequently un s atisfactory and th erefore ,
very trying to the patient T h ere a r e very few .
men w h o c an accomplis h wit h nitrous oxide o xy

gen w h at almo s t anybody c a n d o wit h condu c tive
anae s t h esia provided t h e fundamental prin c iples
,
o f ase p si s and a little anatomi c a l knowle dg e a r e
employe d .
T h e use o f oth er i nhalation an ae sthetic s be s i d es

nitrou s oxide o r nitrous oxide and oxygen i s dan
g e r o u
,
s in spite o f statis tics E t h er rank.s directly
after nitrous oxide in s a fety H o w many men use .
eth er in th eir offices ? The s afest o f all inhalation

anae stheti cs is nitrous oxide and oxygen but it is ,
th e m o s t d i fii cul t to us e wi th anyth in g like uni

,
form success S ucces s i n anaesth esia mean s :

.
1 S afety to patient
. .
2 NO ill after e ffect s

.
-
.
3 A ctual painles s operation

. .
'
T h e fi r s t tw o are frequently ac c omplis h e d ; th e

latter frequently overlooked as the operator does ,
n o t feel the pain The most reliable in formation

.
o n the last point can only be obtained from the
patient I n a large percentage of cases where a n

.
algesia is employed p atients will say I knew ,

“
wh at was going on ; I c ould not move or talk but ,
I felt pain ”
,
and pain means s h o c k .
T h e writer does not mean to imply th at an i d eal

an algesia o r anae sthesia cannot be obtained by i n
h alation meth ods but h e means to state th at in
,
I N H A L A TI O N VER S U S C O N DU C TI VE 205
m any m any c a s e s the ope r a tor d oe s n o t meet with

,
i deal r e sults fi I t is eas ier and les s h a rmful to t h e

"
.
p atient and le s s difficult for the oper a tor to O btai n

i deal results wit h condu ctive anae s th esia p r o p e r ly ,
induced Failure s will be met wit h b y all met h

.
o d s ; not h ing i s perfect in n ature I f it we r e t h er e .

,
would be n o nee d fo r physician s sur geon s o r ,
denti s ts .
A not h er d i s advanta ge o f in h al ation a n aes the s i a

i s t h e ne c es sity of a d mini s tering it as long a s
les s ened o r ab oli sh ed s en s ation i s requ i red In .
nerve blo ckin g w ith novo c ain anae st h e s i a is main ,
ta i n e d fo r a long time usually fo r t h e whole lengt h

,
o f the operation afte r anaest h esi a h as once been
induced .
T h e a dvantages o f c onductive anaes thesi a over

g eneral a na est h e s i a are
1 C ondu c tive anaest h esia (novoc a in ) is le ss
.
h armful to th e p a tient th an the c ontinuou s admin

i s tr a ti o n of an inh alation anaest h eti c .
2 T h ere is n o cumbersome app a ratus required

. .
3 The anae s t h esia lasts a longer time

. .
4 There are n o unpleasant after e ffects

.
-
.
5 T h e patient n o t being un c onscious can as

.
, ,
sist the oper a tor .
6 H emorrh age i s e a sier c ontrolled

. .
*
See R p rt e f C m m itt
o o P r a c ti c
“
o f th D nta l S
ee on e o e e o
i ty
c e f th
o S tat f N w Y rk
e e ana lg ia D t l C m
o e o on es . en a os o s,
N v m b r 19 1 4 ; pag 1266
o e e , e .
206 L O CA L A N AES T H E S I A
7 L. e s s a ss i s t an c e required th a n in inh a l a t i on
anaesth esia .
8 Blocks O ff n o t only painf ul imp ulses but als o

.
,
traumatic S h ock .
T h e write r adv ocates the use o f conductive an

ae s thesia i n al l instances excepting in cases wh ere
,
th e third molars are abscessed I n simple e x tr a c

.
t i ons or operations w hich can be executed in twen

ty to thirty seconds nitrous oxide o r ni trous oxide
,
and oxygen will prove more expeditious than a n

ae s thesia by the cond uc tive meth od as conducti ve,
anae sthesi a requires from ten to twenty minutes ’
time u n til complete cessation of pain is establis h ed .
S mall children are probably be tter served wit h i n

h a lation an ae sthesia ; but in t h e main conduc tive
, ,
anae s thesia h a s come to stay a n d unq uestionably

,
will a l m o s t entirely displace inh alation analgesia

and a n ze s th e s i a in dental and oral surgery .
I f nitrou s oxide and oxygen is used for longe r

Operations it s hould be administered by an ex
,
p o r t and combined with local an aest h esia after

,
t h e
method advocated by C rile .
208 L OCA L A N JE S T H ES I A
a fferent impulses and reduced cerebral imp r e s

s ions .
I n employing nitrous oxide and oxygen th e ,
s afest general anae s th etic we d o n o t block O fi t r au

,
m a tic s h ock n o r do we redu c e the shock cau s ed b v

,
appreh ension and fear o n th e part o f the patient .
I n using conduc tive anaes thesia p r e c e d e d by

s e d a ti v es w e c ome nearer to th e ideal anaes th e s ia
,
than by usin g a n y o ther me th o d .
1 A ppreh en s ion and fea r is redu c ed b y gi vin g

.
b r o m ur a l o r in extreme ca s es opiate s
,
.
2 By nerve blocking we n o t only c ause a pain

.
le ss Operation b ut at the same time cut O ff i m

,
pulses caused by traumatic shock .
I t can be readily seen that a n algesia induce d by

th e inh alation o f N 0 0 causes a certain amount
o f shock ; and therefore conductive anaesthesi a is
, ,
th e meth o d o f choice bot h in operative and s u rgi c al

mouth o p eration s .
R E C OR DS OF C O N DU C T I VE A N JE S T H E S I A S
TH E following table s S h ow t h e record o f o n e hun

dred and fi fty conductive anaest h esia s (ex c epting
tw o by in fi ltration C ases No s 1 49 1 50 ) in oral
,
.
,
surgi c a l and operative dental cases both in pri ,
vate and h ospital practice None o f these are .
selecte d cases but records of patients just a s they

,
presented The fi rst o n e hundred and ten a n ae s

.
th e s i a s were done by the author both at home and ,
at t h e G erman H ospital in Ne w Y ork T h e for ty .
records Of operative dentistry cases were Obtaine d

through th e courtesy of Dr S W A F ranken , of . . . .
Ne w Y ork and Dr H F Barge of L ong I sl a nd

, . . .
,
C ity both o f whic h gentlemen are associated wi th

,
th e author a t th e G erman H ospital C lini c .
K ey to Ta b l es
R U
. .
= r i gh t S ide upper j aw .
upper canine .
L U
. .
: l e ft side upper j aw .
upper th ird mola r .
R L
. .
= r i gh t S ide lower j aw .
lowe r se c ond molar .
L L
. .
: l e ft side lower j aw .
lower fi rst bicuspi d .
209
21 0 L O CA L A N E S T I I ES I A
.
T h e R oman numerals indi c ate t h e age o f t h e p a

tient : VI I I p a ti e n t is eight years Old
=
.
T h e a mount o f a naesth eti c solution inj ected is

expressed in c c m .
The amount o f novo c ain u s ed in a case i s ex

pre s se d i n g r a i n s .
B N b uc c a l nerv e
. .
= .
Time o f w a i ti n g ti m e elap s e d between i n j ec

z
tion and beginning o f operation .
pal a tine canal .
palatine canal .
I n fi l t = i n fi l tr a ti o n
. .
foramen .
No v .
=
p e r cent o f novocain
. .
ccm o f sol ution inj ected

. on each
S ide .
N asal t = . n a s al tampon .
21 2 L O CA L A NE S T H ES I A
C O N D U C T I V E A NE S T H ES I A IN
SI E O
T F I NJ EC T I O N
I m p ac t e d L L . . 8
U n r u p te d L
e . L 5 . l B N 1
. . 8 1;
L L 7 . . 1 B N l
. . 8 l}
7 B N l 2 I}
P r ic e m e n t i t i s
. . .
L L 6. . e B N l
. . 3 1}
R m v al f T u m r
e o o o
R L 8 . t V III
. . ac .
R L 6 . t XV . . ae .
L L O t X III ae
A bs s d L L 6 t X
. . .
ces e . . . ac .
L L 6 t X ac
I m pa t d L L B
. . .
c e
L L O a t XI V
. .
e
A b se d L L 6
. . .
sc es t X . . . ae .
R L 6 a t XVI
. . . e .
R L 6 a t XI II
. . . e .
17 A b c se d L L 6 t IX
s es . . ae .
R L 6 . t X . . ac .
L I 6
L L B
. . . ae t . XII
L L 6
. .
L L 6
. . . ae t . XII
R L 6
. . . ae t . V III
I m pac t d L e . L 8 .
L O W ER j A W IN O R AL S UR GE R Y
R E S U LT REMA R KS
a ft r 2 inj c t i n s
e e o to us e i s l an d b u r
ch e
las te d 1 h u r
,
o p rat i e o n o
Pa t i n t c m p l ain d
e o e o f Di ffi c u lt c as e u s e d c h i e ls s
O f a l i ttl e p i a n d b u rs O p r t i n
,
a n e a o
last e d 45 m i n u t s ; pa
,
e
t i n t m a rk e d n e u r t ic
e o
Pe rf c t An t h e i a
e e s s
ls t Ma nd i b ular fa i l d ; e
2d p r f t
. e ec
B r gr
. . X B c la k
C o ffe e
C h i ld r i d tat d h w c e s e o
p
,
Pe rf c t A n
e th ia v
e s
r h ad
es
e e
“
no ai n
P r fe c t An
e t h e sia e s
P r f c t A n t h ia
e e e s es
Pe rf c t An e t h ia
e s es
B r gr X P rf c t An
e e h s ia e st e
P rf c t A n e t h ia
. .
e e s es
P rf t An e t h ia
e ec s es
P r f c t An e t h i
e e s es a
Pe rf c t A n e st h ia
e l st M a n d i b u la r fa i l d
es e
S h w e d sy m p t m s f C h i ld r i d
o o o c e
An t h s i a
e s e
S h o w d sy m pt m s f C h i l d c r ie d
e o o
An st h s ia
e e
P r f c t An
e e th sia e s e
S h w d s i gn s f
o e C h i ld ie d
o cr
A st h e s i a
ne
P r fe c t An
e th ia e s es
S h w d ign
o e fs C h ild c r i d
s o e
A n st h s ia
e e
Pa t i t ai d h f l t a en s e e
l i ttl pain b ut t e no
u g h t m i nd i t
,
eno o
80 B r g r X l st d 2d M a nd i b u l a r an
a ff t d th e l in gu al
. .
ec e
n e r v al n e 8d i j e o n ec
t i n ga v a fa i r l y g d
.
o e oo
B r gr X
. . P rf c t A n e t h ia
e e An e st h i a
s es es
21 4 L O CA L A N JE S T H ES I A
CO N D U CT IVE A N / E S T H ES IA I N
5
3
8
.
L L 6
. . . ae t . IX
L L 6
. . . ae t . VI II
L L 6
. . . ae t . X II
L L 6
. . . ae t . XIII
L L 6
. . .
R L 6. . . ae t . XIII
32 L L 6
. . . ae t . XII
33 R L 6. . . ae t . XII
34 R L 6. . . ae t . XI
35 I ’
36 P L L 8
. . .
37 P L L 6
. . . 2 2
38 B N I . 2 2
39 P R L 6. . . B N l . 3 2
40 P R L 6. . . B N l . 3 2
41 P L L 4 L hu l 2
n
1t
I
. . . l .
.
n l
-
I
42 P L L 8
. . . B N . 3 2
43 R L 7. . . 2 2
44 P R L 8765
. . L L 6 . 5 2
45 P U n r up t e d L L B
e B N ] 3 2 1
I m pac t e d R L 8
. . . . .
46 . . . B N i
. . 9 2 3
ch o r n i al v la r a b c eo sc ess
w i t h m n tal f i t u l a e s
R L 6
. . . P ul p xt i r pa t i n
e o
R L 8
. . .
R L 6
. . . e t XII
a .
216 L O CA L A NE S T H ES IA
CO N DU C T I V E A N E S T H ES IA I N
S I TE o r I NJ ECT I O N m5
a
.
m 3
o
c
m
v
o
g
1 u
e
3
0 ?
k
.
Fr ac t ur e d R . L 5 .
2 i nj t
’
4
’
s,
u
T mo r o f um e x te nd 1 cc m l ccm 2}
f ro m i de a ro u d
. .
i ng L I -8
’
ea s
tum o r
. . .
Fr a c t u r e d L L O
U ne r u p te d I m pac te d
. .
LL . . 8
R L 6
U ne r u p te d I m p ac te d i nj e c t i o n s
. .
2
L L 5
. .
R L 6
. . . ae t. V III
R L 6 ae t V III
r a tu r d L
. . . .
F c e . L 7
Ab s dR
c e ss e . L 7 .
R L 8
. .
R . L . 6
. a e t. XI II
R . L . 8
R . L . 6 . ae t . XIII
R L 8
I m pac te d R
. .
. L 8 .
t
A f e r th i s t h e a uth o r re t urn e d to th e use o f t
S o lu io n o f N o vo c ai n
R E C O R DS 21 7
L IN
M A ND I B E OR A L S U R G ER Y
R ES U LT REM A R KS
Pe rf t A n e st h i a
ec es
F i t M a n d i b u la r fa i l d
rs e
S e v e r al a t t e m p ts h a d b e e n
m a d e to r e m o v e t h i s r o o t
Ve r y d i ffi c ul t o pe rat i o n
use d c h i se l s a d b u r s
,
n
o p e rat i o n 50 m i n
,
F i r st M a d i b ula r fa i le d se c
n
d p e rf e c t d i fii c ul t c as e
.
‘
o n
u s d c h i se lsa n d b u r s O p r
, ,
e e
at i n la te d o v e r 1 h r
,
o s .
21 8 L OCA L A N IES T H ES IA
'
CO ND U C T I V E A N I E S T H ES I A IN
SITE O F I NJ EC T I O N
71 P Cy t s ex e t nd i ng 1 1 1 1 Nasal t.
*
5 I I} 15
L U 1 -6
‘
. . 1
72 P C y st . L U 3-4
. . 2 1 N asal t . 5 1 I; 15
73 P C y st L U 3 . . .
74 L U G
. .
75 L U 6
P Un ru t d
. .
76 e p e R U 3 . .
77 P L U S
L
. .
78 U 58
. . .
79 R U 6
Tu r r i
. .
80 m o R U 3 eg . . o n
81 P Al v t y
e o lo o m
82 P Frac t u re d R U 8
P I m pa t e d R U S
. .
83 c . .
84 P R U 8 . .
85 P 8 U .
86 P .U 8 .
87 P t 8 U .
88 P W 8 U
m p utat i
.
P t5A
”
R o o o n
89
LU1
F a tur d R U 8
. .
90 r c e
L U 468
. .
91 . . . .
92 M al p d R U 3 o se
d i ng
. .
N r i s x
l
t ec os e en
93
L U 35
94 P F r a t u r d R U 8
. .
c e . . 2 2 i 10
95 P R U 8 2 2 i 10
dL U6
. .
96 P A b e sc sse . . 2 2 i 15
97 P t p m p ut t i 1 I Na s al t 3 2 1 15
q
a o n .
l . 2 l
a
T m po ns o f N o vo c ai n so t
lu io n i n no se ; al so 1 ccm . b y i n fil r tai t o n .
220 L O CA L A N JE S T H ES I A
CO ND U C T I V E A N E S T H E S I A I N
98 P R U B
U ne r u p t d
. . .
99 P e L U 3 . . . N asal t .
1 00 P
1 01 P L U7
P A b sc sse d L U 7
. . .
1 02 e . . .
C O ND U C T I V E ‘ -
A N zE S I I I E S I A
’
IN BOTH U PP E R
S ITE o r I NJR c T I O N IN U PPE R J
A W . S IT E o r
1 08 P L U . .
L 6
LL
.
1 09 P . . 5 .
1 10 P LU4
LL5
. .
R L . 7 5
. . . . .
P R U 6
. . . R L 6 . . .
R E C OR DS 221
R ES U LT R E MA R K S
15 B ro .
g r . Pe r fec t A n e st h e s i a
10 Bro .
g r .
10 Bro .
g r . X
15 Bro .
g r . X
15 B ro .
g r . X
I NJECT . L JA w
.
R ES U LT R EM A R K S
6 1 1} 1§ B r o gr
. . X Pe rf ec t A ne s t h e s ia
i ii i i
6 2 2
222 L OCA L A N E S T H ES I A
C O ND U C T I V E A N E S T H ES IA IN
O PE RAT IO N
1 12 G r u nd d w L ft L 4 a nd 7 f b r i d g abut
o o n e o r e 2
m n ts
.
,
e
1 1 3 Pul p r m v d L ft L w r 6 y m l a r
e o e e o e o
1 1 4 Ca vi t y pr p a r at i
.
e on
1 1 5 C r vi al a i t y p r pa r at i n
e c c v e o
1 1 6 Ca vi t y pr p ara ti n L L
e o
1 1 7 Ca vi t y pr pa r at i n L L 6 7
. .
e o
1 1 8 Ca vi t y pr p arat i
. .
R L 7 6
e o n
1 1 9 P r pa r d avi t y in L L 7 E t ra t d L L 6
. . .
e e c . . . x c e . .
1 20 R m v d pu l p R L 6
e o e 2
1 21 Ca vi t y pr pa rat i n L L 4
. .
e o 2
1 22 C a vi t y pr pa r at i n
. .
e o 1%
1 23 Ca vi t y p r p rat i n L L 6
e a R m v d pu l p L L 4
o e o e 2
1 24 P r pa r d L L b r i d g ab ut m n
.
.
. . .
e e f o r e e ts 2
1 25 Ca vi t y p r p r at i n R L 7 (v r y
.
e a n s i ti v )
o , . . e se e 2
1 26 Pr pa re d c m p u n d a vi t y R
e o o c L 7
P r pa re d v r y se n i t iv e s i
.
, .
1 27 e e s ero on c av i t y ,
L L 7
. . .
1 28 R e m v al f p ul p L L 7
o o , . .
1 29 R e m o va l o f p ul p R L 6 ,
. . 2
1 30Cav i t y pr pa r at i e o n, L L 7 . . 2
131 Cav i t y p r pa ra t i n e o , R L 6 7 . . .
R e c o rd s furn i s h e d b y S . W A . . Fr an k a u, D D S
. .
: a nd H F B rg e , D D S
. . a . . .
224 L OCA L A N JES T H E S I A
C O N D U CT IVE AN E S T H ES IA IN
O PE RA T I O N
1 82 Ca vi t y pr para t i R U 7 6
e on . . . I };
1 33 P u l p r m v a l L U 3
e o . .
1 34 a v i ty p par a t i n L U G
re o I };
1 35 ul p r m va l L U 6
. .
e o I };
1 36 r p a t i n f ro t f
. .
e ra o o o or
L ga Cr o w L U l
o n n
1 37 P r p a a t i n f b r i d ge ab u t
. . .
e r o o
m n ts R U 7 3
e 1%
1 38 Cav i t y p r e pa r t i n L U G S
. . .
a o . . .
1 39 Pr e p ar t i fa r w LU6
o n o r c o n .
1 40 Cav i t y p r parat i e R U 7 6 on 2
Ca vi t y p re pa r t i R
. . .
a o n .
U 7 6
Pu l p r e m v al L U 7
. .
o . .
at s si n
o ne es o
Pu l p r e m val R U 6
Ca vi t y pr e p L U 6 7 l
o
1 42 1% E S
. . .
1 43 a v i t y p r e p
. . . .
Pu l p
r m val L V 3
.
e o
1 44 C av i t y pr e p a r a t i n L U S
. .
o
I 45 Ca vi t y p r p a at i n L U G
. .
e r o . . 1%
1 46 C av i t y p r parat i e L U l o n
147 P u l p r m v al R U l
. .
e o
1 48 Cav i t y p p a r a t i n R U 7
. .
re o . . I };
149 P ul p r emo v al R . U 1 .
*
I }; 1x
1 50 P ul p r emo val R U 5 . .
*
A re t t
I n fi l ra i o n A n e s t hesia .
R E C OR DS 225
U PPE R JA W IN O PE R AT IV E D EN T I S T R Y
R ES U LT R EM A R K S
O P r f c t A ne th e sia N n
e e s o e
O
G
-
a
l
Go o d Pat i n t m p la i n e d
e co
v r y sl i gh t pa i n
e
G P r f c t A ne th s i a
e e s e I fi l t te d gum a b o ut C e n
n ra
t ral w i t h a f w d r p s e o
Pat i n t e m p la i n d f a
co e o
l i tt l pa i n
e
"
“ Pe rf ec t A n e st h s i a
e
a
R U 6 S l i gh t S n sat i n e o
LU
. . .
.
Pe r fe c tA ne s
th e S I a
P rf A n e st h e i a S l i gh t c yan si o s, d i sap
e ec t s
p ea r ed s h r tl y
o .
I n j e c t e d c c m b e tw e e n
n c k a nd a p e x fac i all y
.
I nj e c te d 1 c o m b e tw e e
n e k a nd a pe x o n pal
.
c
at i n e a p ec t s
I j e c t e d I c c m o n L in
n .
gu al u rfac e s
I n j ec te d 1 c c m n B u c c al . o
as p ec t
226 L O CA L A N zE S T H E S I A
R eviewin g t h e preceding ta bles we h ave a total ,
o f o n e h undred and fi fty conductive ane s t h esias ,
o f w h ich seventy are in t h e lower j a w fo r oral ,
s ur g ical ca s es with fi fty nine perfect ane s th esias ;

,
-
o f these fi fty nine t h ree h ad to b e inj ected twice

-
,
.
C a s e No 2 complained o f a little pain C a s es No s

. . .
7 1 7 I 8 20 22 28 33 were ch ildren w h o were a l l

, , , , , , ,
m ore o r le s s fri gh tened I t i s di ffi cult to s ay

.
w hether th e s e c h ildren cried from fri gh t o r pain ,
particularly as s ome o f the s e ca s e s did n o t wince

w hen t h e gum and lips were pricked wit h a pin .
T h e writer once g ave a mandi bular inj ection to a

child t h ree year s o l d fo r the remova l o f an a h
s c e s s e d molar ; the youngster cried very b itterly ,
but s tated that h e felt n o pain but was fri gh tened ,

.
C ase NO 46 was inj ec ted fi ve times and n o a n

.
,
e s t h esia o f the mandibular nerve wa s obtained .
F ailure in t h is case was due to anatomical anom

a ly o f t h e mandible .
C ases No s 2 24 g ave evidence o f only part

.
-
ane s the s ia .
T h e th irty tw o conductive ane sth e s ias in t h e up

-
per j aw i n oral surgical cases were all perfect .
T h e nine conductive ane s thesia s in both upper

and lower j aws were all perfect .
T h e forty ane sth esias in oper a t i ve dentistry

cases were all (excepting C ases No s 1 1 9 1 35 .
, ,
1 38 ) perfect .
S umming up th e experience o f more t h an a

228 L O CA L A N E S T H ES I A
1 . A
bs o lute asepsis .
2 Th e use o f i s oton i c s o l ut i o n s
. .
3 Kn o wl e dge o f a natomi c al l an d m a rks

. .
4 Jud gment o f p a t i ent s p h y s i c al s t a te

.
’
.
5 T h e u s e o f pure n o n o x i d i z ed d rugs ; a di s
.
,
-
co l ored t abl et o r s o lution sh ould n o t b e us e d .
A n y ill e ffe c t s fol l owin g th e us e o f novocain

supra ren in a s bl anc h ing cyan o s i s p e rs piration
, , , ,
dyspnoea o r p al pitation a r e c o un te ra cted by the ,
in h a latio n o f amyl nitrit e o r vap o r o l e o r th e a d

-
mi ni s trat i o n o f c o ffee Th e w r i t e r n eve r h a d o c

.
ca s i on to empl o y more h e r o i c tr e a tmen t .
K EY T o CO N DU C T I VE A NE S T H ES IA F OR E X TR A C T I O N S
Upp e r J a w
3d M ola r, Tuberosity I ccm ; ,

. 1 co m .
W ait 5 1 0 minute s-
.
2d M olar Tubero s ity 1 c cm ;, ,

. I '
c cm .
W ait 5 1 0 minute s-
.
1 s t M o l a r Tubero s i ty 1 cc m ;
, ,
. 1 co m .
Wait 5 1 0 minutes -
.
2d B icu s pid Tuberosity I c cm ; , ,

. I c cm .
W ait 5 1 0 minutes -
.
1 s t Bicus p i d I n fr a o r b i fo r , 1 co m
, . . .
ccm W ait 5 1 0 minutes

.
-
.
C anin e I n fr a o r b i fo r 1 ccm ; A P C
,
. .
, . . . .
, A?
1 ccm .
W a i t 5 10 m inute s
-
.
KEYS 229
L ateral , I n fr a o r b i fo r . .
,
I ccm .
; com .
Wa it 5 10
-
minutes .
C entral , I n fr a o r b i fo r . .
,
I ccm .
; A
1 ccm
), .
Wait 5 10
-
minutes .
L o w er J aw
3d M olar M a ndibul a r , 2 ccm . Wai t 1 0 20

-
m inutes .
2d M olar , M andibular , 2 ccm . W a it 1 0 20

-
minute s .
l s t M olar , M andib ular , 2 ccm . W ait 1 0 20

-
minutes .
2d Bicuspid M andibular o r M ental fo r 1 ccm ;

, ,
.
,
.
and L in gual A s p e ct o f Bic ccm .

,
.
1 s t Bicuspid M andibular o r M ental fo r 1 ccm ;

, ,
.
,
.
an d L in gu a l A spect o f Bi c com .
,
.
C anin e M ental fo r 1 ccm ; M ental foss a o f o p

,
.
,
.
p o s i te side ccm ,
.
L at eral M ental fo r 1 ccm ; M ental fossa of O p

,
.
, .
.
C entral M ental fo r 1 ccm ; M ental fossa o f o p

,
.
,
.
.
A l s o L in gual A s pect o f C anine c cm ; o f ,

.
L ateral ,
ccm ; o f C en tra l
. ccm ,
.
W aiting for L ower 2d Bicuspi d C entral 5 1 0 , ,

-
minute s .
A M andi b ular injection can b e done fo r a l l l ower

teeth ; waiting time is then 1 0 20 minute s -
.
230 L O CA L A N JES T H E S I A
K EY T o C O N DU C TI VE A N E S T H ES I A F O R M U LT I P LE
E X TR A C T I O N S
To A n a e s th e ti z e On e H a lf Up p e r J a w
-
Tuberosity I ccm ,
.
1 ccm .
co m .
I n fr a o r b fo r . .
,
I ccm .
To A n a e s th e ti z e th e Upp e r J a w C o m p l e tely
Tuberosity I ccm o n b oth side s
,
.
,
.
1 ccm o n bot h s ides .

,
.
1 ccm o n bot h sides .

,
.
I n fr a o r b fo r I c cm o n b ot h s i de s
. .
,
.
,
.
To A n a es th e ti z e th e Wh o l e L eft S i d e ,
an d th e
R i g h t Up to an d I n c lud i n g th e C a n i n e
M an dibul a r , 2 ccm (left ) .
M ental fo r , I ccm , on other side (right )

. . .
L in gual A spect o f right side in a nterior p o r
tion 1 ccm
,
.
To A n a e s th e ti z e S ix A n te r i o r Te e th i n M a n di b l e
M ental fo r . ccm o n both sides
,
I .
,
.
L in gual A spect 4 ccm

1
,
. .
To A n a es th e ti z e th e S i x A n te r i o r T ee th, Upp e r
Jaw
I nfraorbital for .
, I ccm on both sides
,
.
I ccm .
1 s t M ol a r,i nj ect facially a b out c ente r o f r oo t ,
1 A c cm lingually
1 ), . ccm ,
.
2d B i cuspid i n ject facially ab out ce nter o f r oot

, ,
1 c cm ; lingually
. ccm , .
1 s t Bicu s pi d inject facially ab out center o f r oot

, ,
1 ccm ; lingually
. ccm ,
.
C anine inj ect facially a b out c enter o f r oot

, ,
1 c cm ; lin gually
. co m ,
.
L ateral inj ect facially a b out cent e r of r oot

, ,
c cm ; lingually
. ccm ,
.
C entral inj ect facially a b out center o f root

, ,
ccm ; lingually
. ccm ,
.
K EY T o L O CA L A NE S T H ES I A IN O P ER A T I VE DE N T I S
TR Y . F O R O P ER A T I O N S UP ON
— —
U pper M olars Tu b erosity I / z ccm wait
l .
minutes .
—
U pper Bicuspid s I n fil tr a te both F acial and
g u al aspect Of process near apex — l
/z I -
wait 5 1 0 min utes -

.
—
U pper C anine I n fraorbital fo r amen I ccm .
5 1 0 mi nutes
-
.
as C anine o r I nfi l tr ate as Bicu s

U pper L ateral
pids o r insert t a mpons dipped in
U pper C entral 20% Novocain s o l into n a r c e
‘
.
.
L ower M ol a r s M andibular injection 2 ccm wai t

-
.
1 0 20 minutes
-
.
CON C LU S I O N S 233
m a ndibular or
inj ection 2
L owe r B i cus Mental for a men
co m a n d .
pi d s 1 c o m w a it 5 1 0 -
mental for a
.
L ow e r C anine minute s
men o r men
.
I n fi l tr a te mental
L ower L ater a l ta l fo ss a o n
fo s s a 1 ccm wait
L o we r C entral 0 p p o s i t e
.
5 1 0 m i nute s -
s i d e fo r cen
.
tr al re gi on ) .
T h e inj ection o f the incisal fossae on both sides

a s we l l as l i ngu a l i n fi ltr a t i on will an e st h etize t h e
four inci s or s .
T h e author h a s a ttempted to pre s ent th e subj ect

o f L oca l A ne st h es i a a s o f interest to the Dental
,
and O ra l S peci ali s t in a s conci s e an d pr a ctical

form a s possible .
Th i s boo k should n o t be loo k ed upon as a Tex t

boo k but as a guide to th e s tudent an d p r a c ti
,
ti o n e r .I n conclusion the writer desires to reiter

a te th a t L ocal A n e sthe s i a i n i t s v a rious form s
i s the staunche s t ally o f the O r a l specialist in

comb ating pain but th at i n i ts though tl e s s and i n
,
c orrect use lur ks d a n ge r .
I t is n o t a met h od to b e employe d fo r s cal in g

teet h o r to gra tify the whim o f a p a tient b ut it ,
is a me a ns o f reducing pain .
A l l typ es o f A n a e s th es i a m us t b e a d m i n i s te r e d
wi th c a uti o n , w h eth e r L o cal o r G en e r a l .

234 L O CA L A NE S T H ES IA
I t i s foolh a rd y to us e w i t h out pro pe r in s t ruo
t i on.
I t i s d an ge r ous i n th e h and s o f th e m an wh o
doe s n o t app re c i ate th e full me an ing o f A s ep s i s .
236 L O CA L A N IE S T H E S IA
P e r m a n g an a te o f P o tas h S o l uti o n
K alii h y p er m an gan
A qu e dest
F ifteen to twenty drops in o n e half glas s o f -
water a good deodorant wash I f used any len gt h

,
.
of time te e th a n d tongue discol or C a n be used

,
.
fo r irrigating s uppurating wound s cy s t c a vitie s , ,
necrotic a r ea s max i llary s in us No t to b e u s ed

,
.
stronger .
L i quo r A lum i n i A c e ta ti s
A lum i n i s ul p h a ti s
A cidi acetici aa
C alc i i carbonici
A qu e dest
Di lute d wit h four o r ten parts o f w a ter well ,
cooled v ery u s eful as an external application in

,
swelling .
Diluted wit h nine o r ten parts o f wate r a good ,
a s tringent mouth wash No t to be used fo r any .
length o f time as a wa s h as the teeth become di s ,
colore d ; the discoloration however i s ea s ily r e , ,
moved w i t h pumice .
L iquor B ur o w i acts li k e t h e abov e ; i t is not O ffi

c i a l in t h i s country .
2 P r es c r i p ti o n s
.
L i q A l um i n i A c e ta ti s , U S P
. . . .
(3 i v )
S Dilute wit h four parts o f water
. an d apply e x
PR E S CR IP T I O N S 237
te r n ally fo r o ne h our th ree times

, a day . L abel
fo r ex t e rnal u s e .
A s a wa s h
L i q A l um i n i A
. c e ta ti s , (3 i v )
S Tw o
. t e a s poonfuls in a h alf gla ss o f wat e r a s -
mout h w a sh L abel fo r e x ternal use

. .
No t to be u s ed before meal s as it mi gh t a fi e c t ,
t h e appetit e .
A n ti s ep ti c Wa s h es
S o l K a h I h yp e r m an g ,
.
( )
3 11
S . F i fteen drop s in o n e h al f -
gla ss of w at e r as
mo uth was h .
R
S o l Hy d r o gen n h yp er o xy d ,
.
(3 i v )
S .O n e tablespoonful in o n e h al f gl a ss o f wat e r -
a s mout h w a sh .
No t to b e u s e d fo r an y len gth o f t i me a s th e ,
teet h b ecome d i s colo red th e ton gue coate d and it , ,
pro duce s a pa s ty tast e .
3
L iq A . n ti s e p ti c us A lk al .
, ( )
3 i v
S . t ab le s poonful i n a gla ss o f w ater as

A
mout h wa sh .
I f Ch lorate o f P ot a sh i s re quir e d t h e fo l lowin g ,
w a sh i s u s efu l
238 L O CA L A N E S T H ES IA
ch lora s
K a lI I 3 i ss
Tr Myrrhe .
3 i
A qu e dest q s a d .
,
. .
3 iii
M S A teaspoonful in
. . o ne -
half gl a s s o f water
as mouth was h .
M i ll e r ’
s Was h
Th ym o l i s gr i i i s s
.
Acidi Benzoici gr xlv .
Tr E ucalypti
. 3 SS
A lc o h o l i s ab s o l . 3 i ii ss
Ol . M enth e pip m xv
S tea s poonful in a glass of water as mouth
. A
wash afte r me al s and before retiring
,
.
A s tr i n g en t Wa s h es
B
L iquor B ur r o w i , or L i q A lum i n i A
. c e ta ti s ,
(3 iv )
S . On e
to two teaspoonfuls in one half glas s -
wa te r a s mouth wash .
S p t M enth e pip
. .
5i
A cidi Tannici gr . v -
gr . x
Tr M yrrh e
. 3 ss
Tr A r n i ce
.
, q . s ad
. .
3 iv
M S . . A teaspoo n ful in o ne -
half glas s o f water
240 L OCA L A NE S T H ES I A
F o r P o s t E x tr a c ti ve P a i n
C aps T r i ge m i n
. aa gr v .
D . N0 vi . .
S . On e c ap s ule every three h ours until rel i eve d .
R
Ph ena c et in e
A s pirine ,
aa gr xxx
.
Div i d e in ch artulas NO vi . .
S On e powder every three

. hours until relieved .
I f an O piate i s required
3
P h enacetine gr x 11 .
Na tr i i bicarb g r xx .
C ode i ne S ulph gr i .
C a ffeine citrat gr i v .
M isc e e t, divide in ch a rtulas NO iv . .
S . On e powder every three hours until relieved .
Inextreme case s where th e pat i ent is ,

s ufi e r i n g
s evere pain and is very restless

B
M o r phi e S ulph gr 4.
1
K alii Bromid . gr xxx

.
A que 3i
S O n e h alf to b e ta k en at once ; b al a nce
.
-
t h ree hour s if necessary ,

.
No n -
r e p i ta n tur
PR E S CR I P T I O N S 241
L ax a ti ves
I t i s alway s advis able to pre s cribe a la x ative in

c a s e s o f alveolar a bscess .
C astor Oil (0 1 R icini ) is o n e o f t h e ide a l d rugs

.
,
but it s unplea s ant ta s t e ma k e s it di ffi cult to a d

minister I t can b e given in g el atin cap s ules
.
wh ich render s it tastele s s an d odorle s s T h e s e .
c a psules are made up in d i fi e r e n t s ize s ; fo r adult s

six gram cap s ule s (6 X 225 min im s ,
about a half ounce ) constitute the usual dos e .
T h ese capsule s are s wallowed easier if they are

moi s tened in water They are best ta k en b efore
.
retiring .
C ascara S agrada can be prescribed in liquid o r

s ol i d form .
Ta b C a s cara S a gr a d a a a
. chocolate coated
,
.
On e to tw o tablet s b e fore retiring .
Or
E x t C ascara S agrada fld
. .
,
1 0 30 minim s
-
.
L i q M a gn e s u C i tr a ti s , U S P
. . . .
S . On e -
half to one . Twelve ounce bottle-
.
F o r th e C o n tr o l o f H e m o r r h a g e
V in ergot e (S quibb s ) 3 iii

’
.
S . A teaspoonful every tw o h ou rs .
A cid i G all i c i 4 0 5 i .
A c idi S ul p h ur i c i d i luti 8 0 5 ii . . . .
A que dest q 8 ad 90 0 3 i i1 i
.
,
. . .
A teaspoonfu l every four h our s .
C al c u l a c ta ti s 5 i ss
Di vide in ch artu l as No v i . .
S . O n e p owder e v ery t h ree hours .
G en e r a l T o n i c
S tr y c h n i e S ul p h a ti s
A c idi A r s e n o i s i
" ui n in e S ul p h a ti s
Ferri S ul p h a ti s A x s i c c a t
et. f .
p i l ue Nxxx
O . .
On e after each meal .

244 L O CA L A N E S T H E S IA
C o c ai n e
A mm o ni a , c o ffee , s t r ych ni a e th e r an d a lc o h o l
,
.
I f c o nvuls ive in typ e tr ea t l ik e s t r ychni ne

,
po i s o nin g .
C o r r o s i ve S ub li m a te
L a r geam o unt s o f egg albumen fo ll owed by ,
s toma ch pump e xt e rn al h eat s timul an t s

-
, ,
.
E th e r
A rt ifi ci a l re s pira ti on ; strychnine h y p o d e r m a t
i c al l y ful l dos e ; friction and hot a ppli c ation s ;
,
d as h eth er o n ch e s t L aborde s met h o d o f tr a c

.
’
tion o f t o n gue .
I o di n e
L ar ge amounts o f starch h o t appl i c ati o n s , ,
emet i c s o r s toma ch pump ; h yp o de rmi c inj e c tio n

-
of alc o h o l am monia atropine di gi tali s

, , , .
I Od o fo r m
S odium bi c arbo n ate to c o mb ine w i t h i o din e ,
al
co h o l d iuret i c s and h o t bla n k et s

, .
M i n e r a l A c i ds
M a gn e s ium , l ime , soap , w hite egg a s a nti o f
dotes ; wh i te of egg ext e rnal h eat oil s and op ium
, ,
to rel i e ve irri tation .
M e r cur y B i c hl o r i d e
S e e C o r r o s i ve S ub li m a te .
A N TI DO T E S 245
M o r p hi n e
E meti cs or stomach pump tann ic ac i d bl a ck-
, ,
c o fi e e electri c ity and o th er measures to k eep p a

,
tient awa k e ; walk him aroun d ; a tropine or s try ch

nine h ypodermatically if respira tion fail s a r ti fi ,
c i a l re s piration ; repeated was h ing of s toma ch .
P erma n ga n ate of potas h .
N o vo c a i n
A m yl nitrite inh al ation ,
co fi ee (see C o c a i n e ) .
Ni tr a te o fS i l ve r
C ommo n sal t a s an ti dote ; opium and oils to
all ay i rr i tat i on al so l a rge amounts of milk and
,
s oap and w ater ; maintain bodily h eat .
P o ta s s i um C h l o r a te
Di uret i cs , s aline i nfusion .
S tr y c hn i n e
I nh alation a m yl nitrite stomach pump tan
o f , ,
nic acid followed by ph ysiologic an tidotes p o ta s

, ,
sium bromide gr 1x an d choral gr xx I f c o n

, .
, ,
. .
vul s i o n s prevent swallowing chloroform patient ,
carefully and anti d otes per rectum in star ch

, , ,
water A myl ni tra te h ypodermatically if rel axa

.
tion does n o t occur .
To produce emesis promp tly administer ap o

mor p hine gr ,
. gr hypodermati c ally
. .
X IV
T R EA T M E N T OF E M ER G E N C IE S
F a i n ti n g,
due to c ardiac depression c au s ing c erebral ,
a ne mia L a y p atient flat h ead lower th an feet ;

.
,
loosen all tigh t cl oth ing and admit fres h a i r G i ve .
A r omati c a m monia Burroughs ,
W ellc ome C o ) by inh ala tion breaking a c ap

.
,
sul e in towe l W h is k ey diluted in wa te r A r o

. .
mati c spirit s o f ammonia or xxx drops diluted

in water .
H i c c o ugh s
S pirits o f camph or o n e dra ch m H o ffman s .
’
a n odyne o ne drach m in water A myl nitrite by i n

.
h al ation .
H c a r tfa i lur e
A drenalin one to tw o drachms i n pint
Of n ormal saline intraveno us ly o r by h y p o de r
,
m o dy s i s .
E p i s ta wi s
P ack nostril tightly with gauze dipped in a d

r e n a l i n (adrenali n 1 drachm to 6 o z of .
water ) an d p re ss t h e ale o f the nose toget h er w i th

,
t h e fing er s .
248 L OCA L A N JES T H ES I A
C o n vuls i o n s
Pl a c e Denhart gag betwee n pat i ent s j aw s s o
’
,
h e c ann ot close his teeth an d bite h i s ton gue .
K eep a pair o f ton gue forceps h andy s o th at th e

,
ton gue can b e grasped that it c annot b e s w a l

,
lowed L ime chl oral and brom i de s ; if vi o l ent a

.
,
littl e chl o r oform by i nhal atio n .

G LO S S A R Y
A b s c es s , a locali z ed collection o f pu s surrounded

by a lymp h wall .
A c o n i te a g enu s o f herbs ; also the poi s onous root s

,
and leave s o f aconitum napellus .
A c ute rapid severe s harp

, , , .
A d r en a li n the active principle o f the suprarena l

,
glan d .
A l ka l o i d an organic ba s e o f v egetable origi n cau s

,
ing toxi c e ffe c ts .
A lum sulph ate o f potassium and aluminu m

, .
A lve o lus bony sock et o f a tooth

,
.
A l ve o l a r p r o c es s portions of j a w bearing t h e
,
teeth .
A l ve o li ti s inflamma tion o f alveolus

,
.
A mm o n i a a pungent ga s NH very so l uble i n

, , a,
water .
A n a lg es i a insensibility to pain
,
.
A n a e m i a a defi ci e ncy o f blood o r red blood c o r

,
p us c l e s ;
primary that caused by disease of th e bl oo d o r
,
the blood making organ s ; -
secondary that due to a distinct cause o r lo s s o f

, ,
bl ood .
A n a e s th e s i a ,
a s tate of in s en s ib il i ty ;
g eneral o n e a fi e c ti n g the wh ole body ;
,
l o c al l imited to a par t of the body ;

,
c ondu c tive due to blo cki n g O ff an a fferent

,
n e r ve ;
r egional l im i te d to a p art s upplied by an a f

,
fe r e n t nerve w h ich h as been ane s th etized ;

infi ltrat i on due to subcutaneous inject i ons
,
.
A n gi n a a s en s e o f su ffocation ;
,
V in c ent s a diph theroid i n flammation d ue to a

’
,
S pirillum and fusiform bacillus ;
L ud w ig s cellulitis of submental and sub m ax i l

’
,
-
l ary ti s sue s .
A n tr um a c avity espe c ially i n bone ;

, ,
o f H igh more c avi ty in th e s uperior maxill a,

.
A n ur i a suppres s ion o f urine

,
.
A r s en i c a ch emic element ; in small do s e s its c o m

,
b i n a ti o n s u s eful a s a toni c ; al s o u s ed a s an
escharotic .
A s ep s i s an abs en c e of septic m atter

, .
A s p i r i n aceto salicyli c a c id ; an anti rheumatic

,
-
remedy ; useful to stop all types o f pain .
A s th m a paroxysma l dyspnoea wi th oppres s ion

, , .
A s tr i n g en t an agent produ c ing cont r action of o r

,
gani e tissue o r th e arre s t o f di s ch arges .
B l a n c hi n g ,
turning pale .
B r o m ur a l proprieta r y combination
,
o f Bromide
and V al erian .
252 L O CA L A N JES T H E S I A
inflammation of endo c ardium th e

E n d o c a r d i ti s , -
,
inn er lini ng o f th e hear t .
E n d o s m o s i s t h e pa ss age o f a l iquid th rough a

,
s eptum from wi th out i nw ar d .
E r g o t a fun gus p a r a s it i c up on r y e (C l av i c eps

,
purpura ) .
E r o ti c perta i ning to s ex ua l pa ss ion

,
.
E ti o l o gy t h e s c i en c e O f th e c au s e s O f di s ea s e s
,
.
E x o s m o s i s t h e pa ss age o f a liqu i d thr ough a s ep

,
tum f r o m w i th in outward .
F ev e r ,di s turb ed nutri tion associated w it h r i s e o f ,
body temperature .
F e ve r s o r e ul c e r s u p po s edly to b e c aused by fever

,
.
G a lli c a c i d,
acid obtained from nutgall s .
G a n g r en e death of soft t i ss ue
,
.
G r a i n the s mallest divi s ion o f a pou n d

, of ,
an ounce .
G r a m unit o f weigh t O f metric system equal s

, ,
grains troy weight , .
H em o gl o b i n , coloring matter of red blood co r
p us c l e s .
H em o gl o b i n o m e te r , an instrument to d etermine
the amo unt o f h emoglobin in th e blood .
H em o p h i li a a di s ease O f t h e b lood pro h ibiting it s

,
normal c o a gulation .
H em o p h i li a c o n e w h o s u ffe rs from h emoph ilia

, .
G LO S S A R Y 253
H em o r r h age, e sc ape o f blood from a ves sel artery ,
ein o r c ap illary ;
v
p ri mary l o ss o f blood at time o f injury ;

,
se c ondary l oss of bloo d after bleed in g h as o n ce

,
sto p ped .
H yp er to n i c h aving greate r ten s ion (o s moti c p re s

,
sure ) .
Hyp o d er m i c unde r the ski n ,

.
Hyp o to n i c having le ss er te n s i on (o s moti c p r e s

,
s ure ) .
I d i o s yn c r a s y ,ind ivi dua l p e cul i arity .
I mp l a n ta ti o n th e a c t o f setting in g r a fti n g O f tis

, ,
s ue from o n e p er s o n to anoth er ;
ph y s io l ogi c g r afting living tissue ;
,
mech ani c al grafting dead ti s sue, .
I n f e c ti o n i nv a s ion b y disea s e germ s

,
.
I n fil tr a ti o n fluid e fi us i o n in to an or g a n o r ti ss ue
,
.
I n tr a ven o us into the vein s ,

.
I o di ae to a p pl y io d ine
,
.
I o d o fo r m y ello w anti s epti c p owder

,
.
I r r i ga ti o n c on s tant wa sh ing
,
.
I s o to n i c i ty s tate of h aving t h e s ame o s moti c p r es

,
s ur e a s t h e blood s erum .
K i l o gr a m , a metri c w eigh t , 1 000 grams .
L a r yn g o l o gy , s p ec i alty treating di s ease Of th e

laryn x .
L ax a ti ve a pu r gative
, .
254 L OCA L A N E S I H ES IA
’ ‘
L eg e a r ti s , a cc ording to th e l a w of t h e art (c o r
r ec tly ) .
L e th a l ,de a dly fatal ca u s in g dea th , ,

.
L o c k j a w t r i s mu s , .
L o c ke d j aw c onditio n w h e n t h e ja w s c a nn ot be
,
opene d o r closed due to s well in g o f t h e s oft

pa r t s .
L ues s yp h il i s
,
.
L ue ti c s yp h i l iti c
, .
L ux a ted l oo s en ed , .
L y s o l a d i s i n fe c tant and anti s e p t i c from cr e s ol

,
.
M a n di b l e th e l owe r j aw
,
.
M a x i ll a, th e j aw .
M a x i lla r y s inu s the antrum o f Hi gh mo r e , .
M e tas ta s i s , a ch a n ge o f s eat in a d i s ease (a can c e r

of th e b rea s t may pro duce metasta s i s in th e
l iv e r ) .
M e tas ta ti c pert a in in g to m eta s ta s i s

, .
M i lli m eter th e t h ousandth pa r t o f a meter

, .
M o us els s o luti o n F e r r i c s ubs ul ph ate in s olutio n, a

’
,
s typ t i c .
My el i ti s inflammatio n o f s p in al marro w
, .
My o c a r di ti s inflammatio n o f h ea r t muscl e
, .
N ec r o s i s , d eath o f b on e .
N ep h r i ti s , i nflammation o f th e kidn ey .
N e r ves , s en s o r y , s ame as a fferent , o n e tra n smi t

tin g f r om periphery to center ;
root s a n ter i o r sensory r oot s ;
, ,
po s t e r io r, m oto r roots .
256 L O CA L A N zES T H E S IA
P y em i a , c o n d itio n wh erei n pyo g eni c b a c te r i a cir

culate i n t h e blood .
P y r a mi d o n a n antipyreti c d eriv a ti ve o f a n te p y r i n
,
.
R a di o g r a p hy ,
t h e a r t o f m ak ing an X r ay pi c ture -
.
R hi n o l o gy th e sc ien c e o f s tructure and disea s e s o f

,
t h e no s e .
R i n g er s s o luti o n an isotoni c so lution c onta i ning

’
,
s odium pota s s ium and calcium ch lor i de

,
.
R o en tg en gr a m see S ki a g r a m ,
.
S e d a ti ve, p r odu c in g a sedative (depre ss ing ) ef
fe et .
S ep ti c em i a , infe c tion mark ed by b a c teria b ein g

p resent in th e bl ood .
S ep ti c relating to s ep s i s (putrefact i on )
,
.
S e r um flui d constituent o f t h e blood separated by

, ,
coa gula tion ;

h or s e from th e h or s e u s e d in th e treatme nt o f
, ,
hemorrh age ;
human s erum from h uma n bl ood
,
.
S h o c k mar k ed lowering o f vi tal a c t ivities due to

,
i njury o r operation .
S i n us a h o ll ow cavity o r po ck et
, .
S i n us i ti s inflammation of a S inus
, .
S ki ag r a m th e fi nis h ed printed X ray picture

,
-
.
S l o ughi n g formation of slough (death of tissue )

,
.
S p a s m a c onvulsive muscul a r contrac tion

, .
G LOS S A R Y 257
S p a ti um p ter yg o m a n d i b ula r e,
a flattened s pa c e
between the mandible and internal pterygoid
muscle through which the mandibular and
,
lin gual nerve s pa ss .
S p hygn o m a n o m e te r instrument to mea s ure t h e ,
b lood pre ss ure .
S te r i l e b arren not fertile free from living m at

, , ,
ter (free from b acteria ) .
S te r i li z a ti o n method o f produ c ing s terility (de

,
s troying b acteria ) .
S tr ep to c o c c us a pyogenic organi s m very virile, ,

.
S typ ti c having the property o f c h ecking h em o r

,
r h a ge .
S ub c uta n e o us ,unde r b eneath th e skin ,

.
S up r a r en i n s ee A d r en a l i n , .
S ur g e r y branch of medicine dealing with opera

,
tive procedure ;
pla s ti c the repair o f defe c tive ti ss ue by tran s
,
plantation .
S y m p hy s i s a junction o f b one , .
Ta b . abbreviation for tablet o r tablets

, .
Ta m p o n a plug o f lint o r cotton

,
.
Ta n n i c a c i d from nut galls astringent and inter

, ,
nal h emo s tatic .
Th r o m bus a b lood clot in a ve ss el at th e point o f

,
O b struction .
Th r o m b o s i s the formation o f a b lood clot

,
.
T o o th o n e of th e organs o f mastication
, .
To x i c i ty a s tate of being poisonous

,
.
258 L OCA L A N JES T H E S I A
Tr a n s fus i o n ,a tran s fer o f blood into the vein s ;

tran s fer o f a l i quid from o n e ve ss el to an
oth er .
Tr a um a a n inju ry wound
, ,
.
Tr a um a ti c s h o c k shock due to injury ,

.
Tr a um a ti s m trauma ,
.
Tr i g e m i n an anti neuralgic
,
-
.
Tr i s m us a spasm of the muscles o f ma s tication

,
.
Ur o l o gi c a l ,
pertaining to U rolo gy (sc ience o f di s
eases o f th e genito u r inary s y s tem ) -
.
Ute r us the womb

,
.
Ute r i n e pertaining to the womb

,
.
Ven o s i ty , looking like a vein b luis h ,

.
TH E GH
C OP Y R I TS OF TH I S B OO K ,
IN A LL E NG L IS H E
S P A K I NG
C OU N TR E I S , A RE OW N ED BY R E BM A N CO N EW Y O R K
.
,
260 I N DE x
C l d a p pl i ca ti n s 1 09 1 25
o o F a i l u r s i n C ndu ctiv A n a s
e o e e
C m p l i c ati n f T th Ex tr a c
, ,
o o s o oo th i 22 7 es a ,
ti n 1 1 5 o Fa intin g 246
C nduc tiv A n a th s i a in O p F ing r p r t c t r 23
, ,
-
o e es e e o e o
Fl p O p r a ti o n 7 7 79 82 83
,
a ti er D nti s tr y 22 1 ve e a e
O ral S u r g r y 2 12
, , , , , ,
e 8 7 88 1 2 2
T c h niqu O f 1 80
, , ,
e e K ni f Auth r 30 e, o
’
s,
C n tra in d i c ati n f L cal

,
o o s or o p r p ara ti n 69 7 1 82
e o , , ,
Ana th ia 1 99 es es F t b ath 1 05
oo
F rc s r t a i ni ng t o th in
, ,
o e e o
A lv l u 49
D gr s Of L ck d j w 1 22
e ee o e a ,
F rc p s T th u pp r 26 27
o e
eo
oo
s,
D iagn i f O p n Ant r u m
os s o e or
29
, , e , , ,
C y t 1 20 s
l w r 27 28 29
Dr i ngs 37 1 06 1 2 5
,
o e , , ,
es s
Dr i ll in g ut a t th 90 93
, , ,
R t 27 28 29
o o
B n
, , ,
Dr ugs 39
o oo , ,
oC utti n g 37
e
An a to m i c a l 3 1
,
Dry h at 1 05 1 06
,
T ngu 34
,
e , ,
o e,
F r in g a t t h int An t rum
o c oo o
t s o f h yp o de rm i c i n j ec ti n
,
Effe c o 1 19
f w a t r 1 33
o e F rac t ur f T th 1 2 1e o oo
S al i n S l
, ,
1 33e o R t 12 1
oo
Ad j i n i n g t t h 1 1 7
,
Hy po t ni c S L 1 34
.
,
o O ,
o oo ,
Hyp r t ni c S l 134
e o o .
,
A lv l u s 1 1 8 eo ,
El v at rs 7 1
e o ,
J aw, 1 1 8
us e o f, 72-76
Gl s ar y 249
E nd c a rd iti s
o D nt al O r i gin o f e ,
G
o
s
s
r a ping upp r f rc p s 42
,
e o e
5
L w r f r p 52
,
o e o ce s,
Ex am inati n O f pati nt 1 4 o e ,
G um ti ss u ab ut r ts 25 e, o oo
m th 1 6 ,
la n ds
on
1 7
,
c a r f 6 9 70 e o , ,
g ,
j w a 1 8 , Ha nd s ar f 9 c e o
t th 25
, ,
oo H adl i gh t 36
e
r t 25
,
,
oo H at Dr y 1 05
e
Ex t r a c ti n D n t s
, , ,
M i s t 1 05
’
24 o o o
Ex t ra ti n Typ s f 41
, ,
c o , e o , H m ph l i
e o21 1 1 1 e a,
N rm al 42
o , tr atm nt 1 1 4 e e
,
st ag s f 42 e o H m r rh g
e o a ft r xt ra cti ng
a e,
,
e e
f r t s 68 69 70 7 2
,
,
o oo , , , , , 1 06
77 79 t r atm nt f 1 08 1 09
e e o
a pi c s f r o t s 7 7
,
, , ,
e o o 241 242
I m p ac t d T th 80 8 1 82
,
,
e ee , , , , caus s o f 1 07 1 09 e , ,
85 86 87 Ho ld in g upp r f rc p s 43 e o e
S c n d L w r M la r i n s t ad
, ,
L w er f rc p s 53 54
,
e o o e o e o o e
f T h i r d 85 Hy t r i c a l p a ti nt s 1 5 23
, ,
o s e e
Un r upted T eth 9 1
,
o f w a te r
, ,
e e Hyp d r m i c inj c ti
o e e on
Ex t ra c tin g t th d u r in g pr
,
,
g ee e 1 33
n an y 1 6 c , S al in S l 1 33
e o .
,
I N DE x 261
Hyp o t o ni c S O L 1 34 , N dl s 1 40
ee e ,
r
Hy pe to ni S o l 1 34 c .
, Car O f 140 1 42 1 43
e , , ,
P l atinu m In d iu m 1 40 ,
I ch th y l 39 1 06
o R u ty 1 41s
I d i y n cra i 200
, , ,
os s es , B r k n 1 41
o e
Im pac t d T th 40
,
e ee 8 0 8 1 82 N rv bl ck in g 1 30
e e o
S upp l y f Up p r t th 1 72
, , , , , ,
85, 86, 87 , 88, 89 o e ee
ty s
,
p e o f 8 0 1 75
In car c ra t d T t Har d p ala t
,
e e ee h S ee I m 1 76 e,
T t L w r t th 1 7 7 1 7 9
.
p a c t e d ee h o e ee -
N r m al Ex t r ac ti n s 40
,
In c i in
s g g u m , 6 9 , 7 0 , 87 , 89 , 9 1 ,
o o ,
95 N v c ain 1 57
o o ,
In d i c at n an d
io s C o n tr a i n d i c a F r m f 1 60
o s o
L c a l An
,
ti n o s fo r o 1 99 A c ti n f 1 60
o o
T t x tr a c ti n s T abl t 1 6 1
,
fo r oo h E o , 24
e s,
Inf c i n s f ll in D nt al
e t o o ow g e Op
e r a ti o n s , 3 O b r v a ti n
se f p a ti en t s 1 4
o o
O d nte c to m y 9 3
,
In l tra ti n na t s i a
fi o A es h e , 1 62 , o ,
1 6 8 , 1 6 9 , 1 70 Od t my 9 8
on o ,
Inj c ti n an d i b u l a r
e o M 1 80 O p nin g Ant r u m a c i d t all y
e c en
T u b r ity
, ,
e os 1 88 1 18
L ck d J w 1 22 1 24
,
ala tin nt r i r
P e A e o , 19 4 o e a , ,
a l atin
P t ri r
e Po s e o , 1 93 O p r at r Attitu d
e o f 6, e o ,
Infra r italo b , 1 95 P iti n f 6 1 65

os o o , ,
Ment al 19 7 O r a l cr w 33
s e
a t r y p r ati c
, ,
of w e , h o de m ,
133 P a ck in g 84 102 1 04 1 08 , , , ,
In s r i n n dl
e t o of ee e fo r i n fi l tr a P ai na ft r xtrac tin g 1 03 2 40
e e
a ft r inj ec ti n s 1 36 1 6 5
, ,
ti n o , 1 67 e o , ,
In str u nt C a r
me s, e o f, 10 2 27 .
In p c ti n
s e o ck t
o f so e , 101 P a la tin inj c ti n Ant r i r
e e o , e o ,
Int r na l d i ati n
e Me c o , 1 05, 1 09 1 94
1 1 2, 1 1 4, 1 22 , 1 2 4, 1 2 5, P s t r i r 193
o e o ,
207 , 238 P a l patin g Ex t r n al Obl iqu e e
I r r i a ti n
g o s ck t
o f o e 10 2 1 0 7 l in 1 8 1 e,
v r gum 69
, ,
P l a c in g f rc p s o e o e
Lax ati v 2 1 1 25 241 f p ati nt 22
,
es , P iti
os on o e
T ll ing p ati nt s a 1 3 f p ra t
, , ,
Li e, e e o o 6 1 65
e or -
Lingua l n rv 1 7 8
, ,
e e, P wd b l w
o er 35 o er
L ck d j w 1 22
,
o e a P t t
o s ex r a c ti tr at m nt 1 0 1 ve e e
Lux ati n f t th 15 Pr gnan c y d T t h Ex t rac
, ,
o o ee , e an oo
ti n 16 o
P r p a r a ti n
,
M an d i bl 1 80 e e f p a ti nt 2 2 o o e ,
M an d i b u l a r inj c ti n 1 80 e o , Pr cr ipti n
es an d F rm u l a o s o e,
onl ft i d 188 e s e, 23 5
M i c tu r iti n Inv l unta r y 22
o o Pr e ssu r in H m rrh ag 108
e e o e,
M uth p r p s 3 1 7 4
, ,
o o , , Pr p r i ta r y A n a th ti c S l u
o e es e o
Mo n th gag , 32 ti n s 1 34
o ,
I N DEx
R em o v a l f I m p ac t d t th o e ee , T ch niqu
e e o f L cal An a
o ce
80 9 0 - th es i a , 1 44, 1 45
Un r upt d t th 9 1 100
e e ee ,
-
In l tr ati n
fi o , 1 64
G um t i u 91 ss e, M a n d i b u lar I j c ti n 1 80 n e o
T th fr m ck t 49 Tub r ity Inj c ti n 1 88

,
oo o so e e os e o
R p l antati n Ph y i l gi c a l 1 1 7
, ,
e o , s o o , P t r i r P a l at i n
os e Inj c ti n
o e e o ,
M c h ani c a l 1 1 6
e 19 3
nt r i r
,
R qui it
e f
s L cal A
es th or o n a es e A e o P a la tin Inj cti n e e o ,
i s a,2 26 228 ,
19 4
o f S l uti n f o L A 1 32
o s or oc . n .
, Inf r a rb ita l Inj c ti n 1 9 5
o e o ,
R tr ac t r
e 34 o s, M n t l Inj c ti n 1 9 7
e a e o ,
R tr m l a r t r ian gl
e o o 1 83 e, C n d u c ti v A na th ia 1 80
o e es es ,
R in g r eS l uti n 1 3 5
s o o , S u r gi c a l Ex tr a c ti n 12 6 o s,
R tati
o f t th 83
on o ee N r m a l Ex t rac ti
o 42 o ns,
t Ex tr ac ti n 68
,
R oo t Ex tr a c ti n s typ 40 o es , R oo o s,
f I m p a c t d T e th
,
N r m a l 40
o ,
R m vale o o e e ,
S u r gi c a l 40 80
v a l f Un r upt d T th
,
R em o o e e ee ,
S d ati v
e 2 3 2 38 2 39 240
es, , , , 91
S n
e f A p si
se o 7 se s, N rm a l R
o t Ex tr ac ti n 42 oo o s,
S r um in H m rr h ag
e 1 14 e o e, S u r gi c a l R t Ext rac ti n oo o s,
S h ck in D n t al O p ra ti n
o 22 e e o s, 78
O ral S u r g r y 207 Th i r c h S l uti n 12 5 235 ’
e e s s o o
Tr atm nt 1 24 T th Ex trac ti n d u r ing P r g
, , ,
e e , oo o e
S ig f 22
ns o nan c y 1 6
Tr atm nt f S ck t a f t r Ex
, ,
S lv nt m d iu m 1 33
o e e , e e o o e e
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Th e

L o cal A n e s the s i a o f t he M a x i lla e

I ll ustr a te d w it h 1 20 T e xt ual F i g ure s an d 8

IN O FF E R I N G th i s little v olume th e auth or doe s no t

Dental S tudent and P ractitio n er and recall to

more ; to day it has become a r eality th a nks to

B raun and Fisch e r .

F o r ca r eful s tudy t h e suc c eedi n g s teps o f th e

T h e auth or expresses h is sincer e t h ank s to t h e

fo r th e loan o f electrotypes and also to th e R e b ,

man 0 0 for t h e interest s h own and valuable a s

s i s tan c e given in th e publi c ation o f t h i s b oo k .

DE N TAL A N D O RAL O PERAT IO NS IN T H E IR

T H E T E CHNI " U E O F LO CAL (I N F ILT RA

VIII . I NDICA T I O NS AND CO N T RAINDICA T I O NS

m atter to w h at part of th e body they are applied .

Di ﬂ e r en t localities o f th e b ody vary in degree o f

s uscepti b il ity to infect i o n T hu s the openin g o f

th e a b dominal cavi ty or t h e explora tion of th e

are s urgical operations just as th e fo rmer and ,

T h e l ate W D M iller in h is work o n T h e M i

c r o Or gan i sm s of th e Human Mouth

list O f 1 65 cases of severe i nfections following den

term i nated fatally S ome s uccumb ed to h eart l e

sion s Oth er s de veloped pulmona ry in fections

oth ers m eni n gitis cerebra l a b scesse s pyemia

septicemia L u d wi g s angina frontal s inusiti s

t h rombo s i s et c Th os e wh o d id not die c arried

o ff s yph i litic infe c tio n s and t h ose w h o ﬁ nally t

wel l went th rough lo n g su ffering and a tryi n g

and o thers of like quality .

surgeon reports two cases in which extraction o f

th e second right and left lower molars re ,

s p ec ti v e l y was at tempted ; the ﬁ rst case devel

oped gangrene O f the soft tissues phlebitis , ,

myeli tis oedema of the lungs and died The sec

o n d patient contracted an osteitis followed by

p h lebi tis and pyemia and also terminated fatally

I n both instances the broken o ff roots had been -

extracted dr a inage established by deep incisions

but it was too late .

S c h wendt reports a case wherein the extraction

r e s ulting i n blindness Baume S pe ak s of a

case of an attempted extrac tion of a S i x year -

molar follo wed by periostitis necrosis pyemia , , ,

pleuro broncho pneumonia and death after tw o

M any a death certi ﬁ cate reads myocarditis ,

nephritis o r pneumonia the patient is laid at rest

and the fact th a t his death is the result o f a tooth

tic endocarditis produced by streptococci which

H o w can such severe conditions result from a

wh en pyogenic organisms reach the walls of bloo d

i s broken up l eu co cytes collect at these points a n d

T h i s thrombus b e c o me s infected w i t h bacteri a and ,

i s b roken u p loos ens , and thus becomes an em

b o l i s m or a n umber of emboli T h ese masse s are

carried along i n th e bl ood s tream a n d may pro

d i ti s or a m yoc a rditi s may result ; or th e s epti c

tion by th e left h eart a n d infect other r emote

T h e re s ear ch es of Bil lings an d R o s eno w o f ,

C h icago and H art z el l of M inneapoli s h av e

pro ven beyond a S hadow of a dou b t that pyogeni c