LYMPHATICS OF THE DENTAL REGION* By FREDERICK B. NOYES, B.A., D.D.S., Sc.D., Chicago, 111. In 1915, assisted by D r. Kaethe W . Dewey, I undertook the investigation of this subject, without any knowledge of Sweitzer’s work. T h e first examination of the literature, revealed his results. T h e demonstration had already been made, but we decided to continue the w ork and, first, to repeat the work of Sweitzer. Follow ing his method, we suc ceeded in demonstrating injected lym phatic vessels in the dental pulp and peridental membrane; which beautifully supported the previous work. Sweitzer had attempted to inject di rectly into the dental pulp but had failed. W e undertook this problem by drilling into the pulp o f the cuspid and first molar, fitting a specially made brass cannula into the hole in the tooth, filling it with Gerota fluid and putting light air pressure on it. T h e results with ten or more dogs were negative. W e had been injecting the blood vessels first with carmin gelatin. Finally, an accident in the blood vessel injection gave us a very imperfect blood injection but a very In 1909 and 1911, Sweitzer, o f Ber positive lymphatic injection. In this ani mal, we were able to fo llo w the blue lin, published the results o f his injection Gerota fluid through the pulp out o f the using a new technic and demonstrating apical foramen, through the peridental injected lymphatic vessels in the dental membrane and bone to the infra-orbital pulp. canal and the inferior dental canal. T h e *R ead b e fo r e the Section on O ral Sur vessels emerged from the infra-orbital g e r y at the M id w in te r C lin ic o f the C h ica g o foramen, follow ed the facial artery and D en tal Society, Jan. 25, 1928. were traced to the first lymphatic gland 1. N oyes, F. B .: R e v ie w o f w o rk on L y m of the submaxillary chain. From the phatics o f D ental O rig in , J. A . D. A ., .14: mental foramen, they passed along the 714 (A p r il) 1927.
T seems needless to spend time ex plaining and emphasizing the impor tance o f a knowledge o f the details o f anatomy o f the lymphatic system as related to the teeth and the dental re gion. A ny one who has any knowledge o f physiology or any experience in sur gery w ill accept the statement that such knowledge is important without argu ment. In a paper which was read before the Seventh International Dental Congress,1 the work in this field, up to that time, was carefully reviewed. For that reason, it will be only briefly sketched here. In the first decade of this century, the great prevalence o f tuberculous in volvement of the lymph glands of the neck prompted investigators, especially in Germany, to seek for a lymph drain age from the pulps o f the teeth to the submaxillary lymph glands. A ll o f their efforts failed, and this led to the widely accepted belief that there were no lym phatic vessels in the dental pulp and to many other faulty deductions.
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inferior border of the mandible to the same gland. Afterwards, we were able to repeat the results by making the lym phatic injection first and the blood ves sel injection second. W h en microscopic sections were made, the injecting material was shown to be in the lymph spaces of the gland. In 1926, E. W . Fish2 published a paper on the circulation o f lymph in the dentin. In this work, D r. Fish clipped off the crown of the cuspid o f a young dog of large breed, exposing the pulp. A hypodermic needle was introduced close to the dentin w all o f the pulp and India ink left in the pulp without pres sure. T h e animal was kept alive for half an hour and then killed. T h e India ink was found to have been carried into the dentinal tubules half way through the dentin. T h e same procedure was fo l lowed, ferrous ammonium citrate being used and the iron precipitated with po tassium ferrocyanid. T h is was found to have passed through the tubules to their anastomoses at the dentino-enamel ju n c tion. D r. Fish concluded that the lymph circulates through the dentinal tubules. Some appearances in our material had suggested to us that the lymph passed into the tubules. I have wanted for a long time to at tack the problem from a new angle and had formulated the plan for the present experiments.
the enamel was ground off with carbo rundum stones down to a shoulder at the gum. T h is shoulder was squared and made to fit the cannula exactly by use of the trephin in the surgical engine. T h e end o f the cannula was sealed to the dentin shoulder by a small amount of hard balsam softened by heat, and then phosphate o f copper was placed around the joint to stabilize and support the cannula. In this way, the dentin-cov ered pulp was left extending into the lumen o f the cannula. T h e cannula was filled with Gerota fluid by means o f a fine pipet and rubber tube from the air pressure tank slipped over the cannula. A pressure of 400 mm. o f mercury was maintained for ten minutes. T h e object is, o f course, to see whether we can in ject the lymphatic vessels from the den tal pulp through the dentinal tubules. W e have not had time to w ork out the dissections and cannot say what the re sults w ill be. In this work, Drs. Schour and Ladd have worked with me. D r. Ladd has used scopolamin morphin and ether for the anaesthetic, and it has been so satis factorily that I have asked him to write the description of its use. TW ILIG H T
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A y e a r -o ld collie d o g w e ig h in g about 12 kg., w a s g iv e n a subcutaneous in jection o f m orp h in sulphate 2 % grains and scopolam in 1 /5 0 . grain . In ten minutes, the d o g becam e d ro w s y , and at the end o f fo r ty -fiv e minutes, W e selected a young collie dog. A he .cou ld be arou sed but w o u ld not stand up. piece of brass tubing about the diameter A t this time, the in jection w as repeated in of the cuspid at the margin o f the gum the same m ann er. A t the end o f the sec on d fo r ty -fiv e minutes, the d o g appeared was cut off, about 2 inches in length, and one end ground flat. From a rat m ore d row sy, but cou ld still be aroused, so a third in jection w a s g iv en , repeatin g the tailed file, a trephin was made, of sam e dosage. A t the end o f thirty minutes, exactly _the same diameter as the brass the d o g w a s in a com atose condition , but there w a s still m uscular rigid ity, so about cannula and with the same thickness of 1 oun ce o f ether w a s adm in istered by the wall. T h e dog was anesthetized, and d ro p m ethod. T h is com p letely rela x ed the 2. Fish, E. W . : P roc. R oy, Soc. M ed ., d o g , and he w a s strapped to the op era tin g table and occa sion a l sm all am ounts o f ether 19: 59-72 (J u n e ) 1926.
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N oyes— Lymphatics o f the D en ta l Region adm in istered in ju st sufficient quantities to m aintain m u scu la r relaxation . A v e r y sa tisfa ctory anesthetic w a s o b tained in this m anner, elim in atin g the usual stru ggle at the induction o f anesthesia, and such sm all am ounts o f ether w ere needed that one m an co u ld p e rfo rm the experim ent and adm in ister the anesthetic at the sam e tim e. W e d o not belie v e that this is the best d osa g e o f tw ilig h t anesthesia to be used, but w ill h ave to w o r k that out w ith fu rth er ex p erim entation.
A fter ten minutes of pressure, the
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heating unit. By disconnecting the air tube from the gelatin bottle, all air is expelled from the tubes and they are filled with physiologic sodium chlorid solution to the end o f the cannula, which is tied into the common carotid artery. T h e descending vena cava is opened and clamps A , B and C are opened. T h e sodium chlorid solution is allowed to run until it comes clear from the vena cava. T hen clamp C is closed and clamp
In je ctin g apparatus used in experim ent described .
cannula was removed and the blood in jection made. F or the benefit o f those who have not made such injections, I have added a cut o f the injecting appara tus. W e now have a controlled air tank, but the first apparatus had an air tank made from a 10 gallon can and a tire pump. T h e bottles containing the physiologic sodium chlorid solution and gelatin mass are placed in a tray of water, kept hot by an electrical water
D opened, and the carmin gelatin passes through the vessels. A s soon as it comes strongly from the vena cava, that vessel is tied and the pressure increased so as to distend the vessels. T h e carotid is then tied, the cannula removed and the head cooled in running water to set the gelatin. I am sorry that no results either posi tive or negative can be reported. 30 N orth M ich ig a n A v en u e.