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(B)
Preface
Comfortable and effective pain control is expected in den-
tistry. To meet this expectation, dental professionals who
administer local anesthesia and nitrous oxide sedation must
be able to think critically and integrate concepts and theo-
ries from multiple perspectives. Regardless of the nature of
individual practice acts, no clinician is exempt from under-
standing and performing allowed techniques to the highest
standards. In other words, patients should reasonably expect
that all credentialed dental professionals are equally knowl-
edgeable about the techniques and drugs they administer.
This second edition represents a broad-based, col-
laborative effort of a well-respected, diverse group of
dental hygiene and dental experts. Local Anesthesia for
Dental Professionals continues to focus on a high level of
knowledge and technical skill for students and clinicians,
enabling the safe, comfortable administration of local an-
esthetic injections and nitrous oxide sedation. Updates in
pharmacological agents and technological advances and
modifications for medical compromise are included that
emphasize the importance of evidence-based practice
highlighting efficiency and safety.
Together with ancillary materials and a companion
DVD, Local Anesthesia for Dental Professionals pres-
ents concepts and techniques with students, instructors,
and practicing clinicians in mind. Ancillary materials in-
clude case studies, in-depth references, clinically applica-
ble appendices, an anatomy review, editable PowerPoint
templates, workbook exercises, a library of text figures,
video clips, skill evaluation forms, word games, and figure
identifications.
vii
Acknowledgments

We wish to recognize the many exceptional educators and clinicians who contributed to this second edition of Local
Anesthesia for Dental Professionals. We are incredibly grateful for the vision and expertise of this diverse and talented
group of professionals who not only share our enthusiasm for pain control but also understand the profound significance
of clarity and accuracy of content. In addition to the many contributors and reviewers who worked tirelessly with us to as-
sure accuracy and readability, we wish to thank the following individuals and companies that so generously shared with us
their time, talents, expertise, and unique resources, all of which have allowed us to enhance this work significantly before
bringing it to press.

Paul Moore, DDS Elizabeth Pratt Ron Oyama

Vance Bingham, DDS
Michael DiTola, DDS
Blake Davis, DDS
Keavin McIntosh, DMD
Stanley Tang, DDS
Jordan Mikel, RDH Karen DiMarco
Sheila Norton, RDH Jack Naughton
Laura Schaffner, RDH Brian Loke
Laura Stoddard, RDH Jon Roberton
Megan Harkness, RDH Lee Clement
Aaron Shepard, RDH
Samantha Shira, RDH
Lynn Stedman, RDH

Pierce College Dental Hygiene Students

Eastern Washington University Dental Hygiene Students

Aseptico, Inc., CAO Group, Cetylite, Inc., DentalVibe, Dentsply Pharmaceuticals,

Gebauer Company, Injex, LED Dental Inc (Velscope), Milestone Scientific, MMJ
Labs, Onpharma, Practicon, St. Renatus, LLC, Septodont USA
We appreciate the considerable contributions of Sean Boynes, DDS and
Royann Royer, RDH to the 2nd edition of this text, especially the addition
of the Nitrous Oxide-Oxygen chapter.
We extend a special thanks to Patrick McKeown, Dysfuntional Breathing
Practitioner, Asthma Care Ireland, Republic of Ireland for his contributions to
our understanding of breathing and anxiety.

We thank our publisher, Pearson Education, for their invaluable

assistance and support. Special thanks to Nikki, Patty and Saraswathi for
all your help on the “home stretch”.

We acknowledge the lifelong vision and commitment to safety and comfort in

oral healthcare of Dr. Stanley Malamed, DDS, and dedicate this edition to the
memory of a truly brilliant modern pioneer, Dr. John Yagiela, DDS, PhD.

viii
Contributors

Section I—Pain Control Concepts Dental Hygiene Program

Johnson County Community College
Chapter 2—Fundamentals of Pain Management Overland Park, Kansas

Ann Eshenaur Spolarich, RDH, PhD Chapter 17—Local Anesthesia Complications

Clinical Associate Professor and Management
USC School of Dentistry
Los Angeles, California Sean G. Boynes, DMD, MS, DAs
Course Director of Clinical Medicine and Pharmacology Director of Dental Medicine
Arizona School of Dentistry and Oral Health Public Health Dentistry
Mesa, Arizona CareSouth Carolina
Clinical Instructor, Dean’s Faculty Society Hill, South Carolina
University of Maryland Dental School Chief Consultant/Owner
Baltimore, Maryland Dentist Anesthesiologist
Dental Medicine Consulting
Jackie Foskett, RDH, BA, CHT Florence, South Carolina
General and periodontal practice (retired)
Certified Clinical Hypnotherapist
Holistic Counselor and Educator Section V—Special Considerations
Founder/Owner of Healing Hypnotherapy for Local Anesthesia
Newcastle, Washington
Chapter 18—Insights for Fearful Patients

Section III—Injection Fundamentals Marilynn Rothen, RDH, MS

Clinical Assistant Professor
Chapter 9—Local Anesthetic Delivery Devices Associate Director Dental Hygiene Master of Science in Oral
Biology Program
Mark N. Hochman, DDS Department of Oral Health Sciences
Private Practice Limited to Periodontics and Orthodontics Manager, Regional Clinical Dental Research Center and Dental
Specialized Dentistry of New York Fears Research Clinic
New York City, New York School of Dentistry
Clinical Associate Professor University of Washington
New York University, College of Dentistry Seattle, Washington
New York City, New York
Clinical Director and Consultant Agnes Spadafora, RDH, BS
Milestone Scientific, Inc. Department of Dental Public Health Sciences and Dental Fears
Livingston, New Jersey Research Clinic (Retired)
School of Dentistry
Chapter 10—Patient Assessment for Local Anesthesia University of Washington
Seattle, Washington
Sean G. Boynes, DMD, MS, DAs
Director of Dental Medicine Chapter 19—Insights from Pediatric Dentistry
Public Health Dentistry
CareSouth Carolina Gregory L. Psaltis, DDS
Society Hill, South Carolina Specialist in Pediatric Dentistry
Chief Consultant/Owner Olympia, Washington
Dentist Anesthesiologist Sean G. Boynes, DMD, MS, DAs
Dental Medicine Consulting Director of Dental Medicine
Florence, South Carolina Public Health Dentistry
CareSouth Carolina
Chapter 11—Fundamentals for Administration Society Hill, South Carolina
of Local Anesthetic Agents Chief Consultant/Owner
Dentist Anesthesiologist
Kimberly Stabbe, RDH, MS Dental Medicine Consulting
Professor of Dental Hygiene Florence, South Carolina
ix
x Contributors

Chapter 20—Insights from Specialties: CareSouth Carolina

Society Hill, South Carolina
Oral Surgery—Melanie Lang, DDS, MD Chief Consultant/Owner
Specialist in Oral Surgery Dentist Anesthesiologist
Spokane, Washington Dental Medicine Consulting
Florence, South Carolina
Periodontics—William C. Lubken, DMD
Specialist in Periodontics Royann Royer, RDH, MPH
Gig Harbor, Washington Educator, Consultant, Clinical Hygienist
Public Health Dentistry
Periodontics—Mark N. Hochman, DDS Southcentral Foundation
Private Practice Limited to Periodontics and Orthodontics Anchorage, Alaska
Specialized Dentistry of New York Advisory Member, Retired Faculty
New York City, New York University of Alaska Anchorage
Clinical Associate Professor Anchorage, Alaska
New York University, College of Dentistry
New York City, New York Fred Quarnstrom, DDS, FADSA, FAGD, FICD, CDC
Clinical Director and Consultant Dental Anesthesiologist
Milestone Scientific, Inc. Private Practice
Livingston, New Jersey Beacon Hill Dental Associates
Seattle, Washington
Endodontics—Albert (Ace) Goerig, DDS, MS
Affiliate Assistant Professor
Specialist in Endodontics
Department of Oral Health Sciences
Olympia, Washington
Dental Public Health Sciences
School of Dentistry
Section VI—Nitrous Oxide-Oxygen University of Washington
Seattle, Washington
Sedation
Chapter 21—Fundamentals for the Administration
of Nitrous Oxide-Oxygen Sedation
Sean G. Boynes, DMD, MS, DAs
Director of Dental Medicine
Public Health Dentistry

Reviewers Elaine Madden, AS, BS, MEd

Sheryl Armstrong, RDH, BSDH, MEd© Cape Cod Community College
Mohave Community College West Barnstable, Massachusetts
Colorado City, Arizona Julius N. Manz, DDS
Sandra Beebe, RDH, PhD San Juan College
Southern Illinois University Farmington, New Mexico
Carbondale, Illinois Linda Munro, RDH
Roderic Caron, DMD Portland Community College
New Hampshire Technical Institute Portland, Oregon
Concord, New Hampshire Debra Sidd, RDH, RF, MEd
Kathleen D’Ambrisi, RDH, MS, PhD Normandale Community College
The Community College of Baltimore County Bloomington, Minnesota
Baltimore, Maryland Marsha Voelker, CDA, RDH, MS
Terry Dean, DMD University of Missouri-Kansas City
Western Kentucky University Kansas City, Missouri
Bowling Green, Kentucky Paula Watson, MS, RDH, RDH, AP
David Lund, DDS University of the Pacific
Truckee Meadows Community College Stockton, California
Reno, Nevada
About the Authors
Kathy Bassett, BSDH, RDH, MEd, is professor and clini-
cal coordinator in the Department of Dental Hygiene at
Pierce College, Lakewood, Washington. She has more than
35 years of clinical experience in both local anesthesia and
restorative expanded functions and currently serves as
course lead for the Local Anesthesia curriculum at Pierce
College. Along with student researchers, she is investigat-
ing the effectiveness of using CCLAD technology as pri-
mary devices when teaching local anesthesia techniques.
Ms. Bassett actively teaches dental hygiene pre-licensure
courses in local anesthesia and restorative expanded func-
tions for the Pacific Northwest Dental Hygiene Institute, also
at Pierce College. In addition, she is an affiliate professor in
the Departments of Oral Health Sciences and Periodontics
at the University of Washington, School of Dentistry.
Arthur DiMarco, DMD, is director of the RIDE program
and affiliate faculty of restorative dentistry at the University
of Washington, School of Dentistry at Eastern Washington
University (EWU), Spokane, Washington, where he is also
professor in the Department of Dental Hygiene. A veteran
of nearly 30 years of clinical practice and more than 20 years
of dental hygiene and dental education, he is course direc-
tor for the Pain Control curriculum for both dental hygiene
and dental students in Spokane. His most recent research
involved the method of application of a fast-acting topical
anesthetic before administering AMSA injections.
Doreen Naughton, RDH, BSDH, has more than 30 years
of clinical experience, including sole proprietorship of
Dental Hygiene Health Services for the past 25 years.
She is an affiliate instructor in the Departments of Oral
Health Sciences and Periodontics at the University of
Washington, School of Dentistry. Additionally, she served
6 years as administrator and instructor of dental hygiene
pre-licensure courses, including local anesthesia and restor-
ative functions, for the University of Washington’s Continuing
Dental Education program.
Ms. Bassett, Dr. DiMarco, and Ms. Naughton have pre-
sented hundreds of local, regional, state, national, and in-
ternational continuing education programs on topics that
include didactic and clinical courses in local anesthesia
for dental healthcare educators, professionals, and corpo-
rate clinical educators. In addition, Ms. Bassett and Dr.
DiMarco have collaborated on numerous publications on
the topic of local anesthesia. Between them, they have re-
ceived numerous honors and awards in recognition of out-
standing contributions and dedication to dental hygiene
and dental education, characterizing excellence in teach-
ing, mentoring, and devotion to student achievement. Ms.
Naughton has received significant state and national rec-
ognition for her outstanding contributions to the profes-
sion of dental hygiene.
xi
 Techniques for Successful Local Anesthesia:
For Dental Professionals DVD

Royann Royer & Carlene Paarmann

ISBN-10: 0132725398 • ISBN-13: 9780132725392

Techniques for Successful Local Anesthesia was developed
in conjunction with the authors of this textbook as a
companion to the text and is calibrated to the recommen-
dations and guidelines specified throughout.
This DVD provides clear, easy-to-follow visual learning
components divided into several units:
The first unit discusses Basic Injection Techniques
that should be utilized when administering any type of
local anesthesia injection. It is further divided into
Maxillary and Palatal Injections (Unit 2) and Man-
dibular Injections (Unit 3). The video then provides
demonstrations of Adjunct Injections and Techniques
(Unit 4), which include a periodontal ligament in-
jection and a video on Adjunct Techniques and
Equipment. Unit 5, Supplemental Videos, contains
additional video clips provided by the authors of
Local Anesthesia for Dental Professionals. A Resource
Unit (Unit 6) contains a presentation on injection tech-
niques for pediatric patients as well as two “Summary
Charts” to print and use as a reference in the operatory.
The DVD will assist the reader of this text by demon-
strating the techniques presented by the authors and will
enhance the learning process of providing successful and
comfortable injections to your patients.

Sold separately at www.pearsonhighered.com

xii
 Section

Pain Control Concepts

Chapter 1 Perspectives on Local Anesthesia for Dental Professionals

Chapter 2 Fundamentals of Pain Management

Chapter 3 The Neuroanatomy and Neurophysiology of Pain Control

 1
Perspectives on Local Anesthesia
for Dental Professionals
O BJ E CT I V E S KE Y TERMS
• Define and discuss the key terms in this chapter. dental local anesthesia
providers 3
• Identify a variety of dental local anesthesia providers in North
fundamentals of pain
America. management 3
• Discuss the responsibilities of local anesthesia providers. troubleshooting 3

2
 chapter 1 • Perspectives on Local Anesthesia for Dental Professionals 3

Introduction
A recent Gallup poll focusing on honesty and ethical
­standards placed dentists at the number 5 spot out of 22
professional occupations, ahead of police officers, chiro-
practors, and members of the clergy (Gallup, 2012). High
levels of confidence are likely similar for dental hygienists,
as well.
As trustworthy as patients may find dental profes-
sionals, it only takes a little pain for patients to begin to
lose confidence, a circumstance that is wholly avoidable.
This text is designed to leverage knowledge and skills in
order to optimize patient confidence. It represents a col-
laboration of experts in the field of dental local anesthesia
and nitrous oxide-oxygen sedation to focus clinicians on
the relevance of technique factors, on appropriate integra-
Figure 1–1 Mastery of Techniques. Mastering a wide variety
tion into clinical decision making, and on troubleshooting
of techniques is critical to safe and effective pain control.
strategies (assessment of inadequacies and their resolu-
tions). These are critical skills every dental professional
can and should have. Confidence in pain control strategies, responding to patient factors, integrating evidence-based
ready troubleshooting skills, and familiarity with pain con- knowledge, and understanding relevant drugs, their ­effects,
trol alternatives are within the grasp of every clinician. indications, and contraindications. Fundamentals also
include developing clinical decision-making skills and
Local Anesthesia Scope of Practice mastering a wide variety of techniques and appropriate
modifications (see Figure 1–1 ■).
Local anesthetics have been available in dentistry since
Factors critical for safe and effective local anesthesia
1884. Dentists have been able to deliver local anesthetic
are well within the grasp of any individual who adminis-
drugs in cartridge form since 1921. Dental hygienists were
ters local anesthetic drugs regardless of their ultimate
first licensed to deliver local anesthetics in the state of
­degree or educational pathway.
Washington, in 1971.
The roles of non-dentist clinicians have expanded in
recent years. Today, in most states and provinces, dental Chapter Questions
­local anesthesia providers, including dental hygienists (and
in some states and provinces, mid-level and/or expanded These questions are provided to generate discussion.
function providers) are allowed to administer local anes-
thesia for effective pain control of the oral cavity. 1. Identify a variety of local anesthesia providers in
Specific requirements for dental hygienists and mid- North America.
level providers vary regarding the type, degree, or extent 2. Identify and discuss the importance of the
of injections, as well as the required extent of supervision, ­fundamentals of pain management.
education, and examination. Clinicians must be knowl-
edgeable regarding the specifics of the practice acts gov- 3. Identify and discuss the responsibilities of local
erning their particular practice locations (Bassett, Boynes, ­anesthesia providers.
& DiMarco, 2011).
References
Philosophy of Responsibility
Bassett, K. B., Boynes, S. G., & DiMarco, A. C. (2011).
Providing safe, effective, and appropriate pain control ­Understand the rules. Dimensions of Dental Hygiene, 9(7),
is a responsibility of all dental local anesthesia provid- 38, 40–41.
ers. This requires knowledge of and competency with Gallup. (2012, December 3). Congress retains low honesty
the ­f undamentals of pain management, which include ­rating. Retrieved July 31, 2013, from http://www.gallup.com/
­conducting comprehensive assessment, recognizing and poll/159035/congress-retains-low-honesty-rating.aspx

Visit www.pearsonhighered.com/healthprofessionsresources to access the student resources that accompany

this book. Simply select Dental Hygiene from the choice of disciplines. Find this book and you will find the
complimentary study tools created for this specific title.
 2
Fundamentals of
Pain Management
O bj e ct i v e s Ke y Terms
• Define and discuss the key terms in this chapter. acute pain 6
chronic pain 6
• Discuss the value of pain as a protective response.
cognitive distraction 10
• Discuss factors that can contribute to an individual’s response debriefing 9
to a painful experience. fight or flight 8
• Discuss the three general types of pain. neuropathic pain 7
nociceptive pain 6
• Differentiate between acute and chronic pain. nociceptors 6
• Explain the differences ­between pain perception and nociception. pain 5
• Discuss the physiological reactions of the sympathetic nervous pain disorders 8
system ­related to pain. pain threshold 5
pain tolerance 5
• Discuss anxiety and fear as they relate to successful anesthesia. polymodal 6
• Give examples of strategies that can help patients cope with PREP 9
fear and anxiety. protective response 5
• Discuss the influence of previous pain experiences on the psychogenic factors 8
­ability to administer local anesthetic injections. relaxation response 10
sensory modality 6
somatic pain 6
sympathetic nervous
system 8
visceral pain 6
visualization 10

4

Introduction
Pain control in dentistry requires the study of local ­anesthesia
and an understanding of the science of pain. This chapter will
provide an introduction to the fundamentals of pain. It will
focus on pain as having both physiological and psychological
aspects. Categories of pain and factors that have an effect on
the ability to tolerate pain will also be discussed.
Pain Perspectives
Pain Experience
Pain is unique and is reported subjectively. Even within an
individual’s unique experience, the perception of pain on a
given day at a given time is not necessarily identical to a pre-
vious or future perception of pain in response to an identical
stimulus. Pain perception (and reactions to the perceptions
of pain) cannot be described as necessarily proportional to
the intensity of physical injury or to the degree of harm.
An individual’s pain experience is influenced by a
number of variables. For example, gender provides both
genetic and hormonal influences. Gender also may add
many complex components, including socially constructed
roles and relationships, personality traits, attitudes, behav-
iors, values, and degrees of power and influence. Other
variables, such as age, physical health, mental health, emo-
tional status, expectations, previous experiences, learned
responses, and ethnic and cultural norms, also impact the
experience of pain and individual reactions to it.
The definition of pain provided by the International
Association for the Study of Pain (IASP) describes it as a
negative experience (see Box 2–1 ■) (Merskey & Bogduk,
1994). While the experience of pain is accurately described
in negative terms, rapid sequences of perception and
­response that make up the experience also serve a protec-
tive function, a decidedly positive benefit.
Avoidance of pain is a strong, innate trait. In dentistry,
painful experiences can lead to a strategy of avoiding pain
and, therefore, treatment. Pain can lead to anxiety and fear,
which may result in heightened perceptions of pain, which
in turn may cause further avoidance of dental care. The abil-
ity to identify factors that can contribute to painful expe-
riences and proactive strategies to avoid unnecessary pain
can ensure patient comfort during treatment (­ Howard,
2007; Pappagallo & Chapman, 2005; Spitzer, 2004).
Box 2–1 The Definition of Pain
The International Association for the Study of Pain defines
pain as “an unpleasant sensory and emotional ­experience
associated with actual or potential tissue damage, or described
in terms of such damage” (Merskey & Bogduk, 1994).
Source: “Definition on Pain”. Copyright © 2014 by International
Association for the Study of Pain. Used by Permission of Interna-
tional Association for the Study of Pain.
chapter 2 • Fundamentals of Pain Management 5
Protective Response
As a physiological reaction to the environment, pain is a
protective response, protecting the body from harm. This
protection is rapid, reflexive, and subconscious.
An example of a protective response to pain is known
as a withdrawal reflex. This reflex prevents damage by
removing tissues from harm when harm is sensed or is
­imminent. When a hot stove is touched, for example, hands
are quickly withdrawn from the stimulus (heat). Without
protective reflexes, the ability to maintain a healthy body
would be seriously compromised. This is the case when an
individual with a spinal cord injury is not able to feel sen-
sations or initiate movement below the level of injury. The
normal protective neuronal activity and subsequent mus-
cular reaction are absent, and there is a constant need for
monitoring and repositioning in order to avoid pressure
sore injuries or injuries caused by thermal stimuli.
The protective response is also linked to behavior.
If an individual has been stung by a wasp in the past, the
mere sight of a wasp might cause the individual to react
in order to avoid a sting. This withdrawal is governed by
memory (Howard, 2007).
Pain Threshold versus Pain Tolerance
The terms pain threshold and pain tolerance are not syn-
onymous. Pain threshold may be defined as the point
at which a stimulus first produces a sensation of pain
(Taber’s Cyclopedic Medical Dictionary [Taber’s], 1997).
Pain thresholds are innate and are highly reproducible
in individuals. They do not usually change appreciably
over time. An individual’s pain threshold is a function
of their physiological reaction to painful stimuli. For
example, in dentistry a pulp tester is used to determine
viability of teeth. Patients will respond when estab-
lished levels of stimulation are perceived. This identifies
threshold of pain.
Pain tolerance may be defined as an individual’s reac-
tion to painful stimuli. It indicates the amount of pain an
individual is willing or able to endure. Tolerance can vary
from day to day and from appointment to appointment,
and may be influenced by current events and stresses. It
can also be altered by environment, experience, and social
attitudes. Research has shown that gender and genetics
also play key roles in understanding individual variations
in pain perception and stimulus processing (Dionne,
Phero, & Becker, 2002).
Common pain stimuli produce highly variable ­reactions
from individual to individual. When using pulp testers, for
example, pain is elicited at reproducible levels, but individu-
als may react to the electric current in markedly different
ways. Both emotional and psychological factors influence
their reactions. These factors are modified by the signifi-
cance individuals place on their present circumstances.
The terms pain tolerance and pain threshold are often
used interchangeably despite distinct differences. Patients
may state that they have very low pain thresholds while
6 section I • Pain Control Concepts
they are actually relating that they are not able to tolerate
a lot of pain.
Pre-appointment medications such as anti-anxiety and
anti-inflammatory agents, and local anesthesia adminis-
tered during appointments, are used to modify a patient’s
tolerance to treatment. It is also important to recognize
that an individual who suffers from long-term pain may
have altered responses and an intolerance to pain of any
nature. Pre-treatment assessment in this area can improve
clinical experiences (American Psychiatric Association,
2000; Pappagallo & Chapman, 2005).
Pain Duration
Pain may be categorized in a variety of ways. A common
classification categorizes pain according to its duration,
acute or chronic. Acute pain may last from a few seconds
to no more than 6 months depending on causative factors.
It is generally caused by tissue damage from injury or dis-
ease. Individuals suffering from acute pain expect to get
better and adopt behaviors that either remove or ease the
cause or causes of pain. For example, a patient experienc-
ing postoperative dental pain may rely on pain relievers
or ice packs to stop the pain. Pain is often a strong motiva-
tor for seeking treatment, regardless of a patient’s level of
dental anxiety and fear.
Chronic pain may be defined as pain that persists for
more than 6 months with or without an identifiable cause.
The longer acute pain continues, the more likely it is to
become chronic. Occasionally, patients who suffer from
chronic pain tend to lose hope of getting better, providing
an unfortunate pathway to depression.
Individuals suffering from chronic pain may be re-
ferred to specialized clinics with experience in managing
long-term patterns of pain. Pain clinics provide a wide
variety of services, including evaluation, education, and
treatment (physical therapy, massage, and acupuncture).
They also teach coping skills that can influence reactions
to pain and modify behavior through appropriate use of
medications and techniques such as biofeedback (Howard,
2007).
Pain and Nociception
Sensory receptors detect a variety of stimuli that are then
relayed to the central nervous system (CNS) for interpreta-
tion. Specific receptors are associated with each type of sen-
sory input. For example, there are specific taste receptors on
the tongue that detect sweet, sour, bitter, and salt. In the eye
there are two types of photoreceptors: cones and rods.
The ability of a stimulus to be detected by a specific
­receptor is known as a sensory modality. Sensory modali-
ties include hearing, sight, touch, taste, and sound. Changes
in temperature are detected by thermoreceptors. Changes
in pressure are detected by mechanoreceptors. Altera-
tions in body chemicals are detected by chemoreceptors
­(Howard, 2007; Pappagallo & Chapman, 2005).
Sensory receptors that detect injury are called
­n ociceptors (see Figure 2–1 ■). Unlike other sensory
receptors, nociceptors are activated by injury and relay
sensory input whether or not individuals are aware that
injury has occurred. This process is influenced by an indi-
vidual’s age, general health, and genetics (Nani, ­Mellow,
& Getz, 1999).
Nociceptors differ in another important way from
other sensory receptors in that they are polymodal, re-
sponding to all types of stimuli. In addition to activat-
ing receptors specific for them, thermal, mechanical, and
chemical stimuli can all activate nociceptors, which relay
pain information to the CNS. Despite obvious differences
between these stimuli, all can be perceived by nociceptors
as painful.
Nociceptors also differ from other sensory recep-
tors in that nociceptors never adapt to stimulation. In the
presence of constant stimulation, nociceptors will always
respond to stimulation. This is a key aspect of the protec-
tive response to pain. Sensory warnings are constantly pro-
vided when injury is pending or occurring.
As previously noted, experience or perception of pain
does not lend itself well to objective measurement. While
this is an accurate statement, pain intensity rating scales
nevertheless can be useful for both patients and clinicians.
They provide patients with a means of communicating
the degree of pain experienced, and they provide clini-
cians with an opportunity to respond appropriately. An
example of a subjective pain intensity measurement tool
is the Wong-Baker FACES Pain Rating Scale. This simple
numeric scale (with associated facial expressions) uses “0”
to represent no pain (very happy face) and “5” to repre-
sent severe pain (crying face) (see Figure 2–2 ■). Other
scales use similar graduated numbers to report the degree
of pain experienced.
Pain Classification by Etiology
Pain may be categorized according to its etiology (American
Psychiatric Association, 2000; Howard, 2007), as follows:
1. nociceptive pain
2. neuropathic pain
3. pain disorders associated with psychogenic factors
In addition, in response to nociceptive input, fear and
other physical conditions can alter the ability to receive,
transmit, interpret, and respond to pain.
Nociceptive Pain
Nociceptive pain is caused by injury or disease in body
­t issues. This pain may be constant or intermittent and
­o ften escalates with movement. Nociceptive pain can
be further subdivided into somatic and visceral pain.
Somatic nociceptive pain occurs on superficial struc-
tures such as skin and muscles and is caused by trau-
matic injuries. The resulting pain may be sharp, aching,
 chapter 2 • Fundamentals of Pain Management 7

Pain
perception point

3 Dorsal horn; location of

Substantia gelatinosa
(pain signal modified)

Spinal ganglia
A-delta fibers
(fast transmission of
sharp, localized pain)

2
1 Nociceptors
(pain receptors) C fibers
(slow transmission of dull,
burning, chronic pain)

Lateral
spinothalamic tract

Figure 2–1 Nociceptors. Nociceptors are sensory receptors that detect when a body tissue has been injured.
Source: BALL, JANE W.; BINDLER, RUTH C., PEDIATRIC NURSING: CARING FOR CHILDREN, ESSENTIALS VERSION,
4th, © 2008. Printed and Electronically reproduced by permission of Pearson Education, Inc. Upper Saddle River, New Jersey.

or throbbing. Visceral nociceptive pain occurs in internal Neuropathic Pain

body cavities and is caused by compression, expansion, Neuropathic pain is caused by nerve injury or dysfunction
stretching, and infiltration. It usually produces squeez- of the sensory nerves in the central or peripheral nervous
ing or gnawing sensations (Howard, 2007; Pappagallo & systems (Howard, 2007; Pappagallo & Chapman, 2005).
Chapman, 2005). There are numerous types of neuropathic pain, most of
8 section I • Pain Control Concepts

0 1 2 3 4 5
No Hurt Hurts Hurts Hurts Hurts Hurts
Little Bit Little More Even More Whole Lot Worst

Figure 2–2 Wong-Baker FACES Pain Rating Scale. Instructions: Point to each face
using the words to describe the pain intensity. Ask the child to choose face that best
­describes own pain and record the appropriate number.
Source: Copyright 1983, Wong-Baker FACES® Foundation, www.WongBakerFACES.org. Used
with permission. Originally published in Whaley & Wong’s Nursing Care of Infants and Children.
© Elsevier Inc.

which are complex and frequently chronic in nature. They
may have inflammatory, noninflammatory, and/or immune
system components. Pain may be generated in the CNS
such as phantom pain from a missing limb or tooth, or it
may occur because of what is referred to as peripherally
generated polyneuropathy, as seen in diabetes. Mononeu-
ropathy is usually associated with a single nerve injury or
compression, which is seen in trigeminal neuralgia, carpal
tunnel syndrome, and post-herpetic neuralgia.
Pain Disorders Associated with Psychogenic Factors
Pain disorders associated with psychogenic factors are re-
lated to mental or emotional issues that affect the experi-
ence of pain. They are diagnosed only after other causes
of pain have been eliminated. They are also diagnosed
far less frequently than nociceptive and neuropathic pain.
­Although not attributable to specific injuries or pathol-
ogy, the experience of pain is real and can occur at any age,
manifesting as head, stomach, chest, or muscle discomfort,
or it may occur in any other location or combination of
locations. Individuals with depressive or anxiety disorders
may experience complications with any type of pain. These
individuals may report pain beyond typical intensities and
durations. In some instances, previously diagnosed physi-
cal pain from known pathogenic origins can be increased
or prolonged by psychogenic factors.
Pain is multidimensional and often requires more than
one treatment modality. These may include psychotherapy,
biofeedback, hypnosis, and antidepressant and nonnarcotic
analgesic medications. Patients with pain ­disorders may re-
spond differently to dental pain (American Psychiatric Asso-
ciation, 2000; Howard, 2007; Pappagallo & Chapman, 2005).
Sympathetic Nervous System and Pain
In response to pain, the CNS simultaneously directs acti-
vation of the sympathetic nervous system. The sympathetic
nervous system stimulates the adrenal medulla, resulting in
release of norepinephrine and epinephrine (see Chapter 6,
“Vasoconstrictors in Dentistry”). These neurotransmitters
mediate so-called “fight or flight” mechanisms, resulting
in a host of potential reactions, including increased heart
rate and blood pressure; dilation of the pupils and the
bronchial and skeletal muscle vasculature; and constric-
tion of mesenteric vessels. Both anticipation of pain and
the perception of pain stimulate this response.
If these reactions occur, they can be exacerbated by
the psychological state of a patient during a dental appoint-
ment. Fearful patients often demonstrate similar sympa-
thetic nervous system reactions before, during, and after
injections. While physical manifestations are similar and are
typically of short duration, all adverse reactions to dental
anesthesia require prompt and appropriate management,
regardless of their etiology (Dionne, Phero, & Becker, 2002;
Howard, 2007; Pappagallo & Chapman, 2005).
Pain Management Implications
for Dentistry
The majority of patients willingly schedule and attend
their dental appointments. Previous dental experiences
have been generally positive. Some avoid dental treat-
ment, primarily because of fears surrounding the admin-
istration of local anesthesia. Their experiences have been
negative, and they are convinced there is little reason to
expect better. In other words, fears override the need for
dental treatment. In order to develop positive treatment
interactions, it is important for clinicians to understand
the etiology of the fear and pain experience. Both physi-
ological and psychological factors contribute to difficulties
­related to treatment.
It has been reported that the main reason individuals
avoid dental appointments is fear (Naini, Mellow, & Getz,
1999). About 40% of patients report some level of anxiety
related to dental treatment, and roughly 5% avoid den-
tistry because of fear of injections. Patients experience fear
on a continuum ranging from mild anxiety to phobia.
Fear can be a barrier to obtaining adequate anesthe-
sia. Fearful patients are typically no less concerned than
others about their need for dental treatment but fear can
prevent them from experiencing successful treatment.
Some patients are fearful only of injections and report
their anxiety and fear subsides following the injection. As-
sessing and addressing fear before injections can ­improve
 chapter 2 • Fundamentals of Pain Management 9

the ­results of anesthesia. Clinicians need to be aware of

strategies associated with treating anxious and fearful
­patients (­ Dionne, Phero, & Becker, 2002; Fiset, Milgrom,
& ­Weinstein, 1985; Milgrom, Weinstein, & Heaton, 2009).
Patient Management Perspectives
Everyone working in dental settings can offer support to anx-
ious or fearful patients. Dental personnel can identify fearful
patients at the time of initial contact whether by telephone
or in person. As with nondental-related fears, it may not be
easy for fearful patients to acknowledge their dental fears or
the degree of their fears. Deliberate ­behavior by clinicians
can be helpful in developing successful patient experiences
and can create an environment that encourages discussions
of fear. For example, using controlled, calm speech and posi-
tive demeanor conveys comfort and instills confidence. Signs
of impatience or disapproval should be avoided.
A standard protocol for all patients including those
with specific fears, will incorporate the following:
1. Ask about previous dental experiences and be attentive
to responses
2. Assure that difficulties during past experiences can be
managed and overcome
3. Involve patients when identifying strategies to help
manage anxiety and fear
Some strategies to help patients cope with anxiety and
fear include a sequence of steps the authors refer to as
PREP (Prepare, Rehearse, Empower, and Praise). Apply-
ing a PREP strategy can build trust and provide reassur-
ance. These steps can be found in Box 2–2 ■, and when used
along with a process known as debriefing can further build
trust and reassurance. Clinicians may find the use of these
stress-reducing techniques helpful for themselves as well.
The debriefing process can be useful when managing
fearful patients. This process allows for discussion periods
at the end of appointments to give patients opportunities
to relate which aspects of treatment went well and which
aspects did not go well. Discussions of treatment to be ac-
complished at future appointments can be quite helpful,
Box 2–2 PREP to Minimize Patient
Anxiety and Fear
To help patients cope with anxiety and fear:
1. Prepare by utilizing relaxation techniques such as
focused breathing, distraction such as music or visual-
ization, and muscle relaxation.
2. Rehearse procedures allowing patients to practice
control and self-calming techniques.
3. Empower patients with strategies that give them con-
trol during procedures such as raising a hand to ask
the clinician to stop.
4. Praise patients for using specific coping techniques
that are helpful to them.
particularly if they rely heavily on patient input when
­ etermining how ambitious the next appointment should
d
be. Plans for modifying aspects that were identified as
not going well can be discussed and then applied to sub-
sequent appointments. By proceeding in this manner, the
patient not only agrees to go to the next step but also has
an active role in determining the content of the step.
It is important that adequate time is scheduled for the
debriefing process. Rushing through discussions does little
to reassure patients that recommendations will be heeded.
Power of Suggestion and Vocabulary
Positive communication and establishing trust are impor-
tant with all patients but especially important for those
who are anxious or fearful. Trust provides a foundation for
relieving anxiety and fear. The power of suggestion is well
documented in the literature. Both pediatric and adult pa-
tients can attach broad interpretations to the terminology
that is used during dental injections. Careful selection of
words can reduce negative imagery that may be associated
with words such as “poke,” “pinch,” “sting,” “burn,” and
“hurt” (Milgrom, Weinstein, & Heaton, 2009). Additional
strategies to enhance positive communication are sug-
gested in Table 2–1 ■.

Table 2–1 Strategies to Enhance Positive Communication

• Display a genuinely warm and caring attitude

• Review treatment plan addressing fears, including of the unexpected and of loss of control

• Obtain permission to begin, addressing fear of loss of control if necessary

• Establish patient control strategy (time-out signal such as raising hand to stop)

• Direct the focus on positive outcomes (“You may feel a bit of pressure.”)

• Acknowledge and compliment success (“You did great with the anesthesia today!”)

• Create positive expectations (“That went well today and I expect your next appointment will too.”)
10 section I • Pain Control Concepts
Cognitive Distraction  The practice of distraction that
actively shifts a patient’s focus away from a stressful situ-
ation to a less stressful point of focus is considered cog-
nitive distraction. Distraction is thought to be one of the
easiest and most familiar coping strategies employed by
dental professionals (Milgrom, 2009). Distraction is more
useful for short-duration procedures on patients with mild
to moderate anxiety; however, it may be less effective dur-
ing the administration of local anesthetics compared with
other procedures. Table 2–2 ■ suggests a variety of distrac-
tion techniques that can be useful for dental patients.
Visualization  Visualization (also referred to as guided
visualization and guided imagery) is a cognitive strategy
to help patients reduce stress and can be especially ben-
eficial in dentistry to manage fears, particularly fear of
needles. Patients who are mentally and physically relaxed
usually experience less discomfort compared with those
who are tense (Milgrom, Weinstein, & Heaton, 2009).
­Visualization often accompanies physical relaxation, a
­behavioral strategy.
Tension can reduce the supply of air reaching the lungs.
Reduced oxygenation contributes not only to anxiety and
stress but also to fatigue and depression, increasing the
perception of stress (Milgrom, Weinstein, & Heaton, 2009).
What is known as focused breathing can increase oxygen-
ation and help patients relax their muscles; at the same time
it can help provide an overall sense of relaxation. Visualiza-
tion can enhance this relaxation by distracting patients from
sources of stress and can provide the relaxation needed to
cope with physical discomforts or their expectation.
Relaxation Response
The relaxation response is a restful state that modifies
physical and emotional responses to stress (Benson, 2000).
Parasympathetic pathways that allow recovery from stress
(fight and flight) are activated by this response that low-
ers heart and respiratory rates, blood pressure, and mus-
cle tension. Physiological relaxation when incorporating
Table 2–2 Suggested Distraction Techniques*
• Light, casual conversation or guided relaxation
• Gate control strategies and devices
• pressure applied with cotton swab to palatal tissues
• gentle lip shaking during needle insertion
• the use of vibration devices
• Audio devices with headphones for music, audio books (selected by patient)
• Television, video devices, and audiovisual glasses (not for highly anxious)**
*Adapted from: DiMarco, A.C., Bassett, K.B., Foskett, J.M. (2012). Mind over Matter. ­Dimensions of Dental Hygiene. Santa Ana,
CA: Belmont Publications.
**Frere, C.L., Crout, R., Yorty, J., McNeil, D.W. (2001). Effects of audiovisual distraction during dental prophylaxis. Journal of the American Dental
­Association, 132(7): 1031–1038.
guided visualization techniques enhances patient coping
skills (Milgrom, Weinstein, & Heaton, 2009).
When patients are well informed, better management
of stress is possible. Explaining the benefits of relaxation to
­patients ahead of time is an important component of success-
ful relaxation response strategies. Securing permission and
consent before guiding patients through a relaxation process
is necessary. (See Table 2–3 ■: Suggestions for Preparing
­Patients for Guided Relaxation and Guided Visualization.)
Guided visualization usually starts with guided physi-
cal relaxation or focusing patients on what has been re-
ferred to as their “inner world” (Naparstek, 1994). The
concept of an “inner world” of thoughts relates directly to
feelings and can be focused toward positive outcomes. It
can distract from specific circumstances such as glancing
at a needle by guiding attention away from the needle to a
pleasant daydream or vacation that has been pre-selected,
for example (Milgrom, Weinstein, & Heaton, 2009).
In this technique, clinicians guide patients to focus on
scenarios of choice (Milgrom, Weinstein, & Heaton, 2009;
Naparstek, 1994; Rossman, 2000). Clinicians support guided
visualizations by verbally cueing patients with details of
images such as colors, sounds, and textures (Milgrom,
Weinstein, & Heaton, 2009). This helps engage imagina-
tions while allowing patients a pleasant inner experience,
away from any currently stressful experience. Speaking
in a slow, soft voice can enhance pleasurable experiences
(­Milgrom, Weinstein, & Heaton, 2009; Naparstek, 1994;
Rossman, 2000). Clinicians can preface relaxation exercises
by informing patients that they are going to do something
different today to help them feel more at ease. It is impor-
tant to seek permission before proceeding by asking if it is
okay to proceed. Suggestions for guided visualization are
provided in Table 2–3 and a guided relaxation and visual-
ization ­sample script can be found in Appendix 2–1 ■.
Hypnosis
Many are intrigued by hypnosis, particularly how it works
and its applications. Growing evidence suggests a strong
 chapter 2 • Fundamentals of Pain Management 11

Table 2–3 Suggestions for Preparing Patients for Guided Visualization

and Relaxation

• 
Demonstrate confidence in a positive outcome
Speak and act with confidence even if you feel awkward or new at using these tools
(patients look to you as a professional for guidance)

• Ask the patient to focus on breathing “(Name), I’d like to invite you to focus your
attention on your breathing.”

• Explain that slow breathing allows more oxygen to get into lungs

• Explain that oxygen allows the muscles to relax better, releasing tension

• Explain that it is easier for the whole body to relax when muscles are relaxed, heart rate
slows, breathing slows, mind and body calm

• Use your voice as a tool by speaking slowly and softly maintaining patience and calmness

link between hypnosis and the physiology of pain for effec-
tive management of pain and anxiety (Beck, 2012). When
in a state of hypnosis, patients usually feel calm and relaxed
and are able to concentrate intensely on a specific thought,
memory, feeling, or sensation while blocking out distractions.
In this state, individuals are more open to suggestion and
become more aware of their inner worlds. Thoughts and im-
ages from this inner world can be used to create a sense of
comfort and pleasure and help reduce fears and anxiety.
Brain imaging studies have demonstrated that while
parts of the brain are registering painful sensations the
anterior cingulate cortex (responsible for attention) is less
engaged in painful sensations. This type of research may
have significant implications for dental local anesthesia.
Although the formal practice of hypnosis requires spe-
cialized training and certification, untrained clinicians can
nevertheless use suggestive words to help promote posi-
tive experiences. Equally important is avoiding words that
may focus attention on anticipation of pain, as previously
discussed (Milgrom, Weinstein, & Heaton, 2009).
An alternative to pharmacological approaches, p ­ atients
with unmanageable levels of anxiety can also be referred
to qualified hypnotherapists who can help them overcome
their fears. A more in-depth discussion of dental fears can
be found in Chapter 18, “­Insights for Fearful Patients.” The
benefits of hypnosis for both patients and clinicians before
and during local ­anesthetic administration may include en-
hancing pain management while reducing anxiety, stress,
and salivation. Hypnosis can also help reduce stimulation
of the gag reflex. In addition to hypnotherapy sessions, self-­
hypnosis is also typically taught for patients to use at future
dental appointments.
Pharmacological Intervention
For some patients, pharmacological intervention may be
helpful and necessary. Nitrous oxide-oxygen sedation,­
oral conscious sedation, intravenous sedation, and general
anesthesia should be discussed with patients as situations
warrant. Pharmacological solutions are especially help-
ful for anxious patients who avoid dental treatment and
present only for emergent care. In these situations, phar-
macological agents may be incorporated into treatment.
For some patients, medical consultation may be necessary.
These individuals often must resort to emergent care be-
cause of their intense fear and avoidance of routine dental
care, and pharmacological agents can be incorporated into
treatment when indicated.
Considerations for Clinicians
The phenomena of anxiety and pain related to dental in-
jections are not limited to patient experience. Clinicians
should also consider their own personal experiences with
pain. Learning to give injections can be unsettling for clini-
cians, especially those who are fearful of receiving injections.
Previous experiences and perceptions can interfere with the
learning process and limit confidence building. On the other
hand, a painful past experience can also provide a positive
motivation to provide comfortable injection experiences for
others. If necessary, psychological therapy may be helpful in
recognizing personal inhibitions that may delay learning and
can undermine clinical success in the delivery of injections.
In some cases, it may be appropriate to recommend in-
tervention with a professional psychologist. More in-depth
strategies for management of patient fear and phobia are
discussed in Chapter 18.
Chapter Questions
1. Which statement best describes pain as a protective
response?
a. Pain is a physiological, conscious reaction.
b. Pain is a psychological reaction based on blood
flow to the injured site.
c. Pain is a rapid, reflexive, subconscious reaction.
d. Pain is a slow, deliberate reaction to avoid further
tissue injury.
12 section I • Pain Control Concepts
2. Which of these groups of variables does not affect the
experience of pain?
a. Sex, genetics, mental health
b. Personality, age, hormones
c. Attitudes, learned responses
d. Body weight, height
3. Which one of the following statements regarding no-
ciception is true?
a. Nociception is polymodal.
b. Nociceptive receptors can distinguish between
chemical and thermal stimuli.
c. Nociception is a physiological and psychological
process.
d. Nociceptive pain is identical in somatic and visceral
structures.
4. Which one of the following is an example of neuro-
pathic pain?
a. Fractured bone
b. Psychological disorder
c. Postsurgery pain
d. Trigeminal neuralgia
5. Which one of the following will help patients cope
with anxiety and fear?
a. Avoid discussions about anxiety and fear.
b. Only the dentist should ask about anxiety and fear
to avoid patient embarrassment.
c. Assure the patient that difficulties during past den-
tal visits could not have been avoided.
d. Prepare, rehearse, empower, and praise patients to
reduce anxiety and fear.
6. In the process of debriefing, which one of the follow-
ing is not useful when managing fearful patients?
a. Patient and clinician discussion period at the end of
each appointment.
b. Patient gives input on the duration and plan for the
next appointment.
c. Future appoints are modified based on the insights
from the patient/clinician discussion.
d. Clinicians select strategies for the patient for his or
her next appointment.
Visit www.pearsonhighered.com/healthprofessionsresources to access the student resources that accompany
this book. Simply select Dental Hygiene from the choice of disciplines. Find this book and you will find the
complimentary study tools created for this specific title.
References
American Psychiatric Association. (2000). Diagnostic and
­statistical manual of mental disorders (4th ed.). Washington,
DC: Author.
Beck, M. (2012). Medical hypnosis: You are getting very healthy.
Health Journal. The Wall Street Journal, http://online.wsj.com/
news/articles/SB10001424052702303815404577333751488988824?
mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%
2Farticle%2FSB10001424052702303815404577333751488988824.
html, accessed May 17, 2014.
Benson, H. (2000). The relaxation response. New York: Harper-
Torch; 1st Avon Books Printing.
Dionne, R., Phero, J., & Becker, D. (2002). Management of pain
and anxiety in the dental office (Chapters 1, 5). Philadelphia,
PA: Saunders.
Fiset, L., Milgrom, P., & Weinstein, P. (1985). Psychophysiological
responses to dental injections. Journal of the American Dental
Association, III, 578–583.
Foskett, J. M. (2007). Calming dental anxiety relaxation script.
Calming Dental Anxiety Seminars. Author.
Frere, C. L., Crout, R., Yorty, J., & McNeil, D. (2001). Effects of
audiovisual distraction during dental prophylaxis. Journal of
American Dental Association, 132, 1031–1038.
Howard, M. (2007). Chronic pain. Institute for Natural Resources
Educational Program. Seattle.
Merskey, H., & Bogduk, N. (1994). Classification of Chronic Pain
(2nd ed). IASP Task Force on Taxonomy. IASP Press, Seattle.
www.iasp-pain.org, accessed January 20, 2014.
Milgrom, P., Weinstein, P., & Heaton, L. (2009). Treating fearful
dental patients: A patient management handbook (3rd ed.).
­Seattle: Dental Behavioral Resources.
Naini, F. B., Mellow, A. C., & Getz, T. (1999). Treatment of dental
fears: Pharmacology or psychology? Dental Update, 26, 270–276.
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central. New York: Hachette Book Group.
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of pain (Chapters 1, 11). New York: McGraw-Hill.
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search: A guide for CIHR peer review committee, final report.
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Title: Araminta

Author: J. C. Snaith

Release date: March 10, 2024 [eBook #73133]

Language: English

Original publication: New York: Moffat, Yard and Company, 1908

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ARAMINTA
 ARAMINTA
BY
J. C. SNAITH
Author of “William Jordan, Junior,” “Broke
of Covenden,” Etc.

NEW YORK
MOFFAT, YARD AND COMPANY
1909
 Copyright, 1908, 1909, by
THE FORUM PUBLISHING COMPANY

Copyright, 1909, by
MOFFAT, YARD AND COMPANY
New York

Published, February, 1909

Second Printing, March, 1909
Third Printing, May, 1909
Fourth Printing, July, 1909
Fifth Printing, August, 1909
 CONTENTS
CHAPTER PAGE
I.The Old Woman of Hill Street 1
II.The Idea Which Came to Her 9
III.Lord Cheriton Looks In 22
IV. Arrival of the First Cause of All Romance 38
V. The Instinct of Mr. Marchbanks Betrays Him 48
VI. Unwarrantable Behavior of Tobias 66
VII. A Throwback 80
VIII. “Caroline Crewkerne’s Gainsborough” 98
IX. In Which Cheriton Drops His Umbrella 108
X. Jim Lascelles Makes His Appearance 119
XI. Miss Perry is the Soul of Discretion 140
XII. Jim Lascelles Takes a Decisive Step 151
XIII. High Revel is Held in Hill Street 161
XIV. Ungentlemanlike Behavior of Jim Lascelles 171
XV. Diplomacy is Called For 193
XVI. Hyde Park 200
XVII. Development of the Female Us 213
XVIII. Fashion Comes to the Acacias 226
XIX. A Social Triumph 243
XX. Miss Perry Has Her Palm Crossed with Silver 256
XXI. High Diplomacy 267
XXII. A Conversation at Ward’s 281
Muffin Makes Her Appearance at Pen-y-Gros
XXIII. 292
Castle
Episode of a French Novel and a Red
XXIV. 304
Umbrella
 XXV. Paris on Mount Ida 322
Jim Lascelles Adds Heroism to His Other Fine
XXVI. 334
Qualities
XXVII. Revel is Held at Pen-y-Gros Castle 348
XXVIII. A Thunderbolt 365
Jim Lascelles Writes His Name in the Visitors’
XXIX. 375
Book
XXX. Good-by 383
XXXI. Disintegration 392
XXXII. Barne Moor 402
Everything for the Best in the Best of All
XXXIII. 410
Possible Worlds
ARAMINTA
 CHAPTER I
THE OLD WOMAN OF HILL STREET

AN old lady who lived in Hill Street was making arrangements to

enter upon her seventy-fourth year.
It was a quarter to nine in the morning by the ormolu clock on the
chimney-piece; and the old lady, somewhat shriveled, very wide-
awake, and in the absence of her toupee from the position it was
accustomed to grace—at present it was in the center of the dressing-
table—looking remarkably like a macaw, was sitting up in bed.
Cushions supported her venerable form, and an Indian shawl, the
gift of her Sovereign, covered her aged shoulders.
There were people who did not hesitate to describe her as a very
worldly-minded, not to say very wicked, old lady. The former of these
epithets there is none to dispute; in regard to the latter, let our
silence honor the truth. It is far from our intention to asperse the
character of one who has always passed as a Christian; nor do we
ascribe to human frailty the sinister significance that some people
do. But as far as this old lady is concerned it is a point upon which
we have no bigotry.
If sheer worldliness of mind is akin to wickedness, the old woman
who lived in Hill Street must have come perilously near to that state.
Her views upon all matters relating to this world were extremely
robust, and years and experience had confirmed her in them. In
regard to the next world she seldom expressed an opinion. In this
she was doubtless wise. Sitting very upright in her bed, with those
glittering eyes and hawklike features the unmistakable mistress of all
they surveyed, she was enough to strike the boldest heart with awe.
Not that temerity was the long suit of Miss Burden, a gentlewoman of
a certain age whose sole mission in life it was to do her good-will
and pleasure in return for board and residence, and forty pounds per
annum paid quarterly.
Duly fortified with a slice of dry toast and a cup of very strong tea,
the old lady said in such a clear and incisive tone that she must have
studied the art of elocution in the days of her youth—
“Burden, cover my head.”
The gentlewoman obeyed the command with delicacy and with
dexterity. Yet it must not be thought that the elaborate mechanism
which adorned the venerable poll fourteen hours out of the twenty-
four was taken from the center of the dressing-table. It was not.
Various ceremonies had to be performed before the moment arrived
for its reception. In its place a temporary, but none the less
marvelous, erection of fine needlework and point lace was produced
by Miss Burden, and arranged like a veritable canopy about the brow
of Minerva.
“Admit Marchbanks,” said the voice from the bed.
The door opened and that personage was ushered in. Mr.
Marchbanks merits a description quite as much as his mistress. Yet
how to do justice to him, that is the problem. The poise of his
bearing, his urbane reserve, his patrician demeanor were those of an
ambassador. His whole being was enveloped in an air of high
diplomacy. His most trivial action seemed to raise the ghost of Lord
John Russell. Like his venerable mistress, he was a Whig to the
core. He had been born, he had been bred, and by the grace of God
he was determined to die in that tradition.
Under the left arm of Mr. Marchbanks was the Morning Post, which
organ of opinion had been warmed by his own hands. In his right
hand he bore a small silver dish. Upon it was a little pile of rather
important-looking correspondence.
With the courtly grace of a bygone age, Mr. Marchbanks bowed to
the occupant of the four-poster—old ladies who live in Hill Street do
not put their faith in new furniture—and his venerable mistress was
pleased to say—
“Good morning, Marchbanks.”
“Good morning, my lady,” said Mr. Marchbanks very gravely; and
then said he with a benevolence that would have made a
considerable fortune in Harley Street: “I trust your ladyship has slept
well.”
“As well as one can expect at my age,” said the occupant of the four-
poster.
No, Mr. Marchbanks did not offer his venerable mistress many happy
returns of her birthday. And to those of our readers who aspire to
serve old ladies who live in Hill Street—and let us not be judged
immodest if we express the belief that many who are inspired with
this excellent ambition will be found among them—a word of warning
may not be out of place. Let us urge these neophytes not to take the
practice of Mr. Marchbanks for their guide. His eminence was the
fruit of years. Remember he had been tipped by the Duke of
Wellington. He had pulled down the coat collar of Lord Palmerston
on more than one occasion; while as for Lord Granville, he knew him
as well as he knew his own father.
“How is Ponto this morning?” inquired the occupant of the four-
poster.
“In excellent spirits, my lady.”
“And his appetite?”
“He has eaten a chicken, my lady, with excellent relish.”
“Humph,” said the occupant of the four-poster, “that dog eats as
much as a Christian.”
In the opinion of Mr. Marchbanks Ponto ate more, but he did not say
so. He was content merely to bow and withdraw with simple yet
ample dignity. The old lady read her letters and glanced at the Court
Circular, the Parliamentary Report, and the Money Market. She then
announced her intention of getting up. Over the divers things incident
to this complex process it is doubtless well to draw the veil. Let it
suffice that an hour and a half later she reached her morning-room, a
veritable dragon in black silk and a brown wig, leaning on an ebony
walking-stick.
The normal condition of her temper was severe, “Acidulated to the
verge of the morose,” said those who had particular cause to respect
it. A considerable, not to say representative body they were. On this
wet morning of the early spring, this seventy-third annual
commemoration of the most pregnant fact of her experience, her
temper was so positively formidable that it smote the officers of her
household with a feeling akin to dismay.
Various causes had contributed to the state of the barometer. For
one thing that impertinent fellow Cheriton had issued his annual
persiflage upon the subject of her birthday. It fell, it appeared, upon
the first of April; a stroke of irony, in Cheriton’s opinion, for which she
had never quite been able to forgive her Creator. Then, again, if you
came to think of it, what had existence to offer an old woman who
had so long outlived her youth; who had neither kith nor kin of her
own; who bored her friends; who rendered her dependents
miserable; who was unable to take exercise; who distrusted doctors
and despised the clergy: a praiser of past times who considered the
present age all that it ought not to be?
Why should this old lady be in a good humor on her seventy-third
birthday? She was a nuisance to everybody, including herself. She
was a vain and selfish old woman, as all the world knew. Yet even
she had her points. Everybody has to have points of some kind, else
they would never be allowed to persist—particularly to their seventy-
fourth year.
For one thing she was good to her pug. Upon that extraordinarily
repulsive and overfed animal she lavished a great deal of affection.
Yet mark the ingratitude of the canine race. How did that misshapen,
dumb, soulless, pampered beast, whose figurehead was like a
gargoyle, and whose eyes were so swollen with baked meats that
they could scarcely revolve, requite the constant care and caresses
of his mistress? Why, by getting fat. There could be no doubt about it
that Ponto was getting fat.
Almost the first thing the old woman did upon what was destined to
prove one of the most memorable days of a long and not particularly
useful life, was to issue an edict. It was to the effect that John, the
second footman, was to exercise Ponto for an hour every morning in
Hyde Park. The manner in which John, who himself consumed more
than was good for a human being, received the edict is no concern
of ours.
It was about a quarter to two—at least it was getting near luncheon-
time—that the rare event happened from which springs the germ of
this history. How it came to pass will never be known. It is a problem
to baffle the most learned doctors and the most expert psychologists.
For at about a quarter to two, just as Miss Burden had returned from
a visit to the circulating library, the occurrence happened. The old
lady of Hill Street was visited by an Idea. To be sure it did not reveal
itself immediately in that crude and startling guise. It had its
processes to go through, like a cosmos or a tadpole, or any other
natural phenomenon that burgeons into entity. The evolutions by
which it attained to its fullness were in this wise.
“Where have you been, Burden?” said the old lady, fixing a cold eye
upon the abashed blue-backed volume under the arm of her
gentlewoman.
“I have been changing a novel at Mudie’s,” said Miss Burden.
“The usual rubbish, I suppose,” said the old woman, giving a grim
turn to her countenance, which rendered that frontispiece an
admirable composite of a hawk and a hanging judge.
“Lord Cheriton said it was the best novel he had read for years,” said
Miss Burden with the gentle air of one who reveres authority.
“Humph,” said the old lady. “Whatever Cheriton is, he has taste at
least. Give it to me.”
Miss Burden handed the blue-backed volume to her mistress. The
old lady opened it warily, lest she should come too abruptly upon a
fine moral sentiment.
“Man uses good English,” she said suspiciously. “Reminds one of the
man Disraeli before he made a fool of himself in politics.”
The next thing that Miss Burden was aware of was that the old lady
was fast asleep.
When Mr. Marchbanks came a few minutes later to announce that
luncheon was ready, his mistress, with the blue-backed volume in
her lap, was snoring lustily. An anxious consultation followed. Her
ladyship had not missed her luncheon for seventy-three years.
The far-seeing wisdom of Miss Burden—doubtless due in some
measure to her pure taste in English fiction—was allowed to prevail.
The state of the old woman’s temper could not possibly be worse
than it had been that morning if the sun was to remain faithful to the
firmament. If she slept undisturbed it might conceivably be better.
Miss Burden was justified of her wisdom. The old lady missed her
luncheon for the first time in seventy-three years. Ideas come to us
fasting; and that is the only explanation there is to offer of how her
Idea came to be born.
 CHAPTER II
THE IDEA WHICH CAME TO HER

IT was a quarter to three when the old woman awoke. She was
alone save for Ponto, her fidus Achates, who was snoring in front of
the fire with his tail curled up in the most ridiculous manner. And yet
she was not alone, for there is reason to believe that her Idea was
already born in her. There can be little doubt that the Idea had
sprung into being, even before she had time to turn, which she did
almost immediately, to the half-pint of claret and the plate of goose
liver pie that Miss Burden and Mr. Marchbanks in consultation had
caused to be laid beside her.
Now do not suppose that the Idea was proclaimed forthwith in its
meridian splendor. Nothing of the kind. It was still in its infancy. It had
to be shaped and reshaped, to be dandled and cosseted, to be born
and born again in the dim recesses of the mind, before it gathered
the requisite force to issue as it were from the armory of Minerva.
At four o’clock precisely it was the custom of this old lady, if the light
and the British climate permitted, to drive the whole length of Bond
Street and once round Hyde Park.
At that hour the sky having cleared sufficiently for the sun to make a
tardy and shamefaced appearance, the old lady, accompanied by
her faithful gentlewoman and her somnolent four-footed beast,
entered the equipage that was drawn up before her door.
It was an extraordinary vehicle. It had yellow wheels and a curious
round body, which, according to scale, was very nearly as fat as
Ponto’s. It was perched up on very high springs, and was in the
forefront of the fashion about the year 1841.
Mr. Bryant and Mr. Gregory, who shared the box-seat, would
doubtless have been in the forefront of the fashion about the same
period. Their broad backs, their box-cloth, the shape and texture of
their hats and the angle at which they wore them unmistakably
belonged to a very early period of the world’s history. No, they did
not wear side whiskers. We don’t know why. Perhaps it was that side
whiskers were either a little in front or a little behind the mode in
1841. But it is enough that Mr. Bryant and Mr. Gregory did not wear
them. And had they worn them, had the present biographer had
reason for one single moment to suspect that Messrs. Bryant and
Gregory had been in possession of these appendages, he would
have given up this history. Really the line has to be drawn
somewhere.
The progress along Bond Street was at the rate of two miles an hour.
The horses, Castor and Pollux by name, were very fat and very
somnolent, the yellow chariot was very unwieldy, and in the
language of Constable X, who touched his helmet at the corner of
Hanover Square, “it took up a deal o’ room.” None the less the
progress of the vehicle was almost royal.
The old lady sat very upright in the center of the best seat, which she
had all to herself. With a nose of the Wellington pattern and a chin to
match, displayed under a canopy of feathers, she looked more like a
macaw than ever. Miss Burden, in charge of Ponto and a pair of
folders with a tortoiseshell handle, was seated opposite at a more
modest elevation.
Every member of the male sex whom this redoubtable veteran
chanced to meet, who had the good fortune to wear his clothes with
a sufficient air of distinction, received a bow from her; and in return
she was the recipient of some highly elaborate and wholly inimitable
courtesies. With these she ranked as “an agreeable old woman.”
With the members of the other sex, which socially the more critical,
who seated in their barouches, their victorias, their broughams, and
their motors, who inclined their own distinguished heads from under
their own barbaric canopies, yet with no vain strivings in the direction
of effusiveness, she was greeted with a half-veiled hostility of the
eyelids, and a whispered, “There goes that old cat.”
We offer no opinion on the justice or the taste of the remark. We
claim no learning in feminology. Why these ladies, each of whom
vied with the other in the propagation of good works, each of whom
was an honored patroness of more than one institution for the
amelioration of the human race, should apply such a figure of
speech to one who was old and venerable it is not for us to
conjecture.
Did they refer to the quantity of feathers she was wearing upon her
helmet? If so, since April 1, 183-, she had caused many a beautiful
and harmless bird to be destroyed. But then they themselves were
wearing similar great canopies of feathers. Did they refer to her
features? We think not, for although her nose was shaped like a
talon of a bird of prey, they were not conspicuously feline. Perhaps it
was that they referred to her personal character. At any rate they are
known to be high authorities upon such a matter as the human
character, and as a rule are very searching in their judgments.
Certainly the old lady proceeding along Bond Street in her yellow
chariot at the rate of two miles an hour had done a fair amount of
mischief in her time; and if health and strength continued to be
vouchsafed to her by an All-wise Creator, before she died she hoped
to do a good deal more.
In her own little corner of her own little parish no old lady was more
respected. Where she was not respected she was feared, and where
she was neither respected nor feared she was very heartily hated. Of
one thing we are sure. There was not a living creature who loved
her, unless it was Ponto, who being a creature without a soul was
denied the consolations of religion.
We don’t believe for a moment that Miss Burden loved her. She had
caused her faithful gentlewoman, who in the space of twenty years
had given all she had had of youth, beauty, and gayety in return for
board and residence and forty pounds per annum, paid quarterly, to
weep too many tears in the privacy of her chamber for such a sacred
emotion as love to requite her persecutor. Yet it is far from our
intention to dogmatize upon the female heart. If we do we are sure to
be wrong. That complex and wonderful mechanism has defeated us
too often. Therefore it is possible that Miss Burden hugged her
chains to her bosom and lavished the poetry pent up in her soul
upon the hand that chastened her. We say it is possible, but we