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ORAL ANAESTHESIA 
 
 LOCAL ANAESTHESIA IN 
 THE ORAL CAVITY 
 
 TECHNIQUE AND PRACTICAL APPLICATION IN 
 THE DIFFERENT BRANCHES OF DENTISTRY 
 
 By 
 KURT HERMANN THOMA, D.M.D. 
 
 Assistant in Anaesthesia, Harvard Dental School, Harvard University 
 
 Assistant in Dental Anatomy, Harvard Medical School, Harvard University 
 
 Fellow of the Harriet N. Lowell Society for Dental Research of Harvard 
 University 
 
 Member of National, State and Local Dental Societies 
 
 BOSTON. MASSACHUSETTS 
 
 RITTER & FLEBBE 
 120 BOYLSTON STREET 
 
^>}0 
 
 (The right of reproduction of the original illustrations is 
 strictly reserved.) 
 
 Copyrighted at the Registry of Copyrights, Washington, D.C., 
 19 1 4. All rights reserved. 
 
CONTENTS 
 
 Page 
 
 I. INTRODUCTION 7 
 
 II. ANATOMY OF THE ORAL CAVITY . 9 
 
 1. OSTEOLOGY 9 
 
 Maxilla 9 
 
 Mandibula ^'^ 
 
 2. NEUROLOGY 25 
 
 The Ophthalmic nerve 25 
 
 The Maxillary nerve 25 
 
 The Spheno-palatine ganglion . . . . Zo 
 
 The Mandibular nerve 31 
 
 III. TOPOGRAPHY 35 
 
 The Mucous membrane of the mouth 35 
 
 The Pterygo-mandibular space .... 38 
 
 IV. PHARMACOLOGY 39 
 
 1. NOVOCAIN 39 
 
 2. SUPRARENIN SYNTHETICUM ... 41 
 
CONTENTS 
 
 3. NOVOCAIN SUPRARENIN COMBINED ?4 
 
 Seidel's 16 Theses 44 
 
 Seidel's method 47 
 
 Ampules . . . . . . . . .47 
 
 Solutions 47 
 
 Tablets, Author's method 48 
 
 4. PHYSIOLOGICAL SALT SOLUTION . 50 
 
 5. DISTILLED WATER 50 
 
 V. INSTRUMENTARIUM ..... 54 
 
 L INSTRUMENTS 54 
 
 2. TABLETS 54 
 
 VL PREPARING OF THE SOLUTION . 58 
 
 Requirements of a solution prepared from 
 
 tablets , 58 
 
 VII. LOCAL ANAESTHESIA 60 
 
 A. SURFACE ANAESTHESIA 62 
 
 Nasal Anaesthesia 63 
 
 B. INFILTRATION ANAESTHESIA ... 63 
 
 The infiltration method in the maxilla . . 63 
 
 Preparing of the patient 64 
 
 Preparing of place for insertion of 
 
 the needle 65 
 
 1. Injection on the labial and buccal sides 66 
 
 2. Injection on the palatal side .... 68 
 
 The infiltration method in the mandibula . 69 
 
 1. Injection on the labial side of lower 
 
 incisors 70 
 
 2. Injection on the lingual side of lower 
 
 incisors 70 
 
 Horizontal injection 70 
 
CONTENTS 
 
 Page 
 
 C. CONDUCTIVE ANAESTHESIA ... 71 
 
 The Conductive method in the Mandible 73 
 
 1. Pterygomandibular injection 74 
 
 2. Mental injection 81 
 
 3. Buccinator injection 84 
 
 The Conductive method in the maxilla 85 
 
 1. Zygomatic injection 85 
 
 2. Infra-orbital injection 86 
 
 3. Incisive injection 89 
 
 4. Posterior-palatine injection ... 90 
 
 5. Spheno-maxillary injection ... 90 
 
 D. GANGLION ANAESTHESIA .... 91 
 
 Injection into the Gasserian ganglion . 91 
 
 Vni. FAILURES AND ILL-EFFECTS IN 
 
 LOCAL ANAESTHESIA 93 
 
 True failures and Ill-effects 93 
 
 a. No anaesthesia is obtained ... 93 
 
 b. Undesirable symptoms during the 
 
 anaesthesia 94 
 
 c. After-eff'ects 96 
 
 Oedema 96 
 
 After-pain 97 
 
 Prolonged anaesthesia .... 97 
 
 Psychological Effects .... 98 
 
 Ill-Effects due to other sources 99 
 
 VIII. PRACTICAL APPLICATIONS OF 
 LOCAL ANAESTHESIA IN DIF- 
 FERENT BRANCHES OF DEN- 
 TISTRY 101 
 
 Table I : Infiltration anaesthesia for the 
 
 teeth only 102 
 
 Table II : Infiltration anaesthesia for the 
 
 teeth and soft tissues 103 
 
 Table III : Conductive anaesthesia for 
 
 the teeth only 104 
 
 Table IV : Conductive anaesthesia for 
 
 the teeth and soft tissues . .105 
 
CONTENTS 
 
 Page 
 
 1. OPERATIVE DENTISTRY 106 
 
 Cavity preparations 10b 
 
 Removal of normal pulps . ..... 107 
 
 Removal of calcified pulps HI 
 
 Removal of pulps with pulp stones . . .111 
 Removal of hypertrophied pulps . .111 
 
 Removal of inflamed pulps 112 
 
 Removal of inflamed pulps complicated 
 
 with periodontitis 112 
 
 Acute alviolar abscess at the Apex . . .112 
 
 Chronic Alviolar abscess 113 
 
 Pericemental abscess 114 
 
 Diagnosis 114 
 
 2. GROWN AND BRIDGE WORK ... 116 
 
 Fitting of bands and cementing bridges . 116 
 Grinding and Devitalizing 118 
 
 3. EXODONTIA 120 
 
 4. ORAL SURGERY 121 
 
 Operation for granulum, root and apex 
 
 amputations 122 
 
 Impacted teeth 130 
 
 Fractures of the jaws 131 
 
 Cysts, Tumors, Necrosis, Odontoma . .131 
 Cleft palate, Hare lip. Amputation of the 
 alviolar process, and Resection of 
 jaws 133 
 
I. INTRODUCTION 
 
 IN these days of nervousness, hysteria and competition, the 
 dentist stands before tlie question : How can I accomplish 
 my work Avith the least discomfort to the patient, in the 
 shortest time and with the most j)erfect result? Local anaesthe- 
 sia fulfills these three requirements in the most ideal manner. 
 If there is no interfering pain, there is no reason why we should 
 not accomplish much better work in nnich less time. 
 
 Does general Anaesthesia or Analgesia fulfill these require- 
 ments? Certainly not. How can Ave perform delicate dental 
 operations, if we have to watch a more or less complicated 
 machine, as Avell as the action of the narcotic on the patient, 
 and how unpractical is general anaesthesia for exodontia and 
 minor oral surgery in the mouth. Mouth prop, inability of the 
 jiatient to cooperate, obscured field of operation by saliva and 
 blood, which is swallowed and inhaled, endless sponging pro- 
 longing the operation, are only some of the disadvantages. 
 This created the desire for something better. 
 
 liut not only in dentistry, also in surg(n'y arose the demand 
 for something safer with less strain, discomfort and danger to 
 the patient. Professor Bier of Berlin developed the infiltra- 
 tiou anaesthesia with cocaine. Cocaine anaesthesia was then 
 introduced successfully into the different branches of Medicine. 
 In dentistry cocaine was injected with much force through a 
 very ehort needle, directly into the gum, producing a velum 
 of white apj)earance. This decreased the pain considerably in 
 extraction. A u'w way of using cocjiiuc in dentistry was 
 introduced by Professor Briggs of Boston in 1890. His method 
 is called [iresvSiire anaesthesia. A pellet of cocaine is placed 
 iif)on tlie exfxisiire of a pulp and pressed in with a small piece 
 
INTRODUCTION 
 
 of iinvulcanized rubber, causing anaesthesia of the pulp for 
 purpose of devitalization. Professor Braun of Zwickau worked 
 out a new technique and system of local anaesthesia, which 
 aroused promptly great interest in our profession. On account 
 of the idiosyncratic behavior of cocaine, men of science looked 
 for a substitute. Among several hundred preparations, "Novo- 
 cain," discovered by Professor Einhorn of Munich was found 
 the best. The dentists of Germany were quick in realizing the 
 advantages of the new technique combined with the new drug. 
 In utilizing for our profession, Braun' s original ideas, different 
 methods of injection, and various ways of preparing of the 
 anaesthetic solution developed. The most distinguished 
 German authors are Braun, Haertel, Fischer, Seidel, Buente, 
 Moral, Steinkamm and Hauptmeyer. 
 
 Local Anaesthesia is based upon thorough knoAvledge of the 
 oral Anatomy, scrupulous asepsis, fresh drugs, and exact tech- 
 nique. 
 
II. ANATOMY OF THE 
 ORAL CAVITY 
 
 Only those structures of the Anatomy of the oral cavity 
 which are intimately connected with Local Anaesthesia shall 
 be considered in this book, 
 
 I. OSTEOLOGY 
 
 The formation and make-up of the maxilla and mandibula, 
 the two bones containing the teeth, is of somewhat different 
 character. The mandible resembles more a flat bone; it even 
 could be compared Avith a rib, while the maxilla is of irregular 
 type, containing the principal air sinuses of the face. 
 
 The maxillary bone encloses a large cavity, the max- 
 Maxilla illary sinus (O. T. Antrum of Highmore). Its 
 
 walls, therefore, are very thin. Of the four sur- 
 faces the anterior and infra-temporal are of special interest to 
 us, also the alviolar, zygomatic and palatal processes, and the 
 infra-orbital, posterior alviolar and posterior palatine fora- 
 mina. 
 
 a. The Anterior surface (O. T. external or facial surface) 
 presents an eminence over the root of the cuspid, called the 
 canine eminence, which separates the incisive from the canine 
 fossa. Above this lies the infra-orbital foramen under which 
 the levator anguli oris takes its origin. The incisive fossa 
 gives origin to the compressor nasi, above and below and more 
 to the median line, to the depressor septi (O. T. depressor alae 
 nasi). 
 
 b. The Infra-temporal surface (O. T. posterior or zygo- 
 matic siirfiic(') is convex, directed bjickwards Jincl inward. It 
 
Fig. 1. Outer surface of Maxilla and Mandibula showing attachments of muscles. 
 
 A : m. Temporalis ; B : m. Masseter ; C : m. Levator anguli oris ; D. m. Compressor 
 
 nasi ; E : m. Depressor septi ; F @ H : m. Buccinator ; G : m. Masseter ; K : m. Depressor 
 
 anguli oris; L : m. Depressor labii inferior; M : m. Depressor menti ; N : m. Platysma 
 
 myoides. 
 
ANATOMY OF THE ORAL CAVITY 11 
 
 forms part of the zygomatic fossa. It is separated from the 
 anterior surface by the zygomatic process. It contains the 
 posterior alviolar foramina. At its posterior and inferior part 
 is a rounded eminence, the tuber maxillare. This gives attach- 
 ments to a few fibers of the external pterygoid muscle. 
 
 c. The Zygomatic process (O. T. Malar process) extends 
 from over the second molar to articulate with the malar bone. 
 Its posterior surface is convex and forms part of the zygomatic 
 fossa. 
 
 d. The Alviolar process is made up of an inner and outer 
 plate, which are connected with numerous ,septa of cancellated 
 bone. The outer plate is continuous with the anterior and 
 infra-temporal surfaces and is marked by vertical ridges corre- 
 sponding with the roots of the teeth. It is quite thin and frail 
 over the incisors, cuspids and bicuspids, containing numerous 
 small foramina, giving the bone a porous appearance. A very 
 thin plate of bone separates the maxillary sinus from the 
 canine fossa. Further back in the region of the molars, the 
 process becomes thicker and a cortical airia, with very few fora- 
 mina is usually found at the root of the zygomatic process. 
 The posterior extremity forms the tuberosity which again is 
 very porous around the alviolus for the wisdom tooth. TJte 
 inner plate of the alviolar process is much heavier and stronger, 
 small pores are evenly distributed throughout its extent. At 
 its upper extremity it joins the palatal process. The alviolar 
 process gives origin to the buccinator muscle at the posterior 
 part of its outer plate, near its upper margin, which reaches as 
 far forward as the first molar or second bicuspid. 
 
 e. The palatal process projects horizontally inward to 
 form the roof of the mouth together with a portion of the pala- 
 tal bone. In the median line of the anterior part, we find the 
 incisive foramen, at the posterior and external sides are the two 
 palatine foramina. 
 
 f. The Infra-orbital foramen is situated immediately be- 
 low the center of the infra-orbital ridge and near the ni)i)er 
 
Fig. 2. Skull showing small foramina in the incisor region of the maxilla and 
 mandibula. Note also Infra-orbital and mental foramina. 
 
Fkj. 3. Skull showing f(jraniiiia in tlic cuspid, bicuspid and molar regions of 
 the maxilla and absence in the mandibula. 
 
14 ORAL ANAESTHESIA 
 
 margin of the canine fossa, above the root of the first bicuspid. 
 It is oval in shape and transmits the infra-orbital nerve and 
 blood vessels. 
 
 g. The posterior alviolar foramina are situated at the pos- 
 terior part of the infra-temporal surface, and are usually two 
 in number. They lead into canals of the same name which 
 transmit the posterior alviolar vessels and nerves. 
 
 h. The Incisive foramen lies immediately behind the in- 
 cisor teeth in the median line. It is formed by four canals, 
 two lateral ones for the descending palatine arteries, and two, 
 one in front and one behind, in the median line, for the naso- 
 palatine nerves. 
 
 i. The Palatine Foramina. There is a larger and a 
 smaller foramen, the first transmits the anterior palatine nerves 
 and vessels, the other lies almost immediately behind it and 
 transmits the middle j)alatine nerve and vessels, which supply 
 the soft palate. The larger palatine foramen is situated at the 
 level of the third molar or in children at the level of the last 
 molar present. It is the outlet of the i^alatine canal made up 
 of the maxillary and palatine bones. 
 
 j. The Maxillary sinus (O. T. Antrum of Highmore), va- 
 ries considerably in shape, size and cai^acity. Its posterior wall 
 is crossed by the posterior alviolar nerves, which they enter by 
 special foramina. On its external wall we find a canal for the 
 middle alviolar nerve, which runs downward and forward to the 
 bicuspid region, and on its anterior wall we find the anterior 
 alviolar canal, in which the anterior alviolar nerves descend. 
 It runs inward toAvards the nose and downward towards the 
 incisors. The superior surface is formed by the floor of the 
 orbit, which contains the infra-orbital canal. 
 
 This bone is much denser than the maxilla, and 
 Mandibula also has much thicker and very cortical layers. 
 It is divided into a body and two rami. The 
 body of the mandible consists of an external and internal sur- 
 face, and of tlie alviolar process. 
 

 1 
 
 ^■■1 
 
 '»-■'. T^^^^^^ 
 
 
 ^^^^^1 
 
 
 g 
 
 ^IH 
 
 / ^^^^^^^F* 
 
 1 
 
 1^1 
 
 ii.f^^ 
 
 
 
 Fig. 4. Palate of a child 6-7 years, note location of incisive and palatine 
 
 foramina. 
 
 Fig. 5. Palate of a child 11-12 years, nntc location of incisive and palatine 
 
 tdraniitia. 
 
Fig. 6. Palate of an adult, note location of incisive and palatal foramina. 
 
 Fig. 7. Palate of senile skull, note location of incisive and palatine foramina. 
 
Fig. 8. Skull with dissected anterior superior alviolar canal. 
 
Fig. 9. Radiograph showing a frontal aspect of the maxillary sinus. Anterior middle 
 and infra-orbital canals, infra-orbital foramen and superior alviolar plexus. 
 
ANATOMY OF THE ORAL CAVITY 
 
 19 
 
 THE BODY OF THE MANDIBLE 
 a. The External surface of the body of the mandible pre- 
 sents the two mental foramina, one on either side, the external 
 obliqne line which is eontinnons from the ramns, and the mental 
 fossa. The mental fossa lies directly beneath the incisor teeth, 
 and is very porons. Showing many small foramina similar to 
 the ones aronnd the roots of the maxillary teeth. These are 
 
 B. 
 
 
 A 
 
 Fig. 10. Cross section through maxilla and mandibula showing difference in 
 makeup of the bone. A. Frontal section through maxillary alviolar process. 
 R. Frontal section through niandihular alviolar process. I'oth in the l)icuspi(l 
 
 region. 
 
 made use of for \\n-, in (ill ration method of local anaesthesia. 
 The H'st of tli<* surface is iiliiiost one; cortical mass. 
 
 b. The Internal surface of tlie liody likewise is iiia<le up of 
 a very heavy hiyci- of lioiic, willi tlic c.xccplion of tlie region of 
 the genial I iiImm-cIcs, wIici-c wc HikI ;i cjiiiinihilcd area. 
 
20 
 
 ORAL ANAESTHESIA 
 
 c. The alviolar process of the mandibula is much 
 stronger than the alviolar process of the maxilla. In the 
 molar region it is even reenforced by the external and internal 
 oblique lines. The alviolar ridge shows perforations, especially 
 well marked in the bicuspid and incisor regions, but the part 
 near the roots and over the apices of the teeth is non-cahiculated 
 with the exceptions mentioned, on both sides of the incisor 
 teeth. 
 
 THE RAMUS OF THE MANDIBLE 
 
 It presents three surfaces, the external, anterior and 
 internal surfaces. 
 
 a. The external surface of the ramus gives attachment 
 to the Masseter muscle. 
 
 b. The anterior surface forms a triangle called the post- 
 molar triangle. Its external boundary is the external oblique 
 line, which starts from the anterior margin of the coronoid 
 process, and passes downward and outward to the external 
 surface of the body of the mandible, where it is continued as a 
 well-marked ridge. This is a pronounced landmark, which can 
 
 Fig. 11. Three mandibles showing different construction of the post-molar triangle, 
 a Internal oblique line, b External oblique line, c Post-molar triangle. 
 
ANATOMY OF THE ORAL CAVITY 
 
 21 
 
 be easily palpitated in the mouth. The internal boundary of 
 the post-molar triangle is the internal oblique line, which is 
 varying, sometimes well marked, other times rounded, and hard 
 to find. The base is formed by the wisdom tooth. The triangle 
 is concave and can be easily felt with the tips of the fingers. It 
 lies behind and externally to the last molar. 
 
 c. The internal surface of the ramus presents about its 
 center the mandibular foramen. This is the opening into the 
 mandibular canal. The margin of the foramen presents at its 
 anterior side a prominent lingula, the mandibular tongue. To 
 this is attached the spheno-mandibular ligament. The man- 
 dibular tongue is varying in size from a tongue like to a thick- 
 ened process. From this a decided groove starts, running 
 obliquely downward, for the mylohyoid nerve and artery. At 
 the angle of the ramus, we find rough oblique ridges, to give 
 insertion to the internal pterygoid muscle. This muscle covers 
 the mandibular foramen completely, with the exception of a 
 circular space. This space is called ptenjgo-mandihular space 
 from its position between the pterygoid muscle and the man- 
 dible. Its outline is the sulcus mandihularis, a groove found 
 around the foramen. 
 
 I'ic. 12. Sulcus mandihularis enclosed by the dotted line. 
 
22 
 
 OILiL ANAESTHESIA 
 
 d. The Mandibular canal (O. T. Inferior dental canal) 
 runs obliquel}^ downward and forward in the substance of the 
 ramus, and then horizontally forward in the body of the man- 
 dible. It lies close to tlie inner compact layer, immediately 
 under the alviolae into which small branches extend, given off 
 from the main canal, for the nerves and vessels which supply 
 the teeth. In the median line anastomosis with the opposite 
 side takes place. 
 
 Fig. 13. Specimen showing dissected mandibular canal. 
 
 e. The Mandibular Foramen (O. T. Inferior dental fora- 
 men ) is situated about the middle of the internal surface of the 
 ramus, halfway between the anterior and posterior border (in 
 a horizontal line varying slightly between the alviolar border 
 and the coronal surface of the molars). Viewing the mandible 
 from in front, it seems covered by the internal oblique line on 
 account of the angle of the ramus to the median line, which 
 varies in different individuals. The inferior alviolar nerves 
 and vessels are protected by the lingula, when entering the fora- 
 men, and therefore an injection for this nerve has to be made 
 above the lingula, into the pterygo-mandibular space. 
 
JNJTOMY OF THE ORAL CAflTY 
 
 23 
 
 f. The Mental foramen lies billow ;iiul hctwciMi the tirst 
 and second bicuspids, usually nearer and s(»nietinies entirely 
 
 ™ _ 
 
 ^^^^i 
 
 K^^' ¥ '^^^'^H 
 
 ^H^ ^' ■ i^l^^B 
 
 
 It^S 
 
 ^s^^^^^ 
 
 k»1»»»l'''>' 
 
 
 ,.._-, -_ 
 
 
 Fkj. 14. Variations of the intc-rnal surface of llie ramus nian<lii)ularis. Note 
 
 tlie lingula, sulcus mandil)ularis. and mandibular foramina in the different 
 
 specimen. The first from a younji the la'-t from a senile individual. 
 
24 
 
 ORAL ANAESTHESIA 
 
 below the second bicuspid. It is the communication with the 
 mandibular canal, and gives exit to the mental nerve and ves- 
 sels. 
 
 Fig. is. Location of mental foramen in a child. 
 
 Fig. 16. Location of mental foramen in adult. 
 
 Fig. 17. Location of mental foramen in senile skull. 
 
ANATOMY OF THE ORAL CAVITY 25 
 
 2. NEUROLOGY 
 
 The trigeminal or Vtli cranial nerve has a larger, or sensory, 
 and a smaller, or motor root. The large root forms the semi- 
 Innar ganglion. The Vth nerve is divided into 
 
 1. Ophthalmic nerve. 
 
 2. Maxillary nerve (O. T. Superior maxillary). 
 
 3. Mandibular nerve (O. T. Inferior maxillary). 
 
 The Ophthalmic nerve supplies no tissue 
 
 The Ophthalmic in the oral cavity. It supplies the eye-ball. 
 
 Nerve the lacrimal gland, the lining of the eye, 
 
 and nasal fossa, the skin of the eyebrow, 
 forehead and nose. It is only so far of interest to us as in 
 some cases of neuralgia the pain is referred to this branch. 
 
 The maxillary nerve comes from the foramen 
 The Maxillary rotudum entering the spheno-maxillary fossa. 
 Nerve Here it gives off — 
 
 The zygomatic branch, supplying the skin of 
 the side of the forehead and of the cheek. 
 
 The spheno-palatine nerves, which form the sensor}", or 
 short, roots of the spheno-palatine ganglion. 
 
 The posterior superior alviolar rami are given off just be- 
 fore the nerve enters the infra-orbital canal. They are two or 
 three in number, but often have a common trunk, and then 
 divide and pass downward on the tuberosity of the maxilla. 
 They give off twigs to the buccal part of the gum and mucous 
 membrane of the cheek; these are called the superior gingival 
 brandies. The posterior alviolar branches enter from the in- 
 fra-temporal surface of the maxilla into the posterior alviolar 
 canals. They supply the mucous membrane of the maxillary 
 sinus, and then take part in the formation of the superior 
 dental plexus, suj)plying the molar teeth, tlie alviolo-dontal 
 membrane and tlie gum. 
 
Fig. 18. Nervus trigeminus; (Vth cranial nerve) 12. N. opticus; 14. ganglion 
 semilunare ; (Gasseri) 15. N. maxillaris; 26. N. mandibularis. 
 
ANATOMY OF THE ORAL CAVITY 
 
 27 
 
 \v. 
 
 c 
 
 ^- 
 
 1 %- 
 
 Co. 
 
 1 
 
 .y^'^^r^^y 
 
 Fig. 19. Schematic drawing of the Nervus maxillaris. V. Ganglion semilunarc ; 
 I. N. opthalmicus; II. N. maxillaris; III. N. mandibularis ; 1. Nn. spheno-pala- 
 tine; 2. Rami alviolares superiores posteriores ; 3. Ramus alviolaris superior 
 medius; 4. N. infra-orbitalis ; 5. Rami palpebrales ; 6. Rami nasales ; 7. Rami 
 labiales; 8. Rami alviolares superiores anteriores; 9. Plexus dentalis superior; 
 10. Ramus dentalis superior; 11. Ramus gingivalis superior; a. F. rotundum ; b. 
 F. ovale; c. Canalis infra-orbitalis; d. F. infra-orbitalis; e. Foramina alviolaria 
 
 posteriores. 
 
 The middle superior alviolar ramus is given off from the 
 maxillary nerve just before it enters tlie infra-orbital canal or 
 from the infra-orbital at its beginning. It runs downward and 
 forward in a special canal on the outer wall of the maxillary 
 sinus, which it often enters on the infra-temporal surface of the 
 maxilhirv bone. It joins into the superior dental plexus, to 
 supply the bicuspid teeth. 
 
 The Infra-orbital nerve. This is the name of the second 
 division, after it cTilcrs the infra-orbital caual. It follows the 
 
28 ORviL ANAESTHESIA 
 
 course of the artery, and soon gives off the middle superior 
 alviolar ramus (if the latter is not given off in the spheno-max- 
 illary fossa) . Before its exit through the infra-orbital foramen 
 it gives off the anterior superior alviolar ramus. After coming 
 to the outside of the face, it divides into the rami infra-orbi- 
 tales. 
 
 Rami infra-orbitals. These are three sets and anastomose 
 with the facial nerves. They are called, palpebral, nasal and 
 labial, and form the facial plexus. 
 
 The Anterior superior alviolar ramus, is the largest. As 
 a common trunk, it runs through a canal in the anterior wall 
 of the antrum ; then divides into a series of branches, supplying 
 the incisor teeth and cuspids, anastomosing with the middle 
 superior alviolar branches by a plexus. These also supply the 
 fore part of the mucous membrane of the inferior meatus of 
 the nose. It is a common observation that by anaesthetizing 
 the mucous membrane of the nose, the patient complains of 
 numbness of the front teeth. This nerve can be reached by 
 injecting into the infra-orbital foramen from the vestibule of 
 the mouth. 
 
 Superior dental plexus. As described, it is formed by the 
 three superior alviolar branches. From it come the branches 
 that supply the teeth and the alviolar process. 
 
 Superior dental rami. They are the small nerve fibers 
 that enter the root of the teeth by the apical foramen to take 
 part in the formation of the pulps, supplying also the alviolo- 
 dontal membrane. 
 
 Superior gingival rami. They are the branches that pass 
 into the alviolar process and supply the gum. 
 
 THE SPHENO-PALATINE GANGLION 
 
 This is deeply placed in the spheno-maxillary fossa. It is 
 heart shaped and lies just below the maxillary nerve from 
 which it receives its two sensory roots. The motor root comes 
 
l-iG. 20. 
 
 palatine part. 
 
 ( V'lli ci'anial nerve ). Ir 
 In tlic Mandilnila : lingual 
 
 tile nia.xilla; naso- 
 iierve. 
 
30 
 
 ORAL ANAESTHESIA 
 
 Fig. 21. Schematic drawing of ganglion spheno-palatinum. V. ganglion semilu- 
 nare ; I. N. ophthalmicus; II. N. maxillaris ; III. N. mandibularis ; 1. Nn. 
 spheno-palatini ; 2. N. vidii; 3. N. petrosus snperficialis major (from N. facialis) ; 
 4. N. petrosus profundus (from carotid plexus); 5. N. pharyngis; 6. N. naso- 
 palatinus ; 7. 8. Rami nasales ; 9. N. palatinus anterior ; 10. N. palatinus medius ; 
 11. N. palatinus posterior; a. F. rotundum; b. F. ovale; c. F. incisivum; d. F. 
 palatinum majus; e. F. palatinum minor. 
 
 from the facial nerve, and is called the large superficial petro- 
 sal ; the sympathetic root comes from the carotid plexus, and is 
 called the deep petrosal. They join and form the Vidian nerve. 
 From the branches of the spheno-palatine ganglion there are 
 of interest to us. 
 
 The Anterior palatine nerve, which passes through the 
 palatine canal, and emerges through the palatine foramen. It 
 is accompanied by the artery, and supplies the hard palate, as 
 far forward as the cuspid teeth. 
 
ANATOMY OF THE ORAL CAVITY 31 
 
 The Middle palatine nerve. This emerges through thvi 
 accessory palatine foramen, supj^lying the soft pahite, nviila 
 ancb tonsils. 
 
 The posterior palatine nerve, supplying the musi^les of tin- 
 soft palate. 
 
 The naso-palatine nerve. This takes tlie course from the 
 spheno-palatine foramen across the inside of the roof of the 
 nose until it reaches the septum. From here it passes down- 
 ward and forward between the periosteum and the mucous 
 membrane to reacli the incisive foramen. It is distributed over 
 the anterior part of the hard palate, anastomosing witli the 
 anterior i)alatine nerve. 
 
 The mandibular nerve is made up of a large, 
 The or sensory, and a small, or motor, part. It 
 
 Mandibular takes its exit from the skull through the fora- 
 Nerve men ovale. Immediately afterwards it di- 
 
 vides into an anterior and a posterior part. 
 The anterior branch is nearly all motor nerves, and sup- 
 plies the muscles of mastication. Its branches are 
 
 Internal pterygoid nerve, 
 ^lasseter nerve. 
 Deep temporal nerve. 
 Buccinator nerve. 
 External pterygoid nerve. 
 Auriculo-temporal nerve. 
 
 TIk; posterior part consists of 
 Lingual nerve. 
 Inferioi- alviolar nerve. 
 
 Of these we wjiiit 1(» consider: 
 
 Buccinator nerve. 1'liis nerve ]>asses ^(»l•^\ ;ii'<l from be- 
 tween the two hejuls of jlie external ))terygoi(l nniscle, then 
 thi-ongh the temi)oral muscle to the surface of the bnccinalof 
 mUHcie. It <livides into two bi-nnches — 
 
 Suijerior ramus, to supply integinent nnd the supei-i(»i- p;ii*r 
 of the bucciruitoi- inuscle. 
 
Fig. 22. Nervus trigeminus: (Vth cranial nerve). In the Maxilla showing the anterior 
 part of the N. maxillaris. In the mandibula showing the N. mandibularis. 
 
ANATOMY OF THE ORAL CAVITY 
 
 ZZ 
 
 Inferior ramus, wliicli passes forward to the angle of the 
 mouth. It supplies the integment of the muscle, and the 
 mucous membrane of the cheek, also the buccal side of the gum 
 in the lower jaw between the first bicuspid and second molar. 
 
 c. 
 
 <.»C 
 
 
 I'lfj. 1.1. Scliematic drawing of ncrviis mandihiilaris. V. ganglion semilunarc; 
 
 1. N. ophthalmicus; II. N. maxillaris; III. N. mandihiilaris; 1. N. huccinatorius ; 
 
 2. X. massetericus ; 3. Nn. temporalis profundus; 4. N. ptcrygoidcus cxternus ; 
 5 X. pterygoideus intcrnus; 6. X. auricolo lcm]joraIis ; 7. X. alviolaris inferior; 
 8. X. lingualis; 9. X. mentalis; 10. X. niylohyoideus ; 11. Ramus dentalis in- 
 ferior; 12. Ramus gingivalis inferior; a. F. mandihularis ; h. F. mentalis; c. F, 
 
 rotundum ; d. F. ovale. 
 
34 ORAL ANAESTHESIA 
 
 The Lingual nerve. This first runs with the inferior alvio- 
 lar nerve, situated on its inner side, but soon passes further 
 forward and descends between the ramus of the mandible and 
 internal pterygoid muscle, passing down at its anterior margin, 
 and finally crossing over to the side of the tongue. It sujjplies 
 the anterior two-thirds of the tongue. On its way it gives off 
 side branches, which run along the inner surface of the man- 
 dible asi far as the anterior part, where it is minutely broken 
 up in the periosteum. This branch supplies the whole lingual 
 surface of the gum. 
 
 The Inferior alviolar nerve (O. T. inferior-dental). This 
 is the largest of the branches of the mandibular nerve. It 
 passes downward with the inferior alviolar artery, at first 
 beneath the external pterygoid muscle, then between the inner 
 side of the ramus and the internal pterygoid muscle. It enters 
 the pterygo-maudibular space, in which it enters the man- 
 dibular foramen, accompanied by the artery. Before doing so, 
 however, it gives off the mylohyoid nerve. The inferior alvio- 
 lar nerve then follows the mandibular canal, forming the infe- 
 rior dental plexus and giving off the mental branch. 
 
 Inferior dental plexus. This is formed by the different 
 branches to the teeth and alviolar process, and in front by anas- 
 tomosis of the nerve coming from the opposite side. 
 
 Inferior dental rami. They enter the roots of the teeth to 
 take part in the formation of the pulp and also supply the 
 alviolo-dontal membrane. 
 
 Inferior gingival rami. They supply the alviolar process 
 and gums. 
 
 The Mental nerve. It is a branch of the inferior alviolar 
 nerve. It emerges through the mental foramen, and supplies 
 the skin of the chin and the mucous membrane of the lower lip 
 and the anterior labial part of the gum, communicating freely 
 with the facial nerve. 
 
III. TOPOGRAPHY 
 
 It is of importance to know the makeup of the 
 The Mucous soft tissue of the mouth, and the relations of 
 Membrane the structures we have to deal with. The mu- 
 of the Mouth cons membrane lines the entire oral cavity. It 
 consists of epithelium and tunica propria. Un- 
 derneath this and forming the deeper part is the submucosa. 
 
 The submucosa consists of thick connective tissue bundles 
 containing numerous elastic fibers, which extend into the peri- 
 osteum, but become finer towards the tunica propria. In the 
 gums, the submucosa is very dense, binding the mucous mem- 
 brane down closely to the periosteum. As it passes into the 
 mucous membrane of the cheek and lip it becomes less dense, 
 and under the reflection of the mucous membrane the submu- 
 cosa is a thick layer of loose connective tissue. The same is true 
 on tlie palatal side. The angle formed by the alviolar and 
 palatal process is filled in with a large amount of connective 
 tissue, containing fat cells and the palatal mucous glands. 
 Over tlie central portion of the hard palate, the subnuicosa is 
 again very thin and extremely fibrous. 
 
 The tiiiiicM ]»r()]»i-i;i is made ii]» of a mass of dense connective 
 tissue bundles, and papilhie are extending into the epithelium. 
 
 Tlie epitlieliiim is the thick covering of the mucous mem- 
 brane. 
 
 'I'lic blood snpi)ly is very free, larger branches are found in 
 tlie submucosa giving off capillaries, which extend into the pa- 
 pillae of the tunica propria, where they freely ramify and anas- 
 tomose These give llie mucous membrane its reddish color. 
 
 Xeives aie iiiiiiieioiis. Primitive nerve fibers extend from 
 tlie suliiiiiicosa iiilo llie |»a|)illae of Hie hiiiica pro|)ria. The 
 
Fig. 24. Section through the upper jaw in the incisor region. A. Enamel; 
 
 B. Dentin ; C. Interglobular spaces ; D. Epithelium ; E. Tunica propria ; F. Sub- 
 
 mucosa; G. Periosteum; H. Outer Plate of alviolar process; I. Inner Plate of 
 
 alviolar process; K. Cement; L. Dental nerves and vessels. 
 
TOPOGRAPHY 
 
 37 
 
 nerve supply seems to be more abundant in the anterior part of 
 the month, while the molar region of the gnm, and the mem- 
 brane over the ramus is hardly sensitive. 
 
 Injections should be made into the loose parts of the sub- 
 mucosa, where the solution is taken up easily with little force. 
 
 Fig. 25. Horizontal section through human head in tlic phme in which mandib- 
 ular conductive anaesthesia is best accompHslicd. a. Glandula parotis; b. Ramus 
 mandibulac; c. Fascia parotidcomasscterica ; d. Nervus alvcolaris inf.; e. A. and 
 V. alvcolaris inf.; f. Sj)atium pterygomandibulare ; g. M. masselcr; h. M. ptery- 
 goid int.; i. Nervus lingualis; k. M. buccinator; 1. Glandulae i)alatinae; m. Art. 
 maxillaris externa; n. Glandulae buccalis; o. Gingiva; p. Labium inferius; 
 q. Lingua; r. Glandulae buccalis; s. M. masseter; t. M. Diagastricus ; u. Art. 
 carotis externa; v. Vena jugularis interna; w. N. vagus, glossopharyngeus and 
 hypoglossus; x. Art. carotis interna; y. Ganglion cervicale superior; z. M. longus 
 
 capitis. 
 
 A, M. rectus capitis anterior; B. Fpistropheus ; C. M. constrictor pharyngis 
 
 .superior; D. Fascia praevertebralis ; ]•'. M. stylopharyngeus ; F. M. styloglossus; 
 
 G. Tonsilla i)alatina ; 11. M. stylohyoidcus. 
 
38 ORAL ANAESTHESIA 
 
 Injecting into the dense submucosa of the gum, as in the old 
 
 method, requires much pressure and is incorrect. 
 
 It also is important not to inject into one of the vessels. 
 
 This can be avoided by moving the syringe slightly forth and 
 
 back. 
 
 The pterygo-mandibular space is bounded ex- 
 
 The Pterygo- ternally by the part of the internal surface of 
 Mandibular the mandibular ramus, enclosed in the sulcus 
 Space mandibularis, internally by the internal pter- 
 
 ygoid muscle. It is a bag-like space filled with 
 connective tissue. In it the alviolar nerve and artery enter 
 the mandibular foramen. The artery lies anteriorly to the 
 nerve and is protected by the lingula, the nerve is more to the 
 median line and posteriorly to the artery. The inferior alviolar 
 vein forms a plexus around the artery. The lingual nerve is 
 seen in a section cut through the pterygo-mandibular space at 
 the anterior margin of the internal pterygoid muscle. 
 
IV. PHARMACOLOGY 
 
 I. NOVOCAIN 
 
 There is no reason today why cocaine, for which so many 
 patients have an idiosyncrasy, should still be used in any branch 
 of medicine. The toxity of cocaine was not so clearly under- 
 stood in the beginning, and occurring deaths were first thought 
 to be due to overdoses. But experience showed that in some 
 cases, very large doses could be administered without any bad 
 effects, while other cases were reported where death occurred 
 from as small a dose as 0.01 gram. Besides the danger of idio- 
 syncrasy, there are a number of diseases where cocaine is con- 
 tra-indicated on account of its toxic action on the general sys- 
 tem, especially on the nerves, kidneys, and heart. These are 
 anaemia, chlorosis, neurasthenia, nephritis, heart diseases, 
 arterio sclerosis and general weakness, often illness. It is also 
 a great disadvantage that cocaine decomposes partly when 
 boiled, losing much of its anaesthesia producing power. 
 
 Therefore a large number of men of science searched for 
 years for a substitute. Professor Braun, the "father of Local 
 Anaesthesia," formulated the following requests, qualities, 
 which the new preparation should possess. 
 
 1. The substitute shall not be inferior to cocaine in its 
 anaesthesia producing i)ower. 
 
 2. It shall be relatively non-toxic. 
 
 3. It shall have no irritating action, even on the most deli- 
 cate tissues. 
 
 4. It nmst be easy to combine it with suprarenin and com- 
 bined, it should not lose of its anaesthesia producing power, 
 neither should it affect the action of the suprarenin. 
 
 5. It must be boibibh*. 
 
40 ORAL ANAESTHESIA 
 
 Among tbe many preparations, which have all been thor- 
 oughly tested out by men like Professor Braun and Professor 
 Bier, Novocain was found to be by far the best. 
 
 It was prepared by Professor Einhorn in Munich, and is the 
 "hydrochlorid of the p-Aminobenzoyldiethylaminoethanol" 
 with the formula : 
 
 N H. 
 
 C O. C, H4. N (C2H5),; H CI. 
 
 Q H, <;;^ 
 
 -D J ^- It IS produced through the action of '^diethyl- 
 Froduction ^ * \^ 
 
 amin'- upon "p-Aminobenzoeacidchlorethylester. 
 
 It occurs in small, colorless and tasteless crystals, 
 Chemical soluble in water (1 :1), and less soluble in alcohol 
 Properties ( 1 :30 ) . It is also soluble in glycerine at 20 Cen- 
 
 tigrades (1:5). Melting point 156 Centigrades. It 
 can be heated without decomjDOsition to 120 Centigrades. 
 
 It shows the general alcaloid reactions, tincture of 
 Reactions iodine j)roduces a brown, picric acid, a yellow pre- 
 cipitate. Alkalies produce a white precipitate, 
 which is soluble in alcohol and ether. 
 
 If one mixes a solution of 0.1 gram Novocain in 5 c.c. of 
 water, and three drops of dilute sulphuric acid with five drops 
 of potassiumpermanganate, we find that the violet color disap- 
 pears at once. This distinguishes Novocain from Cocaine. 
 
 Novocain possesses the same action upon 
 Physiological peripheral sensory nerves as cocaine. The 
 Properties 0.25 per cent solution is sufficient to com- 
 
 pletely anaesthetize even the thick nerve trunks 
 in about ten minues. 
 
 (Pharmacological institute of the University in 
 Clinical Breslau.) Locally applied there is no irritation. 
 Tests even if Novocain is brought upon the most sensitive 
 
 tissue in strongly concentrated solutions, as upon 
 the cornea. General effects upon the system after its absorp- 
 
PHARMACOLOGY 41 
 
 tion are scarcely perceptible, neither the circulation nor the 
 respiration snffers, the blood pressnre is not increased. From 
 experiments it was found that Novocain is seven times less 
 toxic than cocaine. 
 
 The best solution for our purpose is the two per cent 
 Dosage solution, for the infiltration as well as for the con- 
 ductive method. A change of strength is not required 
 for special cases, and I have used it most successfully in cases 
 where cocaine and ether anaesthesia was contra-indicated on 
 account of cardiac, pulmonary or other diseases. The maximal 
 dose is 0.5 gram (Fischer) for subcutaneous injections, but as 
 much as 2 gram has been used subcutaneously, without causing 
 any damage. But in our specialty such a quantity is never 
 called for, and the maximal dose which allows 24 c.c, or 12 
 syringes full of a two per cent solution is hardly ever reached. 
 
 2. SUPRARENIN SYNTHETICUM 
 
 Suprarenin has a great anaemia producing power, and is a 
 strong astringent. It is added to the anaesthetic solution for 
 one of two, or two purposes. First to contract the capillaries 
 and tissue locally, to prevent absorption and infiltration into 
 the soft tissue, therefore increasing duration and strength of 
 the anaestliesia. Secondly, it is added to decrease bleeding in 
 certain operations. It is much superior to adrenoline, or any 
 of the organic substances gained from the suprarenal glands, 
 as it is more staple, keeps better and is less toxic. It is the 
 "Ilydrochlorid of 0-Dioxyphenylethonolmethylamin," and has 
 the chemical formula : 
 
 < 
 
 C H (O Hj C Ho. N H. C H3 
 
 (\\],C OH 
 
 OH H CI. 
 
 r> J >• <J)loracetobreiizkateciiin is irauslormed by me- 
 rroduction , . . ,, , . , , 
 
 tnylamin into Methylaminacetobrenzkatechm. 
 
 \\y reducing this keton we receive the secondary alco- 
 hol called syiitliefic suj)rarenin. 
 
42 ORAL ANAESTHESIA 
 
 Synthetic Suprarenin is a grayish white powder. 
 Chemical It does not dissolve easily in cold nor in hot water, 
 Properties and is insoluble in alcohol and ether. Melting 
 
 point 207-208 Centigrades. 
 Titrated with diluted acids it is very easily soluble and 
 gives a watery clear solution. It is in the market diluted 
 1 :1000. 
 
 Synthetic suprarenin is very sensitive. Free al- 
 Reactions kali, air and especially heat cause its decomposi- 
 tion. It has to be kept in bottles made of special 
 alkali free glass, and should not be exposed to air unnecessarily. 
 It has the advantage over the organic preparation that it can 
 be boiled to some extent. Slightly discolored solutions have 
 toxic or irrigating effects. 
 
 It is the strongest Haemastatic and astringent 
 Physiological known. It causes anaemia and contraction of 
 Properties capillaries and tissues locally, while when in- 
 
 troduced into the circulation it increases the 
 blood pressure. This comes partly from increased heart action, 
 and partly from contraction of the arteriols in the whole body. 
 
 Clinical experiences in different institutions and 
 Clinical hospitals of Europe proved Suprarenin Syn- 
 
 Experiences thetic to be the best substitute for the organic 
 
 preparation. 
 
 Different than with Novocain, I found it of great 
 Dosage importance to vary the amount of Suprarenin for 
 
 individual cases. I have been using the E tablets, 
 which contain 0.000,05 grams suprarenin to 1 c.c, if a two per 
 cent solution is prepared, and I only came to the conclusion 
 that so high a percentage of Suprarenin is not necessary, while 
 treating a patient with grave cardiac and pulmonary disorders. 
 He was referred to me for treatment under local anaesthesia, 
 by another dentist. Considering the seriousness of the situa- 
 
PHARMACOLOGY 43 
 
 tiou, I prepared a special solution containing two per cent 
 Novocain and 0.000,01 gram Snprarenin to 1 c.c. I used the 
 infiltration and conductive methods in the upper and the 
 conductive method in the lower jaw, with perfect result, and to 
 mj surprise I found that' the time of anaesthesia was not 
 decreased. I then tried the new solution on a patient, Avhich 
 had slight toxic effects, immediately after the injection of a 
 solution containing 0.000,05 gram Suprarenin, with encourag- 
 ing result. In conductive anaesthesia of the mandible, we 
 sometimes find that the lip feels perfectly numb, that the den- 
 tine is sufficiently desensitized, but the pulp only partly anaes- 
 thetized. Fischer agreed with me that this is probably due to 
 the fact that the tooth in question is supplied by the central 
 nerve fibers of the nerve trunk, which are not reached by the 
 anaesthetic. This teaches two things, first', that we should 
 allow time enough for the drug to act, and second, that the 
 suprarenin should be used in small percentage for conduc- 
 tive anaesthesia, on account of its astringent action, probably 
 preventing in high concentration the infiltration of the nerve 
 trunk to its center. 
 
 Conclusively I lay the cause of slight toxic effects, post- 
 operatic pain in extraction, post-operatic infection, and oedema 
 as after-effect, as well as incomplete conductive anaesthesia to 
 a too large percentge of suprarenin. 
 
 For general use I found a solution containing 0.000,015- 
 0.000,02 gram of synthetic suprarenin, to 1 c.c. or a 0.0015- 
 {).Wyi'/c solution of suprarenin the best. 
 
 For cases where a deep anaemia is desired, a higher per- 
 centage of 0.000,05 gram per 1 c.c. or 0.005% is recommended. 
 
 For patients with heart diseases, arterio-sclerosis, nephritis 
 and liysteria a lower percentage of suprarenin is advisable. 
 Use not more than 0.000.01 gram to 1 c.c, or 0.001%. 
 
44 ORAL ANAESTHESIA 
 
 3. NOVOCAIN SUPRARENIN COMBINED 
 
 At a congress of German dentists held in Mnenster, Ger- 
 many, at which the German authorities on local anaesthesia 
 met, Seidel proposed sixteen theses formnlating use and dosage 
 of the Novocain-Suprarenin solutions. The problem was thor- 
 oughly discussed by Fischer, Apffelstaedt, Moral, Steinkamm, 
 Hauptmeyer, Buente, Friedmann, Heinemann, Endres, Rilke 
 and Heinze during the two days' meeting and finally accepted 
 by unanimous vote as follows : 
 
 SEIDEL'S 16 THESES 
 
 I. The fresher a Novocain-Suprarenin solution 
 is, the less is its toxity, and the greater is its anaes- 
 thesia producing power. Therefore when exam- 
 ining preparations scientifically, one should only 
 use freshly self-prepared solutions. One can only 
 get a clear picture of the power of the Novocain- 
 Suprarenin solutions, if one is sure that the solu- 
 tion used contains Novocain and Suprarenin pure, 
 and not products of deterioration, 
 
 II. Fresh Novocain and Suprarenin either sep- 
 arate or mixed (solutions) should be clear as 
 water. 
 
 III. For the practice a Novocain solution 
 should only be considered "fresh" and fully active, 
 if clear and colorless. 
 
 IV. The same is true for solutions of supra- 
 renin. Solutions of suprarenin are less stable the 
 more diluted they are. 
 
 V. Mixed Novocain-Suprarenin solution is only 
 to be considered "fresh" directly after the mixing 
 of the dissolved parts. 
 
PHARMACOLOGY 45 
 
 Already iu ten minutes a Xovocain-Suprareniu 
 solution will show discoloration (from high tem- 
 perature, action of light or air), diminishing its 
 power and increasing its toxity. 
 
 VI. A sterile Novocain-Suprarenin solution 
 cannot be made lasting through addition of anti- 
 septics, because the yellow discoloration of the 
 Novocain, and the red discoloration of the supra- 
 renin are due to chemical processes (oxydation) 
 and not bacterial influences. 
 
 Therefore a Novocain-Suprarenin solution should 
 be sterile, but an antiseptic character is not re- 
 quired. 
 
 VII. Antiseptic additions [e. g., Thymol, and 
 others, as in patented preparations (author)] are 
 not only unnecessary but directly injurious. At 
 the present time there is no antiseptic known which 
 is entirely non-irritant in a concentration powerful 
 enough to have sufficient antiseptic properties. 
 
 VIII. Individualizing the concentration of 
 Novocain is not required for the small doses used 
 for dental ])urposes and, contrar}^ to cocaine, it 
 makes no difference whether a certain dose is in- 
 jected in weak or strong concentration, as long as 
 the total doses of 0.2 grams is not transgressed. 
 
 IX. In dentistry where the part to be anaes- 
 thetized (bone and tooth) cannot be infiltrated 
 directly, but where in contrary a diffusion is re- 
 quired, a solution of a comparatively high percent- 
 age can l)e used only. 
 
 X. The best solution for dental purposes is the 
 two per cent solution. 
 
46 ORAL ANAESTHESIA 
 
 XI. The suprarenin concentration has to be 
 changed in many cases. This is required because : 
 
 1. The toxity of the suprarenin is dependent 
 from the concentration in which a certain dosis is 
 given. Tliis is important in arterio-sclerosis and 
 when unintentionally injecting into a vessel. 
 
 2. In many cases a strong anaemia of the field 
 of operation is required, in others bleeding is de- 
 sirable. 
 
 XII. In normal cases the best results are ob- 
 tained if the two per cent Novocain solution con- 
 tains 0.000,02 grams Suprarenin per 1 c.c. 
 
 XIII. In arterio-sclerosis or cardiac disorders a 
 decrease of the suprarenin dosis to 0.000,01 gram 
 is recommended. If strong anaemia is desired an 
 increase to 0.000,05 grams is required. 
 
 XIV. The question what percentage of salt 
 should be added to the solution to make it isotonic 
 is not yet scientifically solved. 
 
 The material presented by Buente and Moral, as 
 well as by Fischer, is not sufficient. 
 
 XV. In practice we find no difference if 0.6 or 
 0.9 gram salt is added to a two per cent solution 
 of Novocain. The amount which also fulfills the 
 theoretical requirements is not yet known. 
 
 XVI. The above requirements cannot be ful- 
 filled in practice by the use of ampules or tablets, 
 ready for a solution of one certain percentage. 
 The operator should prepare and mix the solution 
 himself, as with the method described by Seidel or 
 similar ones. 
 
PHARMACOLOGY 47 
 
 SEIDEL'S METHOD 
 
 SeideFs Method* of preparing the solution is a very scien- 
 tific one. He originated an instrumentarium consisting of au 
 apparatus to produce distilled water and a sterilizer to sterilize 
 tlie bottles, and other instruments used; also to sterilize the 
 two per cent Novocain solution, which is kept in a special 
 bottle. The suprarenin solution 1 :1000 can be bought in Ger- 
 many in small original bottles of 5 c.c, from this the normal 
 pipette constructed as a bottle is filled. Before injecting he 
 prepares the solution by measuring the amount of Novocain 
 solution, and adding as many normal drops of Suprarenin solu- 
 tion as required for the individual case. 
 
 This method no doubt is ideal, but the preparing and ster- 
 ilizing of the solution takes time, and the responsibility is too 
 great to leave in charge of any office help. Also the sensitive- 
 ness of the Suprarenin solution is to be considered. In this 
 country, we have not the facility to get this ingredient directly 
 and in shortest time. If injections are not frequently used 
 there is also a great deal of waste, as the Suprarenin solution 
 does not keep long after the bottle has been opened. The 
 danger to use Suprarenin, the toxity of whicli has been in- 
 creased through influences of air, heat, light or age, is too great 
 to take chances. 
 
 AMPULES 
 
 Ampules containing mixtures of Novocain and Suprarenin 
 are in the market, also patented preparations containing other 
 ingredients. SeideFs Theses Yl and VII discard the latter, 
 the former are also quite far from tlie ideal, Tlieses V calling 
 a mixed solution of Novocain fresh only directly after the 
 mixing. Often the solutions gained from ampules are actually 
 discolored jind, wliat is worse, it is hard to control their age. 
 
 SOLUTIONS 
 
 Solutions pnt up in bottles are still more undesirable than 
 the ampules. After the bottle is once opened the rest deterior- 
 
 * DeutHche Monatschrift fuer Zahnheilkunde Heft. 8-1913. 
 
48 ORAL ANAESTHESIA 
 
 ates quickly from bacterial invasion, and chemical processes 
 night, air, heat.) See Theses VI and VII, also II, V and IX. 
 
 TABLETS: AUTHOR'S METHOD 
 
 I have used solutions prepared from tablets in private prac- 
 tice and school clinics entirely, with the exception only of short 
 periods when I tried out other methods. The tablets of Farb- 
 werke Hoechst I found very satisfactory, they are carefully and 
 scientifically made and very reliable. Professor Braun ex- 
 amines them every year and finds that they are always sterile. 
 This of course is of first importance. I used and recommended 
 the E tablet, but, as explained in a previous chapter, I found 
 that they contain too much Suprarenin, and that it is necessary 
 to vary the amount of Suprarenin. I therefore prepared solu- 
 tions from the D and F tablets. This of course is somewhat 
 complicated for general use. To simplify the technique of pre- 
 paring the solution, Farbwerke Hoechst was kind enough to 
 produce a new tablet. I therefore use now, and recommend 
 for general use. Tablet T. 
 
 Tablets T For all anaesthesia in the oral cavity, either for 
 for purely dontal or for surgical operations, the solu- 
 
 General Use tion is prepared from the T tablets. This tablet 
 dissolved in 1 c.c. of salt solution gives a solution 
 containing two j)er cent Novocain and 0.000,02 gram of Supra- 
 renin to 1 c.c. 
 
 Tablets E If deep anaemia is desired, as in cases of dif&- 
 for Deep cult surgical operations (root amputations, im- 
 Anaemia pacted third molars, etc.), the E tablets can be 
 used to prepare the solution. This tablet dis- 
 solved in 1 c.c. of physiological salt solution gives a solution 
 containing two per cent of Novocain and 0.000,05 gram of Su- 
 prarenin to 1 c.c. 
 
PHARMACOLOGY 49 
 
 Tablet F For abnormal cases, arterio-sclerosis, nephritis, 
 
 combined grave cardiac disorders, hysteria, use two F 
 with tablets plus one E tablet dissolved in 6 c.c. of 
 
 Tablet E salt solution. This gives a two per cent solu- 
 
 tion of Novocain containing only 0.000,009 
 gram of Suprarenin to 1 c.c. 
 
 These solutions I find very satisfactory, and they also come 
 very close to the fulfillment of the Sixteen Theses of Seidel. 
 The solution prepared by dissolving the tablets in the salt solu- 
 tion, just before the injection is made fulfills the requirements 
 of Theses I to X. Thesis V discards solutions of Suprarenin 
 and Novocain, which are not mixed by the operator imme- 
 diately before the injection. In the tablets the two ingredients 
 are mixed in a dry state, in which they are better preserved, and 
 as long as no moisture penetrates into the tube, which is pre- 
 vented by the rubber stopper, they do not deteriorate. When 
 the tablets are dissolved we get a water clear solution which, 
 in accord with Thesis II, is to be considered "fresh." Theses 
 XI, XII, and XIII call for different Suprarenin concentra- 
 tions. There are three concentrations required, the normal 
 strength being 0.000,02 grams, which we get Avitli the "T" 
 tal)let; the increased strength being 0.000,05 grams which we 
 get with the "E'' tablet; and the decreased strength being 
 0.000,01 gram, which is only recommended for very serious dis- 
 orders. If such a solution is recpiired it can be obtained by dis- 
 solving two Y tablets and one E tablet in c.c. of salt solution, 
 tins gives a two per cent Novocain solution Avith 0.000,009 gram 
 Suprarenin. Theses XIV and XV have to do with the salt 
 solution, and Tliesis XVI advocates Seidel's method, which 
 certainly is ideal, but not adaptable for us. 
 
 I li;iv(i proved to my satisfaction that llu; "tablet method" is 
 very little behind the method of "separate solutions,'' if the 
 solution is pn^pared coiiscieiit ioiisly, and if we vary the strength 
 of Suprarenin. 
 
50 ORAL ANAESTHESIA 
 
 4. PHYSIOLOGICAL SALT SOLUTION 
 
 The question whether a 0.6 or 0.9% salt solution with two 
 per cent Novocain is isotonic, is theoretically not yet solved, as 
 seen from Theses XIV and XV. In practice, however, I found 
 Braun's solution very satisfactory; he recommends to add a, 
 very small amount of dilute hydrochloric acid to offset the 
 derogatory action of the glass alkali and to prevent oxidation 
 of the Suprarenin. His solution is : 
 
 Sodii chloridi puriss 2.0 
 
 Acidi hydrochlorid. Diluti gtt.l 
 
 Aquae dest 300.0 
 
 Fill the bottle with this solution and boil it fifteen minutes. 
 Lately, however, a new solution, called Kinger solution, has 
 been recommended. It contains the salts found in the blood, 
 and is claimed to fulfill the requirements better still. It con- 
 tains Calcium chloride, which was found by Professor Guerber, 
 Director of the Pharmacological Institute, Marburg, to im- 
 prove the process of absorption in the tissue, and to stimulate 
 the action of the leukozytes. I have been using the Ringer 
 solution for the last three months ; it contains : 
 
 Sodium chloride 0.50 
 
 Calcium chloride 0.04 
 
 Potassium chloride 0.02 
 
 Aquae dest 100.00 
 
 There are Ringer tablets on the market, which are dissolved 
 in distilled water : ten tablets to 100 c.c. aqua dest. The solu- 
 tion is then boiled for fifteen minutes. These simplify the self- 
 production of the salt solution. 
 
 5. DISTILLED WATER 
 
 The greatest difficulty for the conscientious practitioner is 
 to get perfectly distilled water. The druggist does not keep 
 
I'i';. 26. I'cincI Ajjiiaraliis to ijrodiirc dislillfd water. 
 
52 
 
 ORAL ANAESTHESIA 
 
 the distilled water in aseptic condition, and in a short time it 
 becomes impure by the growth of all kinds of fungi and their 
 products. Vegetations of these often can be seen with the 
 naked eye, swimming around in the bottle. Although the fungi 
 themselves are killed when dissolving the tablets, there are 
 still the dead cells and the previously formed toxins toi be con- 
 
 LooIiTi o- water imlet. i>>-_^ ■ 
 
 Cooli.y\^eitt'\: outlet 
 
 Fig. 27. Schematic drawing of distilled water apparatus. 
 
 sidered. Ehrlich found that Infusions of Salvarsan made with 
 commercial distilled water, caused toxic effects which did not 
 occur if fresh, sterile, distilled water was used. 
 
 It is therefore commendable to have special distilled water 
 prepared by a reliable druggist, which then is measured into 
 the well-cleaned and dealkalied bottle. After adding the 
 Einger tablets cook it for fifteen minutes. 
 
PHARMACOLOGY 53 
 
 For large clinics, it is advisable, and in private practice 
 possible, to produce sterile, toxin-free, distilled water with 
 the Femel Apparatus.* The handling is ver^^ simple. Bottle 
 A is filled with commercial distilled water, and the cooler is 
 mounted with a rubber stopper. Cooling water is connected to 
 the inlet and a tube takes care of the overflow. The outlet for 
 the distilled water is connected by a special glass tube to the 
 bottle. The gas is lit under bottle A (without letting the cool- 
 ing water run) to produce steam, which sterilizes the whole 
 outfit. Now the cooling water is opened carefullj' and allowed 
 to run very slowly. The distilled water runs into the bottle, 
 into which the Ringer tablets are added. 
 
 * F. and M. Laiiti'iischhiser, Berlin X. 39; Chausseestrasse 92. 
 
V. INSTRUMENTARIUM 
 
 The instruments required for quick, safe, and aseptic work 
 are: 
 
 Two Fischer syringes, one mounted in a short hub ^yith a 
 26 mm., the other in a long hub with a 45 mm. iridio-platinum 
 needle. I prefer iridio-platinum needles because it simplifies 
 matters, in that they do not need to be boiled before use, can 
 be used again, and therefore can always be mounted on the 
 syringe ready for use. These do not break. If steel needles 
 are used, Avhich often show specks of rust and oxide, one has 
 to boil them and should only use them once. The platinum 
 needles have to be sharpened from time to time Avith a round 
 engine stone. 
 
 The syringes are kept in a glass jar with absolute alcohol, 
 placed on a stand, together with two porcelain dissolving cups. 
 
 The dissolving cups are graduated, one up to three, the 
 other up to 10 c.c, and are used to measure, dissolve and ster- 
 ilize the anaesthetic solution. They are made of porcelain, 
 which can be cleaned with dilute hydrochloric acid. 
 
 The bottle double corked, contains the Ringer solution. 
 
 A glass tray is used to keep tablets and reserve needles. 
 Also an engine stone to sharpen the needles. 
 
 TABLETS 
 
 Novocain-Suprarenin Synthetic Tablet T.* 
 
 Novocain 0.02 gram. 
 
 Suprarenin Synthetic 0.000,02 gram. 
 
 Novocain-Suprarenin Synthetic Tablets E.* 
 
 Novocain 0.02 gram. 
 
 Suprarenin Synthetic 0.000,05 gram. 
 
 * Farbwerke Hoechst Co., Ill Hudson Street, New York. 
 

 
 (U C _ 
 > 'V 
 O *j <U 
 
 a; C 
 
 be S"^ 
 •^ 5 C 
 
 
 <u -^ 
 be <u 
 C o 
 
 Si 
 
 fc-^ 
 
Fig. 29. Syringes. The small syringe with 27 gauge platinum needle for 
 mucous anaesthesia previous to injecting with the large syringe. The next 
 syringe is Fischer's syringe mounted with the short needle. The third is mounted 
 with the 45mm. long needle, and the last one is mounted with the bayonet piece 
 and a 60mm. long needle. 
 
 
 31 
 
 1 
 
 
 I 
 
 ^m?!^r^^ 
 
 ^^^^ 
 
 WL^^ 
 
 s 
 
 
 H 
 
 
 
 ^^^ 
 
 ■ 
 
 
 ■ 
 
 
 
 ^ 
 
 ■ 
 
 i 
 
 ■i 
 
 1 
 
 ^^^^^H 
 
 Fig. 30. Large and small dissolving cups. 
 
PHARMACOLOGY 
 
 57 
 
 Novocain Tablets F* (for special cases only to combine with 
 the E Tablets). 
 
 Novocain 0.05 gram. 
 
 Ringer Tablets* 
 
 Sodiniii Chloride 0.050 gram. 
 
 Calcium Chloride 0.004 gram. 
 
 Potassium Chloride 0.002 gram. 
 
 Dissolve ten tablets in 100 c.c. of aqna dest and sterilize. 
 
 * Farbwerke Hoechst Co., Ill Hudson Street, New York. 
 
VI. PREPARING OF THE 
 SOLUTION 
 
 Kemove the stand from the jar and wash the cup and syringe 
 in distilled water, to remove all traces of alcohol. Fill cup 
 with Kinger solution to the mark required. 
 
 Heat the solution over the flame to boiling. 
 
 Add tablets as follows : 
 
 For normal cases: One T tablet to each c.c. This gives a 
 solution with : 
 
 Novocain 2% 
 
 Suprarenin 0.000,02 gr. to 1 c.c. 
 
 For deep anaemia: One E tablet to each c.c. This gives a 
 solution with : 
 
 Novocain 2% 
 
 Suprarenin 0.000,05 gr. to 1 c.c. 
 
 For abnormal cases: Two F tablets and one E tablet to 
 6 c.c. This gives a solution with : 
 
 Novocain 2 % 
 
 Suprarenin 0.000,009 gr. to 1 c.c. 
 
 Draw the cup through the flame till the tablets are dissolved. 
 Sterilize needle on the syringe in the flame. 
 Fill the syringe and avoid touching the needle. 
 
 REQUIREMENTS OF A SOLUTION PREPARED 
 FROM TABLETS 
 
 1. It should be immediately used after it has been pre- 
 pared. 
 
 2. The solution should not come in contact with anything 
 except the porcelain cup and the syringe. 
 
The manufacturing of the T tablets will be delayed on 
 account of the war. Use instead : 
 
 For normal cases: One F and one E tablet to 3.5 c.c. This 
 gives a solution with 
 
 Novocain 2% 
 
 Suprarenin 0.000,015 gram to 1 c.c. 
 
PHARMACOLOGY 59 
 
 It should not be left longer than absolutely necessary in the 
 dissolving cup nor in the syringe. The solution is very sensi- 
 tive, being affected and clieniically changed by air, heat, light, 
 and especially by alkalies. 
 
 3. The tablets should not be touched witli hands nor instru- 
 ments, and the tube should be closed immediately after use, 
 with the rubber stopper. The tablets are chemically changed 
 by air, light, and especially by moisture. 
 
 4. The tablets should be white; sometimes the uppermost 
 one discolors from chemical changes, caused by improper hand- 
 ling of the tube. 
 
 5. The solution gained from the tablets sliould be clear as 
 water. 
 
 If it shows any light pink color, it should l)e discarded. 
 
VII. LOCAL ANAESTHESIA 
 
 Local Anaesthesia has successfully progressed not only in 
 minor but also in major surgery since we have been enabled, 
 with the later methods, to obtain a really total anaesthesia. 
 For this progress we are principally indebted to Professor 
 Braun. 
 
 There are now different possibilities to produce local anaes- 
 thesia, named according to that part of the sensory nerve sup- 
 ply into which we decide to inject. 
 
 a. The Surface Anaesthesia, 
 
 b. The Infiltration Anaesthesia. 
 
 c. The Conductive Anaesthesia. 
 
 d. The Ganglion Anaesthesia. 
 
 e. The Spinal Anaesthesia. 
 
 The Surface anaesthesia is only used upon mucous mem- 
 branes which absorb it rapidly. 
 
 The Infiltration method anaesthetizes the peripheral nerve 
 
 endings. 
 
 The Conductive method intercepts a whole nerve trunk 
 
 supplying a certain area. 
 
 The Ganglion anaesthesia is obtained by injecting into a 
 ganglion, anaesthetizing all the regions supplied by its 
 branches. 
 
 The Spinal anaesthesia consists of mixing the anaesthetic 
 solution with the liquor cerebrospinalis, and re-injecting of 
 both into the spine. With this method much larger areas can 
 be anaesthetized, but it is only practical in the lumbar X3art of 
 the body, and therefore of no use in oral surgery. 
 
 In the oral cavity we have mainly to deal with the V Cra- 
 nial nerve, which offers many possibilities for local anaesthesia. 
 
PHARMACOLOGY 
 
 61 
 
 Often the question is asked whether local anaesthesia has any 
 bad effects on the pulp of the tooth, or the tissue in general. 
 Both questions can be answered in the negative. A tooth, if 
 anaesthetized properly by the infiltration or one of the other 
 
 Fig. 31. .Schematic illustration of the inctliods of local anaesthesia recommended 
 
 for dental surgery. 1. Surface anaesthesia. 2. Infiltration anaesthesia. 
 
 .3. Conductive anaesthesia. 4. Ganglion anaesthesia. 
 
62 ORAL ANAESTHESIA 
 
 methods named in this book, is not in danger. We only anaes- 
 thetize the nerve fibers, while the circulation of the pulp is not 
 interfered with to any extent, unless an extremely large amount 
 of Suprarenin should be used. Also the surrounding tissues 
 do not suffer, unless irritant antiseptics are added to the solu- 
 tion, as in some preparations which are on the market. We 
 always inject into connective tissue from which the solution 
 absorbs in one hour to one hour and a half, unless the amount 
 of Suprarenin is too high. It is different, however, if we inject 
 accidentally the whole amount into muscle tissue. From this, 
 absorption takes place very slowly, it sometimes requires 
 several days till all is absorbed, during which time the muscle 
 is stiff, sometimes somewhat swollen, and causes, if it is a 
 muscle of mastication, false ankylosis. This disappears with- 
 out treatment. The danger of injecting into a nerve or vessel 
 is also often questioned. To inject into a nerve trunk has no 
 consequences other than a prompt action of the anaesthetic. 
 Arteries are thick walled and elastic, and therefore are not easy 
 to puncture, they rather go out of the way ; veins and capillaries 
 can be avoided if we move the syringe forth and back while 
 injecting. 
 
 In modern local anaesthesia it is a principle to separate the 
 act of anesthetizing from the operation proper, having a 
 waiting time in between, during which the anaesthesia deepens. 
 
 A. SURFACE ANAESTHESIA 
 
 This method depends upon the absorbing quality of the 
 mucous membrane. It has generally no deep action. If a twenty 
 per cent solution of Novocain made from the F tablets is ap- 
 plied to the gTim it causes superficial anaesthesia sufflcient for 
 fitting bands in bridge work or finishing a filling at the cervical 
 margin. It also can be used previous to the insertion of the 
 needle. There is, however, one method of surface anaesthesia 
 which gives good results, this is the anaesthesia from the nose. 
 
LOCAL ANAESTHESIA 63 
 
 NASAL ANAESTHESIA 
 
 Place a piece of cotton saturated with a twenty per cent solu- 
 tion of Novocain into the inferior meatus of the nasal cavity.. In 
 a short time the solution will penetrate through the mucous 
 membrane of the nose and anaesthetize the incisor teeth of the 
 respective side. 
 
 B. INFILTRATION ANAESTHESIA 
 
 This method depends up(m diffusion of the solution through 
 the pores of the bone, thus reaching the dental nerve, before 
 it enters the tooth. 
 
 For dental anaesthesia use : 
 
 For single-rooted teeth, labial or buccal injections. 
 For multi-rooted teeth, buccal and palatal injections. 
 
 For surgical anaesthesia use : 
 
 For all teeth, labial or buccal and palatal injections. 
 
 The solution is injected into the submucosa, from where it 
 penetrates into the bone, depending upon the action of the 
 Suprarenin to prevent quick absorption. Anaesthesia can be 
 produced in five minutes and lasts one hour. It is at its best 
 in ten minutes, and after half an hour it disappears gradually, 
 the solution being absorbed slowly. 
 
 The maxilla is (as we have seen in another 
 The Infiltration chapter) especially well adapted for the in- 
 Method in filtration method, on account of the thin 
 
 the Maxilla construction of the outer alviolar plate, and 
 
 its porous make-up. This method can be 
 used for any teeth in the upper jaw. The bicuspids and incisors 
 are the easiest to anaestlietize; next come the cuspids and third 
 mohn-s, while the first and second molars sometinies show some 
 difficulties on account of the zygomatic process forming a cor- 
 tical mass over these teeth. 
 
64 
 
 ORAL ANAESTHESIA 
 
 PREPARING OF THE PATIENT 
 
 If local anaesthesia is to be used on a patient the operator 
 has never injected for, or in an entirely strange patient, one 
 should inquire while leisurely conversing whether the patient 
 has any severe illness, requiring a decrease in the percentage 
 of suprarenin. If the subject of injection is opened, the 
 
 Fig. 32. Frontal section through the molar region showing buccal and palatal 
 injection by the infiltration method. 
 
 A. Position of needle for palatal injection; B. Position of needle for buccal or 
 labial injection, a. Sinus frontalis; b. M. orbicularis oris; c. Cellula ethmoidahs; 
 d. Bulbus oculi ; e. Concha nasalis inf.; f. Meatus nasi inferior; g. Concha nasalis 
 media; h. Meatus nasi medius; i. Septum nasi; k. Processus zygomaticus; 
 1. Sinus maxillaris ; m. Plexus dentalis superior ; n. M. masseter ; o. Mi. buccina- 
 tor; p. Dens molaris primus; q. Membrana mucosa buccalis; r. Processus 
 alveolaris; s. Pulpa dentis; t. Membrana mucosa palatinae; u. Processus pala- 
 tinus; v. Cavum oris; w. Cavum buccalis; x. Membrana mucosa alveolaris; 
 y. Glandulae palatinae; z. (1) Radix palatinae; z. (2) Radix buccalis. 
 
LOCAL ANAESTHESLi 
 
 65 
 
 patient usually mentions of his own accord previous disagree- 
 able experiences, if be bas bad any, and tbe operator can con- 
 duct bimself accordingly. Tbis is also tbe time to assure tbe 
 patient of tbe safety of tbis anaesthetic, and of tbe great advan- 
 tage to botb tbe patient and tbe operator, sparing tbe first tbe 
 pain, and allowing tbe latter to use bis best ability to perform 
 tbe operation. 
 
 PREPARATION OF PLACE FOR INSERTION OF 
 THE NEEDLE 
 
 An unclean moutb should first be sprayed out with an anti- 
 septic solution. Hold tbe lip away from tbe gum, and witb a 
 sbort cotton roll wipe all tbe mucus from tbe field of opera- 
 tion. Tlien witb a little bit of cotton dipped in campbo-pbe- 
 ni(pie, or solution of aconite and iodine, equal parts, sterilize 
 and anaesthetize tbe part Avhere tbe needle is to be inserted. 
 In very sensitive patients I use a small hypodermic syringe, 
 with a very fine and sharp platinum needle, and inject a few 
 drops of Novocain solution previous to tbe regular injection. 
 
 I'lf,. 33. Position of operator vvlicn injecting for an upper tooth by the 
 inllltration luctliod. 
 
66 
 
 ORAL ANAESTHESIA 
 
 1. Injection on the labial and buccal side of the Maxilla. 
 
 The point of insertion on the labial and buccal side is half- 
 way between the gum margin and apex of the root. For cus- 
 pids it is advisable to start higher up, and for the molars one 
 should start over the mesial root, or still farther forward, push- 
 ing the needle obliquely backward and upward, to reach a point 
 between and a little higher than the apices of the buccal roots. 
 
 Fig. 34. Radiograph showing the infiltration method for an upper incisor. 
 
 This to overcome technical difficulties. The upper wisdom 
 tooth is sometimes hard to reach, its neck is usually well set in 
 and at a higher level than the other molars. In these cases it 
 is best to use the long needle, insert it very high at the level 
 of the apex, but further forward over the twelve-year molar, 
 and push it backward and inward in horizontal direction. The 
 process around the third molar is very j)orous and anaesthesia 
 
Fig. 35. Radiograph showing the infiltration method for an upper cuspid. 
 
 Fio. .36. Radioj^raph showinf^ the infiltration method for an upper hicuspid. 
 
68 
 
 ORAL ANAESTHESIA 
 
 usually takes easy effect. Generally the short needle is used. 
 Push it, opening directed toward the bone, down to the perios- 
 teum. A drop or two is injected. Now the syringe is best 
 held like a writing pen, and after the first injection has taken 
 effect, push it slowly and carefully upwards, if necessary, in- 
 jecting as you go along, till you are opposite the apex of the 
 root. Here inject slowly and evenly, moving the syringe 
 slightly forth and back, to avoid injecting into a small vein. 
 In this manner a depot of 1 to If c.c. is deposited, into the sub- 
 mucous tissue between mucous membrane and bone. Tiittle 
 
 Fig. 37. Wrong position 
 of needle. 
 
 Fig. 38. Right position of 
 
 needle opening pointing 
 
 towards the bone. 
 
 force is needed to inject. After five to eight minutes, anaes- 
 thesia occurs in the tooth injected for, sufficient to extirpate 
 the pulp without pain. ( See Table I. ) 
 
 2. Injection on the palatal side of the maxillary teeth. 
 
 The palatal gum of the maxilla is supplied by the anterior 
 palatine and naso-palatine nerves, therefore for surgical opera- 
 tions an additional injection to produce anaesthesia of the soft 
 parts is required. Also for the molars, and often for the first 
 bicuspid, a palatal injection is needed to anaesthetize the 
 palatal root. For these injections we start at the gingival 
 margin, push the needle down parallel with the process, and in- 
 ject 0.25 c.c. again into the part which takes up the solution the 
 easiest, the submucous tissue. After five to eight minutes an- 
 aesthesia occurs. (See Table II.) 
 
LOCAL JNJESTHESL4 
 
 69 
 
 AVe have studied the lower jaw and found 
 The Infiltration it porous only in the mental fossa, and at 
 Method in the genial tubercles, while in the region of 
 
 the Mandibula the back teeth the bone is very dense. The 
 infiltration method, therefore, is not advis- 
 able for the lower jaw, except for the four incisors. 
 For dontal anaesthesia use labial injections. 
 For surgical anaesthesia use labial and lingual injections. 
 
 Fig. 39. Radioj^rapli slunving tlie infiltration nutliod for a l(nver incisor. 
 
70 
 
 ORAL ANAESTHESIA 
 
 1. Injection on the labial side of the mandibular incisors. 
 
 Here the procedure is very much like in the maxilla, often, 
 however, it is easier to insert the needle over the tooth next to 
 the one we wish to anaesthetize, pushing it obliquely toAvard 
 the apex of the tooth in question. (See Table I.) 
 2. Injection at the lingual side of the mandibular incisors. 
 
 The procedure is very much like that at the palatal side of 
 the maxilla. The lingual gum is supplied by the lingual nerve. 
 This injection is only necessary in case of extraction of the 
 lower incisors. (See Table II.) 
 
 To avoid repeated puncture of the mucous mem- 
 Horizontal brane, if several adjoining teeth are to be anaes- 
 Injection thetized from the labial or buccal side by the in- 
 filtration method, the long needle is inserted 
 over the apex of the root of the tooth farthest forward 
 or nearest the operator. After having injected for this 
 
 Fig. 40. Radiograph showing the horizontal injection for bicuspid and molar region. 
 
LOCAL ANAESTHESIA 
 
 71 
 
 first tooth, push the needle along the bone in horizontal 
 direction, till you have reached the place opposite the apex of 
 the second tooth ; here again deposit some of the solution and 
 proceed in same manner for the next tooth. This method can 
 be used for a series of teeth in the incisor region, in the upper 
 as well as in the lower jaw, and for anaesthetizing adjoining 
 maxillary bicuspids and molars. The use of the horizontal 
 injection is only advisable in healthy tissue. It is easy to see 
 
 Fig. 41. Radiograph showing the horizontal injection in a coronal section. 
 
 how we would spread an infection, if the needle was passed 
 through an abscess, while anaesthetizing the' first tooth, all the 
 area woubl ))e inoculated. For infected areas we resort to the 
 conductive method. For surgical anaesthesia use tlie conduc- 
 tive iiietliod ;it the palatal side. 
 
 G. CONDUCTIVE ANAESTHESIA 
 
 In tlie conductive method the conductivity of the main trunk 
 of the nerve supplying the teeth and tissues in the oral cavity 
 
72 
 
 ORAL ANAESTHESIA 
 
 is intercepted or blocked at a convenient point, while in the 
 infiltration anaesthesia the drng acts on the peripheral nerves. 
 As the place of insertion is nsually quite removed from the 
 field of operation, we resort to this method, if the infiltra- 
 tion method is contra-indicated on account of septic condi- 
 tions. It is used if the infiltration method cannot be applied, 
 
 •^ 
 
 Tig- 2 
 
 T^p- 5 
 
 n 
 
 Fig. 42. Conductive Anaesthesia. 1. Zygomatic injection; 2. Infra-orbital in- 
 jection; 3. Pterygo-mandibular injection; 4. Mental injection. 
 
LOCAL JXJESTHESLd 73 
 
 on aceoiuit of the anatomical stnu-tnre of the jaw. AVe may 
 resort to it if several teeth supplied by one nerve trunk are 
 to be operated upon, and we use it in combination with the 
 infiltration method for large surgical operations, to combine 
 extensive anaesthesia with anaemia of the field of operation. 
 Halstedt (1885) was the first to use conductive anaesthesia, 
 blocking otf the inferior alviolar nerve at the mandibular fora- 
 men. 
 
 FOR DONTAL OPERATIONS 
 Conductive Method For purely dontal operations we need 
 in the Mandible only anaesthesia of the nerve which 
 
 supplies the teeth. It enters the man- 
 dible through the mandibular fora- 
 men. For anaesthesia of the molars and bicuspids on one side, 
 one injection over the mandibular foramen into the pterygo- 
 mandibular space is sufficient. The cuspid and two incisors 
 are sometimes also anaesthetized, sometimes remain slightly 
 sensitive on account of the anastomosis from the other side. 
 Another injection into the mental fossa, or over the mental 
 foramen of the opposite side is needed in the latter case. For 
 anaesthesia of all the lower teeth, one should use two injec- 
 tions, one over each of the mandibular foramina. 
 
 FOR SURGICAL OPERATIONS 
 
 For surgical operations we need not only anaesthesia of the 
 teeth, but also of the soft tissue surrounding them. On the 
 inner side this region is supplied by the lingual nerve; on the 
 buccal side, by the inferior alviolar nerve; and by the buccina- 
 tor nerve in the region of the first and second molar and second 
 ])i(nspid. Therefore we need anaesthesia of the lingual and 
 Imccinator nerve in addition to the alviolar. The inferior 
 alviolar and lingual nerves can be anaesthetized with the same 
 injection, and often also the buccinator nerve is reached, espe- 
 cially if a large amount is injected. Most frequently, however, 
 it is necessary to inject for the buccinator nerve. 
 
74 ORAL ANAESTHESIA 
 
 Fig. 43. Diagram showing injection into the pterygo-mandibular space. 
 
 a. N. alviolaris inf. ; b. A. alviolaris inf. ; c. N. lingualis ; d. Spatium pterygo- 
 mandibulare ; e. Linea obi. externa ; f. Linea obi. interna ; g. Trigonium retro- 
 molare; h. Ramus mandibulae; i. M. masseter; f. M. Pterygoid int.; 1. Position 
 
 of needle. 
 
 I. PTERYGO-MANDIBULAR INJECTION 
 
 For the right side, stand in front of the patient, palpitate 
 the external oblique line of the ramus, then the internal oblique 
 line with the thumb of the left hand, and finally place the tip 
 of the thumb into the depression between, the post-molar tri- 
 angle. The thumb is left there to guide the insertion of the 
 needle and the other fingers fix the jaw. 
 
 For the left side, place the left arm around the patient's 
 head and palpitate the post-molar triangle with the tip of the 
 index finger. On this side, the index finger serves as guide for 
 the insertion of the needle, while the other fingers are used to 
 hold the jaw. 
 
 Prepare the place of insertion in the usual manner. This 
 injection is the least painful, but, as in all cases of conductive 
 anaesthesia, stferilization of the place where the needle is in- 
 serted and scrupulous asepsis is of utmost importance. 
 
 Place the syringe, mounted with the long iridio platinum 
 needle (45 m.m.) between cuspid and first bicuspid of the 
 
J-IG. 44. Technique of inserting the needle for the Plerygo-mandil)ular injection. 1, 2 and 3, 
 on the right side; 4, 5 and 6, on the left side. 1 and 4, fecliiigof the internal oblique 
 line. 2 and •>, adjusting jjositiftn of the syringe parallel witli the ramus. 3 and 5, reaching 
 
 the pterygo-niandihular space. 
 
76 
 
 ORAL ANAESTHESIA 
 
 opposite side, and insert the needle into tlie mncons membrane 
 1 cm, over the last molar, and close to the finger nail. Inject 
 a small quantity to anaesthetize the superficial structtires. 
 
 Push the needle forward till you feel the internal oblique 
 line. If you do not find it, it is because you are too far to the 
 
 Fig. 45. Pterj-gc-mandibular injection on the right side; position on patient. 
 
 median line, in which case the error can be corrected by punct- 
 uring the mucous membrane at a place more to the outside. 
 
 Push the needle slowly forward and change the direction of 
 the syringe, so as to bring it parallel with the ramus. This 
 
Q-> 
 
 h 
 
[X. 
 
(1( 
 
80 
 
 ORAL ANAESTHESIA 
 
 clianges the position of the baek part of the syringe, bringing it 
 over the incisors, or further back over the bicuspids. 
 
 Now comes the distinction for dental and surgical anaesthe- 
 sia. The lingual nerve lies anterior and medially of the alvio- 
 lar nerve, halfway between the alviolar nerve and the mucous 
 membrane. Therefore, \)j depositing one-third of the solution 
 when the needle is halfway in, we will anaesthetize the lingual 
 nerve. 
 
 Sulcus mandibularis with needle, which is inserted one centimeter over the occlusal surface. 
 
 After the lingual nerve has been injected for, the syringe is 
 pushed along the bone into the pterygo-mandibular space. It 
 should reach the space above the lingula. If we insert the 
 needle too low, it passes over the lingula into the muscle. 
 The needle is now moved slightly forth and back while the 
 injection is made. 
 
 In this way we anaesthetize the lingual and ^the inferior 
 alviolar nerve. If we want anaesthesia of the teeth only, we 
 do not inject till we have reached the pterygo-mandibular space, 
 
LOCAL ANAESTHESLi 81 
 
 where we deposit 1.5 to 2 c.c. In this manner, we avoid an- 
 aesthesia of the lingual nerve. 
 
 It is of double advantage not to inject while inserting the 
 needle. The danger of infiltrating muscle bundles is decreased, 
 and the whole amount of the solution can be utilized to anaes- 
 thetize the inferior alviolar nerve. 
 
 Anaesthesia occurs in fifteen to twenty minutes, and lasts at 
 least one hour. 
 
 In children the needle should be directed slightly down- 
 ward; in old patients slightly upward on account of the differ- 
 ent relation of the mandibular foramen. (See Figure 14.) 
 
 For longer anaesthesia inject two syringes full, or 4 c.c. 
 at once. (See Tables III and IV.) 
 
 The first sign the patient experiences is numbness of the 
 lower lip and, if the lingual nerve is anaesthetized, also numb- 
 ness of the tongue. These are signs of a successful injection, 
 and occur in a very short time. It is important in this anaes- 
 thesia, especially for nerve extractions, to wait till it has 
 reached its deepest stage; this sometimes takes thirty minutes, 
 working from the median line backwards. 
 
 Failures in this injection occur if the internal oblique line 
 is ignored, if the needle loses the contact with the inner side of 
 the ramus, or if the injection is too low. It is important to 
 inject in a horizontal plane one centimeter over the last molar 
 to reach the pterygo-mandibular space above the lingula. If 
 we insert the needle along the bone too far down, we find that 
 a projecting lingula guides the needle directly into the muscle, 
 and this we want to avoid. 
 
 2. MENTAL INJECTIONS 
 
 For the injection into the mental foramen, we insert the 
 needle into the reflexion of the mucous membrane, below the 
 first bicuspid. Holding the finger tip over the foramen, com- 
 press the mucous membrane, and push the needle down and 
 sliglitly back along the bone for several millimeters. AVlien 
 
Fig. 52. Radiograph showing the pterygo-mandihular injection. 
 
84 
 
 ORAL ANAESTHESIA 
 
 Pressing 
 
 felt under the finger inject into the foramen 1 c.c 
 
 while injecting will direct the solution through the mental 
 
 foramen into the mandibular canal. ( See Tables III and IV. ) 
 
 Fig. 53. Radiograph showing injection into the mental foramen. 
 
 3. BUCCINATOR INJECTION 
 
 For the buccinator nerve make one injection, either directly 
 into the mucous membrane supplied by it or, in case of inflam- 
 mation by conductive anaesthesia, inserting the needle just 
 below the Stenson's duct, pushing it backward toward the 
 
LOCAL ANAESTHESIA 85 
 
 ramus. The area supplied by the buccinator nerve varies in 
 different individuals, and it is not always necessary to inject 
 for this nerve specially. Often it is also reached with the 
 pterygo-mandibular injection. 
 
 We have studied the nerve supply in the maxil- 
 Gonductive lary bone and found it much more complicated 
 Anaesthesia than in the mandible. The method to anaesthet- 
 in the ize the maxillary nerve after it comes from the 
 
 Maxilla foramen rotundum is very diflftcult and there- 
 
 fore, we usually prefer to use two injections to 
 block the sensation carried by the superior alviolar nerves, and 
 two injections to anaesthetize the soft tissue of the palate. 
 
 For dontal anaesthesia use to anaesthetize: 
 
 Maxillary molars and bicuspids : zygomatic injection. 
 Maxillary incisors and cuspids : infra-orbital injection. 
 
 For surgical anaesthesia use to anaesthetize : 
 
 Posterior part of maxilla : zygomatic and posterior pala- 
 tine injection. 
 
 Anterior part of maxilla : infra-orbital and incisive injec- 
 tion. 
 
 For large surgical operations use to anaesthetize : 
 Whole maxilla : spheno-maxillary injection. 
 
 1. ZYGOMATIC INJECTION 
 
 Palpitate the zygomatic process of the maxilla, preparing 
 the place of insertion as above and sliding the long needle, 
 keeping close to the bone, upward, backward and inward, 
 depositing the solution while injecting. In this manner the 
 two posterior superior branches and often also the middle 
 superior branch are crossed by the direction of the needle, and 
 anaestlielized ])y the solution, desensitizing the molars and, in 
 favorable cases, also the bicuspids. It is often advisable to 
 
86 
 
 ORAL ANAESTHESIA 
 
 inject in two directions to reach all the superior alviolar 
 branches. The horizontal direction will reach the posterior 
 superior alviolar branches, while the more vertical direction 
 will reach the middle superior alviolar nerve, in the case this 
 is given off before the maxillary nerve enters the infra-orbital 
 canal. The zygomatic injection gives also anaesthesia of the 
 buccal part of the gum. Inject 2 c.c. Anaesthesia occurs in 
 ten minutes and lasts one hour. (See Tables III and IV.) 
 
 Fig. 54. Infra-temporal surface of the maxilla. The posterior superior alviolar 
 branches are shown entering the foramina. One branch is a gingival branch. 
 
 2. INFRA-ORBITAL INJECTION 
 
 Palpitate the infra-orbital foramen and place upon it the 
 tip of the thumb or index finger. With one of the other fingers 
 retract the upper lip and after preparing the place, insert the 
 long needle in the canine fossa, as high as the reflection of the 
 mucous membrane allows. Push it along the bone until felt 
 under the finger. While compressing the soft tissue over the 
 
I-"|(,. 55. Kadioj^ra])!! showing zygrjiiiatic injection. 
 
ORAL ANAESTHESIA 
 
 foramen with the finger, inject slowly and evenly 1 c.c. In this 
 manner the solution is pressed into the infra-orbital canal 
 where it reaches the anterior superior alviolar nerve. Anaes- 
 
 FiG. 56. Infra-orbital injection on the right side. 
 
 thesia occurs in the incisors and cuspid. This injection is only 
 indicated in alviolar abscesses and larger surgical operations. 
 (See Tables III and IV.) 
 
LOCAL ANAESTHESIA 
 
 89 
 
 3. INCISIVE INJECTION 
 
 If anaesthesia of the anterior part of the palate and palatal 
 gum is desired, we insert the needle in the median line, between 
 the two npper central incisors. Pnsh it along tlie hone and yon 
 
 Fig. 57. Radiograph sliowing Infra-orbital injection. 
 
 cannot fail to get into tlie incisive foramen. A few drops pro- 
 duce anaesthesia in the palatal part of the gum behind the max- 
 illary incisors and cuspids, in five minutes. (See Table IV.) 
 
90 ORAL ANAESTHESIA 
 
 4. POSTERIOR PALATINE INJECTION 
 
 To get anaesthesia of the posterior part of the palate and 
 palatal part of the gum, the needle is inserted near the gingival 
 margin of the mesial part of the third molar (in children, of 
 the last molar present.) Push it slightly upward and back- 
 ward, till the palatal process is reached. The main trunk of 
 the nerve passes forward in a groove between the alviolar and 
 palatal process, and if the foramen is not reached exactly, we 
 are sure to anaesthetize the anterior palatine nerve. Inject 
 only a few drops ; if more than 0.3 c.c. is injected, anaesthesia of 
 the soft palate occurs, which is undesirable. The anaesthesia 
 occurs in a few minutes and reaches as far forward as the cuspid 
 teeth. (See Table IV.) 
 
 5. SPHENO-MAXILLARY INJECTION 
 
 In large cases of oral surgery and especially if the entire 
 region of the maxilla is in a pathological condition, we can 
 take resort to the spheno-maxillary injection, anaesthetizing 
 the whole second division of the trigeminal nerve in the spheno- 
 maxillary fossa after it emerges from the foramen rotundum. 
 The point of insertion is below the junction of the zygomatic 
 process of the maxilla and the malar bone. Keeping in close 
 contact with the infra-temporal surface of the maxillary bone, 
 the needle is advanced carefully, obliquely upwards, for four 
 centimeters. (This injection requires a special needle of larger 
 size and five and one-half centimeters in length, mounted most 
 advantageously on the bayonet-shaped piece in the long hub.) 
 Inject a small amount as you go along till you reach the spheno- 
 maxillary fossa, where the main injection is made. The doses 
 should not be too small, 4 c.c. of a two per cent solution will 
 give complete anaesthesia in fifteen minutes. (See Table IV.) 
 
LOCAL ANAESTHESIA 91 
 
 D. GANGLION ANAESTHESIA 
 
 Haertel* describes in liis article some of the largest surgical 
 operations of the face as resections of the maxilla, large tumor 
 operations, and also cases of neuralgia, where he used ganglion 
 anaesthesia of the Vth nerve with great success, either with 
 Novocain or in neuralgia with alcohol. The anaesthesia was 
 mostly produced on both sides by a double injection. 
 
 Fig. 58. Schematic drawing showing the injection into the Gasserian Ganglion. 
 
 INJECTION INTO THE GASSERIAN GANGLION 
 
 Insert the needle in the cheek (after preparing the place 
 in the usual manner) opposite the gingival margin of the second 
 maxillary molar, after anaesthetizing the tissue superficially, 
 push the needle upward between the upper jaw and ramus of 
 the mandible till it reaches the base of the skull striking the 
 l»l;iiiiiiii infratemporale. While inserting the needle we place 
 the index finger of the left hand into the superior part of the 
 vestibuliim oris to prevent the needle from piercing the mucous 
 membrane of the mouth. After having reached the base of the 
 skull, the direction of the needle is adjusted by the following 
 rules: If we look at it from front, we find that it points in the 
 
 * Haifrlel: KortHi-liritic aiif <liiii (iebioto dcr Local A iiaesthesie. Zeitschrift fuer aerztlicho 
 Fortbildiing. 1914. 1. 
 
92 
 
 ORAL ANAESTHESIA 
 
 direction of the pupil of the eye of the same side, and if we look 
 at it from the side it points towards the tubereulum articulare 
 of the zygomatic arch. Feeling our way forward along the 
 bone we reach the third division of the fifth nerve, where it 
 emerges from the foramen ovale. The patient will give a sign 
 of pain when the nerve is reached. The distance up to this 
 
 Fig. 59. Foramen ovale in the skull seen from the position of the operator. 
 
 point is five to six centimeters. Now the needle is inserted 
 one and one-half centimeters into the substance of the ganglion. 
 Inject 1 c.c. of a two per cent solution of Novocain containing 
 0.000,02 gram of Suprarenin to 1 c.c. Scrupulous asepsis is 
 of greatest importance. 
 
VIII. FAILURES AND ILL- 
 EFFECTS IN LOCAL 
 ANAESTHESIA 
 
 Although failures iu general anaesthesia might have grave 
 results, failures in local anaesthesia do not endanger the pa- 
 tient's life as long as the maximal dose is not reached. If we 
 consider the ability local anaesthesia gives us to improve the 
 quality of our work, saving the patient suffering at the same 
 time, and the possibility to do away with the dangers, handi- 
 caps, discomforts, and after-effects of general anaesthesia for 
 exodontia and minor surgical operations in the oral cavity, the 
 small percentage of failures forms a negligible factor, which 
 can be almost entirely eliminated with perfected technique, 
 reliable anaesthetics and careful elimination of infection during 
 and after the operation. We meet failures and ill-effects in 
 local anaesthesia of various kinds: 
 
 A. True failures and ill-effects. 
 
 B. Psychological effects. 
 
 C. Ill-effects due to other sources. 
 
 Failures and ill-effects very frequently occur 
 True Failures not from the injection, but from the psychic 
 andlll-Eftects attitude of the patient, or other causes, 
 
 wliicli we will consider later. True failures 
 can be classified as follows: 
 
 a. No or insufficient anaesthesia is obtained. 
 
 b. Undesiralde symptoms during anaesthesia. 
 C. Aftf-r-effccts. 
 
 a. No anaesthesia is obtained. This can be entirely 
 eliminated, if (Ik; cause is ascertained. If no anaesthesia oc- 
 
94 ORAL ANAESTHESIA 
 
 curs, if it is not sufficiently deep, or if it does not last long 
 enough, we can repeat the injection, avoiding the second time 
 the probable error. In the infiltration method it is important 
 to use the same puncture, not only to avoid unnecessary dam- 
 age to the mucous membrane, but also because the solution 
 might be lost through the first puncture, if a second one is 
 made close by. Failures of result usually come from: 
 
 1. Insufficient knowledge of the anatomy of the oral cavity. 
 
 2. Insufficient apparatus or technique. The anatomy and 
 technique should be clearly in the mind of the operator. After 
 some practice these sources of failure are soon eliminated. In 
 the infiltration method the most frequent causes are, if the part 
 opposite the apex of the root is not reached, or if the contact 
 with the bone is lost. In conductive anaesthesia, if we inject 
 into muscle tissue instead of .into the connective tissue sur- 
 rounding the nerve trunks. This is especially true in the 
 pterygo-mandibular injection, where we are sure to infiltrate 
 the internal pterygoid muscle, if we lose the contact with the 
 ramus or insert the needle too low. In the case where we are 
 too low down, we slide over the lingula into the muscle, this 
 should be avoided. The insertion should be made one centime- 
 ter over the last molar, this is above the lingula. 
 
 3. Inefficient drugs or drugs deteriorated through age, 
 chemical or bacteriological influences. If the solution shows a 
 slight pinkish color it is a sign of changes that have taken place. 
 Anything that deteriorates the drugs decreases their anaes- 
 thesia producing power. Tlie anaesthetic should be fresh and 
 the solution water clear. 
 
 4. Too large percentage of suprarenin is liable to interfere 
 with the infiltration of the center of thick nerve trunks, on ac- 
 count of its astringent properties. 
 
 b. Undesirable symptoms during the anaesthesia. It is 
 
 hard sometimes to distinguish whether such symptoms are due 
 
FAILURES AND ILL-EFFECTS 95 
 
 to psychological effects, or to the anaesthetic. In this chapter 
 we will consider the latter: 
 
 LOCAL SYMPTOMS 
 
 There is pain experienced during the injection. This is 
 due: 
 
 1. From injecting a too cold or hot solution. The solution 
 ought to be of blood temperature. This can be easily obtained 
 by my described method, where the solution is specially pre- 
 pared every time before use. 
 
 2. From drugs (antiseptics) added to the solution to keep 
 the solution sterile. Seidel found in applying the velum test 
 on the cutis of the arm that thymol added to solution produces 
 in some cases severe pain. 
 
 3. From the solution not being isotonic with the blood, too 
 liigh or too low a percentage of salt causes osmotic pressure. 
 
 4. From injecting into an acute abscess, this should be 
 avoided from obvious reasons. 
 
 GENERAL SYMPTOMS 
 
 The heart action may be increased, sweating may occur or a 
 queer feeling in the extremities. If these are not of psycho- 
 logical origin they can only come from: 
 
 1. Tlie suprarenal substances. In the beginning I used 
 adrenolin solution 1:1000, whicli of course deteriorates much 
 quicker than the synthetic suprarenin. I injected into one 
 patient a solution of two per cent Novocain, and three drops of 
 Adrenolin to 1 c.c. After only injecting 0.2 c.c. for a maxillary 
 cuspid, tlie above-mentioned symptoms appeared in extreme 
 degree, cold sweating and muscular pains lasted two hours. I 
 credit the cause to toxic effects from the adrenolin, which I 
 received fresh from the drug store. It was slightly discolored. 
 Since using synthetic sui)rarenin I have had no more such 
 grave experiences, but in some patients I observed every time 
 
96 ORAL ANAESTHESIA 
 
 slight effects of sweating on the forehead or qneer feeling iu 
 the fingers. I credit this to too high percentage of Suprarenin 
 contained in the E tablets, and have therefore asked for the 
 manufactnring of a new tablet, which I recommend for all nor- 
 mal cases. This, the T tablet, contains only 0.000,02 gram 
 Synthetic Snprarenin to 1 c.c. 
 
 Potassium bromide or "valyl" highly recommended by Pro- 
 fessor Kionka, in Breslan, may be given in these cases. The 
 latter is valuable in cases of increased pulse and heart action 
 and trembling. It also can be given as a preventive, one- 
 quarter to one-half hour before the operation, to counteract 
 nervousness. 
 
 In cases of fainting, tip the patient's head between his 
 knees, give aromatic spirits of ammonia, strong black coffee, oil 
 of camphor, or strychnine sulphate. Some of these agents 
 should always be kept handy. Black coffee is a splendid stimu- 
 lant on account of its lasting action. 
 
 c. After-effects. We must consider that after-effects fre- 
 quently occur after operation or extraction, from other reasons 
 than the injection. These will be considered in another chap- 
 ter. After-effects are oedema and after-pain. 
 
 Oedema. This is a simple swelling caused by infiltration 
 of serum. It may be caused : 
 
 1. By solutions which are not isotonic. By traumatism, 
 caused by inserting the needle several times in the same part, 
 correcting the direction. In conductive anaesthesia, by pierc- 
 ing the inferior pterygoid muscle or injecting into the same. 
 This also may cause ankylosis of the mandibula and difficult 
 deglutition. 
 
 2. Through toxic or irritating effects upon the protoplasm 
 from deteriorated drugs, antiseptics or other unnecessary addi- 
 tions to the anaesthetic solution. Also to large percentage of 
 Suprarenin in very sensitive tissue. 
 
FA ILL' RES AND ILL-EFFECTS 97 
 
 3. From iujection into muscles. Although an anaesthetic 
 solution is absorbed quickly and without disturbance from 
 connective tissue, if the percentage of suprarenin is not too 
 high, it is a ditferent question, however, if muscles are infil- 
 trated. Here the absorption is sluggish, and takes sometimes 
 two or three davs. This may cause swelling. In conductive 
 anaesthesia of the mandible, there is great danger to inject into 
 the internal pterygoid nuiscle, which causes swelling and often 
 also false ankylosis and difficult deglutition. 
 
 Oedema not complicated by infection will disappear with- 
 out treatment. 
 
 After-pain. In treating pain after injections, we have to 
 consider that post-operative pain frequently occurs from causes 
 which have nothing to do with the injection. These are consid- 
 ered later. Pain from the injection can only be ascertained 
 after a purely dontal operation. After-pain very seldom occurs 
 from the injection. Causes are: 
 
 1. Deteriorated drugs. 
 
 2. Unnecessary additions to the solution, such as anti- 
 septics. 
 
 3. Infection from non-sterile solution, syringe or needle. 
 
 4. Infection taken up by the needle, from the mucous mem- 
 brane or fluids of the mouth. 
 
 ."). Infection of the puncture during the anaesthesia. 
 (;. Infection of the puncture after the operation, 
 
 PROLONGED ANAESTHESIA 
 
 Cases of prolonged anaesthesia have been reported lasting 
 for several days or weeks. These, however, can always be 
 traced to: 
 
 ]. Injury of a nerve during operation, as in tlie lower jaw, 
 if the tooth sockets come in contact with the mandibular canal. 
 KsjX'cially in impacted wisdom teeth, there is danger of injur- 
 ing the inferior alviohii* nci've. 
 
98 ORAL ANAESTHESIA 
 
 2. Injury of the mandibular canal. Loosening a piece of 
 bone whicb, if pressed downward, can cause anaesthesia by 
 pressing upon the nerve. 
 
 3. Injecting of alcohol causes prolonged anaesthesia, it is 
 therefore important to remove the alcohol carefully from the 
 syringe and dissolving cups. 
 
 In nervous and hysteric persons, the patient's 
 
 Psychological mind and imagination plays a great part in 
 
 Effects the success of the injections and operator, and 
 
 it is well to say a few words in regard to the 
 
 attitude of the operator towards the patient. 
 
 We get so accustomed to our work that we neglect to realize 
 the fear and terror some sensitive patients experience previous 
 to an operation. We forget that many people make it their pas- 
 time to talk about nothing else but symptoms, cures and opera- 
 tions of diseases, and that some are walking encyclopedias 
 of the ill-effects, accidents, or after-effects of drugs, and spread 
 their knowledge among their friends. Some associate every 
 syringe with cocaine, and are terrified of cocaine poisoning, 
 and others are alarmed by the numbness produced by an anaes- 
 thetic, confusing it with paralysis. 
 
 Sometimes the respiration is increased, and the patient per- 
 spires on the forehead. This very frequently is fear, and often 
 is seen after insertion of the needle before a drop is injected. 
 
 The best example is one of the cases I demonstrated on at 
 the Massachusetts State Society Meeting of 1913. While ex- 
 plaining the technique of the injection to the audience, the pa- 
 tient, a mail-carrier of about 30-35 years, collapsed. I had not 
 made any injection, but the patient, which was weakened from 
 severe pain, collapsed from fear caused by the explanation and 
 description of the operation. 
 
 Dr. Frohman had a case for extraction of two wisdom teeth, 
 with somewhat similar experience. Only that the patient 
 fainted after the injection; he succeeded, however, in extracting 
 
FAILURES AND ILL-EFFECTS 99 
 
 one wisdom tooth, and when the patient came back (after two 
 weeks) for extraction of the other wisdom tooth, he hesitated 
 to give an anaesthetic. He nsed the ethyl-chloride spray for 
 a very short time, and at once the same symptoms appeared. 
 
 It is fear which we have to conquer, in all these cases, and 
 the antidotes are, convincing attitude, sureness of result, confi- 
 dence of the operator in himself, and in his success, which will 
 result in confidence of the patient towards the operator. It is 
 well to tell the patient that Novocain has absolutely nothing 
 in common with cocaine and is entirely harmless. Tell them 
 what parts are going to feel numb, so that this does not alarm 
 tliem. 
 
 Post-operative pain and inflammation may 
 Ill-Effects occur after an operation, not caused by the 
 
 Due to Other injection but directly from the wound. It can 
 Sources come: 
 
 1. From a septic wound. 
 
 2. From a wound infected during the operation. 
 
 3. From a wound infected after the operation by the fluid 
 of the oral cavity. A wound in the mouth cannot be kepi 
 aseptic, and is exposed to secondary infection. 
 
 To avoid this inflammation and pain after operations, in- 
 fected tooth sockets should be curetted and washed out with an 
 antiseptic solution. Also the suprarenin should not be admin- 
 istered in the anaesthetic in too high percentage, because the 
 danger of infection is increased through too deep anaemia. 
 For normal cases 0.000,02 gram Suprarenin to 1 c.c. is suffi- 
 cient, allowing enough bleeding to protect the wound. 
 
 Tlie severest part of post-operative pain is usually elim- 
 inated by the long duration of tlie anaesthesia. Dressing the 
 wound witlj gauze containing Novocain powder, after thor- 
 uiiuli ciu'clliiig will be roinid bciicliciMi, still better is Tribel's : 
 
 I^ (Milonil-liydrat 2.0 
 
 (Jamplior 1.0 
 
 Novocain 0.5 
 
 Misce exactissinie 
 
100 ORAL ANAESTHESIA 
 
 or Eiiroform paste : 
 
 19 Orthoform 40.0 
 
 Europhen 60.0 
 
 Liquid petroleum s. q. to make paste 
 
 Internally administer : Trigeminin,* Aspirin or Pyramidon.* 
 Failure and ill-effects therefore can almost always be 
 traced back to the incorrect technique of deteriorated drugs, 
 infection, and fear. And these can be eliminated almost en- 
 tirely. 
 
 I have used local anaesthesia in children, and in adults up 
 to eighty, in patients which collapsed from cocaine, and which 
 have been warned not to have another injection, and I have 
 repeatedly used it on patients with severe heart and jHilmonary 
 disorders of all kinds, with excellent result, and I have the full 
 appreciation of the patients. 
 
 * Farbwerke Hoechst Co., Ill Hudson Street, New York. 
 
IX. PRACTICAL APPLICA- 
 TION OF LOCAL ANAES- 
 THESIA IN DIFFERENT 
 BRANCHES OF DENTISTRY 
 
 The various operations which can be performed under 
 "Local Anaesthesia'' have been mentioned shortly in a previous 
 chapter. To make it clearer Avhat special method is best 
 adapted for a certain case, and to bring out variations benefi- 
 cial for certain cases, the author adds this chapter. It also is 
 intended to be of a more practical nature, suggesting opera- 
 tions, as the amputation of roots, which through local anaes- 
 thesia are brought into the realm of the general practitioner. 
 Two general rules for selecting the method of injection : 
 
 1. Use always the simplest and surest method. 
 
 2. Avoid injecting into pathological tissue. 
 
 Tlie four following tables show what teeth, and what tis- 
 sue, we can anaesthetize Avith tlie infiltration and with the con- 
 ductive method: 
 
TABLE I. INFILTRATION ANAESTHESIA FOR THE TEETH ONLY 
 
 1 MAXILLA 
 
 BUCCAL 
 
 LABIAL 
 
 BUCCAL 
 
 * NOT ALWAYS SUCCESSFUL 
 ON ACCOUNT or THICKNESS 
 OF BONE. 
 
 EMANDIBULA 
 
 BUCCAL 
 
 LABIAL 
 
 (not successful) 
 
 VS9 w} (P<f9 fe 
 
 BUCCAL 
 
 (not successful) 
 
 mK. m IM. UB IB C. _L . £. C. L. C. IB. TTB- IM. IM. ITM. 
 
 (not NE.EOED.) 
 
 LINGUAL 
 
TABLE 11. INFILTRATION ANAESTHESIA OF THE TEETH 
 
 AND SOFT TISSUES 
 
 INAXILLA 
 
 BUCCAL 
 
 LABIAL 
 
 BUCCAL 
 
 ^@©© © ©©©©©© © (iB@®® 
 
 EM m* m* 15 IB C L C C L C IB IB in* I11*¥M 
 
 S (iS w (3 
 
 PALATAL 
 
 n NAIVDIBULA 
 
 * NOT ALWAYS SUCCESSFUL 
 ON ACCOUNT OP THICKNESS 
 or BONE. 
 
 bUCCAL 
 
 LABIAL 
 
 (not successful) 
 
 in im m hb ib c 
 
 (^ (^ (^ ^5 
 L C C L. 
 
 (PM (Ccc 
 
 BUCCAL 
 
 (not successful) 
 
 C IB IB m in in 
 
 LINGUAL 
 
TABLE III. CONDUCTIVE ANAESTHESIA OF THE 
 
 TEETH ONLY 
 
 I.MAX1LLA 
 
 Right right le.ft left 
 
 zygomatic infraorbital infraorbital zygomatic 
 
 'iKt.IM. m. HB. IB.' C. L. C. C. L. C. 'iB. IB. IM. IM. 
 
 inM. 
 
 n.NANDIBULA 
 
 RIGHT LETT RIGHT LEFT 
 
 PTERYGOMANDIBULAR MENTAL FORAMEN MENTAL FORAMEN PTERYGOMANDIBULAR 
 
TABLE IV. CONDUCTIVE ANAESTHESIA OF THE TEETH 
 
 AND SOFT TISSUES 
 
 1. MAXILLA 
 
 RIGHT RIGHT RIGHT LEFT LEFT LEFT 
 
 SPHENO-mXlLLARY ZYGOMATIC INFRAORBITAL INFRAORBITAL ZYGOMATIC bPffiNO-rWUlMY 
 
 OR 
 
 ENTIRE- nAXlLLA 
 
 D.MANDIBULA 
 
 RIGHT 
 
 LEFT 
 
 RIGHT 
 
 PTERYGOMANDIBULAR 
 AND LINGUAL 
 
 MENTAL F. 
 
 MENTAL F. 
 
 LEFT 
 PTERYGOMAHDIBU LAR 
 AND LINGUAL 
 
106 ORAL ANAESTHESIA 
 
 1. OPERATIVE DENTISTRY 
 
 To remove caries and prepare cavities with 
 Cavity normal pulps, for fillings, we need usually 
 
 Preparations anaesthesia of the teeth only. But if the 
 
 gum has to be retracted for cervical cavities, 
 anaesthesia of the gum is advisable to allow the proper adjust- 
 ment of the clamp. 
 
 The first and second maxillary molars sometimes do not 
 respond to the infiltration method, especially in patients with 
 massive bone formations. If the zygomatic process extends 
 far down, it prevents the infiltration of these teeth from the 
 buccal side; in these cases conductive anaesthesia by the zygo- 
 matic method is advisable. If the infiltration method has been 
 used and proves a failure, apply the conductive method at once. 
 If two or three adjoining teeth need to be anaesthetized, use the 
 horizontal injection, proceeding from one tooth to the other 
 without removing the needle. 
 
 The lower molars and bicuspids cannot be anaesthetized 
 singly, the few pores around the alviolar margin are not suffi- 
 cient to assure deep enough anaesthesia, the success is too 
 uncertain to make it practical. If there is a cavity in an in- 
 cisor in addition to cavities in the posterior teeth of the same 
 side, use the conductive anaesthesia up to the median line, and 
 though the pulp might not be entirely anaesthetized in the 
 incisors, on account of the anastomosis, the dentine usually is 
 desensitized to allow cavity preparation. Should the anaes- 
 thesia be unsatisfactory, inject by the infiltration method into 
 the mental fossa, this will anaesthetize the incisor tooth in 
 question completely, in five minutes. The waiting time of fif- 
 teen minutes seems objectionable to some men, but it should be 
 remembered that this is made up easily because the anaesthesia 
 allows us to work much quicker afterwards. If there are sev- 
 eral cavities on one side they can be prepared in one sitting, 
 and the most anterior one should be taken first, because the 
 
PRACTICAL APPLICA TION OF LOCAL ANAESTHESIA 107 
 
 anaesthesia begins in front and works backward. Three, fonr 
 or five teeth sometimes can be prepared for fillings with one 
 injection. (Tables I and III.) 
 
 When preparing a cavity for a filling under anaesthesia, we 
 should be careful that the tooth does not heat up, thermal 
 shocks, though not felt by the patient, may burn the delicate 
 pulp tissue, cause inflammation and subsequently a dead pulp. 
 Also one should bear in mind the anatomy of the tooth because 
 we have put asleep the guard pain, which gives us warning 
 when we approach the pulp-chamber. The pulp-chamber in 
 young patients is of large size, it decreases with age, and in 
 pyorrhetic and gouty patients, it sometimes has receded under 
 the gum line. 
 
 If the cavity is extensive, it is of great value to ascertain the 
 outline of the pulp-chamber by the radiograph, and in all cases 
 it is well to seal the dentinal tubules with carbolic ether rosin 
 after the cavity preparation is completed. This will prevent 
 irritation from the filling, be it permanent, with or without 
 cement lining, or be it temporary. In the latter case we also 
 have the danger of infection, if the filling gets loose or is partly 
 chewed out. Besides protecting the cavity rosin eliminates 
 also the pain caused by the cement when the permament filling 
 (inlay) is set. 
 
 To remove a normal pulj), the anaesthesia is 
 Removal of accomplished in the same manner as described 
 Normal Pulps for cavity preparations (Tables I and III). 
 
 Sometimes from some reason or other we do 
 not get complete anaesthesia of the pulp, especially when anaes- 
 thetizing the lower teeth with the conductive method. Not 
 making a special injection for the incisors, we find that the 
 pulp can be exposed, but on account of the anastomosis from 
 the otiier side, it is still somewhat sensitive. In these cases 
 the anaestlu'sia is (•(unpjctcd surprisingly easy by pressure 
 anaesthesia. Place half of a pugglet of Novocain over the ex- 
 
108 
 
 ORAL ANAESTHESIA 
 
 Fig. 60. Radiograph of maxillaiy incisors showing variation of the pulp cham- 
 ber. Note how the pulp recedes in the region of decay. 
 
 1 
 
 
 1 
 
 f 
 
 Fig. 61. Radiograph of cuspids. Note the open apical foramen in No. 1, and 
 the division of the root canal in No. 4. 
 
 Fig. 62. Radiograph of maxillary first bicuspids. Note large apical foramen in 
 
 the young tooth No. 4. 
 
 Fig. 63. Radiograph of maxillary second bicuspids. Note variations of the root 
 canals. No. 1 with open apical foramen. No. 3, showing two apical canals. 
 
PILiCTICAL APPLICA TION OF LOCAL ANAESTHESIA 109 
 
 Fig. 64. Radiograph of maxillary molars. Normal pulp chamber in No. 1. 
 
 Almost entirely calcified pulp chamber in No. 2. Two apical canals in the palatal 
 
 root of No. 3. Bent buccal root in No. 4. 
 
 A 
 
 Fig. 65. Radiograph of mandibular incisors. Note variations. 
 
 f!lt 
 
 Fig. 66. Radiograph of mandibular bicuspids, showing many abnormalities. 
 
 tRfff 
 
 Fig. 67. Radiograph uf mandibular molars. No. 1, young tooth with open 
 foramen. No. 3 and 4 show calcified pulp chambers. 
 
110 
 
 ORAL ANAESTHESIA 
 
 posure, do not add water but let it dissolve in the moisture 
 secreting from the pulp. When it has become of the consist- 
 ency of a paste, press it down w ith unvulcanized rubber. No 
 pain is caused and the action occurs at once. 
 
 When extracting the pulp one must realize that also the 
 tissue around the tooth is anaesthetized, and should be careful 
 not to injure the tissue beyond the apical foramen, this often 
 causes peridontitis. Insert the broach to the end of the root 
 canal and extirpate the pulp. Use sulphuric acid or sodium 
 potassium treatment to remove all organic tissue from side 
 canals and accessory foramina. The root canals should not be 
 filled the same sitting unless one ascertains the procedure and 
 completion of the filling with a liberal amount of radiographs. 
 On account of the anaesthesia the cooperation of the patient 
 is lost, and we have no giiide to tell us when the filling has 
 penetrated through the apex. 
 
 Central incisor with chronic abscess (lead filling), lateral incisor with pulpitis. Infiltration 
 method was used to extirpate the pulps. 
 
PRACTICAL APPLICA TION OF LOCAL ANAESTHESIA 1 1 1 
 
 In some patients all the teeth have a great 
 Removal of amount of secondary dentin deposited in the 
 Calcified Pulps root canals, which are sometimes entirely 
 
 obstructed, the circulation is interfered with, 
 but nerve libers extend throughout the pulp chamber. It is 
 impossible to anaesthetize a pulp of that sort with pressure 
 anaesthesia, also arsenic preparations are most frequently un- 
 successful. Local anaesthesia is ideal for these cases and, 
 guided by a radiograph, we can open them up to the apex with 
 root canal instruments and drugs or both combined. The 
 method of anaesthesia is the same as above. 
 
 Fig. 69. Rool of lower .second hicu.spid. Its lower end was extremely sensitive 
 
 and inaccessible. Conductive anaesthesia was used to ream the root canal to 
 
 tne ape.x. 1 he hrst bicuspid shows the same condition but is complicated on 
 
 account of a badly bent root. 
 
 Another case where pressure anaesthesia is un- 
 Removal of successful is, if obliteration of the root canals 
 Pulps with or pulp chamber lias taken place. These are 
 Pulp Stones ascertained with the radiograpli and removed 
 
 under local anaesthesia. 
 
 Oflen and iiiosl fr('(|ii('iitly in the six-year 
 Removal of mohirs of children who neglected their teeth, 
 
 Hypertrophied w<' iind Ihc pulp hypci-li-c.phicd and cxI ending 
 f*"'ps way out of the ])nlp chamber. The blood 
 
 supply is increjised :ind sensitiveiu'ss jn-evails 
 in lh<; root canals. Injecl by Ihe inliKnilion method, wliich is 
 
112 ORAL ANAESTHESIA 
 
 preferable whenever it can be applied, but use the E tablet 
 with 0.000,05 gram of Sujjrarenin to 1 c.c. In the lower pos- 
 terior teeth j)roduce anaesthesia with the conductive method, 
 using the T tablet, and after anaesthesia has occurred inject 
 solution made with the E tablet directly into the pulp. The 
 high i3ercentage of Suprarenin in the E tablet causes anaemia. 
 This is the only operation in operative dentistry where we wish 
 to combine anaesthesia with anaemia. Remove the hypertro- 
 phied pulp and cauterize if necessary. 
 
 If the inflammation of the pul]3 has not gone be- 
 Removal of yond the apical foramen, anaesthesia is produced 
 Inflamed as for normal pulps. (Tables I and III.) The 
 Pulps pain will stop as soon as the anaesthesia occurs. 
 
 The pulp then is removed under great care not to 
 infect the area beyond the foramen. (Fig. 68, lateral incisor.) 
 
 The peridontal membrane is inflamed, the 
 Removal of tooth feels long, and pain is increased if the 
 
 Inflamed Pulps tooth is touched. The outer j)late of the 
 Complicated by alviolar process has not yet been affected. 
 Periodontitis Inject by the infiltration or conductive 
 
 method (Tables I and III). The pain will 
 stop and the root canal can be opened. 
 
 The alviolar plate is usually destroyed, sinus 
 Acute Alviolar may be present or not, which usually deter- 
 Abscess at mines the amount of pain. The infiltration 
 
 the Apex method in these cases is contra-indicated on 
 
 account of the danger of deep infection, and 
 producing of pain through increased pressure. Many writers 
 recommend to inject around the periphery of the abscess, but it 
 is not necessary to take this chance, as we get best results with 
 the conductive methods. (Table IV.) The area of infection 
 can usually be entirely avoided. The palatal and lingual gum 
 
PILiCTICAL APPLICA TIOX OF LOCAL ANAESTHESLi 113 
 
 needs ouh' to be anaesthetized if the abscess points towards 
 the palatal or lingual part of the montli. In acute alviolar 
 abscesses, we produce an artificial sinus, and establish the pos- 
 sibility of thorough irrigati<ui from the tooth through the apex 
 and sinus to the nioutli. This is easily done under local anaes- 
 thesia. 
 
 Fig. 70. Acute alviolar abscess of a central incisor. The tooth was verj^ loose 
 
 and very painful on percussion. Nasal anaesthesia was used to open into the 
 
 pulp chamber and lance the abscess. 
 
 In chronic alyiolar abscesses there is usually 
 Chronic Alvi- no sensation in the tooth, and the treatment 
 olar Abscess can be applied to tln^ root canal without 
 anaesthesia. Very frequently, however, 
 there is a graniilniii at the apex wliich (h)es not always 
 yield treatment from the root canal, and has to be remoyed 
 surgically. If it is treated from the root canal there is usually 
 no need of anaesthesia, except the tooth be sensitive on percus- 
 sion. The surgical treatment consists in opening up and cur- 
 etting the apex of the tooth and cavity thoroughly. Amputa- 
 tion of the apex of the root is only necessary if it is infected, 
 partly absorbed or gangreiions. 
 
 Usually tliere is little inflaniination and the infection is 
 confined to the i-egion of the a|»e.\' of the alviolns. In these 
 
114 
 
 ORAL ANAESTHESIA 
 
 cases the infiltration method can be used, and anaesthesia can 
 be produced as in Table II. In cases where the inflammation 
 covers a larger field, the conductive method is preferable, 
 (Table IV.) 
 
 Fig. 71. Chronic alviolar abscesses. No. 1 shows chronic abscess on first and 
 second bicuspid. No. 2 shows chronic abscess on left central carrying a bridge. 
 Right central pulp chamber almost entirely calcified, filling extending into middle 
 of tooth, abscess on the apex. Right lateral shows also a chronic abscess. 
 Patient suffers of rheumatism. No. 3. Chronic abscess on second bicuspid. 
 Small cyst on six-year molar. Teeth feel lame from time to time. 
 
 Abscesses are not always originated from in- 
 Pericemental fected pulps, but often occur on the side of the 
 Abscess root from pockets, perforations or foreign ma- 
 
 terial. These have to be curetted and cleaned, 
 which is a painful process and should be done under local 
 anaesthesia. The gum only needs to be anaesthetized, after 
 Table II or IV, as required for individual cases. 
 
 Sometimes there is obscure pain either of neural- 
 Diagnosis gic character, from mild pulpitis or impacted 
 
 teeth. In the latter case the radiograph can be 
 used for diagnosis, but in the former it is of little use. The 
 pain may be referred to another part, and can be located with 
 local anaesthesia. Inject for the suspected tooth, if your diag- 
 nosis was correct the pain will stop. 
 
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116 
 
 ORAL ANAESTHESIA 
 
 Fig. 74. Patient between 70-80 suffered for years with severe pains of neuralgic 
 character. The Radiograph shows pulp stones in the first and second mandib- 
 ular molars. I used the pterygo-mandibular injection and removed the pulps 
 from both teeth. The pain did not recur. 
 
 2. GROWN AND BRIDGE WORK 
 
 In crown and bridge work we perform the most radical 
 dental operations. Not only do we have to cut off more tooth 
 substance than when excavating, but it is especially the grind- 
 ing which causes a great deal of pain and discomfort. Also it 
 is frequently necessary to devitalize sound teeth. The fitting 
 of bands and cementing of the crown or bridge is also a painful 
 process. At the other hand, it is of greatest importance that 
 this work be performed exactly, because if a tooth is not per- 
 fectly prepared it is impossible to fit a crown which does not 
 irritate nor invite decay. One can safely say that failures in 
 bridge work result more from not being radical enough, than 
 from any other cause, and this again in most cases is due to 
 pain. 
 
 There is only very superficial anaesthesia re- 
 Fitting Bands quired for fitting bands and cementing 
 and Gement- bridges. Injections into the gingival margins 
 ing Bridges are sufficient, but are usually more or less pain- 
 ful. One also can inject between the gum and 
 tooth, this requires great pressure. A sufficient way is to apply 
 a twenty per cent solution of Novocain with brush or cotton. 
 
Fig. 75. Crown and ln'idge case 1, before treatment. 
 
 I*l0. 76. (Jrown and InidKC ca.sc I, after ircalnunl. 
 
118 ORAL ANAESTHESIA 
 
 In bridge work there is usually more than one 
 Grinding and tooth to be operated upon. The conductive 
 Devitalizing method is therefore an ideal help. Also the infil- 
 tration method is sometimes advisable. Usually 
 it is of benefit to anaesthetize both the teeth and soft tissues. 
 Injections given in Tables I, II, III or VI can be used as re- 
 quired. 
 
 Case I. The author prepared with one pterygo-mandibular 
 injection, all the left mandibular teeth to serve as abutments in 
 case figure 75. The lower second molar was devitalized, cuspid 
 and lateral ground for open-faced crowns, and one bicuspid 
 root extracted, all in one sitting. In the upper jaw I injected 
 for the two bicuspids on the buccal side by the infiltration 
 method, separate for each tooth. I devitalized and cut these 
 off for banded post crowns to be attached together, with a 
 dummy on either side. Figure 76 shows case finished; in the 
 lower jaw a sanitary bridge, with j)orcelain chewing surface 
 from lower left lateral to second molar. 
 
 Case II. (Fig. 77.) I have used the zygomatic injection 
 to devitalize the first maxillary molar. It was repaired with a 
 large hand-carved porcelain crown to fill in the spaces on either 
 side. The two maxillary bicuspids I devitalized with the infil- 
 tration method horizontal injection. The central lateral and 
 cuspid were anaesthetized by the horizontal injection, com- 
 bined with the incisive injection to extract the two latter on 
 account of their position. The central incisor I devitalized for 
 a banded post crown. In the lower jaw I used the pterygo- 
 mandibular injection, to prepare the second molar for an all 
 metal crown, to devitalize the first bicuspid for a banded post 
 crown, and the cuspid for a half crown with post. All the 
 grinding and most of the fitting was done under local anaes- 
 thesia. Fig. 78 shows the case completed. 
 
Fig. n . Crown and bridge case II, before treatment. 
 
 "JG. 78. Crown and Ijridge case II, after treatment. 
 
120 ORAL ANAESTHESIA 
 
 EXODONTIA 
 
 Many general practitioners gave up extracting on account 
 of the disturbances which often accompany the administration 
 of a general anaesthetic. The patients, however, have great 
 trust in the family dentist, and very much prefer to have him 
 do the extracting instead of being sent to a specialist. This 
 has as a consequence that frequently roots are suffered to be 
 left in the mouth, being there a continuous source of infection 
 and condemnation. The general j)ractitioner also frequently 
 fears to take upon himself the responsibility of administering 
 a. general anaesthetic, and is not sure to be able to accomplish 
 under the unfavorable circumstances of such an anaesthetic 
 a successful operation. Under local anaesthesia the most dif- 
 ficult extractions are easily accomplished. Everything is fav- 
 orable, there is plenty of time to cut the gaim to get access to 
 badly decayed roots, and if a root is broken there is lots of 
 time and the best possibilities to get it out. 
 
 Extractions always have been accomplished more or less 
 painlessly with injections into the gmm ]3roducing a gingival 
 velum. This of course anaesthetized as a rule the soft tissues 
 only, and was painful on account of the pressure required for 
 the injection. The extraction itself was only i^artly painless 
 because the dontal ramus supplying the tooth and alviolo-dontal 
 membrane was not reached, and the anaesthesia was worthless 
 if a broken-otf root had to be taken out, especially so in the 
 lower jaw. 
 
 For extraction the tooth as well as the soft tissue has to be 
 anaesthetized. If there are only few teeth to be extracted, and 
 these are not adjoining, the infiltration method can be used 
 (Table II) if it is not contra-indicated on account of putrescent 
 conditions or location. For the lower posterior teeth, infected 
 areas or extensive operations, use the conductive method ( Table 
 lY.) The anaesthesia does not only allow the extracting, but 
 also curetting of the sockets, which in most cases is of greatest 
 
PILiCTICAL APPLICA TION OF LOCAL ANAESTHESL4 121 
 
 importance. The tendency of late lias been to use too high a 
 percentage of suprarenal substances causing too great anaemia. 
 This is a false principle. The bleeding should be normal or 
 almost normal, as this is the natural cleaning process of the 
 wound, toxins and other products of inflammation are carried 
 out with the blood. The disadvantage of interfering Avith the 
 normal blood circulation is also obvious, if we consider that a 
 wound in the mouth is continuously exposed to infection, anti- 
 septic dressings of tooth sockets being not advisable, as the 
 healing process should l)e tliat of organization of a blood clot. 
 
 If we diminish the blood circulation of the wound we dim- 
 inish also the natural protection against infection; we give the 
 bacteria one-half or one hour's time to multiply and take pos- 
 session. When the anaesthesia and anaemia wears finally off, 
 we find complications, post-operative pain on account of post- 
 operative infection. This can be avoided easily if we use the T 
 tablets, which contain only 0.000,(12 gram of Suprarenin to 
 1 c.c. 
 
 ORAL SURGERY 
 
 There are today only very few cases of dental surgery where 
 local anaesthesia is not used to greater advantage, with more 
 safety, promising greater success of the operation, and less dis- 
 comfort to the patient than gen(n-al anaesthesia. The only 
 cases where it cannot be used are cases complicated with an- 
 kylosis of tlic mandible. 
 
 To |»nt paliciits 1(» llic sti-aiii :iiid danger of ctlici-, chloro- 
 foi-m, oi- siiuibir general anaesthelics, witli iheir ])sychic, and 
 pliysic pre- and after-effects, for oi-dinai-y cases of exodontia or 
 oral surgery confining a ])alient for days to the hospital or thc^ 
 IkmI, is no more jnst itnible. If we conipare I wo ojterat ions, side 
 by si(h', one niidei- genei-;il anaesi liesJa, with month ju-ops, 
 g<Mieral rehixation (.(' the patient, I lie (idd of oiM'ralion heing 
 eontinnously obscni-ed l.y increased venons bh'eding and saliva, 
 not to spe;ik of bh)od iind |»ns, wliieli is swaHowed and pene- 
 
122 ORAL ANAESTHESIA 
 
 trates into the lungs, the operation being prolonged by endless 
 sponging, which takes up more than half of the time ; and com- 
 pare the other under local anaesthesia with a clear view, bleed- 
 ing almost obliterated, and cooperation of the patient, we find 
 it easy to choose; and it also makes it clear why it is for the 
 operator to choose, and not for the patient. 
 
 Since the introduction of conductive and spinal anaesthesia 
 general anaesthesia has become less popular. The progress 
 which local anaesthesia has made in modern surgery is shown 
 in the report of the university clinics of Marburg and Heidel- 
 berg, where of all operations fifty respectively fifty-four per 
 cent have been performed under local anaesthesia. It is espe- 
 cially used on the head (cranium and face) neck, ribs, hemor- 
 rhoids and all operations on the extremities.* Also the public 
 has quickly become accustomed to local anaesthesia, and has 
 great faith in this new method, which is less disagreeable and 
 less dangerous. 
 
 For large surgical operations ganglion anaesthesia is used; 
 for smaller operations the conductive method is recommend- 
 able. But it should be combined, however, with the infiltra- 
 tion method, to anaesthetize the anastomosis from buccinator, 
 facial or infra-orbital nerves, and in some cases to get anaemia 
 of the field of operation. Use the T tablets for conductive and 
 ganglion anaesthesia ; the T or E tablets for infiltration anaes- 
 thesia; the T tablet if anaemia is not required; the E tablet if 
 the bleeding needs to be decreased so as to give a better view 
 of the field of operation. 
 
 Local anaesthesia gives the general practi- 
 Operation for tioner the possibility of using his skill for 
 Granulum, delicate surgical operations, which in some 
 
 Root and Apex cases are the only means to retain a tooth 
 Amputations without endangering the general health of 
 
 the patient. Since the physician as well as 
 the dentists have become familiar with the grave significance 
 
 * Haertel: Fortschritte auf dem Gebiete der Local Anaesthesie. Zeitschrift fuer aeztliche 
 
 Fortbildung 1914. 1. 
 
PRACTICAL APPLICA TION OF LOCAL ANAESTHESIA 123 
 
 of ail infected apical graiiuluiu, which often is the focns of gen- 
 eral diseases of toxic or infectious cause, and since the radio- 
 graph has become such a simple and popular means of diag- 
 nosis preventing the unconscientious dentist to ignore such 
 cases with placid remarks, we come to realize that our treat- 
 ment of these conditions with medicines placed into the root 
 canal is not sufficient, and that we have to extract the tooth 
 and curette the socket, or perforin on it a delicate operation, 
 which on account of its j)resent importance I will describe in 
 detail. 
 
 Indication. 1. Surgical treatment is indicated in all teeth 
 worth saving where treatment through the root canal is unsuc- 
 cessful, as in all cases where the root is affected, absorbed or 
 gangrenous. No tooth should remain in the mouth with granu- 
 lating peridontitis, giving symptoms of soreness, lameness or 
 pain continuously or at intervals. So-called gum boils, which 
 enlarge from time to time, or sinuses, come under the same 
 head, and are of severer nature than the first named. 
 
 2. Surgical treatment is indicated in cases of well-fitting 
 crowns or bridges, where we find the root canal of an abutment 
 only partly filled. 
 
 3. Surgical treatment is indicated in roots which oi; 
 account of their curving, or on account of obstructions, cannot 
 be filled to the apex. 
 
 4. Surgical treatment is indicated in teeth which have been 
 perforated at the apical part by root canal instruments. 
 
 5. Surgical treatment is indicated if root instruments have 
 been broken off in the root canals, and cannot be removed from 
 the pulp chamber. 
 
 Difficulties. These operations can be performed in all, but 
 are easier in single-rooted teeth. If working at the buccal 
 roots of flu* iif)per teetli one should be careful not to perforate 
 the floor of the antrum. In the lower bicuspids the mental 
 
124 
 
 ORAL ANAESTHESIA 
 
 nerve must be considered. The lower second and third molars 
 and the npper third molars are the most unfavorable teeth to 
 operate upon on account of their position. 
 
 Anaesthesia. Use the conductive combined with the infil- 
 tration method wherever practical, but either can be used alone. 
 Inject as to Tables TI and lY, and in difficult cases use the E 
 tablet for the infiltration injection to get anaemia. 
 
 INJECTION FOR OPERATION ON THE LEFT MAXILLARY LATERAL INCISOR 
 
 Fig. 79. Labial injection. 
 
 Fig. 80. Palatal injection. 
 
 Operation. The operation varies according to the cause. 
 If we operate for a granulum it is sometimes sufficient to cur- 
 ette the apex and the socket, removing all granulated tissue. 
 If the root is affected, partly absorbed or gangrenous, if the root 
 filling does not extend through the apical foramen, or if the 
 apex is perforated, it is necessary to amputate the apical part 
 of the root. If a foreign body is to be removed, it is often 
 sufacient to cut a window on the front surface of the root, and 
 remove it tlirough the pulp chamber. 
 
PRACTICAL A FPU C A TION OF LOCAL ANAESTHESIA 125 
 
 Technique of Granulum Operation. The root canal should 
 be treated before the operatiou is performed. The canal can 
 be filled either before or during the operation. Sterilize \yith 
 iodin, and be sure to have the root filling germ proof and sealed 
 tight, or the filling will be pressed out if a crown with post is 
 cemented on. This is accomplished by i)umi>ing thinly mixed 
 
 Fig. 81. Serie showing am])utati<)n of tlie apex of tlic lower incisor. No. 1 
 
 (top) Diagnosis of the granulated condition. Nos. 2 and 3, Treatment before 
 
 the operation. No. 4, Result after the operation. 
 
 phosj)hale (ciiiciil into I lie canal, and by moistening the gutta- 
 perclia ])oiiil with Ihe same mixture, before inserting it. The 
 gutta-penha |)oiiil is packed (h)\vn into Ihe V(h}\ canal with a 
 snital)le instrument to get a (lose fit on the walls. If there is 
 a wide a])ical foramen, or an artificial ])erforalion at the a])ex, 
 the cement ami also the point will e.xteml beyond, if the fora- 
 men ;inil |»;ii-t (tf Ihe ajiical root can;il is cah-ilied, the root 
 
126 
 
 ORAL ANAESTHESIA 
 
 should be amputated at the place where the fillmg euds. Pre- 
 vious to and after the root canal filling, we take a radiograph 
 for guide and control of the work. 
 Instruments used : 
 
 1. Eetractor. 
 
 2. Knife. 
 
 3. Pliers. 
 
 4. Periostial Raspatorium. 
 
 5. Sharp retractor. 
 
 6. Chisel and mallet or fissure and round burrs. 
 
 7. Small curette. 
 
 8. Scissors. 
 
 9. Sewing outfit. 
 
 To perform the surgical part of the operation, paint the line 
 of incision with tincture of iodine, and make a half-round in- 
 cision to cut loose a flap which is separated from the bone with 
 the sharp raspatorium; it is then retracted with the sharp 
 retractor upward in the upper jaw, and downward in the Jower 
 jaw. If a sinus is present it is well to let the incision go 
 through it. The retractor is held by an assistant. Remove 
 the alviolar plate to uncover the infected area. 
 
 Fig. 82. Showing incision for operation on the left maxillary lateral incisor. 
 
PRACTICAL APPLICA TION OF LOCAL ANAESTHESLi 127 
 
 This is easy as the bone is usually partly destroyed. It is 
 important to have a clear view of the whole extent of the apex 
 of the root. 
 
 1. Curetting only necessary. If the apex is not affected 
 curette the root and alviolar socket and remove all pathological 
 tissue, with suitable curettes. The most difficult part to reach 
 is the part behind the root, which can be curetted with a large 
 spoon excavator. 
 
 2. Amputation is not necessary, but Apical part of root 
 canal is not filled. If the root serves as abutment of a bridge, 
 the removal of which is not wished, but the root canal is only 
 partly filled, amputation is sometimes not advisable because it 
 would weaken the abutment. In these cases we can, after re- 
 moving the granulum, slit the root with a round burr from 
 front, starting from the apex, till we reach the root filling. 
 This part of the root canal is then thoroughly sterilized, best 
 with iodine, dried out and carefully filled with amalgam. 
 Cotton is placed in the cavity to prevent parts of the amalgam 
 to remain unseen in the wound. The amalgam is thoroughly 
 smoothed, the cotton removed and the wound washed out. 
 
 WINDOW OPERATION TO REMOVE BROKEN OFF BROACH 
 IN ROOT CANAL 
 
 8.3. After the window is cut and 
 the broach exposed. 
 
 Fig. 84. After filling of the window. 
 
128 
 
 ORAL ANAESTHESIA 
 
 3. Window Operation. If there is a perforation, we cut 
 it smooth and for retention. If a foreign body is lodged in the 
 root canal, we locate it with the Kadiograph, cut a window over 
 it and with a suitable instrument push it into the pulp cham- 
 ber. Place a i)iece of cotton into the cavity to prevent it from 
 falling out unseen. A smooth broach of sufficient size is now 
 placed into the canal, and the window is filled with amalgam, 
 which is smoothed off carefully. Again prevent amalgam from 
 falling into the wound, wash out and close the wound. Eemove 
 the broach carefully after the amalgam is hard and fill the root 
 canal at a subsequent sitting. 
 
 Fig. 85. Radiographic serie illustrating the window operation. No. 1, shows 
 broken instruments. No. 2, instrument removed. No. 3, root canal and 
 
 window filled. 
 
 4. Root amputation and Apex amputations. In molars, es 
 pecially in pyorrhoetic conditions or cervical caries, it becomes 
 sometimes necessary to amputate an entire root, as the palatal 
 or one buccal root of an upper molar, or the mesial root of a 
 lower molar. This is an easy operation. To amputate the apex 
 only requires more skill. When we have the apical part of 
 the root in plain view, we diagnose whether it is pathological. 
 With a fissure burr we cut it off crossways at a point where it 
 is healthy, and to which the root filling extends. Now comes 
 the most important act, the removal of the granulation tissue. 
 This is removed with a curette till healthy bone is visible on 
 
OPERATION FOR APEX AMPUTATION 
 
 Fig. 86. Root of the tooth is exposed. 
 
 Fig. 87. After amputating the root and 
 curetting of tlic cavity. 
 
 Fig. 88. Sewing of the wound. 
 
130 
 
 ORAL ANAESTHESIA 
 
 all sides. All margins and sharp points are then smoothed 
 with a round burr, and the cavity is thoroughly washed out 
 with a mild antiseptic solution. This is dried up. Before 
 sewing, stimulate the wound with a small instrument, to invite 
 bleeding for the formation of a blood clot. DraM' the flap 
 down and sew it back carefully with horsehair stitches. If a 
 wound heals by first intention, the stitches can be removed in 
 three days. For swelling of the soft tissue, which frequently 
 occurs after such an operation, apply dry heat. If the blood 
 clot should become septic, the stitches have to be removed and 
 the cavity is packed with iodoform gauze to let the wound heal 
 from the inside out. This is not an ideal result, but sufficient 
 for the preservation of the tooth. 
 
 Fig. 
 
 Impacted lower third molars. Both have been removed with the 
 pterygo-mandibular injection. 
 
 Impacted Difficult extractions and especially the removal of 
 Teeth impacted teeth are operations which become more 
 
 and more frequent as civilization progresses. The 
 conductive methods are advisable for anaesthesia, and it is 
 usually not necessary to produce special anaemia. (Tables 
 II and IV.) If we do, we should be careful, however, to pre- 
 vent post-operative infections. The injuries caused by these 
 operations are usually very deep, and if we have anaemia of 
 the field of operation, packing of the wound with : 
 
 Euroform paste 
 
 ^ Orthoform 40 
 
 Europhen 60 
 
 Liquid petroleum s. q. to make paste 
 
PILiCriCAL A F PLICA TION OF LOCAL ANAESTHESIA 131 
 
 is reooiinneiided. In all cases, frequent rinsing of the wound 
 by the patient and washing out daily by the operator is advis- 
 able. If the wound has been packed one can stimulate it at a 
 future sitting to bleeding, to get a blood clot filling the cavity. 
 Then there is no anaemia, and infection will be taken care of by 
 natural means. 
 
 Fig. 90. Impacted cuspids under bridgework. 
 
 To set fractures of the upper or lower jaw, we 
 Fractures of nse local anaesthesia to advantage. Whenever 
 the Jaws the conductive method can be used it is to be 
 
 pi'cferred. The pterygo-mandibular space can 
 be reached from the outside, starting at the inner surface of the 
 lower border of the mandible, directing the needle straight up- 
 ward into tbe ])teryg()-nian(libular space. Also the infra-orbital 
 nerve can be readied from the outside, extending tlie needle 
 directly in and injecting into the infra-orbital canal. Also tlie 
 iidilti-atioii iiictliod iiives sometimes good results. 
 
 Cysts, Tumors, 'l'<> rf'inovc small growths ou the jaws, ])alate, 
 Necrosis, checks, or lii»s, mc again use the conductive 
 
 Odontoma method combined with infiltration around 
 
 tJK' tissue to be i-emoved. 
 
Nl 
 
 
 Fig. 91. Large mandibular cyst with unerupted third molar. One root of the third 
 molar extends below the lower margin of the mandible. 
 
PRACTICAL APPLICATION OF LOCAL ANAESTHESLi 133 
 
 For more extensive operations it 
 Cleft Palate, Hare Lip, is usually necessary to anaesthet- 
 Amputation ot the ize the whole division of the fifth 
 
 Alviolar Process, nerve, supplying the region in 
 
 Resection of Jaws question. For cleft palate we an- 
 
 aesthetize the second division with 
 the spheno-maxillary injection. Injections into the incisive, 
 posterior and accessory palatine foramina are also indicated. 
 For amputation of the superior alviolar process, the zygomatic, 
 infra-orbital, incisor and post palatine injections are sufficient 
 For amputations of the lower alviolar process, use the pterygo- 
 mandibular injection, and in both cases condnne the conductive 
 with the infiltration method. For larger operations, as ampu- 
 tations of the upper or lower jaw, Haertel* (clinic of the 
 University of Berlin) reconnnends the Ganglion anaesthesia. 
 He describes the following operations, which have been per- 
 formed successfully under ganglion anaesthesia : Six resections 
 of the upper jaw, two extirpations of the tongue, two sarcoma 
 of the nasopharynx, on orbital tumor, and three smaller opera- 
 tions about the jaws. 
 
 * Archiv fuer Klinische Chirurgie, Dezember, 1912. 
 
INDEX 
 
 Abscess, pericemental, 114 
 Adjoining teeth, anaesthesia of, 106 
 After-effects, 96 
 After-pain, 97 
 Alcohol jar, 54 
 Alviolar abscess, acute, 112 
 Alviolar abscess, chronic, 113 
 Alviolar process of the mandible, 12 
 Alviolar process of the maxilla, 11 
 Ampules with Novocain Suprarenin 
 
 solution, 47 
 Amputation of alviolar process, 133 
 Amputation of root, 128 
 Amputation of root apex, 128 
 Anaesthesia, conductive, 60, 71 
 
 ganglion. 60, 91 
 
 infiltration, 60, 63 
 
 not obtained, 93 
 
 prolonged, 97 
 
 spinal, 60 
 
 surface, 60, 62 
 
 undesirable symptoms, 94 
 Anaemia in extraction, 120 
 Anatomy of the oral cavity, 9 
 Apex amputation, 128 
 Antidotes for fainting, 96 
 Antrum of Highmore, 14 
 Arterio sclerosis, 49 
 Author's method of preparing the 
 solution, 48 
 
 B 
 
 Bicuspids, anaesthesia of mandibular, 
 
 106 
 Bier, 7 
 Braun, 8, 60 
 
 Braun's requirements of a substitute 
 
 for cocaine, 39 
 Buccinator injection, 84 
 Buente, 8 
 
 Calcified pulps, removal of. 111 
 
 Canine fossa, 9 
 
 Cardiac disorders, 49 
 
 Cavity preparations, 106 
 
 Cementing bridges, 116 
 
 Chronic alviolar abscess, 113 
 
 Cleft palate, 133 
 
 Cocaine, 7, 39 
 
 Conductive anaesthesia, 71 
 in the mandible, li 
 in the maxilla, 85 
 
 Conductive method, 60 
 
 Crown and bridge work, 116 
 
 Cups to prepare solution, 54 
 
 Curetting of alviolar sockets, 120 
 technique, 127 
 
 Cysts, 131 
 
 Distilled water, 50 
 
 Femel apparatus, 51 
 Devitalization of normal teeth, 107, 118 
 Diagnosis of pain, 114 
 
 E 
 
 EiNHORX, 8, 39 
 Euroform paste, 100, 130 
 Exodontia, 120 
 External oblique line, 20 
 Extraction of teeth, 120 
 
136 
 
 INDEX 
 
 Failures and ill-effects in "Local 
 
 Anaesthesia," 93 
 Fainting, 96 
 Fear, 98 
 
 Femel apparatus, 51 
 Fischer, 8 
 Fitting bands, 116 
 Foramen, incisive, 14 
 
 infra-orbital, 11 
 
 mandibular, 21, 22 
 
 mental, 19, 23 
 
 palatine, 14 
 
 posterior superior alviolar, 14 
 Foreign body in root canal, 128 
 Fractured jaws, 131 
 
 G 
 
 Ganglion anaesthesia, 60, 91 
 
 "General Anaesthesia" versus "Local 
 Anaesthesia," 7, 93, 121 
 
 Granulum of the alviolo-dontal mem- 
 brane, 113 
 
 Granulum operation, 122 
 technique, 125 
 
 H 
 
 Haertel, 8, 133 
 
 Halsted, 72, 
 
 Hare-Hp, 133 
 
 Hauptmeyer, 8 
 
 Hypertrophied pulps removed, 111 
 
 I 
 
 Ill-Effects in Local Anaesthesia, 93, 
 
 99 
 Impacted teeth, 130 
 Incisive foramen, 14 
 
 injection, 89 
 Incisors, anaesthesia of mandibular. 
 
 106 
 Infection from injection, 97 
 
 post-operative, 99, 121 
 Infiltration anaesthesia, history, 8 
 method, 60, 63 
 
 in the mandibula, 69 
 in the maxilla, 63 
 
 Inflamed pulps, removed, 112 
 Infra-orbital foramen, 11 
 
 injection, 86 
 Injection, buccinator, 84 
 
 Gasserian ganglion, 91 
 
 horizontal, 70 
 
 incisive, 89 
 
 infra-orbital, 86 
 
 mental, 81 
 
 on labial and buccal side of the 
 maxillary teeth, 66 
 
 on labial side of mandibular in- 
 cisors, 70 
 
 on lingual side of mandibular in- 
 cisors, 70 
 
 on palatine side of maxillary 
 teeth, 68 
 
 posterior palatine, 90 
 
 pterygo-mandibular, 74 
 
 rules, 101 
 
 spheno-maxillary, 90 
 
 tables, 102, 103, 104, 105 
 
 zygomatic, 85 
 Insertion of needle, preparing place 
 
 for, 65 
 Instrumentarium, 54 
 Internal oblique line, 21 
 
 pterygoid muscle, 21 
 Introduction, 7 
 
 Jar for syringe, 54 
 Jaws fractured, 131 
 Jaws, resection of, 133 
 
 K 
 
 Kalium bromide — See potassium bro- 
 mide 
 
 Local Anaesthesia, 60 
 
 versus general anaesthesia, 
 7, 93, 121 
 
 M 
 
 Mandibula, 14 
 body, 19 
 ramus, 20 
 
INDEX 
 
 137 
 
 Mandibular nerve, 31 
 Maxilla, 9 
 Maxillary nerve, 25 
 Maxillary sinus, 14 
 Mental fossa, 19 
 
 injection, 81 
 Molars, anaesthesia of mandibular, 106 
 
 anaesthesia of maxillary, 106 
 Moral. 8 
 Mucous membrane of the mouth, 35 
 
 N 
 
 Nasal anaesthesia, 63 
 
 Necrosis, 131 
 
 Needle for injection, 54 
 
 Nephritis, 49 
 
 Nerves, anterior palatine, 30 
 
 anterior superior alviolar ramu;:, 
 
 28 
 
 buccinator, 31 
 
 inferior alviolar, 34 
 
 inferior dental plexus, 34 
 
 inferior dental rami, 34 
 
 inferior gingival rami, 34 
 
 infra-orbital, 27 
 
 infra-orbital rami, 28 
 
 lingual, 34 
 
 mandibular, 31 
 
 maxillary, 25 
 
 mental, 34 
 
 middle palatine, 31 
 
 middle superior alviolar ramus, 27 
 
 naso palatine, 31 
 
 ophthalmic, 25 
 
 posterior palatine, 31 
 
 posterior superior alviolar rami, 25 
 
 spheno-palatine, 25 
 
 spheno-palatine ganglion, 28 
 
 superior dental plexus, 28 
 
 superior dental ramus, 28 
 
 superior gingival ramus, 28 
 
 zygomatic, 25 
 Neurology, 25 
 Novocain, 39 
 
 clinical tests, 40 
 
 discovered, 8 
 
 dosage, 41 
 
 physiological properties, 40 
 
 production, 40 
 
 pugglets, 107 
 
 reaction, 40 
 
 Novocain-Suprarenin combined, 44 
 Suprarenin in ampules, 47 
 Suprarenin in solution, 47 
 Suprarenin in tablets, 48 
 
 O 
 
 Odontoma^ 131 
 
 Oedema, 96 
 
 Operation for granulum. 122 
 
 for granulum, technique, 125 
 Operative dentistry, 106 
 Ophthalmic nerve, 25 
 Oral surgery, 121 
 Osteology, 9 
 
 Pain post-operative, 99, 121 
 
 Pericemental abscess, 114 
 
 Peridontitis removal of pulps, 90 
 
 Posterior palatine inject on, 90 
 
 Potassium bromide, 96 
 
 Practical application of Local Anaes- 
 thesia, 101 
 
 Preparing of the solution. Author's 
 method, 48 
 
 Preparing of the solution, Seidel's 
 method, 47 
 
 Pulp chamber of teeth changes, 101 
 
 Pulps, calcified, removal of. 111 
 hypertrophied, removal of. 111 
 inflamed, removal of, 112 
 normal, removal of, 107, 118 
 with pulp stones, removal of, 111 
 
 Q 
 
 Quantity of solution to be injected 
 at one time, 41 
 
 R 
 
 Ramus of mandible, 20 
 Removal of calcified pulps, 111 
 hypertrophied pulps. 111 
 inflamed pulps, 112 
 normal pulps, 107 
 pulps with pulp stones, 111 
 pulps with peridontitis, 112 
 Requirements of a solution prepared 
 frrim tablets, 58 
 
138 
 
 INDEX 
 
 Resection of jaws, 133 
 
 Ringer solution, 50 
 
 Ringer tablets, 50, 57 
 
 Root amputations, 128 
 
 Root canal with foreign body, 128 
 
 Rules for injections, 101 
 
 Seidel, 8 
 
 Seidel's Sixteen Theses, 44 
 
 method to prepare Novocain Su- 
 prarenin solution, 47 
 Sharpening of the needle, 54 
 Solution, preparing of, 58 
 
 requirements if prepared from 
 
 tablets, 58 
 preparing. Author's method, 48 
 Spheno-maxillary ganglion, 28 
 
 injection, 90 
 Spinal anaesthesia, 60 
 Steinkamm, 8 
 
 Submucosa of mucous membrane, 35 
 Substitute for cocaine, Braun's re- 
 quirements, 60 
 Sulcus mandibularis, 21 
 Suprarenin syntheticum, 41 
 
 chemical properties, 42 
 clinical experiences, 42 
 dosage, 42 
 
 physiological properties, 42 
 production, 41 
 reaction, 42 
 Surface anaesthesia, 60, 62 
 Symptoms, during anaesthesia, unde- 
 sirable, 94 
 Syringes, 54, 56 
 
 Table I. Infiltration anesthesia of 
 
 the teeth only, 102 
 Table II. Infiltration anaesthesia 
 
 of the teeth and soft tissue, 103 
 Table III. Conductive anaesthesia of 
 
 the teeth only, 104 
 Table IV. Conductive anaesthesia 
 
 of the teeth and soft tissue, 105 
 Tablets of Novocain Suprarenin, 48 
 Tablets E, 49, 54 
 F, 49, 54 
 F + E, 57 
 Ringer, 50, 57 
 T, 48, 54 
 Teeth impacted, 131 
 Topography, 35 
 Tuber maxillare, 11 
 Tumors, 131 
 
 U 
 
 Undesirable symptoms during anaes- 
 thesia, 94 
 
 Valyl, 96 
 
 W 
 
 Waiting time of anaesthesia, 106 
 Window operation, 128 
 Wisdom teeth impacted, 130 
 
 Zygomatic fossa, 11 
 injection, 85 
 process, 11 
 
LIST OF ILLUSTRATIONS 
 
 FxG. Page 
 
 1. Outer surface of maxilla and mandibula showing attachments of muscles 10 
 
 2. Skull showing small foramina in the incisor region of the maxilla and 
 
 mandibula 12 
 
 3. Skull showing foramina in the cuspid, bicuspid and molar regions of 
 
 the maxilla and absence in the mandibula 13 
 
 4. Palate of a child 6-7 years IS 
 
 5. Palate of a child 11-12 years 15 
 
 6. Palate of an adult 16 
 
 7. Palate of senile skull 16 
 
 8. Skull with dissected anterior superior alviolar canal 17 
 
 9. Radiograph showing a frontal aspect of the maxillary sinus .... 18 
 
 10. Cross section through maxilla and mandibula showing difference in 
 
 make-up of the bone 19 
 
 11. Three mandibles showing different construction of the post molar 
 
 triangle 20 
 
 12. Sulcus mandibularis enclosed by the dotted line 2) 
 
 13. Specimen showing dissected mandibular canal 22 
 
 14. Variations of the internal surface of the ramus mandibularis ... 23 
 
 15. Location of mental foramen in a child 24 
 
 16. Location of mental foramen in adult 24 
 
 17. Location of mental foramen in senile skull 24 
 
 18. Nerves trigeminus; ( Vth cranial nerve) 26 
 
 19. Schematic drawing of the Nervus maxillaris 27 
 
 20. Nervus trigeminus (Vth cranial nerve) 29 
 
 21. Schematic drawing of ganglion spheno-palatinum 50 
 
 22. Nervus trigeminus: (Vth cranial nerve). In the maxilla showing the 
 
 anterior part of the N. maxillaris. in the mandibula showing the 
 
 N. mandil)ularis 32 
 
 23. Schematic drawing of nervus mandibularis S3 
 
140 LIST OF ILLUSTRATIONS 
 
 Fig. Page 
 
 24. Section through the upper jaw in the incisor region 36 
 
 25. Horizontal section through human head in the plane in which man- 
 
 dibular conductive anaesthesia is best accomplished 37 
 
 26. Femel apparatus to produce distilled water 51 
 
 27. Schematic drawing of distilled water apparatus 52 
 
 28. Bottle for Ringer solution. Jar filled with absolute alcohol. Syringes 
 
 and dissolving cups, and glass tray 55 
 
 29. Syringes . '. 56 
 
 30. Large and small dissolving cups 56 
 
 31. Schematic illustration of the methods of local anaesthesia recom- 
 
 mended for dental surgery 61 
 
 32. Frontal section through the molar region showing buccal and palatal 
 
 injection by the infiltration method 64 
 
 33. Position of operator when injecting for an upper tooth by the infil- 
 
 tration method 65 
 
 34. Radiograph showing the infiltration method for an upper incisor . . 66 
 
 35. Radiograph showing the infiltration method for an upper cuspid ... 67 
 
 36. Radiograph showing the infiltration method for an upper bicuspid . . 67 
 
 37. Wrong position of needle 68 
 
 38. Right position of needle, opening pointing towards the bone .... 68 
 
 39. Radiograph showing the infiltration method for a lower incisor ... 69 
 
 40. Radiograph showing the horizontal injection for bicuspid, and molar 
 
 region 70 
 
 41. Radiograph showing the horizontal injection in a coronal section . . 71 
 
 42. Conductive Anaesthesia: 1. Zygomatic injection. 2. Infra-orbital in- 
 
 jection. 3. Pterygo-mandibular injection. 4. Mental injection . . 72 
 
 43. Diagram showing injection into the pterygo-mandibular space ... 74 
 
 44. Technique of inserting the needle for the pterygo-manidbular injection 75 
 
 45. Pterygo-mandibular injection on the right side; position on patient . 76 
 
 46. Pterygo-mandibular injection on the right side; position on patient . 77 
 
 47. Pterygo-mandibular injection on the left side; position on patient . 78 
 
 48. Pterygo-mandibular injection on the left side; position on patient . 79 
 
 49. Sulcus mandibularis with needle 80 
 
 50. Radiograph showing needle inserted" in right position above the lingula 82 
 
 51. Radiograph showing needle inserted too low, sliding along the lingula 
 
 into the muscle 82 
 
LIST OF ILLUSTRATIONS 141 
 
 T^ Page 
 
 Fig. 
 
 52. Radiograph showing the pterygo-mandibular injection 83 
 
 53. Radiograph showing injection into the mental foramen 84 
 
 54. Infra-temporal surface of the maxilla 85 
 
 ... 07 
 
 55. Radiograph showmg zygomatic mjection °' 
 
 56. Infra-orbital injection on the right side 88 
 
 57. Radiograph showing infra-orbital injection 
 
 58. Schematic drawing showing the injection into the Gasscrian ganglion 91 
 
 59. Foramen ovale in the skull seen from the position of the operator . 92 
 
 lAQ 
 
 60. Radiograph of maxillary incisors 
 
 108 
 
 61. Radiograph of cuspids 
 
 62. Radiograph of maxillary first bicuspids 108 
 
 63. Radiograph of maxillary second bicuspids 108 
 
 1 0Q 
 
 64. Radiograph of maxillary molars 
 
 65. Radiograph of mandibular incisors 
 
 66. Radiograph of mandibular bicuspids 109 
 
 67. Radiograph of mandilmlar molars 
 
 68. Central incisor with chronic abscess (lead filling), lateral incisor with ^^^ 
 
 pulpitis 
 
 69. Root of lower second bicuspid 
 
 70 Acute alviolar abscess of a central incisor H^ 
 
 , . , , ... 114 
 
 71. Chronic alviolar abscesses 
 
 72. Pericemental abscess caused by perforation of the tooth by a post . 115 
 
 73. Pericemental and alviolar abscess on a maxillary cuspid 115 
 
 74. Patient suffered with severe pains of neuralgic character. The Radio- 
 
 graph shows pulp stones 
 
 117 
 
 76. Crown and bridge, case 1, after treatment 
 
 graph shows pulp stones 
 
 75. Crown and bridge, case I, before treatment 
 
 117 
 
 119 
 
 77. Crown and bridge, case II. before treatment 
 
 119 
 
 78. Crown and bridge, case 11. after treatment 
 
 . . 124 
 
 79. Labial injectK)n 
 
 ... 124 
 
 80. Palatal injection 
 
 81. Serie showing amputation of the apex of the lower incisor . . . . 12o 
 
 82. Shr.wing incision for oi)eration on the left maxillary lateral incisor . 126 
 
 83. .'\ftcr the window is cut and the broach exposed 
 
1 42 LIST OF ILL US TRA TIONS 
 
 Fig. Page 
 
 84. After filling of the window 127 
 
 85. Radiographic serie illustrating the window operation 128 
 
 86. Root of the tooth is exposed 129 
 
 87. After amputating the root and curetting of the cavity 129 
 
 88. Sewing of the wound 129 
 
 89. Impacted lower third molars . 130 
 
 90. Impacted cuspids under bridge-work 131 
 
 91. Large mandibular cyst with unerupted third molar 132 
 
/I 
 
 R^:.510 
 
 T36 
 Copy 1 
 
 Thoma 
 
 Oral anaesthesia. 
 
 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) 
 
 RK510T36C.1 
 
 Oral anaesthesia; local anaesthesia in t 
 
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