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Cohen’s TWELFTH
EDITION

PATHWAYS
of
the
PULP
EDITORS
LOUIS H. BERMAN, DDS, FACD
Clinical Associate Professor
Department of Endodontics
School of Dentistry
University of Maryland
Baltimore, Maryland
Faculty
Albert Einstein Medical Center
Philadelphia, Pennsylvania
Private Practice
Annapolis Endodontics
Annapolis, Maryland
Diplomate, American Board of Endodontics

KENNETH M. HARGREAVES, DDS, PhD, FICD, FACD

Professor and Chair
Department of Endodontics
Professor
Departments of Pharmacology, Physiology (Graduate School),
and Surgery (Medical School)
President’s Council Endowed Chair in Research
University of Texas Health Science Center at San Antonio
San Antonio, Texas
Diplomate, American Board of Endodontics

Web Editor
ILAN ROTSTEIN, DDS
Associate Dean of Continuing Education and Chair
Division of Endodontics, Orthodontics, and General Practice Dentistry
Herman Ostrow School of Dentistry
University of Southern California
Los Angeles, California
ELSEVIER
3251 Riverport Lane
St. Louis, Missouri 63043

COHEN’S PATHWAYS OF THE PULP, TWELFTH EDITION ISBN: 978-0-323-67303-7

Copyright © 2021 by Elsevier Inc. All rights reserved.

Previous editions copyrighted 2016, 2011, 2006, 2002, 1998, 1994, 1991, 1987, 1984, 1980, and 1976.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to
be administered, to verify the recommended dose or formula, the method and duration of administra-
tion, and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

International Standard Book Number: 978-0-323-67303-7

Content Strategist: Joslyn Dumas

Senior Content Development Manager: Luke Held
Senior Content Development Specialist: Jennifer Wade
Publishing Services Manager: Julie Eddy
Book Production Specialist: Clay S. Broeker
Design Direction: Patrick Ferguson

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 About the Editors

Louis H. Berman
Dr. Berman received his dental degree from the University of Maryland School of
Dentistry and his Certificate in Endodontics from the Albert Einstein Medical Center. He
is Clinical Associate Professor of Endodontics at the University of Maryland School of
Dentistry and a Clinical Instructor and Guest Lecturer at the Albert Einstein Medical
Center. He has lectured internationally in the field of endodontics and has published in
several peer-reviewed international dental journals as well as co-authoring textbook
chapters on numerous topics in various endodontic textbooks. He is past president of
the Maryland State Association of Endodontics and is a member of the Journal of End-
odontics Scientific Advisory Board. A Diplomate of the American Board of Endodontics
and Fellow of the American College of Dentistry, Dr. Berman has been in full-time
private practice in Annapolis, Maryland since 1983.

Kenneth M. Hargreaves
Dr. Hargreaves is Professor and Chair of the Department of Endodontics at the
University of Texas Health Science Center at San Antonio. He is a Diplomate of
the American Board of Endodontics and maintains a private practice limited to
endodontics. He is an active researcher, lecturer, and teacher and serves as the
Editor-in-Chief of the Journal of Endodontics. He is principal investigator on several
nationally funded grants that combine his interests in pain, pharmacology, and
regenerative endodontics. He has received several awards, including a National In-
stitutes of Health MERIT Award for pain research, the AAE Louis I. Grossman
Award for cumulative publication of research studies, and two IADR Distinguished
Scientist Awards.

Ilan Rotstein
Dr. Rotstein is Professor and Chair of Endodontics, Orthodontics, and General Practice
Residency and Associate Dean at the Herman Ostrow School of Dentistry of the Univer-
sity of Southern California in Los Angeles. He is on the Executive Leadership Team of the
School of Dentistry and an ambassador member of the University of Southern California.
He has served in leadership roles for various dental organizations, including Chair of
the International Federation of Endodontic Associations’ Research Committee; as a
committee member of the American Association of Endodontists and European Society
of Endodontology; and as a scientific reviewer for international endodontic and dental
journals. He has also served as President of the Southern California Academy of Endo-
dontists, Israel Endodontic Society, and International Association for Dental Research—
Israel Division and as Chair of the Israel National Board of Diplomates in Endodontics.
Dr. Rotstein has published more than 150 scientific papers and research abstracts in
the dental literature as well as chapters in international endodontic textbooks, includ-
ing Pathways of the Pulp, Ingle’s Endodontics, Endodontics: Principles and Practice, Seltzer
and Bender’s Dental Pulp, and Harty’s Endodontics in Clinical Practice. He has lectured
extensively in more than 25 countries throughout 5 continents.

iii
This page intentionally left blank
 Dr. John Ingle
The development of every edition of Cohen’s Pathways of the
Pulp, for all of its editors and contributors, is a journey into
both the future and the past of endodontics. What we as
clinicians know today and the care that knowledge enables
us to provide to our patients are the result of the curiosity,
dedication, and commitment of the teachers, researchers,
and clinicians who have come before us. Dr. John Ingle,
who contributed to the science, practice, and teaching
of endodontics for more than 7 decades, is one of those
extraordinary pioneers.
Dr. Ingle began his career as an educator at the Univer-
sity of Washington in Seattle, where he taught periodon-
tics. While teaching, he became interested in the new field
of endodontics and, perhaps drawing on the example of
his pioneer great-grandfather, Daniel Boone, he entered
a specialty program in endodontics at the University of
Michigan to explore this new discipline, earning graduate
degrees in endodontics and periodontics.
As an educator and clinician, Dr. Ingle knew the impor-
tance of evidence in establishing the efficacy of endodontic
treatment as a new specialty. To meet this need, he evalu-
ated the results of endodontic treatment in 3000 patients
and presented his findings to the annual session of
the American Association of Endodontists in 1953. The
Washington Study established proof of outcome for endo­
dontic treatment and remains a seminal work in the
literature for our field.
New fields offer many new challenges to their pioneers,
and Dr. Ingle soon turned his attention to the development
of standardization of endodontic instruments. His work
resulted in the metric measurements and the 0.2 taper of
endodontics files that were established in 1957.
In 1965, Dr. Ingle brought together his experience
as both a clinician and an educator in the publication of
his foundational textbook Ingle’s Endodontics. Now in its
sixth edition, Ingle’s Endodontics has provided an essential
evidence-based reference to students and clinicians for
more than 50 years.
While Dr. Ingle’s many accomplishments are known and
admired, the attributes of his character are equally revered.
Dr. Ingle was modest about his many contributions to end-
odontics and was unfailingly generous in his support and
encouragement of others. The compassion and empathy
that motivated his work were experienced by all those he
touched throughout his long and exemplary career and life.
It is with profound gratitude and appreciation that we
dedicate this twelfth edition of Cohen’s Pathways of the Pulp
to Dr. John Ingle, a scholar, a leader, and a gentleman.
v
Contributors

Anita Aminoshariae, DDS, MS Serge Bouillaguet, DMD, PhD

Professor Professor and Head of the Endodontic Unit
Endodontics Division of Cardiology and Endodontology
School of Dental Medicine School of Dental Medicine
Case Western Reserve University University of Geneva
Cleveland, Ohio Geneva, Switzerland

Abdulaziz A. Bakhsh, BDS, MClinDent, Nicholas Chandler, BDS (Lond), MSc (Manc),
MEndo (RCSed) PhD (Lond), LDSRCS (Eng), MRACDS (Endo),
Endodontist FDSRCPS (Glas), FDSRCS (Edin), FFDRCSI, FICD
Department of Restorative Dentistry Professor of Endodontics
Faculty of Dentistry Faculty of Dentistry
Umm Al-Qura University University of Otago
Makkah, Saudi Arabia Dunedin, New Zealand

Bettina Basrani, DDS, PhD Gary S.P. Cheung, PhD, BDS, MDS, MSc, FHKAM,
Program Director FCDSHK (Endo), SFHEA, FICD, FAMS, FRACDS,
MSc Endodontics MRACDS (Endo), FDSRCSEd
Department of Endodontics Clinical Professor
University of Toronto Division of Restorative Dental Sciences
Toronto, Canada Associate Dean of Undergraduate Education
Faculty of Dentistry
Ellen Berggreen, PhD University of Hong Kong
Professor Pokfulam, Hong Kong
Biomedicine
University of Bergen Till Dammaschke, Prof, Dr Med Dent
Head of Research Dentist and Assistant Medical Director
Vestland County Department of Periodontology and Operative Dentistry
Bergen, Norway Westphalian Wilhelms University
Münster, Germany
Louis H. Berman, DDS, FACD
Clinical Associate Professor Didier Dietschi, DMD, PhD, Privat-Docent
Department of Endodontics Senior Lecturer
School of Dentistry School of Dental Medicine
University of Maryland Department of Cardiology and Endodontics
Baltimore, Maryland University of Geneva
Faculty Geneva, Switzerland
Albert Einstein Medical Center Adjunct Professor
Philadelphia, Pennsylvania School of Dentistry
Private Practice Department of Comprehensive Care
Annapolis Endodontics Case Western Reserve University
Annapolis, Maryland Cleveland, Ohio
Diplomate, American Board of Endodontics
Anibal Diogenes, DDS, MS, PhD
George Bogen, BS, DDS Assistant Professor
Senior Lecturer Endodontics
Department of Endodontics University of Texas Health Science Center at San Antonio
School of Dentistry San Antonio, Texas
University of Queensland
Brisbane, Australia Melissa Drum, DDS, MS
Diplomate, American Board of Endodontics Professor and Advanced Endodontics Director
Endodontics
Ohio State University
Columbus, Ohio

vi
 CONTRIBUTORS vii

Conor Durack, BDS NUI, MFDS RCSI, James L. Gutmann, DDS, Cert Endo, PhD, FICD,
MClinDent (Endo), MEndo RCS (Lond) FACD, FIAD, FAAHD, FDSRCSEd, Dipl ABE
Specialist Endodontist and Practice Partner Professor, Chair, and Postdoctoral Program Director
Riverpoint Specialist Dental Clinic Endodontics
Limerick, Ireland College of Dental Medicine
Nova Southeastern University
Bing Fan, DDS, PhD Davie, Florida
Professor and Chair Professor Emeritus
Endodontic Center Restorative Sciences/Endodontics
School and Hospital of Stomatology College of Dentistry
Wuhan University Texas A&M University
Wuhan City, China Dallas, Texas
Adjunct Professor Honorary Professor
Department of Endodontics Stomatology
Dental College of Georgia School of Stomatology
Augusta University Wuhan University
Augusta, Georgia Wuhan, China

Mohamed I. Fayad, DDS, MS, PhD Kenneth M. Hargreaves, DDS, PhD

Director of Research and Clinical Associate Professor Professor and Chair
Department of Endodontics Department of Endodontics
College of Dentistry Professor
University of Illinois at Chicago Departments of Pharmacology, Physiology (Graduate
Chicago, Illinois School), and Surgery (Medical School)
President’s Council Endowed Chair in Research
Ashraf F. Fouad, DDS, MS University of Texas Health Science Center at San Antonio
Distinguished Professor and Vice-Chair San Antonio, Texas
Comprehensive Oral Health Diplomate, American Board of Endodontics
Adams School of Dentistry
University of North Carolina George T.-J. Huang, DDS, MSD, DSc
Chapel Hill, North Carolina Professor and Director for Stem Cells and Regenerative
Therapies
Inge Fristad, DDS, PhD Department of Bioscience Research
Department of Clinical Dentistry University of Tennessee Health Science Center
University of Bergen Memphis, Tennessee
Bergen, Norway
Vincent J. Iacono, DMD
Bradley H. Gettleman, DDS, MS Distinguished Service Professor, Chair, and Tarrson
Private Practice Professor of Periodontology
Assistant Clinical Professor Periodontology
College of Dental Medicine Stony Brook University
Midwestern University Stony Brook, New York
Glendale, Arizona
Diplomate, American Board of Endodontics Bradford R. Johnson, DDS, MHPE
Associate Professor and Director of Postdoctoral
Gerald N. Glickman, DDS, MS, MBA, JD Endodontics
Professor Department of Endodontics
Department of Endodontics University of Illinois at Chicago
Texas A&M College of Dentistry Chicago, Illinois
Dallas, Texas
Diplomate, American Board of Endodontics Scott C. Johnson, DMD
Clinical Assistant Professor
Kishor Gulabivala, BDS, MSc, FDSRCS, PhD, Endodontics
FHEA, FACD Midwestern University College of Dental Medicine,
Professor of Restorative Dentistry and Endodontology, Arizona
Consultant in Restorative Dentistry, and Head of Glendale, Arizona
Endodontology and Restorative Dental Sciences
Eastman Dental Institute William T. Johnson, DDS, MS, FICD, FACD
University College London Professor Emeritus
London, United Kingdom University of Iowa
Iowa City, Iowa
viii CONTRIBUTORS

Bill Kahler, DClinDent, PhD Matthew Malek, DDS

Honorary Associate Professor Post Graduate Program Director
School of Dentistry Endodontics
University of Queensland College of Dentistry
Brisbane, Australia New York University
New York, New York
Asma A. Khan, BDS, PhD
Associate Professor Donna Mattscheck, DMD
Endodontics Private Practice
University of Texas Health Science Center Endodontics
San Antonio, Texas Advanced Endodontics
Tigard, Oregon
James C. Kulild, DDS, MS
Professor Emeritus Madhu K. Nair, BDS, DMD, MS,
Endodontics Lic Odont (Sweden), PhD, Dipl ABOMR
School of Dentistry Professor and Director of Radiology, Assistant Dean of
University of Missouri, Kansas City Graduate Clinical Programs, and Director of the Oral
Kansas City, Missouri and Maxillofacial Radiology Residency Program and the
Imaging Center
David J. Landwehr, DDS, MS Diagnostic Sciences
Fellow College of Dentistry
American Academy of Oral and Maxillofacial Pathology Texas A&M University
Private Practice Limited to Endodontics Dallas, Texas
Capital Endodontics
Madison, Wisconsin Umadevi P. Nair, BDS, MDS, Dipl ABE
Chief Executive Officer
Alan S. Law, DDS, PhD Nair Endodontics PLLC
Adjunct Associate Professor Dallas, Texas
Restorative Sciences
University of Minnesota Yuan-Ling Ng, BDS, MSc, RCS, PhD. FHEA
Minneapolis, Minnesota Professor of Endodontology and Programme Director in
President Endodontology
The Dental Specialists Restorative Dental Sciences (Endodontics)
Minneapolis, Minnesota Eastman Dental Institute
University College London
Linda G. Levin, DDS, PhD London, United Kingdom
Adjunct Associate Professor
Department of Endodontics John M. Nusstein, DDS, MS
University of North Carolina at Chapel Hill Professor and Chair
Chapel Hill, North Carolina Division of Endodontics
Ohio State University College of Dentistry
Martin D. Levin, DMD Columbus, Ohio
Adjunct Professor
Department of Endodontics Donald R. Nixdorf, DDS, MS
University of Pennsylvania Professor
Philadelphia, Pennsylvania Diagnostic and Biological Services
Adjunct Assistant Professor
Roger P. Levin, DDS Department of Neurology
Chairman and Chief Executive Officer University of Minnesota, Twin Cities
Management Minneapolis, Minnesota
Levin Group, Inc. Research Investigator
Owings Mills, Maryland Health Partners Institute for Education and Research
Bloomington, Minnesota
Louis M. Lin, BDS, DMD, PhD
Professor Shanon Patel, BDS, MSc, MClinDent, MRD,
Department of Endodontics PhD, FDS, FHEA
New York University College of Dentistry Consultant Endodontist
New York, New York King’s College London Dental Institute and Specialist
Practice
London, United Kingdom
 CONTRIBUTORS ix

Christine I. Peters, DMD Avishai Sadan, DMD, MBA

Senior Lecturer Dean
School of Dentistry Herman Ostrow School of Dentistry
University of Queensland University of Southern California
Brisbane, Australia Los Angeles, California
Adjunct Clinical Professor
Arthur A. Dugoni School of Dentistry Frank Setzer, DMD, PHD, MS
University of the Pacific Assistant Professor, Endodontic Clinic Director, and
San Francisco, California Director of Predoctoral Endodontic Program
Department of Endodontics
Ove A. Peters, DMD, MS, PhD University of Pennsylvania
Professor Philadelphia, Pennsylvania
School of Dentistry
University of Queensland Stéphane Simon, DDS, MPhil, PhD, HDR
Brisbane, Australia Senior Lecturer
Adjunct Professor Department of Endodontics
Arthur A. Dugoni School of Dentistry Paris Diderot University
University of the Pacific Paris, France
San Francisco, California
Jose F. Siqueira, Jr., DDS, MSc, PhD
Tara F. Renton, BDS, MDSc, PhD, FDS RCS, Adjunct Professor
FRACDS (OMS), FHEA Postgraduate Program in Dentistry
Professor Faculty of Dentistry
Oral Surgery Grande Rio University
King’s College London Rio de Janeiro, Brazil
London, United Kingdom
Franklin Tay, BDSc (Hons), PhD
Domenico Ricucci, MD, DDS Department of Endodontics
Private Practice Augusta University
Endodontics Augusta, Georgia
Cetraro, Italy
Aviad Tamse, DMD
Isabela N. Rôças, DDS, MSc, PhD Professor Emeritus
Adjunct Professor Department of Endodontology
Postgraduate Program in Dentistry Goldschlager School of Dental Medicine
Faculty of Dentistry Tel Aviv, Israel
Grande Rio University
Rio de Janeiro, Brazil Fabricio B. Teixeira, DDS, MS, PhD
Chair and Professor
Robert S. Roda, DDS, MS Endodontics
Adjunct Clinical Faculty College of Dentistry and Dental Clinics
Advanced Education in General Dentistry University of Iowa
Arizona School of Dentistry and Oral Health Iowa City, Iowa
Mesa, Arizona
Yoshitsugu Terauchi, DDS, PhD
Paul A. Rosenberg, DDS CT and Microendodontic Center
Professor Endodontics
Endodontics Intellident Medical Corporation
College of Dentistry Yamato City, Japan
New York University
New York, New York Edwin J. Zinman, DDS, JD
Lecturer
Ilan Rotstein, DDS Department of Periodontology
Associate Dean of Continuing Education and Chair University of California, San Francisco
Division of Endodontics, Orthodontics, and General San Francisco, California
Practice Dentistry
Herman Ostrow School of Dentistry
University of Southern California
Los Angeles, California
New to This Edition
The radiographic interpretation of odontogenic and non­
odontogenic lesions is exactly that: an “interpretation.”
This new twelfth edition boasts a completely new chapter
entitled Lesions That Mimic Endodontic Pathosis that eluci­
dates and differentiates lesions that may appear as endo­
dontic origin. This is a perfect adjunct to the chapters on
Diagnosis and Radiographic Interpretation.
The chapter on Managing Iatrogenic Events has been
completely rewritten to include an expansive section on
injury to the inferior alveolar nerve.
Damage to the inferior alveolar nerve secondary to endo­
dontic treatment is an avoidable dilemma. There is now
specific content elaborating on the avoidance and manage­
ment of these types of injuries.
Root resorption and root fractures can be some of the
most difficult defects to clinically manage. The Root Resorp­
tion chapter on these subjects has been completely updated
and will prove beneficial to the clinician and academician.
This edition updates all of the previous chapters to reflect
the changes in the literature since the last edition.
New Chapter Organization
Chapters have been reorganized and grouped into three parts:
Part I: The Core Science of Endodontics, Part II: Advanced
x
Science Topics, and Part III: Advanced Clinical Topics. The
twelve chapters in Part 1 focus on the core clinical con­
cepts for dental students, while the chapters in Parts II and
III provide the information that advanced students and
endodontic residents and clinicians need to know. In addi­
tion, three additional chapters are included in the online
version.
The new organization better reflects the chronology of
endodontic treatment.
Digital Content
New features included on the companion site include:
n Three chapters found exclusively online:
n Chapter 26: Bleaching Procedures
n Chapter 27: Endodontic Records and Legal Responsi­
bilities
n Chapter 28: Key Principles of Endodontic Practice
Management
n Case Studies
Review Articles
n
n Review Questions
n Videos

The foundation of the specialty of endodontics is a gift from
the generations of great endodontists and researchers be-
fore us. They guided us with the goals of treatment, the
benefits of their advancements, and the frailties of their
deficiencies. From volumes of research, we have collectively
built a virtual library of knowledge that leads us to the evi-
dence we need for mastering our clinical procedures and
benefiting our patients. As we look into our future, we
should be directed toward developing the necessary tools
for maximizing our outcomes with consistency, longevity,
and, above all, patient well-being.
Over the past several decades, we have gone from arsenic
to sodium hypochlorite, from bird droppings to gutta-
percha, from hand files to motor-driven files, from culturing
to one-visit appointments, from 2D to 3D radiography, and
from pulp removal to pulpal regeneration. Yet still, the
clinical and academic controversies are pervasive.
With patients living longer and with the inescapable
comparison of endodontics to endosseous implants, the
demand for endodontic excellence has greatly increased.
Surprisingly, we still base our diagnosis on a presumed and
almost subjective pulpal status. Imagine a future in which
endodontic diagnosis could be made more objective by
noninvasively scanning the pulp tissue. Imagine algorithms
built into all digital radiography for interpreting and
extrapolating disease processes. CBCT has made a huge
impact on endodontic diagnosis, but can we enhance these
digital captures with a resolution that would approach
microcomputed tomography, and with less radiation? Will
these 3D scans guide us not just with diagnostic objectivity,
but also with direct treatment facilitation to guide us dur-
ing surgical and nonsurgical treatment? Truly, we are now
on the cusp of gaining the knowledge and technology
for accomplishing this. As for clinical visualization, will 3D
visualization and monitor-based observation change the
way we visualize and implement our procedures? Will our
procedures still be done with the fine motor skills of the
Introduction
clinician, or with the augmented reality of digital microsur-
gical devices? In the years to come, will we be able to truly
eliminate all of the canal microorganisms, biofilms, and
pulpal tissue? Will we be facilitating our canal cleaning with
less toxic and more directed irrigants? Once we are finally
able to totally clean and disinfect the canals to a microscopic
level, will we have an obturation material that finally satis-
fies ALL the material requirements that Dr. Louis Grossman
enumerated at the inception of our specialty? Will this obtu-
rating material be newly regenerated vital pulp?
Clearly, our endodontic future lies in out-of-the-box
thinking, with the next generation of transformations
coming with collaborations not just from within the bio-
logical sciences, but also in conjunction with physicists,
chemists, engineers, and a multitude of other great inno-
vative minds. The predictability of endodontics must be
incontestable, not just with better technology to guide us
toward greater success, but also to better elucidate exactly
when endodontic treatment cannot be successful. Our fu-
ture needs to focus on predictability and consistency, which
will only be achieved with disruptive technologies, rather
than persisting with variations and modifications of our
current convictions. As a specialty, we have advanced by
leaps and bounds since our inception; but we are still in our
infancy with a brilliant future ahead of us. Since 1976,
and now with 12 editions, Cohen’s Pathways of the Pulp has
always been about the art and science of endodontics, with
an emphasis on evidenced-based direction rather than an-
ecdotal guidance. The dedicated contributing authors have
generously given their time to meticulously describe what
is considered the state of the art of our specialty. We are
hopeful that future editions will guide us toward enhanced
endodontic outcomes, with the never-ending pursuit of
endodontic excellence.
Louis H. Berman
Kenneth M. Hargreaves
xi
Contents

PART I THE CORE SCIENCE 15 Microbiology of Endodontic Infections, 585

JOSÉ F. SIQUEIRA, JR. and ISABELA N. RÔÇAS
OF ENDODONTICS
16 Pathobiology of Apical Periodontitis, 619
1 Diagnosis, 2 LOUIS M. LIN and GEORGE T.-J. HUANG
LOUIS H. BERMAN and ILAN ROTSTEIN

2 Radiographic Interpretation, 34 PART III ADVANCED CLINICAL

MADHU K. NAIR, MARTIN D. LEVIN, and UMADEVI P. NAIR
TOPICS
3 Lesions That Mimic Endodontic Pathosis, 78 17 Evaluation of Outcomes, 652
DAVID J. LANDWEHR
YUAN-LING NG and KISHOR GULABIVALA
4 Diagnosis of the Nonodontogenic 18 Root Resorption, 711
Toothache, 115 SHANON PATEL, CONOR DURACK, DOMENICO RICUCCI,
ALAN S. LAW, DONALD R. NIXDORF, and DONNA MATTSCHECK and ABDULAZIZ A. BAKHSH

5 Case Assessment and Treatment Planning, 139 19 Management of Endodontic Emergencies, 737
PAUL A. ROSENBERG and MATTHEW MALEK FABRICIO B. TEIXEIRA and GARY S.P. CHEUNG

6 Pain Control, 162 20 Managing Iatrogenic Events, 756

JOHN M. NUSSTEIN, MELISSA DRUM, and ASMA A. KHAN YOSHITSUGU TERAUCHI and TARA F. RENTON

7 Tooth Morphology and Pulpal Access 21 The Role of Endodontics After Dental Traumatic
Cavities, 192 Injuries, 808
JAMES L. GUTMANN and BING FAN BILL KAHLER

8 Cleaning and Shaping of the Root Canal 22 Chronic Cracks and Fractures, 848
System, 236 LOUIS H. BERMAN and AVIAD TAMSE
OVE A. PETERS, CHRISTINE I. PETERS, and BETTINA BASRANI
23 Restoration of the Endodontically
9 Obturation of the Cleaned and Shaped Root Canal Treated Tooth, 870
System, 304 DIDIER DIETSCHI, SERGE BOUILLAGUET, AVISHAI SADAN,
ANITA AMINOSHARIAE, WILLIAM T. JOHNSON, JAMES C. KULILD, and KENNETH M. HARGREAVES
and FRANKLIN TAY
24 Vital Pulp Therapy, 902
10 Nonsurgical Retreatment, 343 GEORGE BOGEN, TILL DAMMASCHKE, and NICHOLAS CHANDLER
ROBERT S. RODA, BRADLEY H. GETTLEMAN, and SCOTT C. JOHNSON
25 Endo-Perio, 939
11 Periradicular Surgery, 411 GERALD N. GLICKMAN and VINCENT J. IACONO
BRADFORD R. JOHNSON, MOHAMED I. FAYAD,
and LOUIS H. BERMAN

12 Regenerative Endodontics, 475

ANIBAL DIOGENES, STÉPHANE SIMON, and ALAN S. LAW

PART II ADVANCED SCIENCE TOPICS

13 Structure and Functions of the Dentin-Pulp
Complex, 512
INGE FRISTAD and ELLEN BERGGREEN

14 Pulp Reactions to Caries and Dental

Procedures, 557
ASHRAF F. FOUAD and LINDA G. LEVIN

xii
PART I

THE CORE SCIENCE

OF ENDODONTICS
PART OUTLINE 1. Diagnosis, 2 8. Cleaning and Shaping of the Root Canal
System, 236
2. Radiographic Interpretation, 34
9. Obturation of the Cleaned and Shaped
3. Lesions That Mimic Endodontic Pathosis, 78
Root Canal System, 304
4. Diagnosis of the Nonodontogenic
10. Nonsurgical Retreatment, 343
Toothache, 115
11. Periradicular Surgery, 411
5. Case Assessment and Treatment Planning, 139
12. Regenerative Endodontics, 475
6. Pain Control, 162
7. Tooth Morphology and Pulpal Access
Cavities, 192
 1 Diagnosis
LOUIS H. BERMAN and ILAN ROTSTEIN
CHAPTER OUTLINE Art and Science of Diagnosis
Chief Complaint
Medical History
Dental History
History of Present Dental Problem
Dental History Interview
Examination and Testing
Extraoral Examination
Intraoral Examination
Soft-Tissue Examination
Intraoral Swelling
Intraoral Sinus Tracts
Palpation
Percussion
Mobility
Periodontal Examination
Pulp Tests
Thermal
Electric
Laser Doppler Flowmetry
Pulse Oximetry
Special Tests
Bite Test
Test Cavity
Staining and Transillumination
Selective Anesthesia
Radiographic Examination and Interpretation
Intraoral Radiographs
Art and Science of Diagnosis
Diagnosis is the art and science of detecting and distin-
guishing deviations from health and the cause and nature
thereof.6 The purpose of a diagnosis is to determine what
problem the patient is having and why the patient is having
that problem. Ultimately, this will directly relate to what
treatment, if any, will be necessary. No appropriate treat-
ment recommendation can be made until all of the whys
are answered. Therefore, careful data gathering as well as
a planned, methodical, and systematic approach to this
investigatory process is crucial.
Gathering objective data and obtaining subjective find-
ings are not enough to formulate an accurate clinical
diagnosis. The data must be interpreted and processed to
determine what information is significant, and what infor-
mation might be questionable. The facts need to be col-
lected with an active dialogue between the clinician and
the patient, with the clinician asking the right questions
2
Digital Radiography
Cone-Beam Computerized Tomography
Magnetic Resonance Imaging
Cracks and Fractures
Crack Types
Vertical Root Fractures
Perforations
Clinical Classification of Pulpal and
Periapical Diseases
Pulpal Disease
Normal Pulp
Pulpitis
Reversible Pulpitis
Irreversible Pulpitis
Previously Treated
Previously Initiated Therapy
Apical (Periapical) Disease
Normal Apical Tissues
Periodontitis
Symptomatic Apical Periodontitis
Asymptomatic Apical Periodontitis
Acute Apical Abscess
Chronic Apical Abscess
Referred Pain
Summary
and carefully interpreting the answers. In essence, the pro-
cess of determining the existence of an oral pathosis is the
culmination of the art and science of making an accurate
diagnosis.
The process of making a diagnosis can be divided into five
stages:
1. The patient tells the clinician the reasons for seeking
advice.
2. The clinician questions the patient about the symptoms
and history that led to the visit.
3. The clinician performs objective clinical tests.
4. The clinician correlates the objective findings with the
subjective details and creates a tentative list of differential
diagnoses.
5. The clinician formulates a definitive diagnosis.
This information is accumulated by means of an orga-
nized and systematic approach that requires considerable
clinical judgment. The clinician must be able to approach

the problem by crafting what questions to ask the patient
and how to ask these pertinent questions. Careful listening
is paramount to begin painting the picture that details the
patient’s complaint. These subjective findings combined
with the results of diagnostic tests provide the critical infor-
mation needed to establish the diagnosis.
Neither the art nor the science is effective alone. Estab-
lishing a differential diagnosis in endodontics requires a
unique blend of knowledge, skills, and the ability to inter-
pret and interact with a patient in real time. Questioning,
listening, testing, interpreting, and finally answering the
ultimate question of why will lead to an accurate diagnosis
and in turn result in a more successful treatment plan.
CHIEF COMPLAINT
On arrival for a dental consultation, the patient should com-
plete a thorough registration that includes information per-
taining to medical and dental history (Figs. 1.1 and 1.2).
This should be signed and dated by the patient, as well as
initialed by the clinician as verification that all of the sub-
mitted information has been reviewed (see Chapter 27 for
more information).
The reasons patients give for consulting with a clinician
are often as important as the diagnostic tests performed.
Their remarks serve as initial important clues that will help
the clinician to formulate a correct diagnosis. Without
these direct and unbiased comments, objective findings
may lead to an incorrect diagnosis. The clinician may find a
dental pathosis, but it may not contribute to the pathologic
condition that mediates the patient’s chief complaint. In-
vestigating these complaints may indicate that the patient’s
concerns are related to a medical condition or to recent
dental treatment. Certain patients may even receive initial
emergency treatment for pulpal or periapical symptoms in
a general hospital.93 On occasion, the chief complaint is
simply that another clinician correctly or incorrectly ad-
vised the patient that he or she had a dental problem, with
the patient not necessarily having any symptoms or any
objective pathosis. Therefore, the clinician must pay close
attention to the actual expressed complaint, determine the
chronology of events that led to this complaint, and ques-
tion the patient about other pertinent issues, including
medical and dental history. For future reference and in order
to ascertain a correct diagnosis, the patient’s chief com-
plaint should be properly documented, using the patient’s
own words.
MEDICAL HISTORY
The clinician is responsible for taking a proper medical his-
tory from every patient who presents for treatment. Numer-
ous examples of medical history forms are available from a
variety of sources, or clinicians may choose to customize
their own forms. After the form is completed by the patient,
or by the parent or guardian in the case of a minor, the cli-
nician should review the responses with the patient, par-
ent, or guardian, and then initial the medical history form
to indicate that this review has been done. The patient “of
record” should be questioned at each treatment visit to
determine whether there have been any changes in the
patient’s medical history or medications. A more thorough
1 • Diagnosis 3
and complete update of the patient’s medical history should
be taken if the patient has not been seen for over a year.51,52
Baseline blood pressure and pulse should be recorded for
the patient at each treatment visit. Elevation in blood pres-
sure or a rapid pulse rate may indicate an anxious patient
who may require a stress reduction protocol, or it may indi-
cate that the patient has hypertension or other cardiovas-
cular health problems. Referral to a physician or medical
facility may be indicated. It is imperative that vital signs
be gathered at each treatment visit for any patient with
a history of major medical problems. The temperature
of patients presenting with subjective fever or any signs or
symptoms of a dental infection should be taken.57,80,105
The clinician should evaluate a patient’s response to the
health questionnaire from two perspectives: (1) those medi-
cal conditions and current medications that will necessitate
altering the manner in which dental care will be provided
and (2) those medical conditions that may have oral mani-
festations or mimic dental pathosis.
Patients with serious medical conditions may require
either a modification in the manner in which the dental
care will be delivered or a modification in the dental treat-
ment plan (Box 1.1). In addition, the clinician should be
aware if the patient has any drug allergies or interactions,
allergies to dental products, an artificial joint prosthesis,
organ transplants, or is taking medications that may nega-
tively interact with common local anesthetics, analgesics,
sedatives, and antibiotics.80 This may seem overwhelming,
but it emphasizes the importance of obtaining a thorough
and accurate medical history while considering the various
medical conditions and dental treatment modifications that
may be necessary before dental treatment is provided.
Several medical conditions have oral manifestations,
which must be carefully considered when attempting to
arrive at an accurate dental diagnosis. Many of the oral
soft-tissue changes that occur are more related to the medi-
cations used to treat the medical condition rather than to
the condition itself. More common examples of medication
side effects are stomatitis, xerostomia, petechiae, ecchymo-
ses, lichenoid mucosal lesions, and bleeding of the oral soft
tissues.80
When developing a dental diagnosis, a clinician must
also be aware that some medical conditions can have
clinical presentations that mimic oral pathologic
lesions.13,28,32,74,80,102,107,133 For example, tuberculosis in-
volvement of the cervical and submandibular lymph nodes
can lead to a misdiagnosis of lymph node enlargement
secondary to an odontogenic infection. Lymphomas can
involve these same lymph nodes.80 Immunocompromised
patients and patients with uncontrolled diabetes mellitus
respond poorly to dental treatment and may exhibit recur-
ring abscesses in the oral cavity that must be differentiated
from abscesses of dental origin.43,76,80,83 Patients with iron
deficiency anemia, pernicious anemia, and leukemia fre-
quently exhibit paresthesia of the oral soft tissues. This find-
ing may complicate making a diagnosis when other dental
pathosis is present in the same area of the oral cavity. Sickle
cell anemia has the complicating factor of bone pain, which
mimics odontogenic pain, and loss of trabecular bone pat-
tern on radiographs, which can be confused with radio-
graphic lesions of endodontic origin. Multiple myeloma can
result in unexplained mobility of teeth. Radiation therapy
4 PART I • The Core Science of Endodontics

TELL US ABOUT YOUR SYMPTOMS

LAST NAME FIRST NAME

1. Are you experiencing any pain at this time? If not, please go to question 6. Yes No

2. If yes, can you locate the tooth that is causing the pain? Yes No

3. When did you first notice the symptoms?

4. Did your symptoms occur suddenly or gradually?

5. Please check the frequency and quality of the discomfort, and the number that most closely
reflects the intensity of your pain:

LEVEL OF INTENSITY FREQUENCY QUALITY

(On a scale of 1 to 10)
1 = Mild 10 = Severe

1 2 3 4 5 6 7 8 9 10 Constant Sharp

Intermittent Dull

Momentary Throbbing

Occasional

Is there anything you can do to relieve the pain? Yes No

If yes, what?

Is there anything you can do to cause the pain to increase? Yes No

If yes, what?

When eating or drinking, is your tooth sensitive to: Heat Cold Sweets

Does your tooth hurt when you bite down or chew? Yes No

Does it hurt if you press the gum tissue around this tooth? Yes No

Does a change in posture (lying down or bending over) cause your tooth to hurt? Yes No

6. Do you grind or clench your teeth? Yes No

7. If yes, do you wear a night guard? Yes No

8. Has a restoration (filling or crown) been placed on this tooth recently? Yes No

9. Prior to this appointment, has root canal therapy been initiated on this tooth? Yes No

10. Is there anything else we should know about your teeth, gums, or sinuses that would assist us in our

diagnosis?

Signed: Patient or Parent Date

Fig. 1.1 ​Dental history form that also allows the patient to record pain experience in an organized and descriptive manner.
 1 • Diagnosis 5

TELL US ABOUT YOUR HEALTH

LAST NAME FIRST NAME

How would you rate your health? Please circle one. Excellent Good Fair Poor

When did you have your last physical exam?

If you are under the care of a physician, please give reason(s) for treatment.

Physician’s Name, Address, and Telephone Number:

Name Address

City State Zip Telephone

Have you ever had any kind of surgery? Yes No

If yes, what kind? Date

Date

Have you ever had any trouble with prolonged bleeding after surgery? Yes No
Do you wear a pacemaker or any other kind of prosthetic device? Yes No
Are you taking any kind of medication or drugs at this time? Yes No

If yes, please give name(s) of the medicine(s) and reason(s) for taking them:

Name Reason

Have you ever had an unusual reaction to an anesthetic or drug (like penicillin)? Yes No

If yes, please explain:

Please circle any past or present illness you have had:

Alcoholism Blood pressure Epilepsy Hepatitis Kidney or liver Rheumatic fever

Allergies Cancer Glaucoma Herpes Mental Sinusitis
Anemia Diabetes Head/Neck injuries Immunodeficiency Migraine Ulcers
Asthma Drug dependency Heart disease Infectious diseases Respiratory Venereal disease

Are you allergic to Latex or any other substances or materials? Yes No

If so, please explain

If female, are you pregnant? Yes No

Is there any other information that should be known about your health?

Signed: Patient or Parent Date:

Fig. 1.2 ​Succinct, comprehensive medical history form designed to provide insight into systemic conditions that could produce or affect the patient’s
symptoms, mandate alterations in treatment modality, or change the treatment plan.
6 PART I • The Core Science of Endodontics
Box 1.1 Medical Conditions That Warrant
Modification of Dental Care or Treatment
Cardiovascular: High- and moderate-risk categories of endocardi-
tis, pathologic heart murmurs, hypertension, unstable angina
pectoris, recent myocardial infarction, cardiac arrhythmias,
poorly managed congestive heart failure.57,80,105
Pulmonary: Chronic obstructive pulmonary disease, asthma,
tuberculosis.80,129
Gastrointestinal and renal: End-stage renal disease; hemodialy-
sis; viral hepatitis (types B, C, D, and E); alcoholic liver disease;
peptic ulcer disease; inflammatory bowel disease; pseudomem-
branous colitis.25,34,48,80
Hematologic: Sexually transmitted diseases, human immuno-
deficiency virus (HIV) and acquired immunodeficiency syndrome
(AIDS), diabetes mellitus, adrenal insufficiency, hyperthyroidism
and hypothyroidism, pregnancy, bleeding disorders, cancer and
leukemia, osteoarthritis and rheumatoid arthritis, systemic lupus
erythematosus.35,43,76,80,83,88,100,135
Neurologic: Cerebrovascular accident, seizure disorders,
anxiety, depression and bipolar disorders, presence or history of
drug or alcohol abuse, Alzheimer disease, schizophrenia, eating
disorders, neuralgias, multiple sclerosis, Parkinson disease.36,44,80
to the head and neck region can result in increased sensitiv-
ity of the teeth and osteoradionecrosis.80 Trigeminal neu-
ralgia, referred pain from cardiac angina, and multiple
sclerosis can also mimic dental pain (see also Chapter 4).
Acute maxillary sinusitis is a common condition that may
create diagnostic confusion because it may mimic tooth
pain in the maxillary posterior quadrant. In this situation
the teeth in the quadrant may be extremely sensitive to cold
and percussion, thus mimicking the signs and symptoms of
pulpitis. This is certainly not a complete list of all the medi-
cal entities that can mimic dental disease, but it should alert
the clinician that a medical problem could confuse and
complicate the diagnosis of dental pathosis; this issue is
discussed in more detail in subsequent chapters.
If, at the completion of a thorough dental examination,
the subjective, objective, clinical testing, and radiographic
findings do not result in a diagnosis with an obvious dental
origin, then the clinician must consider that an existing
medical problem could be the true source of the pathosis. In
such instances, a consultation with the patient’s physician
is always appropriate.
DENTAL HISTORY
The chronology of events that lead up to the chief complaint
is recorded as the dental history. This information will help
guide the clinician as to which diagnostic tests are to be per-
formed. The history should include any past and present
symptoms, as well as any procedures or trauma that might
have evoked the chief complaint. Proper documentation is
imperative. It may be helpful to use a premade form to record
the pertinent information obtained during the dental history
interview and diagnostic examination. Often a SOAP format
is used, with the history and findings documented under the
categories of Subjective, Objective, Appraisal, and Plan. There
are also built-in features within some practice management
software packages that allow digital entries into the patient’s
electronic file for the diagnostic workup (Figs. 1.3 and 1.4).
History of Present Dental Problem
The dialogue between the patient and the clinician should
encompass all of the details pertinent to the events that
led to the chief complaint. The clinician should direct the
conversation in a manner that produces a clear and concise
narrative that chronologically depicts all of the necessary
information about the patient’s symptoms and the develop-
ment of these symptoms. To help elucidate this informa-
tion, the patient is first instructed to fill out a dental history
form as part of the patient’s office registration. This infor-
mation will help the clinician decide which approach to
use when asking the patient questions. The interview first
determines what is going on in an effort to determine why it
is going on for the purpose of eventually determining what is
necessary to resolve the chief complaint.
Dental History Interview
After starting the interview and determining the nature of
the chief complaint, the clinician continues the conversa-
tion by documenting the sequence of events that initiated
the request for an evaluation. The dental history is divided
into five basic directions of questioning: localization, com-
mencement, intensity, provocation or attenuation, and
duration.
Localization. “Can you point to the offending tooth?”
Often the patient can point to or tap the offending tooth.
This is the most fortunate scenario for the clinician because
it helps direct the interview toward the events that might
have caused any particular pathosis in this tooth. In addi-
tion, localization allows subsequent diagnostic tests to
focus more on this particular tooth. When the symptoms
are not well localized, the diagnosis is a greater challenge.
Commencement. “When did the symptoms first occur?” A
patient who is having symptoms often remembers when
these symptoms started. Sometimes the patient will even
remember the initiating event. It may have been spontane-
ous in nature; it may have begun after a dental visit for a
restoration; trauma may be the etiology; biting on a hard
object may have initially produced the symptoms; or the
initiating event may have occurred concurrently with other
symptoms (e.g., sinusitis, headache, chest pain). However,
the clinician should resist the tendency to make a prema-
ture diagnosis based on these circumstances. The clinician
should not simply assume “guilt by association” but instead
should use this information to enhance the overall diagnos-
tic process.
Intensity. “How intense is the pain?” It often helps to
quantify how much pain the patient is actually having. The
clinician might ask, “On a scale from 1 to 10, with 10 the
most severe, how would you rate your symptoms?” Hypo-
thetically, a patient could present with “an uncomfortable
sensitivity to cold” or “an annoying pain when chewing”
but might rate this “pain” only as a 2 or a 3. These symp-
toms certainly contrast with the type of symptoms that
prevent a patient from sleeping at night. Often the intensity
can be subjectively measured by what is necessary for the
diminution of pain (e.g., acetaminophen versus a narcotic
pain reliever). This intensity level may affect the decision to
treat or not to treat with endodontic therapy. Pain is now
considered a standard vital sign, and documenting pain
intensity (scale of 0 to 10) provides a baseline for compari-
son after treatment.
 1 • Diagnosis 7

Fig. 1.3 ​When taking a dental history and performing a diagnostic examination, often a premade form can facilitate complete and accurate documen-
tation. (Courtesy Dr. Ravi Koka, San Francisco, CA.)
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of The Devil's
picture-books
 This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
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eBook.

Title: The Devil's picture-books

Author: Mrs. John King Van Rensselaer

Release date: June 21, 2022 [eBook #68367]

Language: English

Original publication: United States: Dodd Mead and Co, 1890

Credits: deaurider, Les Galloway and the Online Distributed

Proofreading Team at https://www.pgdp.net (This file
was produced from images generously made available
by The Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK THE DEVIL'S

PICTURE-BOOKS ***
 Transcriber’s Notes

Obvious typographical errors have been silently corrected. All other spelling and
punctuation remains unchanged.
 Plate 1.

THE
DEVIL’S PICTURE-BOOKS

A History of Playing-Cards

BY

MRS. JOHN KING VAN RENSSELAER

AUTHOR OF CROCHET LACE, ETC.

ILLUSTRATED

NEW YORK
DODD, MEAD, AND COMPANY
PUBLISHERS

Copyright, 1890
By Dodd, Mead, and Company

All rights reserved

 University Press
John Wilson and Son, Cambridge
 PREFACE.

T he “Devil’s Books” was the name bestowed upon Playing-cards

by the Puritans and other pious souls who were probably in
hopes that this name would alarm timid persons and so prevent their
use. Whether or not his Satanic Majesty originated Playing-cards, we
have no means of discovering; but it is more probable that he only
inspired their invention, and placed them in the hands of mankind,
who have eagerly adopted this simple means of amusing
themselves, and have used it according to the good or evil which
predominated in their own breasts. Many learned men have written
books or treatises on Playing-cards, and I am indebted for a large
part of the information contained in this history to “Les Cartes à
Jouer,” by M. Paul la Croix; “Facts and Speculations about Playing-
cards,” by Mr. Chatto; “The History of Playing-cards,” by the Rev.
Edward Taylor; and “The History of Playing-cards,” by Mr. Singer.
These books are now out of print, and somewhat difficult to obtain;
and I hope, by bringing into a small compass the principal features
set forth in them, I shall be able to place before a number of readers
interesting facts that would be otherwise unobtainable.
Hearty thanks are due to the custodians of the National Museum
in Washington, who have aided me in every way in their power, and
also to the many kind friends who have sought far and wide for
unique and uncommon packs of cards, and helped materially by
gathering facts relating to them for me.
That many nations have cards peculiar to their own country and
almost unknown beyond its boundaries may be a matter of surprise
to some; that such ordinary and familiar objects as Playing-cards
should have a history, will astonish others. My hope is that the
subject will interest my readers as it has done me. Any facts
concerning Playing-cards or any communications relating to rare or
curious packs will be gladly received by the author, who would like to
add to her collection.
M. K. VAN RENSSELAER.
New York, 1890.
 CONTENTS.
PAGE
The Tarots, or the First Cards 11
Chess 21
Engraving 33
Materials 41
Name 49
Classification of Packs of Cards into Suits 55
Cards of Different Countries, viz.:—
China 65
Egypt 69
India 70
Cashmere 74
Persia 77
Italy 80
Germany 83
Spain 88
France 90
England 102
America 112
Japan 131
The King 139
The Queen 151
The Knave 161
Aces and Other Cards 171
Use and Abuse 179
Pips, Suits, and Colours 191
Odds and Ends 201
 LIST OF ILLUSTRATIONS.
PLATE
Persian 1
Tarot 2
Tarot 3
Chinese 4
Cashmere. Cards owned by Lockwood de Forest, Esq. 5, 6
Italian Cards showing the Suits of Swords, Maces, Money, and
7
Cups. Owned by Mrs. J. K. Van Rensselaer
German Cards showing the Aces of Grün, Roth, Schellen, and
8
Herzen. Owned by Mrs. J. K. Van Rensselaer
Remains of the Pack supposed to have been used by Charles VII. of
9
France, date 1425. In the Cabinet des Estampes, Paris, France
Elizabeth of York 10
Cards found by Mr. Chatto in a Black-Letter Volume formerly in
the Cathedral Library, at Peterborough, England. Now in the 11
Print Room of the British Museum
Found in an Old Edition of Claudian, Early English 12
Cards on which Invitations were Written. Owned by Mrs. Ten Eyck
13
and Miss Crowninshield. Date 1763
Geographical Cards. Owned by Richard H. Derby, Esq., M.D. Date
14
1795
North American Indian Cards, Apache Tribe. Cut out of Deerskin and 15, 16,
painted by themselves. National Museum, Washington, D.C., U.S.A. 17
North American Indian Gambling-Sticks, Haida Tribe, Queen
Charlotte Islands. Carved on Cubes of Wood. National Museum, 18, 19
Washington, D.C., U.S.A.
North American Indian Gambling-Sticks, Alaska Tribe. Painted on
20
Cubes of Wood. National Museum, Washington, D.C., U.S.A.
Japanese Cards, each one representing a Week in the Year. Owned 21, 22,
by Mrs. J. K. Van Rensselaer 23, 24
 THE DEVIL’S PICTURE-BOOKS
“The Ladies arm-in-arm in clusters,
As great and gracious a’ as sisters;

On lee-lang nights, wi’ crabbit leuks,

Pore owre the devil’s pictured beuks.”

Burns.
THE DEVIL’S PICTURE-BOOKS.
 THE TAROTS.
A youth of frolic, an old age of cards.

Hone: Every-Day Book, ii. 98.

T HE origin of Playing-cards and their inventor is still a subject of

speculation, and will probably remain forever undiscovered.
Almost every country in Europe has through her scholars laid claim
to having been the first to use cards; and many documentary and
other proofs have been brought forward to substantiate their
assertions, which are based upon ancient laws, common traditions,
or contemporary illustrations.
That cards were brought from the East to Europe about the time of
the Crusades, and probably by the home-returning warriors, who
imported many of the newly acquired customs and habits of the
Orient into their own countries, seems to be a well established fact;
and it does not contradict the statement made by some writers, who
declare that the gypsies—who about that time began to wander over
Europe—brought with them and introduced cards, which they used,
as they do at the present day, for divining the future. Cards may well
have become known by both means, and they spread rapidly over all
of what was then considered the only civilized part of the world; and
the proofs that have been brought forward show that they were
known nearly simultaneously in Italy, Spain, France, Germany, and
England, and point to a common origin not to be found in any one of
these countries.
 Plate 2.

The first cards known in Europe, and which were named Tarots,
Tarocchi, etc., seem to differ in almost every respect from those of
the fifteenth century, although these probably inspired their invention.
The latter resemble much more those of the present day than they
do the original Tarots. The first packs consisted of seventy-eight
cards,—that is, of four suits of numeral cards; and besides these
there were twenty-two emblematical pictured cards, which were
called Atous, or Atouts,—a word which M. Duchesne, a French
writer, declares signifies “above all.” This word used in French has
the same meaning as our word Trump. The marks which distinguish
the Tarot suits are usually Swords, Cups, Sticks, and Money; and
each one consists of fourteen cards, ten of which are “pips” and
three or four “coat” cards,—namely, King, Queen, Knight, and
Knave. The Queen was not always admitted. These suits seem to be
the origin of the modern packs; and the emblems used on them have
been adopted in many countries where the Atout part was discarded
while the rest of the pack with its original symbols was retained.
Mr. Singer gives a graphic description of these cards and the
games to be played with them, and says that “among different
nations the suits [as will be hereafter shown] are distinguished by
marks peculiar to themselves, while only the general features of the
numbered cards headed by figures or court cards have been
retained.”
The second division of the Tarot pack, called Atouts, are
numbered up to twenty-one, each of these having its proper value;
and besides all these there is one, not numbered and not belonging
to the division of the suit cards, which is called a Fou, and in playing
the game is designated Mat, or il Matto. This “Joker,” as we should
term it, has no value of its own, but augments that of any of the
Atouts to which it may be joined, and is sometimes played instead of
a Queen, being then called “her Excuse.”
These Atouts are each represented by a print which is supposed
to resemble some character, and the name is generally placed on
the card. Among them are an Emperor, a Cupid, a Chariot, a Hermit,
a Gallows, Death, The Day of Judgment, a Pope, Fortune,
Temperance, Justice, the Moon, the Sun, etc. The order in which
they are placed is not always the same, and is seemingly
unimportant. The game may be played by two or four persons. “The
one who holds the ‘Fool’ regains his stake; ‘La Force’ (or Strength)
takes twice as much from the pool, while ‘La Mort’ (or Death) most
appropriately sweeps the board.”
It is said that the distribution of the suit cards has a peculiar
signification. Each one is distinguished by an emblem which
represents the four classes into which communities were once
divided. First comes the Churchman, represented by the Chalice (or
Copas); next in rank, the Warrior, whose emblem is the Sword; third,
the Merchant, symbolized by a Coin; and fourth, the Workman with
his Staff. It will be shown hereafter that almost all writers on the
subject allow the possibility of the divisions of the suits being shown
in the cards.
The earliest known specimens of these Tarot cards are now to be
found in the Cabinet des Estampes in Paris, and are supposed to
have formed part of the pack which was painted for King Charles the
Seventh of France in 1393, to cheer and amuse him during an illness
which had been caused by a coup-de-soleil in 1392, and which
made him a melancholy but not a dangerous lunatic. M. Paul la Croix
describes these Tarots as having been most delicately painted and
resembling in treatment the illuminations of manuscripts. They are
on a golden background on which dots forming an ornamental
pattern were impressed. A border of silver surrounded and as it were
framed each picture, through which a dotted line twisted spirally like
a ribbon. M. la Croix points out that this dotted line, in his language
technically termed a tare (which also means a “fault” or “defect”),
was a sort of fluting produced by small holes pricked into the
substance of which the cards were made, and fancies that to these
Tares the Tarots owe their name. Other writers, however, dispute this
derivation of the word, and discover new ones for themselves which
are generally quite as fanciful and far-fetched.
 These well preserved Tarots are eighteen centimetres by nine, and
are painted in water colours on a thin card. The composition of the
figures is ingenious and artistic. The drawing is correct and full of
character, and the colours are still brilliant. A narrow border of black
and white checks surrounds each one. This border is a piece of
checkered paper pasted on the back of the card and neatly folded
over its edge as if to protect it, showing on the face of the card and
forming a frame for the pictures. This fashion of having a checkered
or diapered back was closely followed in many of the countries
where cards have been used; and these backs are still seen,
although this old pattern (which, as will hereafter be seen, had
probably a very interesting origin) has been generally discarded, and
each card-maker adopts a different device with which to decorate the
backs of his cards according to his own fancy. In France the backs
are generally plain, and coloured red, pink, or blue. In Spain the
pattern is dotted on the surface in lines and circles, while in other
countries interlaced and meaningless designs are employed.