THE MODERN PRACTICE 
OF TOOTH-EXTRACTION  
THE MACMILLAN COMPANY 
NEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 
MACMILLAN & CO., Limited 
LONDON • BOMBAY • CALCUTTA 
MELBOURNE 
THE MACMILLAN CO. OF CANADA, Lid. 
TORONTO THE MODERN PRACTICE 
OF TOOTH-EXTRACTION 
BY 
LESTER RICHARD CAHN, D.D.S. 
THE MACMILLAN COMPANY 
1924 
All rights reserved PRINTED IN THE UNITED STATES OF AMERICA 
Copyright, 1924, 
By THE MACMILLAN COMPANY. 
Set up and electrotyped. Published September, 1924. THIS BOOK IS AFFECTIONATELY DEDICATED 
TO MY PARENTS CONTENTS 
CHAPTER PAGE 
Preface vii 
I. Introduction - Anaesthesia - Armamen- 
tarium-Sterilization 1 
IL Examination of Patient-Pre-operative 
Care 14 
III. Indications and Contra-indications for 
Extraction-Position of the Operator 
and Patient-Operation of Extraction 22 
IV. Removal of Roots and Apices-The Care 
of the Gums and Process in the Mul- 
tiple Extraction of Teeth .... 44 
V. Accidents 56 
VI. After-pain . 64 
VII. Haemorrhage-Syncope-Shock ... 71 
VIII. Post-operative Care 86 
IX. Vaccino-therapy in Dental Surgery . . 92 
X. Blood-pressure-Pulse-Temperature . 110 PREFACE 
I have prepared this book primarily for the gen- 
eral practitioner and student, and have purposely 
omitted a description of the technique of removal 
of impacted and unerupted teeth, because I believe 
that their removal is an oral surgical operation, of 
sometimes serious dimensions, and that unless the 
general practitioner is especially equipped and 
trained for operations of this type, it would be 
wiser to refer these cases to a specialist. As for 
the discussion of the technique of anaesthesia, there 
are so many splendid books devoted to this sub- 
ject, that it would be superfluous in a work of this 
kind. 
The whole important subject of tooth extrac- 
tion seems to have been somewhat neglected in 
the past, so I have tried to make this a text for 
the general dentist-although the oral specialist 
will find points of interest in it as well. 
I have dwelt at some length upon the pre-opera- 
tive care of the patient, and methods of observing 
the patient's physical condition, because very often 
VII VIII 
PREFACE 
a successful outcome to an operation depends upon 
a full consideration of these subjects. 
My belief that the after-care of the patient and 
wound is as important as the operation itself has 
led me to take up this phase fully. 
This book is based solely upon my own experi- 
ences and ideas and the operations herein described 
have been evolved by me, although perhaps there 
are others who have thought of and performed them 
in the same way. 
New York City. 
L. R. C. THE MODERN PRACTICE 
OF TOOTH-EXTRACTION CHAPTER I 
INTRODUCTION-ANAESTHESIA-ARMAMENTARIUM 
STERILIZATION 
Introduction 
In order to efficiently remove teeth with a mini- 
mum amount of trauma to the tissues, a definite 
technique must be acquired. The placing of the 
beaks of the forceps over the gums and alveolar 
process, and crushing these tissues, is brutal and 
not to be countenanced. With a correct understand- 
ing of the anatomy of the teeth and jaws, proper 
instrumentarium and anaesthesia, a surgical tech- 
nique can be evolved that will place the extraction 
of teeth on the same plain with any other minor 
surgical operation. 
The removal of tonsils is attended with all the 
preparation of an operation, and yet the extraction 
of some teeth is much more difficult, and as equally 
precarious as any tonsillectomy. Why then should 
not the removal of teeth be given its just place in 
the realm of minor surgery? 
1 2 
THE MODERN PRACTICE 
Anaesthesia 
In the opinion of the writer, local anaesthesia is 
the one of choice. There is scarcely a case where 
it cannot be used. With the use of procain we are 
assured of a safe anaesthesia, and a lengthy enough 
one to perforin our operation carefully, and with 
the cooperation of the patient. Most of the mu- 
tilating results in tooth extraction occur under the 
use of general anaesthetics. The excuse that some 
people are too nervous for local anaesthesia is a poor 
one, because by proper pre-operative treatment, and 
gentle handling, the nervous patient is changed to 
a calm one. In young children there may be some 
difficulty in controlling them, and in these cases 
only is general anaesthesia indicated. When we 
consider the magnitude of the operations performed 
by Braun and others, often on debilitated patients, 
we can readily understand the advantage of this 
method of anaesthesia, and the feasibility of its use 
in so comparatively a simple operation like tooth 
extraction. 
In dental surgery local anaesthesia can be divided 
into infiltration anaesthesia and conduction anaes- 
thesia. The choice of either of these two methods 
depends upon the character of the case to be oper- 
ated upon. In the greater majority of cases, in the 
upper jaw, infiltration anaesthesia will suffice. For OF TOOTH-EXTRACTION 
3 
the lower posterior teeth conduction anaesthesia is 
the one of choice. The lower anterior teeth can be 
very satisfactorily anaesthetized by the infiltrative 
method. Infiltration anaesthesia should not be ad- 
ministered with a short needle, plunged through the 
periosteum to the bone, and a great deal of pres- 
sure exerted. An inch steel needle, about 26 guage, 
is introduced into the muco-buccal fold above, or 
below, as the case may be, the tooth to be extracted. 
It is advanced toward the apex of the tooth, and 
about 2 c.c. of the solution deposited. A few drops 
on the palatal or lingual surface will complete the 
anaesthesia. If it is deemed necessary to use con- 
duction anaesthesia, the following injections are 
made: for the upper posterior teeth, including the 
second bicuspid, the tuberosity and posterior pala- 
tine injections, with slight infiltration over the sec- 
ond bicuspid; for the upper anterior teeth and first 
bicuspid, the infra-orbital and anterior palatine in- 
jections. Occasionally, it is necessary to infiltrate 
palataly about the first bicuspid, and labially above 
the central incisor, in order to block sensation from 
anatomosing nerves. The lower molars, bicuspids, 
and anterior teeth up to the median line are blocked 
by the mandibular injection, with labial infiltration 
about the anterior teeth. Frequently, the long buc- 
cal nerve has to be blocked, and this is accomplished 4 
THE MODERN PRACTICE 
by inserting the needle into the muco-buccal fold 
opposite the lower first molar. The mental injec- 
tion is rarely used. For a more detailed description 
of the technique of these injections, the reader is 
referred to larger works on local anaesthesia in the 
oral cavity. 
Instrumentarium 
The minimum amount of instruments compatible 
with efficiency is all that is required. Some men 
have become accustomed to certain types of instru- 
ments, and obtain good results from their use, and 
to these, they should be loyal. However the anat- 
omy of the tooth to be extracted, and its position in 
the mouth, must be considered in selecting the for- 
ceps. There are a lot of freak forceps made, sup- 
posedly to facilitate our operations. These are only 
fads to catch the eye of the dentist, and increase 
the sales of the manufacturer, and should be rele- 
gated to the discard. The forceps that have proven 
most valuable to me are (Fig. 1): 
For upper 1st and 2nd molars. .S. S. W. No. 53, 
right and left 
For upper third molars S. S. W. No. 10 
For upper anterior teeth and bicuspids.S. S. W. 
No. 32. 
For upper roots S. S. W. No. 65 
For lower molars. .An English pattern forceps, OF TOOTH-EXTRACTION 
5 
so fashioned that the teeth can be grasped 
while standing in front of the patient. 
For lower bicuspids and anterior teeth. .S. S. W. 
No. 63 or 151 
For lower rootsS. S. W. No. 151 or 63 
Fig. 1.-The author's selection of forceps. (1) S.S.W. No. 151, 
(2) English pattern forceps for lower molars, (3) S.S.W. No. 63, 
(4) S.S.W. No. 32, (5) S.S.W. No. 53R, (6) S.S.W. No. 53L, 
(7) S.S.W. No. 10. 
The only elevator I use, both for upper or lower 
roots, is the S.S.W. No. 12C. 
The following are the accessory instruments, 
dressings and drugs: 
1. Syringe for local anaesthesia, fitted with the 
appropriate needle. 
2. Scalpel 
3. Lance 
4. Periosteal elevator 
5. Gum scissors 
6. Two narrow chisels 6 
THE MODERN PRACTICE 
7. Mallet 
8. Tissue forceps 
9. Narrow beaked rongeur forceps 
10. Broad-beaked rongeur forceps 
11. Three sizes of curettes 
12. Fine haemostats 
13. Needle holder 
14. Suture material. Either fine black silk, No. 
00 or dermal suture. 
15. A 10 c.c. irrigating syringe fitted with a 
blunt needle. The ordinary Luer syringe is 
very satisfactory for this purpose. 
16. 2 c.c. glass Luer syringe for hypodermic 
medication. 
Dressings 
Gauze wipes 
i/2-inch and inch iodofrm gauze strips 
One-inch roller bandage 
Drugs 
1. Churchill's Tr. of Iodine 
2. Tr. of iodine and ether, equal parts, after the 
formula of Dr. Ivy 
3. An ounce bottle of adrenalin chloride 
4. Adrenalin chloride in ampoules for injection 
5. Ampoules of camphor in oil 
6. Strychnine sulphate gr. l/60th tablets. 
7. Nitro glycerine gr. 1/lOOth tablets 
8. Morphine sulphate gr. l/8th tablets 
9. Aromatic spirits of ammonia Fig. 2.-Operating tray prepared with all necessary instruments. Note small hypodermic 
syringe, with ampoules of adrenalin chloride 1-1000, and camphor in oil, in readiness for 
emergencies. OF TOOTH-EXTRACTION 
9 
10. Normal saline solution 
11. Alcohol (grain) 
12. Triple bromides of Burrowes Welcome & Co. 
13. Novocain powder 
14. White and mentholated vaseline 
15. 10% solution of nitrate of silver 
16. Peroxide of hydrogen 
17. A solution of iodoform 1 oz. and collodion 7 
oz. 
While all these instruments are not necessary in 
the average extraction, nevertheless, if an emergency 
arises, their presence and use is indispensable. The 
drugs should be kept where they can readily be 
reached, and it is my practice to have the small 
glass hypodermic syringe, together with the stimu- 
lants, on the operating tray. (Fig. 2.) 
Sterilization 
While sterilization does not have to be elaborate, 
it should be thorough. Under this heading, we will 
discuss the personal care taken by the operator, care 
of the operative field, and sterilization of the instru- 
ments and dressings. 
Personal Care Taken by the Operator.-In op- 
erating within the mouth, it is hardly practical to 
wear rubber gloves. Tactile sense and free digital 
manipulations are necessary, and unless a man has 
become accustomed to the use of gloves, he will be 10 
THE MODERN PRACTICE 
greatly hampered. If the patient is known to have 
syphilis or if there are suspicious looking lesions in 
the mouth, and there is no time to have a Wasser- 
mann test performed, the operator should wear rub- 
ber gloves, but this is done more as a protection to 
himself than to the patient. Gloves can be sterilized 
in several ways. They may be immersed in a solu- 
tion of bichloride of mercury, 1-1000, and then 
rinsed in sterile water prior to the operation. They 
also can be boiled, or placed in the auto-clave. The 
simplest and safest method is to boil them in the 
sterilizer, dry them between the folds of a sterile 
towel, and then powder them with sterile talcum 
powder. 
The hands and forearms should be scrubbed with 
the tincture of green soap, and the nails cleaned 
with an orange wood stick, and kept short. It is 
advisable to keep the hand brushes and the orange 
wood sticks in an antiseptic solution, such as bi- 
chloride of mercury, 1-5000. 
The short-sleeved, long white gown is to be worn 
by the operator, in preference to the customary 
short white coat. A sterile towel can be pinned to 
the front of the gown and changed for each opera- 
tion. 
Sterilization of the Operative Field and Dressing 
the Patient.-It is not possible to thoroughly steril- OF TOOTH-EXTRACTION 
11 
ize the oral cavity. Nature, however, has conferred 
a peculiar immunity upon the tissues of the mouth 
that makes them fairly resistant to infection. We 
can nevertheless try to render the operative field 
as sterile as possible, without using drugs that are 
caustic to the tissues. The mouth should first be 
rinsed with an antiseptic. A solution made up of 
equal parts of peroxide of hydrogen and water is 
a most satisfactory mouth-wash. If the operation 
is not urgent, and the mouth is particularly dirty, 
removal of the tartar and polishing the teeth should 
first be done, especially if we expect to suture or 
perform any kind of flap operation. 
The tissues themselves are first painted with the 
tincture of iodine. Dr. Ivy recommends a per 
cent solution made up of equal parts of the ordinary 
tr. of iodine and ether. The claim for this solution 
is that it dries quicker, and is not caustic. I have 
been in the habit of using Churchill's Iodine with 
good success, and have not found it to be deleterious 
to the tissues. However, it is well to bear in mind 
to use only fresh iodine solutions. After the iodine, 
grain alcohol is applied. Iodine has a tendency to 
darken the tissues, especially Churchill's Iodine, and 
obscure our operative field. Alcohol removes this 
stain. Another reason for the use of alcohol is to 
prevent any possible caustic action from the iodine. 12 
THE MODERN PRACTICE 
There are some patients whose tissues are sus- 
ceptible to the action of this drug. In the vast 
percentage of cases we are ignorant of this fact, 
so that an application of alcohol following the 
iodine, will often prevent after-annoyance. The 
patient is covere'd with sterile towels or a sterile 
cover that extends below the knees. The hair also 
is draped with a sterile towel. 
Sterilization of Instruments.-All instruments, 
glass, and enamel ware, are to be boiled for 15 min- 
utes, prior to the operation. This includes sharp 
cutting instruments, such as scalpels, chisels and 
scissors. There is no method of sterilization as safe 
as boiling. To prevent rust, a pinch of bicarbonate 
of soda, or the plain washing soda, can be added 
to the water. Knives, scissors, or chisels, if found 
to be dull, are first sharpened on an arkansas stone, 
washed off, and the blades, or cutting edges, 
wrapped in cotton or gauze. They are then placed 
in the sterilizer to boil. The cotton or gauze will 
prevent the blades from becoming dull. 
Suture materials are also boiled. Several needles 
are threaded, and the needles passed through a 
small piece of gauze, the thread or horse-hair, as 
the case may be, wound about the gauze. Care must 
be taken not to entangle the material. 
Sterilization of the hypodermic syringe depends OF TOOTH-EXTRACTION 
13 
upon the type used. All glass syringes of the Luer 
type are boiled. If the Fischer syringe is used, it 
is kept in a 70 per cent alcohol-glycerine solution. 
It is my custom to use a 3 c.c. Fischer syringe. This 
is kept in a container filled with a solution of 
alcohol 70 parts and glycerine 30 parts. The syringe, 
prior to using, is washed out thoroughly with boiled 
sterile water, so as to remove all traces of the 
alcohol. After use, the syringe is rinsed out with 
ether, and then filled with the sterilizing solution. 
This is then expelled and the cap placed on the 
syringe, which is immediately returned to the con- 
tainer. I use only steel needles, and they are boiled 
just before using. 
Towels and gauze wipes are best sterilized in the 
auto-clave, or in some type of steam-pressure ster- 
ilizer. The wipes are made up into small packages 
of twelve, and wrapped in a little linen container. 
After the instruments and accessories have been 
sterilized, and cooled (this can be done by trans- 
ferring the metal instruments to a basin containing 
either a 2 per cent lysol, or a 1 per cent pheno] 
solution), they are placed on the operating stand, 
which has previously been washed with alcohol, 
and covered with a sterile towel. The instruments 
are then also covered with another sterile towel. CHAPTER II 
EXAMINATION OF PATIENT-PRE-OPERATIVE CARE 
The examination of the patient consists of a 
(1) general examination, and a (2) local examina- 
tion; that is, the examination of the area to be 
operated upon. Before any examination takes 
place, the name, address, age and occupation should 
be taken by the nurse or assistant. 
General Examination.-It is not incumbent upon 
the dental surgeon to make a physical examination 
of every patient that presents for extraction. How- 
ever, there are several salient points that should be 
observed, and will act as a guide to the operator, 
as to the proper handling of the case. They are 
the color of the skin, whether it is pale, florid, etc., 
pupils, demeanor, respiration, breath, pulse, and 
occasionally blood pressure. 
Pallor of the face may indicate anemia, or weak 
heart action. A florid complexion may indicate high 
blood pressure, while whiteness or chalkiness of the 
skin is often seen in cases of nephritis. A golden 
yellow hue is frequently indicative of jaundice, 
Examination of Patient 
14 OF TOOTH-EXTRACTION 
15 
especially if the cornea are also yellow. Cyanosis 
and blueness of the skin is seen in cases of serious 
heart disease, and in pulmonary disturbances. In 
some cases, the blueness might be caused by over- 
doses of some drug, which reduces the haemoglobin, 
such as acetanilid or antipyrine. Such cases are very 
likely to be seen in dental practice, as these drugs 
are often taken for the relief of pain. 
A staring, unmoving pupil (Argyll-Robertson 
pupil), taken together with a shuffling, incoordinate 
gait, is often indicative of locomotor ataxia. Bulg- 
ing eyes might indicate exophthalmic goitre. 
The demeanor is an excellent guide as to whether 
or not the patient needs pre-operative care. A 
highly nervous patient should certainly be given 
some sedative. One that seems dull and lethargic, 
and answers questions only when asked, and then 
only in monosyllables, must be carefully watched. 
This patient may be entering upon the verge of 
shock due to fright, and if this is thought to be 
the case, the operation should be deferred, if possible, 
to a later date. 
Noting of the respiration is often of aid. Difficulty 
in breathing may be due to heart failure, and lack 
of nutrition of the respiratory center. Heavy, wheez- 
ing, and labored breathing is often seen in the 
asthmatic. 16 
THE MODERN PRACTICE 
The pulse is probably the most important thing 
to observe, and should be taken in every case. A 
feeble rapid pulse may indicate poor heart action, 
dilatation of the heart, or myocardial degeneration. 
A rapid full pulse may be due to the absorption 
of toxins and is frequently indicative of an active 
infection. In the latter case, it is well to take the 
temperature. A short, sharp pulse may indicate 
aortic regurgitation. The intermittent pulse, or 
one that occasionally drops a beat, may indicate 
great ventricular fatigue, seen in some cases of 
high blood pressure. 
A radial artery that is difficult to compress, and 
can be rolled about under the fingers, indicates 
hardening of the arteries, especially if the vessels 
about the temples are prominent. In cases of this 
type, the systolic blood pressure should be taken 
with the sphygnomanometer. 
The odor of the breath often informs us of some 
organic disease, that may make the extraction of 
teeth dangerous, unless precautionary measures 
are first taken. In diabetes, for instance, the breath 
has a peculiar sweetish odor. The smell of acetone 
on the breath is a dangerous indication and should 
preclude operating. In cases of pus and necrosis, 
the breath has a distinctive fetid odor. 
Local Examination.-The local examination is OF TOOTH-EXTRACTION 
17 
divided into the (1) physical, and the (2) radio- 
graphic. 
Physical.-The physical examination consists of 
inspection of the oral cavity, tooth and surrounding 
tissues, including palpation for enlarged lymph 
nodes. 
Swellings should be palpated to see whether there 
is any fluctuation, or whether they are solid or due 
to cysts. In large cysts, there is a distinctive crack- 
ling of the tissues on pressure, due to thinning of 
the alveolar walls. 
The condition and color of the gums and oral 
mucous membrane must be observed. If there is 
pallor of the mucous membrane, we should be on 
the lookout for anemia or some circulatory defi- 
ciency. Turgid, congested gums, and oral mucosa, 
may indicate valvular disease of the heart, espe- 
cially of the valves of the right side of the heart, 
wherein the return flow of blood is interfered 
with. 
Suppurative periodontoclasia, Vincent's Infection, 
and mucous patches should be sought for. When the 
mouth is particularly dirty and there is much pus 
exuding from the necks of the teeth, unless impera- 
tive, the extraction should be deferred until the 
mouth has been cleaned. In Vincent's Infection, 
no extractions are to be entertained until the disease 18 
THE MODERN PRACTICE 
is cured. If mucous patches are seen, the patient 
should be questioned as to syphilis, and if the 
extraction is not urgent, the patient should be 
referred for a Wasserman test. However, if the 
tooth must be removed immediately, the operator 
would be wise to protect himself by wearing rubber 
gloves. 
The tooth is inspected as to its firmness in the 
jaw. The thickness of the alveolar plates should be 
determined also, in order to judge where the force 
of extraction is to be applied. A loose tooth does 
not always mean a tooth affected with alveolar 
absorption. The crown alone may be loose, due to 
a fracture, and the operator will be baffled into 
believing that the tooth is simple to remove. Very 
often, the tooth is in the seat of some diseased 
condition, such as carcinoma, necrosis, or cyst, and 
is loose because of the loss of its bony support. 
Enlarged lymph nodes are indicative of some active 
infection. Where there is a solid tumor mass in 
the mouth and the lymph nodes, in anatomic 
relationship, are enlarged, malignancy is to be 
suspected. 
Radiographic Examination.-No tooth should be 
extracted unless it has been previously radiographed. 
The radiogram will disclose the shape, number, and 
position of the roots. It will also enlighten the OF TOOTH-EXTRACTION 
19 
operator as to whether any exostosis exists, or 
whether there is any pathological condition at the 
apex. 
The radiogram requires but a few moments to 
take, and develop, and is the most helpful adjunct 
we have to guide us as to the proper operative 
procedure. 
Pre-Operative Care 
The pre-operative care is determined by the 
examination of the patient. If the patient appears 
normal and not unduly excited, no pre-operative 
medication is necessary. It might be said in passing 
that in the vast majority of cases we do not have 
to resort to pre-operative medication, but we must 
always be on the watch for those cases, where it 
is indicated. The patient should at all times be 
assured that the operation will be painlessly per- 
formed, and that he or she should have no fear. 
If the tooth appears to be a difficult one to remove, 
the patient is acquainted with this fact beforehand. 
Also that the operation will require some little time, 
but that all measures will be taken to have it done 
as quickly and painlessly as possible. 
If the patient is highly nervous, the triple 
bromides of Burroughs, Welcome & Co. (one tablet 
dissolved in a half a glass of water), given fifteen 20 
THE MODERN PRACTICE 
minutes before operating, will act as a most satis- 
factory sedative. 
When upon examination, the blood-pressure is 
found to be high, the amount of adrenalin in the 
anaesthetic solution is lowered. If the blood pressure 
is unduly high, the operation should be deferred 
until it has been reduced. If, however, the extraction 
is urgent, it is wise to demand the presence of the 
family physician. 
Diabetics should be sugar-free before being 
operated upon. In known cases of severe heart 
disease, compensation of the heart muscle should 
be attempted to be established. If the extraction 
is imperative, the family physician is again 
demanded in attendance. 
We will occasionally meet with cases of severe 
heart trouble, or excessively high blood pressure 
that demand immediate attention, and we are 
unable to get a physician to be present. In these 
cases, pre-operative medication is indicated. In 
the case of the high blood pressure, if the adrenalin 
content of the anaesthesia is lowered to a minimum, 
if not entirely left out, and if the patient is given 
a tablet of nitro-glycerine, 1-100 gr., to be dissolved 
on the tongue, we can usually tide this patient over 
the operation very nicely. In cardiac disease, the 
heart can usually be stimulated enough to proceed OF TOOTH-EXTRACTION 
21 
with the extraction, by the administration of the 
tincture of digitalis, 10 drops in a little water, or 
strychnine sulphate 1-60 gr. given hypodermically, 
or a tablet dissolved on the tongue. 
In all events, the operator should be calm and 
self-reliant, and the patient treated with the utmost 
kindness and assurance. The psychic effect upon 
the patient of gentleness and tranquillity goes a 
long way toward inspiring confidence, and often 
accomplishes a great deal more than medication. 
"Calamity howling" is to be deprecated. While a 
severe case is not to be treated lightly, nevertheless 
the patient should not be frightened unduly. CHAPTER HI 
INDICATIONS AND CONTRA-INDICATIONS FOR EXTRAC- 
TION-POSITION OF THE OPERATOR AND PATIENT 
-OPERATION OF EXTRACTION 
Indications and Contra-Indications for Extraction 
Indications.-With the advent of modern root- 
canal therapy, and the advances made in ortho- 
dontia, there seems to be less indication for the 
removal of teeth than formerly. The following are 
the prime indications for the extraction of teeth: 
1. All teeth that will not yield to correct root- 
canal therapy and surgery. There are very 
many teeth that can be safely retained in 
the mouth by the correct treatment with one 
of the modern methods of root-canal ther- 
apy. In single-rooted teeth, apicoectomy 
may be resorted to. Where these methods 
fail, the tooth must be removed. 
2. Teeth affected with periodontoclasia. Where 
more than two-thirds of the bony support 
is lost, the tooth should be extracted. 
3. Teeth that are the cause of cysts and 
necrosis. 
4. Teeth whose pulps must be removed, but 
where the canals cannot be filled properly. 
22 Fig. 3.-Position of operator in extracting upper left bicuspids 
and molars. Fig. 4.-Position of operator in extracting upper anterior teeth. Fig. 5.-Position of operator in extracting upper right bicuspids 
and molars. Fig. 6.-Position of operator in extracting lower bicuspids and 
molars. OF TOOTH-EXTRACTION 
31 
5. Teeth that hinder the proper construction of 
a bridge or denture. 
6. Teeth that are acting as a focus of infection. 
Contra-Indications.-There are really no contra- 
indications in the tooth per se, except that no 
tooth should be extracted that can be brought back 
to a state of health by proper treatment. The 
contra-indications lie in the patient's condition. 
The following diseases forbid the extraction of teeth, 
unless they are controlled beforehand: 
1. Severe anaemia of any type, especially per- 
nicious anaemia. 
2. Jaundice. 
3. Haemophilia. 
4. Severe heart trouble. 
5. Excessively high blood pressure. 
6. Diabetes. 
However, where pain makes the extraction 
imperative, chances must be taken, and any 
untoward sequelae will have to be combated as 
they arise. 
Position of Operator and Patient 
In extracting all upper left molars, bicuspids and 
all upper anterior teeth, the operator stands to the 
right and slightly in back of the patient. (Figs. 3 
and 4.) The chair is lowered until the head of 32 
THE MODERN PRACTICE 
the patient is on about a level with the cnest of 
the operator. The patient sits fairly bolt upright. 
The left arm of the operator is crooked about the 
head of the patient, and the head is pressed against 
the lower part of the operator's chest. In the case 
of the molars and bicuspids, the cheek is held away 
Fig. 7.-Position of forceps in extracting lower molars and 
bicuspids, while standing in front of the patient. Note position 
of the left hand in protecting the jaw from any possibility of 
fracture. 
with the index and third fingers, while with the 
anterior teeth the lip is held away with the index 
finger, and the third finger is placed on the palate 
opposite the tooth to be extracted. Fig. 8.-Position of operator in extracting the lower anterior teeth. OF TOOTH-EXTRACTION 
35 
In extracting the upper right molars and bicus- 
pids, the operator stands in front and to the right 
of the patient. (Fig. 5.) The patient assumes the 
same position in the chair as above, but the chair 
is raised until the face of the patient is on a level 
with that of the operator's. The cheek is held 
away with the thumb or index finger of the left 
hand. 
In extracting the lower molars and bicuspids, the 
operator stands in front and to the right of the 
patient. (Fig. 6.) The patient still maintains the 
same position in the chair, but the chair is again 
lowered until the head of the patient is once more 
on the same level with the operator's chest. The 
index and middle fingers are placed on either side 
of the tooth and the thumb is placed on the under 
surface of the body of the mandible. 
In removing the lower anterior teeth, the operator 
stands more directly in back and only slightly to 
the right of the patient. (Fig. 8.) The chair and 
patient are kept in the same position as for the 
extraction of the molars. The lower lip is held 
away with the index finger and the thumb is placed 
on the lingual surface of the jaw, while the rest of 
the hand is under the chin as a brace. 
Where it is decided to remove teeth in both jaws 
at the same sitting, those in the lower jaw should 36 
THE MODERN PRACTICE 
be extracted first. If the upper teeth are removed 
first, the blood from the wound is liable to obscure 
the operator's vision. 
Operation of Extraction 
Stellwagon, in an article on the extraction of 
teeth, in "The American System of Dentistry", 
divides the steps of extraction into three: 
1. Grasping of the tooth. 
2. Loosening of the tooth. 
3. Removal of the tooth. 
This is a most satisfactory division and aids the 
description of the operation greatly. 
Fig. 9.-Dissection of skull showing the position of the upper 
teeth in their alveoli. Note thickness of the palatal alveolar 
plate in comparison with the buccal and labial plates. (For per- 
mission to use this picture I am indebted to Dr. Dunham, of the 
Dental Digest.) OF TOOTH-EXTRACTION 
37 
Grasping of the Tooth.-The forceps beaks should 
be placed under the free margin of the gums and 
pushed up or down, as the case may be, as far as 
Fig. 10.-Mandible with the teeth ground down showing their 
positions in the alveolar process. 
possible. The forceps are then closed tightly on 
the tooth. 
Loosening of the Tooth.-The attachments of 
the tooth to the socket are broken by the proper 38 
THE MODERN PRACTICE 
movement of the tooth. A knowledge of the 
anatomy of the teeth, their position in the alveoli, 
as well as the alveolar process and the jaws, is 
essential. (Figs. 9 and 10.) 
The upper central incisors are loosened with a 
slight rotating movement, and then by moving the 
tooth labially and palataly, with the strongest force 
toward the labial. 
The upper laterals cannot as a rule be rotated, 
because of the shape of their roots and also because 
they generally have small, fine apices, with a slight 
distal curve. Rotating these teeth would in many 
cases break off the apex and complicate the extrac- 
tion. They are loosened with a labial-palatal 
movement. 
The upper canines are loosened in much the same 
manner as the centrals. A great deal of force is 
sometimes needed to break the attachments of this 
tooth, and care must be exerted not to fracture 
too much of the alveolus. 
The upper bicuspids are loosened with a buccal- 
palatal movement, the stronger force being applied 
buccally. The upper first bicuspid has two roots 
and very often fractures at the palatal root. Care 
must be exercised to prevent this accident from 
happening. 
The upper first and second molars are loosened Fig. 11.-Showing method of elevating and loosening upper third molars. OF TOOTH-EXTRACTION 
41 
with the buccal-palatal movement, again exerting 
the greater force buccally. 
Upper third molars have the same force applied 
to them as in the case of the first and second molars, 
except when they assume a buccal position. In 
this case, an elevator (No. 12C, S.S.W.) can be 
inserted between the third and second molars and 
the third molar elevated downward and distally. 
(Fig. 11.) This will sufficiently loosen the tooth, 
so that it can be easily grasped, and removed with 
the forceps. 
The lower incisors and laterals cannot well be 
rotated because of the narrowness of their roots, 
and also because they are often so close together, 
that rotation would loosen the adjoining tooth. 
A labial-lingual movement, with the stronger force 
labially, will dislodge them. 
The lower canines are loosened in the same man- 
ner as the incisors and laterals, although in some 
cases rotation toward the distal will aid in breaking 
the attachments. 
The lower bicuspids frequently present difficulties 
in loosening, since they are often affected with 
excementosis. In the normal tooth, rotation, with 
a strong buccal movement, will loosen them. 
The lower first and second molars have their 
attachments broken by a bucco-lingual movement. 42 
THE MODERN PRACTICE 
Very often the buccal plate is thicker than the 
lingual one, and stronger pressure can be applied 
toward the lingual plate. However, it must be borne 
in mind not to injure the lingual nerve, which runs 
along the lingual surface of the body of the man- 
dible, in the region of the lower molar teeth. 
The lower wisdom teeth are usually situated more 
buccally than lingually, so that the thickest portion 
of the bone is lingually; hence, pressure must be 
used in a buccal direction. 
The Removal of the Teeth.-After the attach- 
ments of the tooth have been broken, its delivery 
is quite simple, by using gradual traction down- 
ward and outward. Occasionally, the upper molars 
will have to be drawn downward and palataly. 
The tooth must be removed slowly and gradually, 
so that as little process as possible, preferably none 
at all, is taken with the tooth. If any gum adheres 
to the tooth, the withdrawal should be stopped, and 
the gum freed from the tooth with a sharp lance 
or scissors. If this precaution is not heeded, a 
very ugly tear may result, which will necessitate 
suturing. 
The Use of the Elevator.-The principle of the 
elevator is based upon that of the lever. We have 
embodied the power, fulcrum and resistance in this 
operation. The power is the strength exerted by 
the operator. The fulcrum is usually the adjoining OF TOOTH-EXTRACTION 
43 
tooth, and the resistance is the root. By a lifting 
movement the root can be raised out of the socket. 
Sometimes we can protect the fulcrum tooth by 
placing our finger over it and elevating against the 
finger. (Fig. 12.) The flat side of this instrument 
is placed against the root and the convex side 
against the fulcrum. The blade portion should be 
Fig. 12.-Showing method of elevating roots. Note the posi- 
tion of the elevator and finger of the left hand acting as the 
fulcrum. 
forced between the root and wall of the socket, 
if possible. 
Great care must be exerted in elevating roots, 
not to loosen the fulcrum tooth. If the root does 
not come out easily, it is better practice to remove 
it by one of the surgical methods. CHAPTER IV 
REMOVAL OF ROOTS AND APICES-THE CARE OF THE 
GUMS AND PROCESS IN THE MULTIPLE 
EXTRACTION OF TEETH 
No operator is so infallible as to never break a 
tooth during extraction. This in no way detracts 
from his ability. It is impossible to remove some 
teeth in toto, due to malformations of their roots. 
If, however, this accident should occur, the broken 
portion must not be left in the jaws. It has been 
the custom of some men to leave these fragments 
behind, telling the patient that nature would 
exfoliate them. This is bad practice, because it 
has been found that these root-ends are not always 
expelled, and often became serious foci of infec- 
tion. Properly administered local anaesthesia gives 
us ample time to immediately remove, both care- 
fully and painlessly, these fractured roots and apices. 
If a crown should be broken off during extraction, 
an elevator can be inserted between the root and 
the socket, and by using the adjoining tooth as a 
The Removal of Roots and Apices 
44 OF TOOTH-EXTRACTION 
45 
fulcrum, the root can be raised with a lifting 
movement. Care must be taken not to loosen the 
adjoining tooth. Very often, by insinuating the 
narrow beaks of the root forceps underneath the 
gum, the root can be extracted. We must, however, 
be careful not to mutilate the tissues. 
There are those cases, where an apex is fractured, 
or a root is broken too deeply in the jaw to be 
removed by either the elevator or root forceps. For 
example, this may happen during the extraction 
of an upper lateral, which has a fine apex curved 
distally, and is prone to break at this point. In 
these types of cases, some operators lay back a 
muco-periosteal flap, remove the outer plate of the 
alveolus, extirpate the root, and then suture the 
flap back in position. This operation leaves a 
deformity in the alveolar process and makes pros- 
thetic replacement difficult. The following technique 
is much more satisfactory and is applicable to the 
removal of apices and roots of all anterior teeth, 
upper second bicuspids, lower bicuspids, buccal roots 
of upper first bicuspids, and occasionally the buccal 
roots of the upper first and second molars. 
A semi-lunar incision about three-quarters of an 
inch in length is made in the region of the fractured 
apex. (Fig. 13.) The concavity of the incision is 
oward the apex, and the convexity toward the crown 46 
THE MODERN PRACTICE 
of the tooth. It is identically the same as the inci 
sion made for the operation of apicoectomy. A muco • 
periosteal flap is raised, and a window cut either with 
a bur, or chisel in the outer plate of the alveolus, 
in the vicinity of the apex. (Fig. 14.) The apex 
is exposed, pried loose with an elevator, or small 
Fig. 13. Fig. 14. 
Fig. 13.-Primary incision. Fig. 14.-Flap raised and window 
being cut in the outer plate with a bur. 
chisel, and removed through the alveolar opening. 
(Fig. 15.) If any pathological tissue is present, it 
can be conveniently curetted away through this 
same opening. The edges of the bone are then 
rounded and the wound irrigated. The flap is 
returned to its former position and held there with OF TOOTH-EXTRACTION 
47 
sutures. (Fig. 16.) The gum about the incision is 
carefully dried, and the area painted with a solution 
of iodoform, oz. 1 and collodion, oz. 7. This solution 
dries quickly and protects the wound from the pos- 
sibility of infection from the mouth. It will remain 
in place from twenty-four to forty-eight hours. 
Fig. 15. Fig. 16. 
Fig. 15.-Apex exposed, and being extirpated with an elevator. 
Fig. 16.-Flap returned to its original position and held in place 
with sutures. 
Healing of the incision takes place by first intention, 
and in four or five days the sutures can be removed. 
Care must be taken in performing this operation on 
lower bicuspids, not to injure the mental nerve. 
When a larger fragment of the root is broken, 
than an apex, the alveolar opening is made of 48 
THE MODERN PRACTICE 
sufficient size to admit of the free delivery of the 
fractured piece. 
This operation retains the continuity of the 
alveolar ridge, and makes the future prosthesis 
simpler and better looking. 
If the palatal root of the upper molars or first 
bicuspid is broken off, the septum between the roots 
is removed with the bur or a fine beak rongeur 
forceps. The root can then be very easily elevated. 
In the case of a lower molar root being fractured, 
the same procedure is followed out. 
The Removal of Molars Where the Crown Is 
Badly Decayed, or Has Been Broken Off During 
the Extraction.-Very often, an upper or lower 
molar will present itself for extraction where the 
crown is so badly decayed that it will immediately 
snap off at the neck. In these cases, it is best to 
remove the broken-down crown at once. The patient 
should be told that this is intended, otherwise he 
will think that the tooth was accidentally fractured 
and will lose confidence. The remaining roots are 
removed according to the following technique. Let 
us take, for example, the upper first molar, although 
the lower molars can be removed in the same way. 
Two parallel vertical incisions are made, one, 
slightly mesially, and the other distally, to the tooth 
to be operated upon. (Fig. 17.) The incisions need OF TOOTH-EXTRACTION 
49 
Fig. 17. 
Tig. 18. 
Fig. 19. 
Fig. 17.-Position of incisions. Fig. 18-Flap raised and the 
outer plate being removed by means of a short, sharp chisel. 
Fig. 19.-Bifurcation of roots exposed and the roots being severed 
with a bur. 50 
THE MODERN PRACTICE 
not extend to the apex, but merely half way up 
the root. A muco-periosteal flap is then made and 
retracted. With a small sharp chisel, enough of 
the buccal alveolar plate is removed to extend barely 
above the bifurcation of the buccal roots. (Fig. 18.) 
With a fine cross-cut fissure bur, placed against the 
bifurcation (Fig. 19), the buccal roots are divided, 
running the bur toward the palatal root. The cut- 
ting is then continued mesially and distally so as 
to sever the palatal root from the buccal roots. 
We have thus divided these roots one from the 
other. The area is now irrigated to wash away the 
grindings, and dried with sterile gauze. The roots 
can now be easily removed with the elevator and 
root forceps. All rough edges of alveolus are 
straightened and smoothed, and the flap restored 
to its original position. It is rarely necessary to 
use sutures to hold it in place. 
The advantages of this operation are that: (1) it 
leaves a clean wound; (2) there is no traumatism 
to the tissues; (3) it is quickly performed; (4) 
there is scarcely any after-pain. 
Occasionally, the roots may be exostosed or curved 
to such an extent that they cannot be removed unless 
the greater portion of the buccal alveolar plate is 
taken away. In cases of this type, the incision is 
extended to the apices of the tooth, and a larger OF TOOTH-EXTRACTION 
51 
flap retracted. The roots are divided in the same 
manner described above and the buccal plate slowly 
chiseled away. Care must be taken not to chisel 
too quickly or with too much force, because a large 
strip of alveolus may become dislodged. From time 
to time, the roots can be attempted to be pried 
loose, and very often one or two of the roots will 
be elevated out, or grasped and removed with the 
root forceps. Sufficient outer plate is taken away 
until the remaining root or roots, as the case may 
be, can be delivered through the opening. The 
alveolus is then straightened, all thin and rough 
edges are removed, including a goodly portion of 
the septum, and the area irrigated. The method 
of closing the wound, that is, the return of the flap, 
is determined by the amount of alveolus removed. 
Where not much of the outer plate has been taken 
away, the flap can be returned to its original posi- 
tion, sutures not being necessary. But where a 
large amount of alveolar plate is taken away, the 
following technique for the closure of the wound 
has been found most gratifying. 
The outer plate is removed with rongeur forceps 
until we have a freely pendulous flap. The mesial 
and distal sides of the socket are well rounded, 
leaving no sharp edges. The gum covering the 
palatal plate now is loosened with a periosteal 52 
THE MODERN PRACTICE 
elevator, and enough of the palatal plate removed 
to leave this portion of the gum also free. (Fig. 20.) 
The removal of this plate is determined by the 
length of the buccal flap. All we need is enough 
free gum on this side, so that we can get approxima- 
tion with the buccal flap. The latter is now brought 
Fig. 20. Fig. 21. 
Fig. 20.-Outer plate removed, leaving the buccal flap hanging 
pendulous. Palatal mucosa raised. 
Fig. 21.-Buccal flap sutured across socket to palatal mucosa. 
across the socket toward the palatal flap and the 
parts approximated and held with sutures. (Fig. 21.) 
The edges of the flap need not necessarily touch. 
Of course, this is preferable, but may entail too 
much bone removal. The flaps should be brought 
in as close apposition as possible. The same OF TOOTH-EXTRACTION 
53 
procedure works equally as well in the lower 
jaw. 
This method of closing the wound is preferable 
to the ordinary returning of the flap to its original 
position, as it does away with the packing of the 
socket, and leaves the wound closed, without fear 
Fig. 22. Fig. 23. 
Fig. 22.-Part of outer plate and septum removed. Buccal flap 
freed from bone, (a) Palatal mucosa, (b) palatal plate, (c) septum, 
(d) outer plate, (<?) buccal flap. 
Fig. 23.-Buccal flap laid in socket in much the same manner as 
one does in certain types of cyst operations. 
of the ingress of food. It is especially useful where 
the antrum has been opened, either purposely or 
accidentally. 
In those cases where too much plate has not been 
removed, and the socket is not too deep, we will 
very often find that instead of suturing the flap 
across, we can lay it in the socket, forming a sort 54 
THE MODERN PRACTICE 
of lining, as is done in large cyst operations. This 
protects the socket and facilitates healing. (Figs. 
22, 23 and 24.) 
The Care of the Process Where a Number of 
Adjoining Teeth Are Removed.-Very often, we 
are called upon to remove two or more adjacent 
teeth. This leaves 
a jagged wound 
and healing takes 
considerable time. 
Also, when the 
tissues do finally 
heal, the alveolar 
ridge is left in an 
irregular or 
"bumpy" condi- 
tion, and it is some- 
times extremely 
difficult to fit dentures or bridges in these mouths. 
Frequently, the periosteum contracting over little 
sharp edges of alveolar process is the cause of a 
severe and insidious neuralgia. We can therefore 
avoid much future discomfort to the patient by 
Fig. 24.-Model made two weeks 
after this method had been performed. 
Note the splendid healing and ex- 
tremely slight deformity. OF TOOTH-EXTRACTION 
55 
proper attention to the process directly after the 
extractions. 
Small vertical incisions are made on either side 
of the operative field, and the labial gum and perios- 
teum raised and retracted. Any interdental connec- 
tions are severed with a fine curved scissors. The 
rough and protruding edges of the alveolus are 
removed with the rongeur forceps and smoothed 
with large mastoid curettes. The area is now irri- 
gated and the flap returned to its place. By running 
a finger over the gum, we can discover any sharp 
points that may be present. If any are found, the 
flap is again raised and the sharp edge removed. 
When we are certain that the alveolus is smooth, 
the uneven edges of the gum are trimmed and the 
flap laid back in place. It is not necessary to suture 
or pack the wound. The gum is carefully dried and 
the iodoform-collodion solution applied. Healing 
takes place promptly and usually without any pain. CHAPTER V 
ACCIDENTS 
The following are the accidents that may com- 
plicate tooth extraction: 
1. Fracture of the tooth. 
2. Loosening of the adjacent tooth. 
3. Fracture of the alveolus. 
(a) Fracture of the tuberosity. 
4. Opening of the antrum. 
(a) Forcing tooth into the antrum. 
5. Dislocation of the jaw. 
6. Fracture of the jaw. 
Fracture of the Tooth.-This is the commonest 
accident that may happen during the extraction 
of a tooth. The fractured portion must be removed 
and this can be done by any of the methods 
described in the preceding chapter. 
Loosening of the Adjacent Tooth.-As a rule, 
this accident is due to carelessness on the part of 
the operator. It is most liable to happen in remov- 
ing the lower incisor teeth or in attempting to 
elevate a root. There are those cases, though, where 
one tooth is fused to another. This is a compara- 
56 OF TOOTH-EXTRACTION 
57 
tively rare occurrence and can be determined before- 
hand by a radiogram. If a tooth should become 
loosened, it can be ligated to its neighbors with 
orthodontic wire, or Chinese grass line. The tooth 
will, as a general rule, become tight again. However, 
this accident is avoidable, and every operator should 
take care to see that it does not occur. 
Fracture of the Alveolus.-The alveolar process 
is fractured in a more or less degree in the vast 
majority of extractions. If the piece broken off is 
a small one, it should be immediately removed and 
the edges of the alveolus rounded with the rongeur 
forceps and curettes. Even fairly large pieces of 
process should be removed, as there is little likeli- 
hood of their becoming re-attached, and, if left, 
necrosis of the process may follow. 
In extracting upper wisdom teeth, the tuberosity 
is liable to fracture. There is not much to do in 
these cases, but to remove the broken piece, trim 
the rough edges of bone, and cut away the redundant 
gum. Sometimes the edges of the gum can be 
approximated and sutured together over the gap 
created. 
Opening Into the Antrum; Forcing a Root Into 
the Antrum.-Very often the palatal roots of the 
upper first and second molars, and sometimes the 
roots of the bicuspids, penetrate the maxillary sinus, 58 
THE MODERN PRACTICE 
and, consequently, in removing these teeth, the an- 
trum is opened. This calls for no treatment, unless 
the patient is suffering from a mixillary sinusitis. If 
the case is uncomplicated, the socket can be lightly 
packed with iodoform gauze to prevent food from 
entering and changed daily for a few days. 
Occasionally, a root may slip into the antrum. 
This is liable to happen while trying to. elevate these 
roots. When it does occur, the root must by all 
means be removed, as its presence may cause a 
severe infection of the antrum. There are several 
methods for its recovery. We should try the simplest 
one first. After the root has entered the antrum, a 
radiograph is taken, to try to locate its exact posi- 
tion. The opening into the antrum is then enlarged 
with fine-beak rongeur forceps, and a surgical bur. 
A large enough opening should be made that would 
admit the tip of the little finger. Of course, it must 
be understood that we do not actually put our 
finger into the wound. In doing any operation 
involving the maxillary sinus, absolute asepsis is 
imperative. After the opening has been made of 
sufficient size, we can try irrigating the sinus through 
the socket, with a mild boric acid solution. Fre- 
quently the root can in this way be washed out. 
If this is not successful, we can introduce a silver 
probe, bent at an angle and slightly hooked at the OF TOOTH-EXTRACTION 
59 
end. By groping along the floor of the antrum with 
this instrument, we may be able to "fish" out the 
root. If both of these methods do not succeed, the 
antrum must be enlarged sufficiently so that we 
can see into it. A muco-periosteal flap is raised, 
and the outer alveolar plate removed, until we have 
a clear view into the antrum. An antrum lamp is 
introduced and the sinus thoroughly inspected. The 
root now will be seen and can easily be grasped 
with a mouse-tooth forceps or "teased" out with a 
curette. The method of closing the antrum presents 
a problem and is governed by the condition found 
within the antrum itself. Where we have been suc- 
cessful in removing the root without taking the 
outer alveolar plate away, we can irrigate the sinus 
and pack the socket with iodoform gauze. This 
treatment will usually suffice. The gauze is changed 
daily until granulation takes place and the antrum 
is entirely closed. The majority of these cases make 
an uneventful recovery. We must, however, be 
watchful, for we might have unwittingly introduced 
some infection into the antrum, no matter how 
scrupulous our asepsis might have been. 
If the outer plate has been removed, and the 
antrum is clean, we can then close the wound by 
suturing the flap across the socket in the same 
manner described for the closing of the socket where 60 
THE MODERN PRACTICE 
a root has been removed surgically. In this case, 
however, a piece of iodoform gauze is inserted 
between the sutures to insure drainage in case any 
untoward event should happen. 
If the antrum should be found diseased, the 
routine treatment for maxillary sinusitis is carried 
out. For a description of this treatment, the reader 
is referred to works on oral surgery. 
Dislocation of the Jaw.-In the removal of lower 
teeth, the mandible is liable to become dislocated. 
Occasionally, this may also happen, if the patient 
attempts to open the mouth too far. It is an 
awkward accident, but can easily be remedied. The 
chair is lowered as far as possible, and the back 
adjusted so that the patient sits bolt upright. The 
operator stands over the patient in a straddled 
position. After wrapping the thumbs well in cotton, 
they are placed on the occlusal surfaces of the lower 
molar teeth, and the under surface of the body of 
the mandible grasped firmly with the rest of the 
hand. By pressing the mandible downward and 
backward, and tilting the chin upward, the condyle 
is slipped back over the emenentia articularis into 
the glenoid fossa. (Fig. 25.) The jaws are then 
held together with a Barton bandage for twenty- 
four hours. 
Fracture of the Jaw.-The mandible is liable to Fig. 25.-Position of the operator and patient in reducing a dis- 
location of the mandible. Note how the thumbs of the operator 
are protected by wrapping them in cotton. OF TOOTH-EXTRACTION 
63 
fracture, due to some diseased condition of the bone, 
such as necrosis, large cysts, fragitalis ossium. It 
also may be fractured by undue force applied in 
extraction, especially in the region of the mental 
foramen. This accident, while it rarely occurs, is 
most distressing, both to the patient and to the 
operator. 
The treatment of these cases is the setting of 
the jaw, being guided by the occlusion of the teeth, 
and then wiring the mandible to the maxilla accord- 
ing to one of the approved techniques. If there is 
any diseased condition of the jaws present, it must 
be treated accordingly. CHAPTER VI 
AFTER-PAIN 
Pain after the extraction of a tooth is a fairly 
common occurrence. It is usually due to: (1) a 
faulty anaesthetic solution; (2) probing for land- 
marks with the hypodermic needle; (3) trauma to 
the tissues; (4) infection of the socket; or the so- 
called "dry socket." 
The Ancesthetic Solution.-Great care must be 
exerted in using fresh isotonic solutions. The injec- 
tion of hypo- or hypertonic saline vehicles often 
causes great distress. All anaesthetic solutions should 
be freshly prepared immediately before use. I have 
seen dentists keep an uncorked stock bottle of some 
local anaesthetic on their cabinets, and when a 
patient presented for the extraction of a tooth, dip 
their syringe into the bottle, and inject this solution. 
No good can come from such practice, and it cannot 
be too strongly condemned. I use the procain- 
suprarenin tablets and dissolve them in sterile 
normal saline solution immediately before injecting. 
Where a man does not wish to go to this trouble, 
64 OF TOOTH-EXTRACTION 
65 
several reliable manufacturers are now putting out 
ampoules of procain solution, ready for immediate 
use. Unless an operation is sure that he can prepare 
a sterile isotonic local anaesthetic, he is better off to 
use these ampoules. 
Probing for Landmarks With the Hypodermic 
Needle.-Frequently, in probing for a foramen the 
periosteum is scraped. This especially occurs in the 
mandibular injection. A proper knowledge of the 
anatomy of the jaws and the various exits of the 
branches of the trigeminus nerve will obviate a 
great deal of groping and probing for these foramina. 
Treatment.-Pain due to these causes can easily 
be differentiated from that caused by an infected 
socket, because it is usually confined to the point of 
injection. In the mandible the patient will often 
complain of discomfort in opening the mouth. Little 
can be done. The pain will wear off as the tissues 
heal. Sedatives are prescribed, as well as warm 
mouth washes. A ery often, dry heat applied to the 
face will afford some relief. However, this should 
not be advised if we suspect the presence of any 
infection. 
Traumatic Injuries to the Tissues.-Lacerating 
extractions are the cause of a great deal of after- 
pain. They are most liable to occur under general 
anaesthesia. If the tooth is removed gently with 66 
THE MODERN PRACTICE 
the minimum amount of disturbance to the tissues, 
much will have been done to avoid after-pain. If 
a root is broken off during extraction, it should be 
removed surgically, according to the methods de- 
scribed in the previous chapters. 
Treatment.-Under local anaesthesia, all lacerated 
soft tissue is trimmed with a fine curved scissors. 
Loose pieces of alveolus are removed, and rough 
edges of bone smoothed with rongeur forceps and 
spoon curettes. The wound is then irrigated with 
a warm antiseptic solution, and packed lightly with 
iodoform gauze. Warm mouth washes and some 
sedative is prescribed. 
The So-Called "Dry Socket."-Painful sockets 
after extraction occur quite frequently. The pain 
arising from this condition is sometimes excruciat- 
ing, preventing sleep and making the patient mis- 
erable. Some men have attributed this condition 
to a lack of bleeding in the socket, but this is only 
a description of one of the symptoms. It is an 
alveolitis, or osteitis of the socket, due to a low- 
grade infection. 
Symptoms.-The chief subjective symptom is 
great pain of a neuralgic character. The patient is 
harassed and unable to sleep. I have seen patients 
lose five pounds in a week during an attack of this 
kind. Objectively, the socket is devoid of healthy OF TOOTH-EXTRACTION 
67 
granulations. There is no healing clot, and if a 
swab is introduced into the socket it will be found 
to have an offensive odor. 
Treatment.-Many remedies have been suggested 
for the relief of this condition. There is little need 
of placing anodynic or anaesthetic dressings in the 
socket, or prescribing sedatives, unless the cause is 
removed, and that is, combating the infection 
present. 
Under complete local anaesthesia, the socket is 
irrigated, in order to wash out all particles of food. 
The necrotic walls and the floor of the socket are 
next thoroughly curetted, until healthy bone is 
reached; this is indicated by bleeding from the walls 
of the socket. The wound is again irrigated, dried, 
and swabbed out with Churchill's Iodine. The socket 
is now packed with iodoform gauze into which has 
been incorporated procain powder, rubbed up in 
white vaseline, or better in mentholated vaseline. 
This paste is easily made by placing procain powder 
and mentholated vaseline in a mortar, and rubbing 
them up together with the pestle. The gauze is then 
dipped in the paste and carried into the socket. 
Mentholated vaseline is preferable to the plain, 
because the menthol is both anaesthetic and anti- 
septic. 
A most useful adjunct to the treatment of "dry 68 
THE MODERN PRACTICE 
socket" is the injection of a mixed vaccine, as an 
aid to overcome any deep infection in the tissues. 
The most useful of these vaccines is the one of 
Dr. Goldenberg of Paris. It can be injected intra- 
orally, and is a mixed stock vaccine, made 
from bacteria taken from the oral cavity. It is so 
concentrated and treated that small doses, which 
are necessarily needed to be injected in the mouth, 
contain the desired amount of bacteria to be effec- 
tive. There is little or no local reaction. The use 
of vaccines has such an important place in com- 
bating post-operative infections, that I have devoted 
a chapter to their special use in dental surgery. 
The packing in the socket is changed daily until 
all pain has subsided, which is a good indication 
that the infection is controlled. Warm mouth 
washes and sedatives are also prescribed. If the 
patient has lost much sleep, some hypnotic, such 
as allonal, can be given. Sleep to these patients is 
a great boon, and all efforts should be made to 
induce it. 
Prophylaxis of After-Pain.-Post-operative pain 
is sometimes more easily prevented than controlled. 
It behooves us, therefore, to take precautionary 
methods to prevent it. Careful preparation of the 
anaesthetic solution, together with its proper intro- 
duction, will go a long way to accomplish this. OF TOOTH-EXTRACTION 
69 
Gentle handling of the tissues during the operation 
will also aid in preventing after-pain. In cases 
where the socket is suspected of being infected, it 
is well to curette the walls and, after irrigating, 
insert a light dressing of iodoform gauze. 
Before closing this chapter, I should like to cite 
the following case, as it is illustrative of a most 
important point, and also emphasizes the need of 
close examination and correct diagnosis, as to the 
source of pain. 
"Mrs. B. Removed the upper right first molar. 
The extraction was accomplished without any 
difficulty. Three days later the patient returned 
with the most excruciating pain in the region where 
the tooth had been removed. On examination, the 
socket appeared to be healing nicely and there was 
no inflammation about it. I looked at the adjoining 
teeth and found a deep cavity beneath the free 
margin of the gum on the distal surface of the 
second bicuspid. There was a severe pulpitis present 
with exposure of the pulp. As much decay was 
removed as possible, the cavity irrigated with a 
warm bicarbonate of soda solution and oil of cloves 
sealed in. The pain disappeared immediately." 
Cases of this kind have been frequently brought 
to my attention. It is fairly common to find cavities 
in the teeth adjoining those that are removed, espe- 70 
THE MODERN PRACTICE 
daily if the extracted tooth happened to be crowned, 
or had a large filling in its approximal surface. The 
patient may not experience any discomfort until 
the adjacent tooth is removed. The cavity is then 
exposed to thermal change and the fluids of the 
mouth, and a pulpitis results. 
In all cases of extraction, it is wise to examine the 
teeth on either side of the socket, and if a cavity is 
present, to seal some antiseptic sedative in it. CHAPTER VII 
HAEMORRHAGE-SYNCOPE-SHOCK 
Haemorrhage following tooth extraction is not 
very common. Unless the patient is a true haemo- 
philiac, or is suffering from some condition that has 
altered the character of the blood, such as anemia, 
jaundice or diabetes, the haemorrhage is not danger- 
ous. Before removing a tooth, it is wise to question 
the patient as to whether they bleed freely or are 
true "bleeders." As a rule, a haemophiliac will 
convey this information to the operator without 
being asked. If there is excessive bleeding from 
our needle puncture, it is often indicative of the 
fact that the patient bleeds freely. 
Prevention of Haemorrhage.-In cases where it is 
known that we are dealing with patients that are 
predisposed to haemorrhage, precautionary measures 
must be taken to increase the coagulation time of 
the blood. Any disease responsible for this condition 
should be corrected, if possible, by the family 
physician. Some people bleed freely without having 
any organic reason for it. To them, calcium lactate 
71 72 
THE MODERN PRACTICE 
can be administered, 20 grains three times a day, 
for several days before the operation. 
Causes of Hemorrhage Following Tooth Extrac- 
tion.-The causes of post-extraction haemorrhage 
are either local, that is, some condition within the 
wound itself that prevents the blood from clotting, 
or general, in which the blood itself lacks some 
element that delays its coagulation. 
Local Causes.-Very often, a piece of loose 
alveolus is present in the socket that interferes with 
the clotting of the blood, or there may remain some 
granulomatous tissue which is very vascular, and 
keeps continually oozing. Occasionally, in the lower 
jaw, necrosis of the socket may penetrate to the 
inferior dental canal, and cause a sloughing of the 
inferior dental artery. 
Treatment of Local Causes.-The first thing to 
do in all cases of haemorrhage is to make a careful 
examination of the socket. It is best to re-anaesthe- 
tize the area, so as to do this more thoroughly. 
All blood clot is picked out and the socket irrigated 
with a warm saline solution. The wound is then 
dried with sterile gauze, and inspection made as 
to whether the bleeding is coming from the gum, 
or the socket proper. If the bleeding is coming 
from the gums, simple pressure on the tissues, with 
gauze saturated with a solution of adrenalin- OF TOOTH-EXTRACTION 
73 
chloride, 1-1000, will, as a rule, be sufficient to stop 
it. The pressure can be continued by placing a 
piece of modeling compound over the gauze, chill- 
ing the compound, and having the patient close 
on it. 
When the bleeding comes from the socket, the 
cause must be ascertained. If any loose pieces of 
alveolus are present, they should be removed. A 
fine curette can be passed to the bottom of the 
socket and granulomatous tissue felt for. We can 
readily tell if there is any of this tissue present by 
the soft, velvety "feel" conveyed to us by the 
curette's contact with it. If granulations are present, 
they must be thoroughly scraped away, even if it 
necessitates surgical exposure of the socket. If we 
find that the inferior dental canal has been opened, 
pressure on the bleeding parts will usually cause a 
cessation of the haemorrhage. It is almost impossible 
to ligate the inferior dental artery, and I have never 
seen any bleeding from it that could not be stopped 
by pressure. 
After the socket has been thoroughly cleaned, it 
is then irrigated and dried. Iodoform gauze satu- 
rated with adrenalin-chloride is packed tightly in 
the socket, and over this modeling compound is 
placed and the patient told to close the teeth. 
A most useful adjunct to the treatment of local 74 
THE MODERN PRACTICE 
haemorrhage is the sub-mucous injection around the 
socket of a weak adrenalin solution. Five drops of 
adrenalin-chloride, 1-1000, to 10 c.c. of normal 
saline are the proportions used. Seven or eight 
minums of this solution are injected buccally and 
the same amount palataly or lingually, about the 
bleeding socket. This procedure works excellently, 
and it is my practice to use it in every case of local 
haemorrhage. 
The patient is kept in the office until all bleed- 
ing has ceased. The modeling compound is then 
removed and the patient instructed to stay quietly 
at home, and to keep cold applications on the 
outside of the face for the remainder of the day. 
The packing is kept in the socket for three days, 
and is then gently removed. It is rarely necessary 
to repack the wound. 
Hemorrhage Due to General Causes.-There are 
several diseases that alter the condition of the blood 
to such an extent that its coagulation time is greatly 
decreased. These are haemophilia, probably the 
most important of all; pernicious anemia, scurvy, 
diabetes, jaundice, and purpura. Haemorrhage asso- 
ciated with these conditions often assumes fatal 
proportions and taxes the skill of the operator 
to stop. 
Hemophilia.-This disease is probably the com- OF TOOTH-EXTRACTION 
75 
monest cause for fatal haemorrhage following the 
extraction of a tooth. It is now believed that it 
is due to a deficiency in the quality or quantity of 
the prothrombin. Probably the deficiency is more 
in the quality than in the quantity. It is thought 
to be a congenital defect in the prothrombin 
whereby it takes much longer to form thrombin. 
Haemophilia bears certain oddities, in that bleeding 
in some parts of the body may prove more fatal 
than in others. Wounds below the neck may not 
bleed excessively, while cuts, bruises, or operative 
wounds of the cheeks, gums, or lips may result in 
death. In haemophilia it is the capillaries rather 
than the arteries that ooze. There is no evidence 
on hand to show whether haemorrhage of purpura, 
scurvy, pernicious anemia, or jaundice have the 
same pathology, although they act in the same way. 
Treatment.-Haemophiliacs are best placed in the 
hospital for treatment. The clotting of the blood 
may be hastened by the injection of horse serum, 
or, if this is not available, diphtheria antitoxin will 
answer the same purpose. Very often, whole blood 
taken from a parent, or, in urgent necessity, from 
the operator himself, injected into the patient, will 
stop the haemorrhage in some cases. In the last few 
years, blood transfusion has proven very successful 
and has saved the lives of many haemophiliacs. 76 
THE MODERN PRACTICE 
Syncope and Shock 
Syncope is due to cerebral anemia, while shock 
is a condition of depressed vitality. It is more than 
likely that syncope is a forerunner, in a great many 
cases, of shock. I have classified two types of 
syncope: (1) Operative syncope, that is, fainting 
or collapse during the anesthetization or operation; 
and (2) post-operative syncope. The latter type 
may occur several hours, or even a day, after the 
operation. 
Operative Syncope.-This condition is frequently 
due to psychic reasons. It is strange to say, but 
syncope of this type is observed more often in the 
big, athletic fellow than in the frail, little woman. 
Syncope is sometimes caused by failing heart action. 
The musculature of the heart, not being able to 
drive the blood to the brain, causes a cerebral 
anemia. 
It might be well to digress here for a moment, 
and take up the peculiar symptoms seen after the 
injection of procain-suprarenin. Many of us have 
noticed some untoward results immediately after, 
and sometimes during, the injection. While they 
are almost always of a transitory nature, neverthe- 
less, they are most distressing to the operator and 
patient. Of course, a lot of these cases are psychic, 
and we can notice the patient paling, immediately OF TOOTH-EXTRACTION 
77 
after the insertion of the needle, without discharging 
a drop of our solution. There are, however, a group 
of cases where the psychic element does not enter. 
The symptoms presented by these patients are: 
palpitation of the heart (tachycardia), pains across 
the lower lumbar region, sometimes abdominal pain, 
and frequently loss of power in the arms or legs, 
usually of only one side. The face becomes pale, 
the lips bluish, and the pulse rapid. Respiration 
is sometimes interfered with, and they have some 
difficulty in breathing freely. Of course, as was 
stated above, these symptoms are fortunately of 
short duration, and I have never seen a case, no 
matter how severe the symptoms, where I could not 
continue and complete the operation after a few 
moments' rest. 
It is my opinion that the reason for these symp- 
toms is the suprarenin in the solution. These 
patients are suffering from some endocrine disorder. 
They probably are unaware of this fact, and al- 
though they may suffer from some mild symptom 
do not pay any attention to it. The injection of the 
adrenalin brings out this disorder and causes the 
symptoms we see. It acts in much the same way as 
the Goetsch test for hyper-thyroidism. This test is 
the injection of adrenalin, and brings out certain 
definite symptoms in those suffering from an over- 78 
THE MODERN PRACTICE 
secretion of the thyroid gland. These symptoms are 
almost identical with those witnessed after the in- 
jection of our procain solution; namely, palpitation, 
loss of muscular tone of the extremities, and lumbar 
and abdominal pain. I am firmly of the belief that 
wherever we see these in patients, after the injection 
of the procain solution, these patients are suffering 
from some endocrine disorder, probably hyper- 
thyroidism, and that it is the adrenalin or supra- 
renin in the solution that brought them about. The 
two following cases are of interest: 
"Miss B. F., age 35. Have injected this patient 
over a period of three years for various operations 
in the mouth, without any symptoms whatever. A 
short time ago, I had occasion to inject her again, 
and in two or three minutes after the injection she 
complained of palpitation and general muscular 
weakness of the legs and arms. In a few moments 
the symptoms passed off and she was well enough 
for me to continue the operation. However, it 
seemed strange that after all the injections she had 
had, this one should affect her so. On close ques- 
tioning, she said that the tachycardia had lately been 
troubling her, but that she had not paid any atten- 
tion to it, and also that of late she had been feeling 
very nervous. There is little doubt that she is suffer- 
ing now from some endocrine dysfunction, probably OF TOOTH-EXTRACTION 
79 
hyperthyroidism, and that the adrenalin in the solu- 
tion had brought out the symptoms recorded." 
The following case brings out clearly the role 
played by the adrenalin in a true case of goitre, 
and the symptoms were the severest I have ever 
seen: 
"Miss R., age 47, suffered from an exophthalnr 
goitre. I injected 2 c.c. of a 2% procain-suprarenn. 
solution, and in a moment or two she complained of 
severe pain in the abdomen and lower part of her 
back. The tachycardia was most distressing and the 
patient became greatly frightened. In two or three 
minutes the pain and palpitation passed off and I 
was able to proceed with the extraction." 
The points that I wish to make clear in citing this 
case are the effects of suprarenin in cases of un- 
doubted hyperthyroidism and goitre, and the rapid- 
ity with which they pass off. However, where we 
definitely know that the patient is suffering from 
this ailment we should be careful to reduce the 
adrenalin content of our solution. In some cases, 
the minutest amount of suprarenin will cause these 
symptoms, and if they should occur the operator 
need not be frightened, as they quickly pass away 
and do no harm. There really is no definite treat- 
ment for these patients, as far as we are concerned, 
except to allow them to remain quiet until they feel 80 
THE MODERN PRACTICE 
easier, and if they are nervous, to give them a bro- 
mide. 
Symptoms.-To return to the symptoms of syn- 
cope; they are paling of the face and lips; beads 
of cold perspiration break out upon the forehead, 
and the face becomes waxy and the nose elongated. 
It will be found that in mild cases of syncope, or 
the average faint, the pulse will remain strong, al- 
though a trifle accelerated. In the severer types, 
the pulse will be found to be weak, thready and 
very fast. 
Treatment.-At the first signs of these symptoms, 
it is best to stop all operating and restore the pa- 
tient. In most cases, placing the patient's head be- 
tween their knees will cause the blood to rush to the 
anemic brain and restore consciousness. (Fig. 26.) 
When this has returned, a drachm of aromatic spir- 
its of ammonia in half a glass of water will revive 
the patient sufficiently to continue the operation. 
No drug should be forced in the patient's mouth 
until consciousness has been restored, and the 
patient is able to swallow. 
Where these measures do not succeed in restoring 
the patient, the faint may be assuming a more seri- 
ous nature, and the condition may be approaching 
a stage of shock, or the heart may be failing. 
The patient should be stretched out in the chair Fig. 26,-Method of reviving a fainting patient. The head is 
forced down between the knees. OF TOOTH-EXTRACTION 
83 
with the head lower than the feet. Tight clothing 
is loosened and the pulse carefully observed. It will 
be found to be feeble and extremely rapid. It is 
also advisable to take the systolic blood pressure. 
This will be found to be low, and if it should fall 
below 90 mm. of Hg. the condition is serious. Hy- 
podermic medication is now imperative. The most 
rapid of the stimulants at our command to-day is 
adrenalin chloride. Seven minums of the 1-1000 
solution should be injected subcutaneously in the 
deltoid region of the arm. In many cases the pa- 
tients have the sleeves of their clothing rolled down 
over their arms, and as quick action is necessary, the 
sleeve can be pushed up and the injection made in 
the forearm. Pituitrin can also be used in the same 
manner, but its action is slower than adrenalin, al- 
though more lasting. The action of adrenalin is 
rapid, but not of long duration, and other medica- 
tion is indicated, to retain what has been accom- 
plished by the adrenalin. Hot black coffee by 
mouth, provided the patient can swallow, strych- 
nine sulphate, 1/60 gr. or camphor in oil, can be in- 
jected. As soon as sufficient recovery has been made 
the patient is carefully carried to a rest room and 
laid upon a couch. The feet are raised and the 
shoes removed. Warm blankets are wrapped about 
the patient and a hot-water bag placed at the feet. 84 
THE MODERN PRACTICE 
This is done to increase the body heat, for in shock 
the body heat is greatly lowered, and in cases of 
failing heart, warm skin and extremities decrease 
the peripheral resistance to the heart, and lessen the 
work of this organ. 
The systolic blood pressure should be taken from 
time to time, and a rise will indicate improvement. 
Where the blood pressure does not rise after treat- 
ment, or where it is becoming progressively lower, a 
physician had better be consulted, preferably the 
family doctor. The patient may have to be sent to 
a hospital, where more drastic treatment, such as 
saline infusion, or even blood transfusions can be in- 
stituted. Steadily decreasing blood pressure is in- 
dicative of progressive shock, or in some cases failing 
heart muscle. 
If the blood pressure rises again, and the patient 
is feeling better, he can be allowed to return home, 
with the admonition to go immediately to bed and 
keep warm. He should also be advised to keep 
himself under the care of a physician for the time 
being. 
Unless the extraction is absolutely imperative, the 
operation is deferred for a few weeks. In the mean- 
time, the patient can consult a physician and be 
treated for whatever ailment might have contributed 
to the attack of syncope. OF TOOTH-EXTRACTION 
85 
Post-operative Syncope.-This condition, while it 
does not occur frequently, is far more serious than 
that which takes place during an operation. The 
patient may leave the office with a strong pulse and 
feeling well, and several hours later collapse. These 
cases should receive the attention of the family 
physician, as they sometimes terminate fatally. 
Probably the best treatment for them is body 
warmth, obtained by the method described above, 
and transfusion of saline solution. Morphine injec- 
tions to induce sleep have proven beneficial. Crile 
advises the administration of morphine, given every 
hour until the respirations have reached twelve. 
However, it must be given with caution, and should 
not be administered if the finger nails are blue. 
Adrenalin chloride is useful in raising the blood 
pressure, and can be added to the saline solution. 
Fluids are of value and are supplied by the infusions. 
We are not often called upon to treat these patients, 
but when the occasion arises, the dental-surgeon 
should be in a position to recognize it and sug- 
gest the proper treatment. CHAPTER VIII 
POST-OPERATIVE CARE 
Post-operative care is as important as the oper- 
ation itself. After-care can be divided into: 
1. Care taken by the operator. 
2. Care taken by the patient at home. 
The After-care Taken by the Operator.-No mat- 
ter how simple the extraction has been, the patient 
should be advised to return the next day for observa- 
tion of the wound. If the tissues are healing, the 
patient is dismissed with the admonition to return 
if any untoward symptoms should arise. 
Some sockets heal slowly and sluggishly. There 
may be no pain, but just a lack of regeneration of 
the tissues. The cause of slow healing may be local, 
such as a low-grade infection of the tissues, or gen- 
eral, due to an alteration in the chemistry of the 
blood, as in the case of diabetes. Chronic infections 
like syphilis and tuberculosis also retard healing 
after extraction. 
The treatment of slow healing depends upon the 
86 OF TOOTH-EXTRACTION 
87 
cause. The patient in all cases should be referred 
to a physician for a general examination, including 
urinalysis and the Wassermann test. Locally, the 
socket can be lightly curetted to encourage bleeding, 
for which no anaesthesia is necessary, and cauterized 
with a 10 per cent solution of nitrate of silver, to 
stimulate granulation. 
No treatment aids healing of oral tissues better 
and quicker than vaccines. I have often noted how 
quickly and painlessly sockets healed where vaccines 
were injected, concomitantly with the extraction of 
teeth, in treating cases of focal infection. It has 
been my practice to use mixed stock vaccines in all 
cases of sluggish healing. Formerly, they were in- 
jected in the deltoid region of the arm, but after 
visiting Dr. Goldenberg in his laboratory in Paris 
and seeing the merits of his vaccine, I now use it 
to the total exclusion of all others. The following 
case is illustrative of the value of vaccino-therapy in 
just these types of cases. 
"Mrs. F., age 50. I removed the upper left cen- 
tral, lateral canine, first bicuspid and straightened 
the alveolar process. The operation was accom- 
plished easily, but the patient had considerable dis- 
comfort afterwards. The sockets showed no sign of 
healing, even though they were stimulated with light 
curettement and applications of silver nitrate. She 88 
THE MODERN PRACTICE 
was referred then to her family physician for a gen- 
eral examination, which was negative. I next used 
Goldenberg's vaccine, and after the first injection 
there was a marked cessation of pain and the wound 
looked better. By the fourth injection the wound 
was healing nicely, and the patient was entirely free 
from all discomfort. I continued with the injections 
until I had given her six. I then removed the upper 
right central, lateral, canine, and the first and second 
bicuspids, and did quite an extensive alveolar re- 
section. There was no after-discomfort, and within 
one week a denture could have been inserted. Three 
weeks later, the patient had her permanent dentures. 
Contrast this last result with the first. The first 
wound took more than two months to heal; the 
second was healed in one week, and undoubtedly the 
success of this second operation was due to the use 
of vaccines." 
In cases where a flap has been sutured, the con- 
dition of the circulation of the flap must be watched, 
and if the latter looks red and congested, the circula- 
tion is aided by gentle massage and applications of 
warm isotonic solutions, held in the mouth. The 
union of the flap must also be observed. If there 
is no union in five or six days, the parts should be 
re-anaesthetized and the edges of the flap freshened 
and resutured. The patient's health is inquired into OF TOOTH-EXTRACTION 
89 
and a few injections of vaccine given to combat 
local infection. These measures will, as a general 
rule, hasten the union of the tissues 
In cases of normal healing, the sutures are re- 
moved in four or five days. 
After-care Taken by the Patient.-The patient 
should be advised as to the proper home treatment 
of any exigency that may arise, such as pain, swell- 
ing, and the prevention of infection of the operative 
wound. 
For the relief of pain, I have found nothing better 
than aspirin. Two five-grain tablets every three 
hours, with plenty of water, is the dosage prescribed. 
If the aspirin has a tendency to upset the digestion, 
a teaspoonful of bicarbonate of soda can be added to 
the water. However, there are those patients that 
cannot take aspirin at all, and to them I am in the 
habit of prescribing pyramidon, five grains every 
three hours. In cases of very severe pain it might 
be necessary to give one-eighth of a grain of mor- 
phine hypodermically. Warm mouth washes also 
give relief. 
Where a patient is suffering from nervous irrita- 
bility and is restless, there is no drug I have 
found more efficient, than the triple bromides, 
made by Burroughs, Welcome & Co. One tablet 
is dissolved in a half glass of water, and can be 90 
THE MODERN PRACTICE 
taken every four hours until the patient feels their 
effect. 
To control swelling, cold applications on the out- 
side of the face are most gratifying. Swelling is apt 
to follow extractions, especially where any chiselling 
has been done. An ice-bag kept over the oedematous 
parts for ten minutes every hour, will relieve the 
congestion of the tissues. Another soothing, cold 
dressing is a tablespoonful of the Tincture of Ham- 
mamselis in a glass of water. A cloth is satu- 
rated with this solution and kept over the affected 
area. 
For the prevention of post-operative infections of 
the wound, mouth washes are prescribed. For the 
ordinary simple case of extraction, warm saline so- 
lutions will answer the purpose. They can be pre- 
scribed in the form of a teaspoonful of salt to a glass 
of warm water. This solution is soothing and 
cleansing, and promotes absorption of the inflam- 
matory exudates. 
Where extensive operations have been performed, 
or where several teeth have been removed, any one 
of the following formulae in recommended: 
Acidi Salicylici gr. xxv. 
Glycerini 5 v. 
Aquae Menthae Piperitae § vi. OF TOOTH-EXTRACTION 
91 
3 
Acidi Borici 5 ss. 
Potassii Chloratis 3 i. 
Aquae Menthae Pip . 5 vi. 
Sodii Chloridi 
Sodii Boratis aa 3 ss. 
Glycerini 3 iss. 
Aquae Gaultheriae 5 vi. 
If infection of the wound has taken place, which 
is usually indicated by a graying of the edges of 
the socket and pain in the operative field, a mouth 
wash of mercuro-chrome, 220 soluble, is given. I 
do not prescribe this drug, but supply the patient 
with a little of it, with instructions to put just 
enough crystals in a glass of water to give the water 
an orange color. Two or three crystals will answer 
this purpose. The action of this drug is rapid, and 
is the most efficient mouth wash I have tried. CHAPTER IX 
VACCINO-THERAPY IN DENTAL SURGERY 
The value of vaccines in the routine practice of 
dental surgery is so great that I have devoted a 
chapter to their especial consideration. Let us 
briefly review the theories of infection and immun- 
ity, upon which this method of therapy is based. 
Injection.-When micro-organisms have passed 
the normal barriers of the skin or mucous mem- 
branes, and have invaded and proliferated in the 
deeper tissues, the process is spoken of as infection. 
Before infection takes place there are two prelim- 
inary steps; namely, contamination and invasion. 
Contamination is the presence of bacteria on the 
surface of an article or substance, while invasion 
is the penetration of bacteria without proliferation, 
into the deeper tissues. We cannot have infection 
without invasion, and we cannot have invasion with- 
out contamination. However, unless the micro-or- 
ganisms proliferate, infection does not take place. 
This is extremely important to bear in mind. 
Where we have infection caused by bacteria gain- 
ing entrance into the individual from outside 
92 OF TOOTH-EXTRACTION 
93 
sources, we have what is known as exogenous infec- 
tion, in contra-distinction to endogenous infection, 
caused by bacteria already present in the tissues 
themselves. 
Avenues of Infection.-There are various routes 
whereby bacteria can gain entrance to the body. 
These avenues are: 
1. Skin and mucous membrane. 
2. Respiratory organs. 
3. Digestive tract. 
4. Genital organs. 
5. Placenta. 
Normal Defenses against the Invasion of Bac- 
teria.-Nature has provided a number of ways to 
protect the body against the invasion of micro-or- 
ganisms. They are known as the normal defenses 
of the body, and any change in these defenses pre- 
disposes the tissues to infection. They are: 
1. Surface layer of epithelium, which offers 
mechanical obstruction. 
2. Surface discharges, such as saliva. These 
discharges act by means of mechanically 
washing away the bacteria. They also are 
supposed to possess a certain amount of 
germicidal power, and it is claimed there are 
anti-bodies present also in these discharges. 
3. Cells of certain excreting glands are thought 
to have germicidal power. 94 
THE MODERN PRACTICE 
Mechanism of Invasion.-Any disturbance of the 
foregoing defenses will permit of invasion of the 
tissues. Besides these, there are certain bacteria 
that have the power of breaking down the natural 
defense of the tissue, such as the diphtheria bacillus. 
Infection can also be started by the so-called wan- 
dering cells carrying micro-organisms to various 
parts of the body. These are known as cryptogenic 
infections. Leucocytes, in performing their phago- 
cytic functions, sometimes act in the same way as 
these wandering cells. 
However, invasion does not mean infection, as 
was stated before, and consequently the latter 
process can only take place when: 
1. The micro-organisms are virulent. 
2. When they invade the body through appro- 
priate channels. 
3. When they are in sufficient number. 
4. When the host is susceptible. 
5. When the bacteria are able to resist the de- 
fensive powers of the host, through agencies 
aside from their offensive forces. 
The virulence of a micro-organism is its disease 
producing power, and is dependent upon its toxicity 
and aggressiveness. The toxicity is the kind and 
amount of the poison elaborated by the bacteria. 
There are two types of poisons or toxins; the endo- OF TOOTH-EXTRACTION 
95 
genous, which are those that diffuse into the sur- 
rounding tissues and are readily absorbed; and the 
exogenous, which are contained in the micro-organ- 
ism itself, and are liberated only upon the death of 
the cell. 
Aggressiveness is the power of a micro-organism 
to enter, live and multiply in the body fluids. 
Where infection by more than one specie of 
bacteria takes place, it is known as a mixed infection. 
Generally speaking, all infections of the mucous 
membranes are mixed infections. 
Where micro-organisms originate in a primary 
focus and are carried via the blood and lymph to 
other parts of the body, there to set up metastatic 
lesions or secondary foci, the process is known as 
focal infection. 
Immunity 
Immunity is the effective resistance of the 
body against infectious micro-organisms and their 
products. 
Theories of Immunity.-The two chief theories 
to-day are the cellular theory, or the Theory of 
Phagocytosis of Metchnikoff, and the humoral 
theory, of which the Side Chain Theory of Ehrlich 
is the most important. 
Phagocytosis.-The leucocytes and other cells 96 
THE MODERN PRACTICE 
were regarded by Metchnikoff as being able to 
engulf living, as well as dead, bacteria and cellular 
debris. These cells were called phagocytes and were 
divided into two classes: namely, the microphages 
and the macrophages. The microphages consisted 
chiefly of the polymorphonuclear leucocytes, while 
the macrophages were made up of the large mono- 
nuclear lymphocytes, ameboid cells of the spleen, 
alveolar cells of the lungs, endothelial cells of serous 
cavities and lymph spaces, bone corpuscles, giant 
cells of bone, and embryonic connective tissue cells. 
The most important of the phagocytes are the 
polymorphonuclear leucocytes and the large 
lymphocytes. 
These cells are attracted or repelled from the site 
of infection by the action of a chemical agency, 
produced by the bacteria, which exerts a force 
known as chemotaxis. That force that attracts the 
cell is positive chemotaxis, while the repellant force 
is negative chemotaxis. 
There is also a substance in the blood known as 
an opsonin, which changes the bacteria so that they 
become susceptible to the phagocytes. In other 
words, opsonins are anti-bodies that render bacteria 
vulnerable to phagocytes. 
The Side Chain Theory of Ehrlich.-Ehrlich 
compares the body cell to the benzol ring of chem- OF TOOTH-EXTRACTION 
97 
istry. That, from the central molecule of the cell 
there radiates a number of processes or side chains, 
known as receptors. These receptors are supposed 
to have a distinct affinity for toxins circulating in 
the blood. The toxin molecule is also supposed to 
be made up of two portions, the haptophore por- 
tion, which combines with the receptors, and the 
toxophore portion, in which lies the poisonous 
action. 
The toxin molecule floating in the fluid surround- 
ing the cell, becomes firmly locked to one of the 
receptors by means of its haptophore portion. 
Having combined with the side chain of the cell, 
the toxin may be potent enough to kill the cell, 
and if a large number of cells are so destroyed 
disease and probably death may follow. On the 
other hand, although one receptor may have been 
destroyed, the cell is capable of repairing its loss, 
and producing more receptors. In fact, the receptors 
may be produced in such excess that they find no 
room for attachment to the cell, and are thrown 
into the blood stream, there to circulate. These 
receptors, or anti-bodies, as they are now called, 
have the power of combining with the original 
toxins that produced them and render them harm- 
less. These toxins that stimulate the formation of 
receptors are known as antigens. In diphtheria, the 98 
THE MODERN PRACTICE 
antigen is a soluble toxin, and the cast-off receptors 
stimulated by them are the anti-toxins. 
As new discoveries were made, Ehrlich enlarged 
his theories to embrace them, but always upon his 
fundamental principles. To-day we have anti-bodies 
or receptors of three orders. The first, or original, 
is anti-toxin. The second order comprises the 
and precipitins; and the third, the 
hoemoly sins, bacteriolysins and the cyto-toxins. 
Antigens and Anti-bodies 
Antigens are substances that cause the formation 
of anti-bodies in the body fluids. There are specific 
and non-specific antigens. Those substances that 
cause the formation of anti-bodies, but are hostile 
to them alone, are known as specific antigens. Now 
we know that some foreign substances may act, if 
injected, as a general stimulant upon the body cell, 
to produce anti-bodies, not related to the agents 
injected. These foreign substances are non-specific 
antigens, and upon this theory non-specific protein 
therapy is based. 
Antigens are colloids, and of a protein nature. 
Every protein can act in some degree as an antigen, 
and anti-bodies can be produced not only by bacteria 
and their poisons, but also by such proteins as serum 
of other animals, egg-albumen, milk, etc. OF TOOTH-EXTRACTION 
99 
Anti-bodies.-Those substances produced by the 
cells in reaction to some antigen are known as anti- 
bodies. They are found in the various fluids of the 
body, but the greatest amount is in the blood. 
Anti-bodies are commonly found in inflammatory 
exudates also. 
The tissues concerned in their production are 
thought to be the leucocytes and blood-forming 
organs, such as the spleen, lymphatic tissue, and 
bone marrow. The liver is also believed to play 
some part in their formation. 
There are those that think there is a local pro- 
duction of anti-bodies, that is, immune substances 
are formed at the site of infection. One of the chief 
exponents of this conception is Besredka of Paris, 
and upon this theory, the vaccine of Goldenberg 
is based. 
Besredka believes that bacterial infections have 
a tendency to electively attack certain organs. For 
example, the micro-organisms of anthrax and small- 
pox attack the skin, while those of typhoid and 
dysentery attack the intestinal mucosa. He, there- 
fore, concludes that tissues that are liable to certain 
infections can confer immunity to these infections. 
This is proven to be true by experiment. If, for 
instance, the bacteria of anthrax is injected into a 
guinea pig, either intramuscularly or into the peri- 100 
THE MODERN PRACTICE 
toneal cavity, no anti-bodies are formed, and the 
animal is not immunized to an infection of anthrax. 
But if an anti-anthrax vaccine is introduced into 
the skin, the guinea pig is rendered immune to 
these micro-organisms. This theory of local immun- 
ization and production of anti-bodies shows also 
that the route of introduction of a vaccine is a 
matter of importance, and that the vaccine should 
be made to follow the same path taken by the 
infective agents. 
There are two kinds of immunity: natural and 
acquired. Acquired immunity is again divided into 
active acquired immunity and passive acquired 
immunity. 
Natural Immunity.-This is the type of immunity 
inherent in an animal or person. It is, however, 
never absolute. 
Active Acquired Immunity.-Immunity that is 
brought about by activity of the cells, as a result 
of having had a disease, or through artificial inocu- 
lation with a vaccine made up of the causative 
bacteria. It is brought about by accidental infection, 
by inducing the disease by artificial inoculation of 
the disease itself. This is an obsolete and dangerous 
method. And, thirdly, by vaccination. 
Types of Immunity OF TOOTH-EXTRACTION 
101 
Passive Acquired Immunity.-This is the im- 
munity acquired by an animal or person, wherein 
their cells do not form the anti-bodies, but they 
are introduced in a serum taken from some other 
animal, which has been rendered immune to the 
infection and has produced the specific anti-bodies. 
Examples of these serums are diphtheria anti-toxin 
and tetanus anti-toxin. 
Vaccines 
The commonest method of procuring active 
acquired immunity is by the injection of vaccines. 
Wright's definition of a vaccine is, "sterilized and 
enumerated suspensions, which furnish when they 
dissolve in the body, substances which stimulate 
the healthy tissues to a production of specific 
bacteriotropic substances, which fasten upon, and 
directly or indirectly, contribute to the destruction 
of the corresponding bacteria." 
They are made by first procuring the infected 
material, and preparing pure cultures of the bacteria 
present, then making a suspension of these bacteria 
in normal saline solution, and killing them with 
heat or a chemical. Finally, they are counted so 
as to get the proper dosage. So many bacteria are 
contained in 1 c.c. of the solution. It is good 
practise to prepare a vaccine in which each c.c. 102 
THE MODERN PRACTICE 
contained the maximum number of the bacteria 
desired. 
Vaccines may be stock or autogenous. An 
autogenous one is made especially from the bacteria 
procured directly from the patient, while stock 
vaccines are prepared from bacteria not taken from 
the patient, but having the same characteristics. 
They are prepared in advance and are always avail- 
able. Opinion is divided as to the relative merits 
of autogenous and stock vaccines. If possible, 
autogenous vaccines are preferable. However, it is 
not always possible to recover the identical micro- 
organism responsible for the disease, and in acute 
infections, such as cellulitis, pneumonia, etc., much 
time would be lost waiting for the preparation of 
an autogenous vaccine. Hence, stock vaccines are 
indicated in these cases. In mixed infections, such 
as occur in the oral cavity, stock vaccines are of 
as much service as autogenous ones. For protective 
immunization, stock vaccines are also used. As far 
as non-specific immunization is concerned, stock 
vaccines are as desirable as the autogenous. 
Sensitized Vaccines are those composed of living 
bacteria immersed in their own immune serum. 
They possess no advantage over the ordinary type 
and are little used. 
When only one strain of a bacterium is contained OF TOOTH-EXTRACTION 
103 
in a vaccine, it is monovalent. Where several strains 
of the same bacterium are used, the vaccine is 
polyvalent. If the vaccine is composed of different 
kinds of micro-organisms, it is known as a mixed 
vaccine. 
Generally, stock vaccines should be polyvalent, 
and those used in the oral cavity, mixed. 
Vaccino-therapy 
Vaccino-therapy aims at artificially creating anti- 
bodies in the tissues, to create immunity to some 
definite infectious process. 
The Method of Introduction of Vaccines.-In the 
vast majority of cases, vaccines are given sub-cutane- 
ously. The most favorable site is the deltoid region 
of the arm, near the insertion of the muscle. The 
syringe and needle are boiled, and the skin painted 
with iodine and then alcohol. The skin is picked 
up between the thumb and forefinger, and the needle 
plunged under it. (Fig. 27.) 
The effects of the inoculation are: local, that is, 
the reaction taking place at the site of injection; 
focal, the reaction taking place at the lesion; and 
constitutional. This is the general reaction the 
patient has, such as headache, rise in temperature, 
and general lassitude. These general reactions are 
usually due to an excessive dose, but may occur 104 
THE MODERN PRACTICE 
in patients that previously showed no reactions 
at all. 
The local and constitutional reactions are mostly 
due to the influence of the protein constituents of 
the vaccine. 
The intervals between doses depends upon the 
reaction of the last one. It is better to wait too 
Fig. 27.-Technique of making a hypodermic injection in the 
deltoid region of the arm. This method is the same for the 
introduction of vaccines, narcotics or stimulants. OF TOOTH-EXTRACTION 
105 
long than to inoculate too quickly. The dosage 
varies with the following factors: Whether the 
infection is acute or chronic; the nature of the 
micro-organism; and the age of the patient. 
In acute infections, the dose is small and fre- 
quently given, while in chronic infections the dose 
is larger, but administered at longer intervals. It 
is always better, when in doubt, to give small doses 
and watch the reaction. Children tolerate fairly 
large doses, but the dosage should depend upon the 
weight and not the age. 
In the treatment of oral infections, stock vaccines 
are used, and they should contain streptococci, 
staphylococci, pneumococci, and the micrococci 
catarrhalis. Each c.c. should be made up of equal 
amounts of these organisms, to make one billion, 
and the initial dose is 0.1 c.c. Subsequent injections 
are given at intervals of from five to seven days, 
gradually increasing the amount until 1 c.c. is 
reached. 
Goldenberg's Vaccine.-Basing his treatment upon 
the local immunization theory of Besredka, Golden- 
berg of the Institut Pasteur de Paris formulated 
a vaccine that could be injected directly into the 
oral mucosa. It was necessary for him to prepare 
a concentrated vaccine, since large quantities of 
solution could not be conveniently used in the 106 
THE MODERN PRACTICE 
mouth. Also, he had to eliminate the local reaction 
as much as possible. This was accomplished by the 
following technique. The usual solution, normal 
saline, in which the bacteria are suspended, was 
replaced by a substance, itself active. This was 
accomplished by making a mixture of the bacteria 
procured from some active infection in the mouth, 
such as suppurative periodontoclasia. This mixture 
was then divided into three unequal parts. One-half 
was used as the excipient to replace the normal 
saline solution. The microbes in this portion were 
treated with a 10 per cent solution of caustic soda, 
for twenty-four hours at 37° C., and the solution 
was then neutralized with hydrochloric acid. 
One-quarter of the original mixture was next 
heated to between 60° and 70° C. to kill the bacteria, 
and the remaining part of the original mixture was 
treated with formol for the same purpose. The last 
two portions were emulsified in the excipient and 
0.5 per cent phenol was added. This fluid was now 
so diluted that each c.c. contained 20,000 million 
bacteria. The dosage was arranged in drops, each 
drop corresponding to 0.05 c.c. and contained about 
1,000 million organisms. 
Technique of Its Use.-The injection is made in 
the muco-buccal fold. (Fig. 28.) Care must be 
taken not to inject deeply, as in the administration OF TOOTH-EXTRACTION 
107 
of a local anaesthetic. The needle should just barely 
penetrate the mucosa, so that it can be seen beneath 
the tissues. When the fluid is discharged, there 
should form a wheal. The most convenient place 
Fig. 28.-Technique of making an intra-oral injection of Gold- 
enberg's vaccine. The needle is barely inserted beneath the 
mucous membrane in the muco-buccal fold. 
for injection is in the muco-buccal fold about the 
upper or lower canine regions. 
The first dose consists of one drop, with an 
interval of four days before the second injection. 
The second dose is two drops, choosing another site 108 
THE MODERN PRACTICE 
for the injection. It is my habit to start over one 
cuspid, and make each injection over another 
cuspid, returning to the first place on the fifth 
injection. The third injection is made forty-eight 
hours later, the dose consisting of three drops. 
Dr. Goldenberg advises injecting in several places, 
where the dose is more than three drops. This is 
based on the theory that the more tissue utilized, 
the more anti-bodies manufactured. I usually inject 
in two places where the dose is more than three 
drops. 
The injections are now made until six drops are 
reached. This is the maximum dose, and five injec- 
tions of six drops each are made at intervals of 
forty-eight hours. The course of treatment com- 
prises ten injections. However, there is no definite 
rule. Some cases require only five or six injections, 
while others show no improvement until twelve or 
more have been given. If, during the course of 
treatment, excessive reaction should follow an 
injection, three or four days are allowed to elapse, 
and the same dose repeated. If no reaction then 
occurs, increase in the dosage can be made. 
There is rarely any reaction following the use of 
this vaccine. Constitutionally, there is practically 
none at all, while locally there might be a slight OF TOOTH-EXTRACTION 
109 
swelling at the point of injection, rarely accompanied 
by annoying pain. 
Indications for the Use of Vaccines in Dental 
Surgery.-Vaccino-therapy can be used in the prac- 
tise of dental surgery, wherever infection exists in 
the oral cavity. It is especially indicated in: 
1. Osteitis of the socket (Dry Socket). 
2. Slow healing of operative wounds. 
3. Pericoronal infections about lower third molars. 
4. Suppurative Periodontoclasia (Pyorrhea Alve- 
olaris). 
Conclusion.-While vaccines are not panaceas for 
all ailments, if intelligently used, they offer us a 
most valuable adjunct to our surgery. CHAPTER X 
BLOOD-PRESSURE-PULSE TEMPERATURE 
Blood-Pressure 
One of the most useful adjuncts to the dental 
surgeon in making a diagnosis as to the fitness of 
a patient for operation, is the measurement of the 
blood-pressure. 
Definition.-Blood-pressure, according to Hirsch- 
felder, is the term used to indicate the pressure 
which the blood is exerting upon the walls of the 
vessel in which it is to be measured (lateral pres- 
sure), or upon the column of blood ahead of it, in 
the direction in which it is flowing (end pressure). 
In understanding blood-pressure, we must deter- 
mine three factors: Systolic, diastolic, and pulse 
pressures. 
$?/s£oZic pressure represents the total energy 
expended by the heart. 
Diastolic pressure is the entire load of pressure 
borne by the whole arterial system during systole. 
In other words, it is the pressure in the arterial 
system minus the force of the ventricular systole. 
110 OF TOOTH-EXTRACTION 
111 
Pulse pressure represents the efficiency of the 
heart and indicates the extent to which it over- 
comes the peripheral resistance. 
For ordinary routine dental practice, determina- 
tion of the systolic blood-pressure is all that is 
necessary. 
In the determination of blood-pressure, we use 
an instrument known as a sphygmomanometer. 
There are two types of this instrument in use to-day. 
The difference between them is that one measures 
the pressure by means of a column of mercury, while 
the other has a spring gauge of the araenoid 
barometer type. For dental use, the gauge 
manometer is best, as it is more portable and can 
conveniently be adjusted to the patient while seated 
in the operating chair. 
The sphygmomanometer is composed of three 
parts: The sleeve portion, in which is the rubber 
bag; a pump with a release valve, and the 
manometer. The idea of the instrument is to 
determine the amount of force, measured in milli- 
meters of mercury (mm. Hg.), necessary to oblit- 
erate the lumen of a given artery. 
Technique of Application.-The sleeve is applied 
to the arm above the elbow. It is not important 
which arm is used, although some authorities advise 
the use of the left arm. The arm should be bare, 112 
THE MODERN PRACTICE 
but this is often difficult to obtain, especially where 
we want to make a hasty examination of the blood- 
pressure in cases of collapse or shock. Where we 
do take the blood-pressure over clothing, 10 to 15 
mm. Hg. should be deducted from the amount reg- 
istered on the gauge. The portion of the sleeve con- 
taining the bag is placed on the arm first and the 
rest of the sleeve wound about in the manner of a 
bandage, tucking the last portion under one of the 
folds. The pump is attached to one of the tubes 
leading from the bag and the manometer is attached 
to the other. (Fig. 29.) 
Methods of Taking Blood-Pressure.-There are 
three recognized methods: 
1. Auscultatory 
2. Oscillatory 
3. Palpatory 
The auscultatory method is the most accurate of 
the three, although the palpatory one will answer 
all the purposes of the dental surgeon. For deter- 
mination of the diastolic pressure, the only accurate 
method is that of auscultation. It is rarely necessary 
for the dentist to take this pressure, but there may 
arise some occasion when it might be desired. 
Consequently, it will be necessary to give a brief 
description of the method of auscultation. OF TOOTH-EXTRACTION 
113 
The stethoscope is used in this method. The 
sleeve and compression bag are adjusted to the arm 
above the elbow, and the bell of a binaural stetho- 
scope placed over the brachial artery, right below 
the bend of the elbow. The radial pulse is also 
Fig. 29.-Showing technique of taking blood-pressure by the 
palpatory method using the spring gauge type of sphygmoma- 
nometer. 114 
THE MODERN PRACTICE 
sought. Air is pumped into the compression bag 
until the pulse at the radial artery disappears. With 
the stethoscope now at the brachial artery, a little 
more air is pumped into the bag and then gradually 
released. When the pulse returns at the wrist, a 
distinct tapping will be heard in the stethoscope, 
and the reading on the gauge, when this tapping 
first appears, represents the systolic pressure. This 
is known as phase 1. As the air continues to escape, 
a murmuring sound is now heard through the 
stethoscope (phase 2), and as the air further 
continues to escape, the murmur becomes sharper 
(phase 3). Finally, the sound fades away and dis- 
appears (phase 4). Just as the sound begins to fade 
away, the reading is taken on the gauge and this 
represents the diastolic pressure. 
To get the mean pressure, we add the systolic 
and diastolic pressures together and divide by two. 
The pulse pressure is obtained by subtracting 
the diastolic from the systolic pressures. 
As was stated before, for ordinary routine denial 
practise the determination of the systolic pressure 
by palpation will suffice. The technique is as 
follows: 
The sleeve, gauge and pump are adjusted as 
described above, and the radial artery felt for. The 
compression bag is now inflated until the pulse at OF TOOTH-EXTRACTION 
115 
the wrist disappears. The air is continued into the 
bag for 20 or 30 mm. Hg. more and then released 
slowly. At the moment when the pulse returns, the 
reading on the gauge is recorded, which represents 
the systolic blood-pressure. 
Normal and Abnormal Blood-Pressure.-A sys- 
tolic pressure ranging from 105 to 145 mm. Hg. is 
regarded as normal in adults. In children it ranges 
from 85 to 110 mm. Hg. The systolic pressure in 
women is about 10 mm. Hg. lower than in men. 
A normal diastolic pressure is between 25 to 50 
mm. Hg. lower than the systolic, while a normal 
pulse pressure ranges from 25 to 50 mm. Hg. 
A systolic pressure below 100 mm. Hg. or above 
150 mm. Hg. is abnormal, while a diastolic pressure 
above 105 mm. Hg. is pathological. A pulse pressure 
below 25 mm. Hg. and above 50 mm. Hg. is abnor- 
mal. In discussing variations from the normal in 
blood-pressure, we recognized two types: High 
blood-pressure, or hypertension; and low blood- 
pressure, or hypotension. 
Hypertension.-This may be transitory, when due 
to physiological causes, such as emotion, menstrua- 
tion, after-eating, during defecation, and also atmos- 
pheric conditions. Persistent hypertension is seen 
in arterio-sclerosis, kidney diseases, uraemia, aortic 
regurgitation, brain tumors, and alcoholism. 116 
THE MODERN PRACTICE 
Hypotension may also be physiological, but this 
is again transitory. Micturition, exercise, hunger, 
and atmospheric influences, all contribute to tem- 
porary low blood-pressure. Permanent hypotension 
is usually associated with chronic infectious diseases, 
such as tuberculosis. In active infectious conditions, 
like typhoid, pneumonia, scarlet fever, diphtheria, 
and sometimes rheumatism, the blood-pressure is 
also low. 
Endocrine dysfunction often causes permanent 
hypotension, especially any deficiency in the secre- 
tion of the adrenal glands. In shock, the blood- 
pressure is extremely low, and the lower the blood- 
pressure the more serious the shock. 
Pulse 
It may seem superfluous to discuss the pulse, yet 
there are a great many who cannot definitely tell 
what the pulse is, or its significance. And it might 
not be amiss to state there are those who cannot 
accurately take it. 
De/imtwn.-The popular conception of the pulse 
is the expansion of an artery due to the blood 
discharged into the aorta. This, according to 
Mackenzie, is not the case. Physiologists claim 
that the expansion in an artery is so slight as to 
have its existence denied. In large arteries, there OF TOOTH-EXTRACTION 
117 
may be some expansion, but in such vessels as the 
carotid and radial, it is so minute as to be negligible. 
What is recognized to-day as the pulse is "the sud- 
den increase of pressure within the artery, pressing 
against our finger, when we compress the artery" 
(Mackenzie). Each sudden increase represents the 
ventricular systole. 
Method of Taking Pulse by Digital Examination. 
-Any superficial prominent artery can be used for 
the taking of the pulse. However, to do this properly 
it is necessary to compress the artery against a bone. 
The anaesthetist uses the temporal artery as it 
passes over the zygoma in front of the tragus of 
the ear. For all general purposes, the radial artery, 
as it passes over the end of the radius, is the 
one of choice. The tips of the index, middle, 
and third fingers are placed on the artery, and 
the thumb is placed on the under side of the 
wrist. 
What to Note in Examining the Pulse.-The 
pulse conveys to us certain information by not- 
ing the: 
1. Rate per Minute.-The number of beats per 
minute can conveniently be counted by noting the 
number of beats in fifteen seconds and multiplying 
by six. This method is only used if we are certain 
the patient is well. If we are at all suspicious of 118 
THE MODERN PRACTICE 
the condition of the patient, the pulse should be 
counted over a period of a full minute. 
2. Rhythm.-Whether the pulse is regular, irregu- 
lar or intermittent. 
3. Size, force and character of the pulse. That 
is, whether the pulse is large, moderate, or small; 
deliberate, or sudden; strong, or weak; dicrotic. 
4. Resistance of the artery to pressure. 
Rate.-The pulse varies greatly, according to age. 
In the new-born child it is between 135 and 140; 
at one year, from 120 to 130; at two years, 105; 
at four years, 97; at ten years, 90; at fifteen years, 
78; and from twenty to middle adult life, 70 to 72. 
These figures are not absolute, and the rates vary 
in perfectly normal people. The rate is influenced 
by taking exercise, eating, nervousness, pain and 
fever. We must not lose sight of the fact that 
the majority of patients coming to our offices are 
highly excited, or in pain, and we are most apt to 
find the pulse rate in these people rapid. Fear 
causes paralysis of the vagus nerves, and conse- 
quently increases the heart rate, while fever also 
accelerates the rate, by virtue of the heat acting 
as a stimulant to the heart. Hyperthyroidism and 
goitre are accompanied by an extremely rapid pulse. 
In collapse the pulse rate is also very fast. 
Intermittency and irregularity of the pulse is OF TOOTH-EXTRACTION 
119 
often seen in cases of ventricular fatigue, sometimes 
accompanied by high blood-pressure. Blocking of 
the contraction wave in the bundle of His causes 
irregularity of the pulse. This is due to an over- 
dose of digitalis, disease, or toxemia of acute 
infections. 
Character, Size and Force of the Pulse.-The 
volume of the pulse is due to the amount of blood 
sent out from the heart at each systole, and also 
to the ability of the aortic valves to prevent 
regurgitation. 
Hypertrophy of the heart and stimulation of the 
vagi through fear, etc., causes a large full pulse. 
In aortic regurgitation we find a short sharp pulse, 
known as the "trip hammer", or "Corrigan Pulse". 
In mitral regurgitation, or mitral stenosis, the 
pulse is small in volume because the left ventricle 
cannot receive enough blood to throw out into 
the aorta. 
Degeneration of the heart muscle, as well as the 
infectious fevers, result in a seemingly large wave, 
due to relaxation of the arterial walls. However, 
the pressure is low and the rate rapid. 
In aortic stenosis, we find the pulse small, and 
there is delay in its transmission to the wrist. Great 
feebleness is often associated with dilatation with- 
out hypertrophy, myocardial degeneration, both 120 
THE MODERN PRACTICE 
chronic and acute, and exhaustion of the heart 
muscle in acute diseases. 
A dicrotic pulse is one in which the second beat 
comes upon the first before the latter is completed. 
It is seen in some cases of fever. 
The resistance of the artery to pressure often 
indicates the condition of the artery wall. This 
pressure can be determined by pressing the vessel 
against the end of the radius. By rolling the artery 
under the fingers, a healthy one can be told from 
one that is diseased. A normal artery, when it has 
been compressed, can hardly be felt after the pulse 
wave has left, while a pathological one will feel 
more or less hard, like a piece of rubber tubing. 
There may be either fibroid or atheromatous 
degeneration present. A pulse that requires a great 
deal of pressure to obliterate is indicative of high 
arterial tension, or one of the aforementioned 
degenerations. High tension and arterial hardness 
must be distinguished. Both can be present together 
or one can be present without the other. Calcareous 
deposits can be felt by moving the fingers along the 
long axis of the artery. 
Fever and Temperature 
We often hear of a patient having fever, or 
running a high temperature. What is really the OF TOOTH-EXTRACTION 
121 
significance of these terms and what is their 
physiology and pathology? 
Definition.-Fever is the reaction of the previously 
healthy body against the organisms of disease and 
their products (Jack). Adami says that fever is 
the process of adaptation to such toxic agencies as 
can be neutralized by the development of anti- 
bodies. 
It is a protective reaction, and is indicative of 
the resistance of the body. 
Pathology - General Changes. - While certain 
fevers may be provoked by specific agencies, mostly 
bacterial, yet the general changes taking place in 
the body are usually the same, regardless of the 
infective agent. 
1. The blood is dark and more fluid, with a 
decrease in the erythrocytes. However, there is an 
increase in the leucocytes (leucocytosis). 
2. The muscles are darkly colored, and show 
granular degeneration. 
3. The heart is softened and dilated. 
4. The internal organs are softened and congested, 
especially the spleen, liver and kidneys. 
5. The lungs may be congested. This is usually 
not so much due to the fever process, as it is to 
the position of the patient (Hypostatic Congestion). 
Physiology of Fever.-The toxins exert not only 122 
THE MODERN PRACTICE 
a direct influence upon the tissues themselves, but 
also on the heat-regulating system in the brain and 
cord. This heat-regulating mechanism controls not 
only the heat production, but also the heat loss of 
the body. The excess heat is due to the disturbance 
of the heat-regulating mechanism, and also to the 
increase in tissue waste, caused by the destruction 
of the cells by the toxins. The excretory organs 
being congested and swollen, this waste cannot be 
excreted from the body. There are also the follow- 
ing secondary disturbances present in fever: Head- 
ache and delirium, or coma and prostration due to 
a disturbance of the central nervous system. All 
excretions except sweat are diminished. The urine 
is scanty and frequently contains albumen. There 
is little saliva, and the mouth and tongue are dry. 
Respiration is accelerated, due to stimulation of the 
respiratory centers, and the pulse is full and rapid, 
because of the stimulating effect of heat on the 
heart. The pulse may also be dicrotic and soft. 
Excessive heat production with diminished loss 
of heat sometimes causes a spasm of the cutaneous 
vessels, which produces a sense of cold and shiver- 
ing, accounting for the chills often seen in the onset 
of fevers. The chill passes quickly, as soon as the 
spasm produces enough heat to warm the skin. OF TOOTH-EXTRACTION 
123 
Types of Fever.-We recognize three types of 
fevers: The continual, where the temperature 
remains above normal throughout the illness-for 
example, pneumonia; remittent, where the tem- 
perature is always above normal, but where it 
fluctuates during the day-for example, tubercu- 
losis; intermittent, where during some time in the 
day the temperature returns to normal or subnormal 
-for example, malaria, occasionally pyaemia. 
The onset of fever may be sudden, as in pneu- 
monia, grippe and some acute pyogenic infections; 
or it may be gradual, coming on with an evening 
rise of temperature, increasing a degree or so, for 
successive days, as in chronic infections. 
The fever may decline rapidly by crisis, or grad- 
ually by lysis. 
Temperature.-By temperature is meant the 
degree of sensible heat or cold. The instrument 
used for the measurement of this degree is the 
thermometer. In the practise of medicine and 
dentistry we use what is known as a clinical ther- 
mometer. In this country it is graded in terms of 
Fahrenheit, and ranges from 92° F. to 110° F. The 
temperature can be taken by mouth, axilla or 
rectum. In dental practice, temperature by mouth 
is most advisable. It is taken by placing the end 124 
THE MODERN PRACTICE 
of the thermometer containing the mercury well 
underneath the tongue, and having the patient close 
the lips, not the teeth. 
Normal temperature by mouth is 98.6° F., 
although in summer it may reach 99° F. Anything 
above this point is regarded as fever, and below 
as sub-normal. Temperature by rectum is some- 
what higher. In acute alveolar abscess, the tem- 
perature may reach 104° F. A rise in temperature 
is always indicative of infection, usually of bacterial 
origin, although occasionally in typhoid fever, it 
may be sub-normal. 
In shock, haemorrhage and disturbance of some 
of the endocrine glands, the temperature is sub- 
normal. INDEX INDEX 
Accessory instruments, 5. 
Accidents complicating extrac- 
tion, 56. 
Acquired immunity, 100. 
Active immunity, 101. 
Adjacent tooth, loosening of, 56. 
Adrenalin, effects of, 77. 
After-pain, 64; prophylaxis of, 
68. 
Aggressiveness of bacteria, 94, 
95. 
Alveolar plates, condition of, 18. 
Alveolar process, care of when 
many teeth are removed, 54. 
Alveolus, fracture of, 57; posi- 
tion of lower teeth in, 37; po- 
sition of upper teeth in, 36. 
Anaesthesia, 2; conduction, 2, 3; 
infiltration, 2, 3; local, 2; 
procain, 2. 
Anaesthetic solution, 63; pain 
due to, 63; treatment of, 65. 
Anterior teeth, lower, position 
of operator in extracting, 33, 
35; upper, position of opera- 
tor in extracting, 25. 
Antibodies, 97, 98, 99; orders 
of, 98. 
Antigens, 97, 98; non-specific, 
98; specific, 98. 
Antitoxins, 98. 
Antrum, closing of, 59; forcing 
a root into, 57; opening into, 
57. 
Apex, fracture of, 45; removal 
of, 44, 45. 
Argyll-Robertson pupil, 15. 
Armamentarium, 4. 
Arteries, 16; resistance of to 
pressure, 118, 120. 
Auscultatory method of taking 
blood-pressure, 112. 
Bacteria, aggressiveness of, 94, 
95; defences against, 93; 
mechanism of, 94; toxicity 
of, 94. 
Bacterial infections, 99. 
Bicuspids, loosening of lower, 
41; loosening of upper, 38; 
position of forceps in ex- 
tracting lower, 32; position 
of operator in extracting 
lower, 29, 35; position of op- 
erator in extracting upper, 
23, 27, 35. 
Bleeders, 71 and see Haemo- 
philia. 
Blood-pressure, 110; abnormal, 
115; definition, 110; dias- 
tolic, 110, 115; high, 20; 
mean, 114; method of tak- 
ing, 112; auscultatory, 112; 
palpatory, 113; normal, 115; 
127 128 
INDEX 
Blood-pressure, oscillatory, 112; 
systolic, 110, 115. 
Breath, odor of, 16. 
Broken molars, removal of, 48. 
Canines, loosening of lower, 41; 
loosening of upper, 38. 
Cardiac cases, 20. 
Care, post-operative, 86; by 
operator, 86; by patient, 89; 
pre-operative, 19. 
Central incisors, loosening ot 
upper, 38. 
Chemotaxis, 96; negative, 96; 
positive, 96. 
Churchill's iodine, 11. 
Closing of antrum, 59. 
Conduction anaesthesia, 2, 3. 
Congestion, hypostatic, 121. 
Complexion of patient, 14. 
Contamination, 92. 
Continual fever, 123. 
Contra-indications for extrac- 
tion, 31. 
Corrigan pulse, 119. 
Crisis, 123. 
Cryptogenic infections, 94. 
Curved roots, 50. 
Cyanosis, 15. 
Decayed molars, removal of, 48. 
Defences against bacterial in- 
vasion, 93, 94. 
Demeanor of patient, 15. 
Diabetics, 20. 
Dicrotic pulse, 120. 
Dislocation of jaw, 60, 62. 
Dressing of patient, 10. 
Dressings, 6. 
Drugs, 6. 
Dry socket, 66; pain due to, 
66; symptoms of, 66; treat- 
ment of, 66, 67; vaccines in 
treatment of, 68. 
Dysfunction, endocrine, 116. 
Ehrlich, side chain theory of, 
96. 
Elevating, of roots, 43; of up- 
per third molar, 39. 
Elevator, 5; use of, 42. 
Endocrine dysfunction, 116. 
Endogenous infection, 93; tox- 
ins, 94. 
Examination of patient, 14; 
local, 16; physical, 17; radio- 
graphic, 18. 
Exogenous infection, 93; tox- 
ins, 95. 
Exostosed roots, 50. 
Extraction, accidents compli- 
cating, 56; contra-indications 
for, 31; from both jaws, 35; 
indications for, 22; operation 
of, 36; position of forceps 
in, 32; position of operator 
in, 23, 25, 27, 29, 31, 33, 35. 
Fainting patient, to revive, 81. 
Fever, 120; continual, 123; 
definition of, 121; general 
changes in, 121; intermit- 
tent, 123; pathology of, 121; 
physiology of, 121; remittent, 
123; types of, 123. 
Florid complexion, 14. INDEX 
129 
Focal infection, 95. 
Forceps, 4, 5; position of in 
extracting lower molars and 
bicuspids, 32. 
Forcing a root into antrum, 57. 
Forearms, care of, 10. 
Fracture of alveolus, 57; of 
apex, 45; of jaw, 60; of tooth, 
44, 56. 
Fused teeth, 56. 
Gauze wipes, sterilization of, 13. 
Gloves, sterilization of, 10; use 
of, 10. 
Goldenberg's vaccines, 68, 87, 
105, 106. 
Grasping of tooth, 37. 
Gums, condition of, 17. 
Haemophilia, 71, 74; treatment 
of, 75. 
Haemorrhage, 71; causes of, 72; 
local, 72, general, 74; pre- 
vention of, 71; treatment of, 
72. 
Hands, care of, 10. 
Haptophore, 97. 
Hypertension, 115. 
Hypodermic needle, probing 
for landmarks with, 65; pain 
due to, 65. 
Hypodermic syringe, steriliza- 
tion of, 12. 
Hypostatic congestion, 121. 
Hypotension, 116. 
Immunity, 95; acquired, 100; 
active, 100; natural, 100; 
Immunity, passive, 101; theo- 
ries of, 95, 96; types of, 
100. 
Incisors, loosening of lower, 41; 
loosening of upper, 3S. 
Indications for extraction, 22. 
Infection, 92; avenues of, 93; 
bacterial, 99; cryptogenic, 94; 
endogenous, 93; exogenous, 
93; focal, 95; mixed, 95; post- 
operative, 91; to prevent, 90; 
Vincent's, 17. 
Infiltration, anaesthesia, 2, 3. 
Injuries to tissues, 65; pain due 
to, 65; treatment of, 66. 
Inspection of tooth, 18. 
Instrumentarium, 4. 
Instruments, 4; accessory, 5; 
sterilization of, 12. 
Intermittent fever, 123. 
Iodine, Churchill's, 11; Ivy's, 
II use of, 11. 
Irritability, nervous, 89. 
Ivy's iodine, 11. 
Jaw, dislocation of, 60, 62; 
fracture of, 60. 
Landmarks, probing for, 65; 
pain due to, 65. 
Lateral incisors, loosening of, 
38. 
Local anaesthesia, 2; examina- 
tion, 16. 
Loose tooth, 18. 
Loosening of adjacent tooth, 56. 
Loosening of tooth, 37, 38, 39, 
41, 42. 130 
INDEX 
Lower teeth, position in alveoli, 
37. 
Lower anterior teeth, position 
of operator in extracting, 33, 
35. 
Lymph nodes, enlarged, 18. 
Lysis, 123. 
Macrophages, 96 
Microphages, 96 
Mixed infection, 95 
Molars, broken, removal of, 48; 
decayed, removal of, 48; 
loosening of, 38, 41, 42; 
method of elevating and 
loosening, 39; position of 
forceps in extracting, 32; po- 
sition of operator in extract- 
ing, 23, 25, 27, 29, 31. 
Mucous patches, 18. 
Natural immunity, 100. 
Nervous irritability, 89. 
Nervous patients, 19. 
Normal temperature, 124. 
Odor of breath, 16. 
Opening into antrum, 57. 
Operative field, sterilization of, 
10. 
Operative syncope, 76, 80. 
Operator, personal care taken 
by, 9; position of, 23, 25, 27, 
29, 31, 33, 35. 
Opsonin, 96. 
Oscillatory blood-pressure, 112. 
Pain, due to anaesthetic solu- 
tion, 63, 65; due to dry 
socket, 66, 67; due to probing 
for landmarks, 65; post-op- 
erative, 64, 68, 89. 
Painful sockets, 66. 
Pallor, 14. 
Palpatory blood-pressure, 113. 
Passive immunity, 101. 
Patches, mucous, 18. 
Patient, complexion of, 14; de- 
meanor of, 15; dressing of, 
10; examination of, 14; 
nervous, 19; position of, 31; 
post-operative care of, 86, 89. 
Periodontoclasia, suppurative, 
17. 
Phagocytes, 96. 
Phagocytosis, 95. 
Physical examination, 17. 
Plates, alveolar, condition of, 
18. 
Position of operator, 23, 25, 27, 
29, 31, 33, 35; of patient, 31. 
Post-operative care, 86; by op- 
erator, 86; by patient, 89; in- 
fection, 90, 91; pain, 64, 68, 
89, swelling, 90; syncope, 85. 
Pre-operative care, 19. 
Probing for landmarks, pain 
due to, 65 
Procain anaesthesia, 2. 
Process, alveolar, care of when 
many teeth are removed, 54. 
Pulse, 16, 116; character of, 118, 
119; Corrigan, 119; definition 
of, 116; dicrotic, 120; feeble, 
119; force of, 118, 119; full, 
119; intermittent, 118; irregu- INDEX 
131 
lar, 118; large, 119; method 
of taking, 117; pressure, 111, 
114; rate of, 117, 118; resist- 
ance, 118, 120; rhythm of, 
118; sharp, 119; short, 119; 
size of, 118, 119; small, 119; 
trip-hammer, 119; what to 
note in, 117. 
Pupil, Argyll-Robertson, 15; 
staring, 15. 
Radiographic examination, 18. 
Receptors, 97; orders of, 98. 
Remittent fever, 123. 
Removal of apices, 44, 45; of 
broken molars, 48; of de- 
cayed molars, 48; of roots, 
44, 48; of teeth, 42. 
Respiration, 15. 
Roots, curved, 50; elevating of, 
43; exostosed, 50; forcing of 
into antrum, 57; removal of, 
44, 48. 
Side chain theory of Ehrlich, 
96. 
Socket, dry, 66, 67, 68; painful, 
66; slow healing of, 86, 87. 
Solution, anaesthetic, pain due 
to 63, 65. 
Sphygmomanometer, 111; ap- 
plication of, 111. 
Staring pupil, 15. 
Sterilization, 9; of gauze 
wipes, 13; of gloves, 10; of 
hypodermic syringe, 12; of 
instruments, 12; of operative 
fields, 10; of suture materials, 
12; of towels, 13. 
Subnormal temperature, 124. 
Suprarennin, effects of, 77. 
Suppurative periodontoclasia, 
17. 
Suture materials, sterilization 
of, 12. 
Swellings, 17; post-operative, 90. 
Syncope, 76; operative, 76; 
symptoms, 80; treatment, 80; 
post-operative, 85. 
Syphilis, 18. 
Syringe, hypodermic, steriliza- 
tion of, 12. 
Teeth, and see Tooth; fused. 
56; position of in alveoli, 36, 
37. 
Temperature, 120, 123; normal, 
124; subnormal, 124. 
Thermometer, 123. 
Tissues, injuries to, a cause of 
pain, 65, 66. 
Tooth, and see Teeth; fracture 
of, 44, 56; grasping of, 37; 
inspection of, 18; loose, 18; 
loosening of, 37; of adjacent, 
56; of wisdom, 42; removal 
of, 42. 
Towels, sterilization of, 13. 
Toxicity of bacteria, 94. 
Toxins, 94; endogenous, 94; 
exogenous, 95. 
Toxophore, 97. 
Traumatism, a cause of pain, 
65, 66. 
Trip-hammer pulse, 119. 
Upper teeth, position of 'in 
alveoli, 36. 132 
INDEX 
Vaccines, 87, 101, 109; auto- 
genous, 102; dosage of, 104; 
effects of, 103; constitutional, 
103; focal, 103; local, 103; 
Goldenberg's, 68, 87, 105, 106; 
in treatment of dry socket, 
68; indications for, 109; 
method of introducing, 103, 
106; mixed, 103; monovalent, 
103; polyvalent, 103; prepa- 
ration of, 101; sensitized, 102; 
stock, 102. 
Vaccino-therapy, 92, 103. 
Vincent's infection, 17. 
Wipes, gauze, sterilization of, 
13. 
Wisdom teeth, loosening of, 42.