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Endodontic Therapy 6th Edition Franklin S Digital
Instant Download
Author(s): Franklin S, Weine DDS
ISBN(s): 9780323019439, 0323019439
Edition: 6
File Details: PDF, 43.75 MB
Year: 2003
Language: english
ENDODONTIC THERAPY
FRANKLIN S. WEINE, BS, DDS, MSD, FACD, FICD
Professor Emeritus, Loyola University (Chicago); Formerly
Professor and Director, Post-Graduate Endodontics, Loyola
University School of Dentistry, Maywood, Illinois; Visiting
Professor of Endodontics, Osaka Dental University, Osaka, Japan
SIXTH EDITION
0-323-01943-9
Mosby An Affiliate of Elsevier

Selected artwork by: Sandy Cello Lang and Don O'Connor

Photography by: Oscar Izquierdo and Al Hayashi

Mosby

An Affiliate of Elsevier

11830 Westline Industrial Drive

St. Louis, Missouri 63146

ENDODONTIC THERAPY ISBN 0-323-01943-9

Copyright © 2004, Mosby, Inc. All rights reserved.

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. Permissions may be sought directly from Elsevier's
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phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail:
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then "Obtaining Permissions."

NOTICE

Dentistry is an ever-changing field. Standard safety precautions

must be followed, but as new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy
may become necessary or appropriate. Readers are advised to
check the most current product information provided by the
manufacturer of each drug to be administered to verify the
recommended dose, the method and duration of administration,
and contraindications. It is the responsibility of the licensed
prescriber, relying on experience and knowledge of the patient,
to determine dosages and the best treatment for each individual
patient. Neither the publisher nor the author assumes any
liability for any injury and/or damage to persons or property
arising from this publication.

The Publisher
Previous editions copyrighted 1996, 1989, 1982, 1976, 1972

Library of Congress Cataloging-in-Publication Data

Weine, Franklin S.

Endodontic therapy/Franklin S. Weine.—6th ed.

p.; cm.

Includes bibliographical references and index.

ISBN 0-323-01943-9

1. Endodontics. I. Title.

[DNLM: 1. Endodontics. WU 230 W423e2004]

RK351.W44 2004

617.6'342-dc22 2003059284

Publishing Director: Linda L. Duncan

Executive Editor: Penny Rudolph

Senior Developmental Editor: Kimberly Alvis

Publishing Services Manager: Linda McKinley

Designer: Gail Hudson

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

JAMES K. BAHCALL, DMD, MS

Assistant Professor and Chairman

Department of Surgical Sciences, Marquette University

Milwaukee, WI

MANUEL A. BUSTAMANTE, DDS

Private Practice, Endodontics

Los Angeles, CA

JAMES A. DEWBERRY, Jr, DDS, FACD

Private Practice Limited to Endodontics

Dallas, TX

SERGIO KUTTLER, DDS, FICD

Associate Professor and Chairman

Department of Endodontics;
Associate Director, Postgraduate Endodontics;

Director, Advanced Education Programs

Nova Southeastern University, College of Dental Medicine

Fort Lauderdale, FL

CHARLES Q. LEE, DDS, MS

Associate Professor

Department of Endodontics, University of Missouri, School of

Dentistry

Kansas City, MO

ARTURO VENTURA MORALES, DDS, MS

Professor

Department of Endodontics, National University Autonomous of

Mexico, Dentistry School

Mexico City, Mexico

JEROME V. PISANO, DDS, MS, FACD, FICD

Formerly Clinical Associate Professor

Department of Endodontics, Loyola University School of

Dentistry

Maywood, IL

STEVEN R. POTASHNICK, DDS, FACD

Private Practice, Prothodontics

Chicago, IL

JAMES B. SATOVSKY, DDS

Private Practice, Endodontics

Hollywood, FL

SHERWIN STRAUSS, DDS

Private Practice, Dentistry

Chicago, IL

CHRISTOPHER S. WENCKUS, DDS, FICD

Associate Professor and Head

Department of Endodontics, University of Illinois at Chicago,

College of Dentistry

Chicago, IL

JEFFREY L. WINGO, RPh, DDS

Private Practice, Periodontics

Memphis, TN

PREFACE

During the ten years since the publication of my fifth edition,

endodontic treatment has taken an abrupt change. This
alteration was alluded to in its incipiency in that book with the
introduction of nickel titanium files and mechanical handpieces
driving rotating instruments. In truth, the previous five editions
had railed specifically against the potential danger attendant to
the use of the latter technique. As the current edition was being
written, endodontic treatment clearly became a technologically
driven procedure.

Canals are being measured by electronic apex locators,

preparation is performed by mechanical means, and many
canals are filled using heating units to soften the sealing
materials. All of these methods are not only presented in this
book, but actually, they are featured. However, it is important to
realize that when technology is not completely understood, it can
be dangerous. Even the most positive studies indicate that apex
locators are accurate just over 90 percent of the time. In
preparing curved canals, mechanically driven instruments may
become susceptible to breakage. Depending upon the
preparation method used, softened gutta-percha may be forced
into the periapical tissues. Discussion of how to avoid these
pitfalls is also emphasized.

Although I use many of the new products in my clinical practice,

my own method of treatment has not changed a great deal since
the publication of my first edition in 1972. I do use all of these
newer techniques, but not exclusively, and usually to supplement
my traditional forms of therapy. As I read the current endodontic
literature and listen to lectures, I notice these new procedures
are endorsed in a manner that almost negates the efficacy of the
treatment modalities of the past. Interestingly, many of the
completion radiographs demonstrating current trends are not
followed by a realistic period of postoperative evaluations. For
this reason, I have endeavored to get as many long-term follow-
up films of my previously published cases as was possible,
accepting the fact that many of the patients shown in earlier
editions were middle-aged or older at the time of treatment.
Patients who responded to my request were able to return or
have their own dentist send me the desired radiographs and
evaluations, providing the evidence that the tried and true
classical methods of therapy were very effective. In this edition,
we have included almost 70 cases illustrating long-term success
of 17 to 35 years. One example of a long-term follow-up is
demonstrated on the cover of the book.*

Being cognizant of the interest maintained by general dentists in

clinical treatment, several other changes were made for this
edition. Chapters 3 and 4 of the previous editions on the biology
of pulpal and periapical tissues, so well written by Marshall
Smulson and aided by Steve Sieraski, Sue Ellenz, and others,
have been removed. Some of this material is still present in the
clinically oriented chapters. However, the major thrust of this
edition is to present clear and accurate information on clinical
treatment procedures.

A considerable amount of information on new materials and

techniques are presented, some by contributing authors. Jerry
Pisano, who has contributed material since the second edition,
again has completely revamped his chapter, emphasizing the
new nomenclature of the bacteria that we deal with during
treatment and the latest views concerning the maintenance of
asepsis. Chris Wenckus discusses the use of newer techniques for
canal filling. Arturo Ventura Morales has provided new views of
access preparations for obtaining the most direct path to the
apex. Jim Satovsky and Jim Bahcall have added material on new
aids for surgical and nonsurgical treatment. Other material was
added by Manny Bustamante, Steve Potashnick, Charles Lee,
Sergio Kuttler, and Jeff Wingo. Mark Oliver and Allen Horn (of
Dentsply/Tulsa Dental) were very liberal in their advice and
products for investigations. I appreciate all of their efforts to
improve the contents of this book.
*ABOUT THE COVER
The three-part figure shown on the book cover is taken from
Figure 11-16, found on page 472. At the time of therapy, teeth
with communicating apical and lateral pockets were considered
to be "untreatable." The left film shows initial files in place. The
middle film is the final filling with laterally condensed gutta-
percha, the distal pocket could no longer be probed. The right
film demonstrates the tooth 26 years after endodontic treatment.

I also appreciate the many suggestions offered to me in person

and by mail from clinicians and educators from all over the
world for additions and improvements of items in past editions.
Many of these recommendations formed the basis of my clinical
investigations and, ultimately, to future editions. Although their
names are not listed, except for in some of the bibliographies,
their ideas were always considered and evaluated.

New drawings for this book were provided by Sandy Cello Lang
(who also worked on the previous two editions) and Don
O'Connor, and photography was developed by Oscar Izquierdo
and Al Hayashi (Loyola University, Medical Photography).
Editorial assistance was provided by Penny Rudolph and her
associates, Kimberly Alvis and Courtney Sprehe.
I have worked diligently in many areas so that dentists all over
the world might make Endodontic Therapy an integral part of
their practices, even if it meant referral to a competent colleague.
Literally millions of teeth have been saved, at least partially, by
the previous five editions. This fact alone has made my
professional career very satisfying. I wish all of my readers
continued success in endodontics.

Frank Weine
 1

CHAPTER 1 BASIS FOR SUCCESSFUL ENDODONTICS

As dentists became increasingly aware that natural teeth
function more efficiently than any replacement, they found it
worth additional effort to retain pulpally involved teeth. In the
practice of dentistry the role of endodontics has greatly
broadened in scope in the past 40 years. Although many factors
are responsible, the most important reason behind this growth is
the extremely high predictability of endodontic success.

Recent studies, compiling records of patients treated in dental

schools and by general practitioners, indicate that 95% success is
obtainable in endodontics. Increased experience, continued
professional study, and training at the postgraduate level may
further enhance this success ratio. Despite their recent
popularity, implants do not approach this percentage.

Acceptance and the high predictability of endodontic therapy are

often taken for granted by both practitioners and patients. To
help one appreciate more fully the circumstances surrounding
and the effort that has gone into the art and science of
endodontics, a brief history will be presented.
1
2
HISTORY OF ENDODONTICS

Effect of Hunter's Address

After the turn of the twentieth century, the finger of scorn and
ridicule was pointed at the treated tooth, and routine extraction
of such teeth was advocated in both dental and medical journals.
The lowest point in the history of endodontics occurred shortly
after an address by William Hunter, an English physician, at
McGill University in 1910 on "The Role of Sepsis and Antisepsis in
Medicine." Much of his subject matter came from an earlier,
relatively unnoticed paper by W.D. Miller, who in 1891 had
expounded the intimate relationship between the dental and
medical professions. Hunter vehemently criticized the prosthetic
dentistry of the United States in particular, asserting that gold
fillings, caps, bridges, and dentures were being built around and
upon islets of frank infection and that, instead of eliminating
sepsis, these restorations were responsible for its perpetuation.

Hunter was really speaking of periodontal rather than periapical

disease and even suggested scaling and debridement procedures
that would be readily accepted by the periodontists of today as
potential solutions to the problem. Despite the many hazards
restricting their efforts, a number of dentists of that time were
able to perform a high caliber of endodontic therapy. Without
radiographic and bacteriologic control, however, a considerable
number of endodontic cases ended in failure. Dentists who
disagreed with the philosophy of endodontics or were unwilling
to spend the greater time required for therapy (as compared with
extraction) eagerly publicized the failures. Billings and Rosenow
applied Hunter's views to the pulpless tooth, and their animal
experiments indicated a definite relationship between periapical
and systemic disease.

Early Use of X Rays

Rhein soon adopted the roentgen ray for endodontic use to
determine canal length and degree of filling. These initial
radiographs were used by some as adjuncts to treatment, but
they were used by others to evaluate previous therapy
performed without such help. Even when x-ray guidance is
coupled with present advanced knowledge, some cases are
difficult to treat. Endodontic therapy performed in the
nineteenth and early twentieth centuries without radiographs or
the knowledge of bacteriology, and later evaluated by x-ray
studies, was determined, in general, to be an abysmal failure.
Rather than recognize the limitations that had forced earlier
workers to have so many failures and attempt to organize a
regimen that would increase chances for success, members of the
health professions demanded extraction of pulpless teeth for
their patients and, in fact, full-mouth extractions for patients
with chronic diseases.

Not desiring criticism from physicians and happy to take the

easier way out that tooth removal afforded, dentists subscribed
to wanton extraction in preference to endodontic or periodontal
therapy. The net result left many persons with impaired
nutrition because they were unable to masticate properly certain
foods required in a balanced diet.

Reacceptance of Endodontics
Fortunately some pioneer endodontists—Coolidge, Prinz, Sharp,
Blayney, Appleton, and others—launched a counterattack against
the extractionists. By demonstration of successful cases based on
sound biologic principles, these men illustrated methods by
which strategic teeth could be saved without any danger to the
patient's health—in fact, with improvement in health.

By the late 1930s the corner had been turned in endodontics, and
treatment of the pulpless tooth had become an integral part of
dentistry. Continued research on a clinical and laboratory basis
developed techniques, methods of evaluation, and selection of
materials to further increase the success ratio. The American
Association of Endodontists was formed to disseminate interest
and develop increased skill in the area. Under the direction of Dr.
Louis Grossman of Philadelphia, international conferences on
endodontics were held where interested persons from all over
the world met and discussed mutual problems.

PRINCIPLES OF ENDODONTIC THERAPY

The results of these organizations and efforts by the pioneers of
the field led to the development of basic principles of endodontic
practice. Because research and clinical analysis have caused
elimination or alteration of some earlier guidelines, I want to
enumerate the principles and philosophies that are the basis for
this text.

Objective
The objective of endodontic therapy is restoration of the treated
tooth to its proper form and function in the masticatory
apparatus, in a healthy state.

Dentists must realize that initiation of endodontic therapy for a

patient would not be a responsibility taken lightly. Although
those who in the past decried endodontic treatment as a
significant health hazard were surely incorrect in their basic
premise, improper therapy may have a negative effect on a
patient's systemic condition. By the same token, proper
endodontic treatment may alleviate a systemic condition not
thought to be related to a dental problem. Figure 1-1 illustrates
such a situation.

Basic Phases of Therapy

There are three basic phases in endodontic treatment. First is the
diagnostic phase, in which the disease to be treated is
determined and the treatment plan developed. Second is the
preparatory phase, when the contents of the root canal are
removed and the canal prepared for the filling material. The
third phase involves the filling or obliteration of the canal to gain
a hermetic seal with an inert material as close as possible to the
cementodentinal junction.
FIGURE 1-1
 Patient who had been under treatment by otolaryngologist for
recurrent maxillary left sinusitis for over 1 year. A, Preoperative
film, straight view, indicating periapical lesion extending from
second bicuspid and eroding the floor of the left maxillary sinus. B,
Immediate postoperative film, straight view. C, Angled view from
the distal. As soon as the canals were prepared (Type II canal
system), the sinusitis stopped. Canals were filled with laterally
condensed gutta-percha and Wach's paste sealer. D, One year
later, lesion had decreased in size considerably. E, Three years
after original treatment, the crown and post had been dislodged.
The entire wall of the sinus adjacent to the treated tooth had been
reconstituted, according to the radiograph. F, Five years after
original treatment; compare to A. G, Twelve years after original
treatment, still perfect healing. (Restoration by Dr. James Discipio,
Berwyn, Ill.)

Endodontic therapy may be thought of as a tripod, with the

perfectly treated tooth on a pedestal and every leg representing a
basic phase. If any leg is faulty, the entire system may fail.
Although every leg is a separate portion, in the overall situation
each phase must be meticulously carried out to obtain success.
Every facet of treatment must be performed in a predetermined
manner, with every step having its definite position in the series
of procedures. Therefore much of this book, as well as other
clinically oriented endodontic literature, is presented in a
carefully outlined form to emphasize the importance of following
the same step-by-step procedure for every case.

Importance of Debridement
Endodontic therapy is essentially a debridement procedure that
requires the removal of the irritants of the canal and periapical
tissue if success is to be gained. The debridement may be carried
out in various ways as the case demands and may include
instrumentation of the canal, placement of medicaments and
irrigants, and, in some cases, surgery. No cases lend themselves
to successful treatment without a significant degree of
debridement.

From time to time emphasis in clinics or papers is given to

various methods of canal filling, and the necessity for correct
debridement is not always properly emphasized. Although
preparation of the canal is often tedious and its results are not
immediately evident when a postoperative radiograph of a canal
filling is viewed, there is no doubt that canal debridement is of
paramount importance. When a canal is properly prepared, any
of the accepted methods of filling will almost certainly produce a
successful result.

Use of the Rubber Dam Mandatory

As complex dentistry has developed, with restorative techniques
utilizing telescopes, splints, superstructures, copings, etc.,
endodontic access is often extremely difficult. For this reason it is
frequently best to be sure of proper access to the canal before
rubber dam application so that the surrounding structures may
be used as a guide. However, once access is obtained, the rubber
dam should be placed immediately and under no circumstances
should an enlarging instrument be used without its presence.
Several excuses are given for avoiding the use of a rubber dam in
endodontic therapy, but all are basically procrastinations and
easily refutable. Some of the excuses offered are the additional
time required for application (rarely more than a few seconds),
plans for the tooth to be left open anyway, and lack of
supragingival tooth structure (a crown-lengthening procedure
may be performed).

The original use of the rubber dam was to aid in the gaining of
an aseptic environment, and this is still a major purpose. Of
equal importance is confinement of the irrigants, most of which
are distasteful. The greatest need, however, is to prevent the
aspiration of an instrument, a potentially grave matter. The
mental anguish experienced by the dentist guilty of such an
incident, plus the current attitudes of the courts in such matters,
makes the placement of a rubber dam an extremely small
premium for the excellent insurance it provides (Figure 1-2).

The Kansas Supreme Court ruled that the general dentist

performing endodontic treatment on a patient must apply the
same precautions during therapy as those employed by an
endodontic specialist. There is no question that whereas many
general dentists do not utilize the rubber dam during endodontic
therapy, virtually all endodontists keep the dam in place. If a
patient aspirates an instrument because of the failure of the
dentist to place the dam, the practitioner is considered negligent,
according to the Kansas Supreme Court, because the precautions
normally taken by the specialist were not applied.

Great Respect Due the Periapical Tissue

During Treatment
Although some techniques advocate intentional irritation of
periapical tissue, many studies have indicated that all
enlargement and filling procedures should be carried out within
the canal. These studies have shown that even where there are
large radiolucencies, when debridement and filling are carried
out within the confines of the canal, healing will take place in
most cases without surgery. Overinstrumentation is the most
frequent cause of post-operative pain. Because the dentist should
always be concerned with the elimination or reduction of pain,
an accurate determination of canal length must be made and
strictly adhered to during the enlargement and filling
procedures. Proper treatment of periapical tissues also means
that caustic drugs should not be used as medicaments.
 FIGURE 1-2

Chest x-ray film showing aspirated file (arrow) in bronchial tree.

Rubber dam was not used because dentist intended to leave the
tooth open. (Courtesy Dr. Paul Hoffer, University of Chicago
Hospitals.)

Even though endodontic therapy involves working within the

tooth, it is the surrounding structures and their response that
determine success or failure.

Proper Restoration the Culmination of

Success
Sufficient confidence is warranted in the endodontic result to
insist that a proper restoration be placed on the treated tooth as
soon as possible. Nothing is more disheartening than to see a
well-treated tooth require extraction because of fracture
following the placement of a restoration that does not afford
cuspal coverage. Equally discouraging is a fracture or secondary
caries that develop when the posttreatment temporary filling is
retained for an extended period to see if success has been gained
(Figure 1-3). A greater number of endodontically treated teeth
are lost because of fracture due to improper restorations than
because of poor endodontic result. Proper restoration of the
treated tooth is an integral part of therapy and must be
explained to the patient as a part of the treatment plan.

Other discouraging situations transpire when the restorative

dentist places an inadequate or improper crown, onlay, or
amalgam restoration; fails to provide cuspal protection when
needed; or fabricates an inadequate or damaging post/core
system.

Postoperative Observation Necessary

Despite the high degree of success, some failures will occur.
Some of these may be successfully re-treated, and many will heal
after surgery. Unless the patient is impressed with the necessity
for recall, some of the initial failures that can be reversed will
not be intercepted in time.

Case Presentation to Set the Stage

A case presentation should be given to each patient for any phase
of dental treatment, whether the treatment needed is only an
oral prophylaxis or encompasses a full-mouth reconstruction. If
endodontic procedures are required in an overall treatment
plan, the reasons for such therapy should be explained. At the
time that the endodontic portion is to be commenced, a further
examination should be given. Case presentation for endodontics
should briefly explain the responsibilities of the patient and the
dentist, the time involved, the prognosis, and the fee (including
restoration). Most patients prefer a brief description of the
phases of therapy, and a suggested method of presentation will
be found in Chapter 2.
 FIGURE 1-3

A, Immediate postoperative film of mandibular first molar, slight

angle from the mesial, in 14-year-old patient. The case was quite
difficult due to the extreme curvature of the distal root, but the
result was excellent. Canals were filled with laterally condensed
gutta-percha and Wach's paste sealer. B, Eighteen months later, no
permanent restoration had been placed, and decay had passed
through the furcation. Despite the excellent treatment, the tooth
was lost. Note the mesial tipping of the second molar is already
present.

FIGURE 1-4

Four-year postoperative radiograph shows maxillary first molar

with normal radiographic appearance. File was broken in
mesiobuccal canal; however, because the tooth was asymptomatic
with normal periapical tissue before treatment, the case was
completed. Canal had been enlarged to size 25 before accident,
and file is very close to apical foramen. (Restorations by Dr. Rod
Nystul, formerly of Park Ridge, Ill.)

At times a patient will be seen for the first appointment on an

emergency basis when endodontics is required, and a proper
case presentation is difficult to perform. Correct procedure then
is to make a brief explanation of the need to retain the involved
tooth and utilize the available time to ensure the patient has
relief from pain. Time should be allowed at the next appointment
for the presentation.

INDICATIONS AND CONTRAINDICATIONS

There are few true contraindications to endodontic therapy. Two
frequent causes for the extraction of pulpally involved teeth are
a patient's inability to afford the fee for endodontic work and a
dentist's inability to perform the necessary service adequately.
The few true contraindications include insufficient periodontal
support, a canal unsuitable for instrumentation or for surgery, a
tooth that is not restorable after therapy, the presence of massive
resorption, a nonstrategic tooth, or a vertical fracture.

Contraindications

Patient Unable to Afford Fee.

The significance of this category is diminishing for two reasons,
one economic and one educational. As society increases in
affluence and as many employee fringe benefits are extended to
include dental treatment, the fee for endodontic care is brought
within the reach of a greater portion of the population than ever
before. Also, with the dental IQ of the public increasing as a
result of hygiene programs in schools, magazine articles,
television programs and commercials, and other publicity, more
patients are understanding the true value of each tooth as an
integral part of the chewing mechanism and are able to realize
that retention of the tooth in question is well worth the fee
involved. On a purely economic basis, the fee for endodontic
therapy plus restoration is usually less than the fee for a
replacement by a fixed partial denture, making the retention of
the tooth a more reasonable undertaking than its loss and
replacement.

Inability of the Dentist.

With improved instruments and filling materials, the
performance of endodontic therapy has become much easier
than it was only a few years ago. Continuing instructional
courses are offered by most dental institutions and dental
societies in an effort to increase the knowledge and skill of those
interested. Many states are now making continuing education
courses mandatory for license renewal. The use of extracted
teeth for practice in the procedures of endodontic treatment
gives excellent exercise in improving technique. For these
reasons, the ability of the average dentist to perform routine
treatment is enhanced. In addition, there is an excellent
geographic distribution of enough specialists and general
practitioners with skill in endodontics who are able to retain all
but the most complicated cases on a referral basis.
Insufficient Periodontal Support.
In evaluating periapical and/or pulpal disease, the practitioner
must make a complete periodontal evaluation. Unless sufficient
support is present to ensure retention of the tooth, endodontic
treatment is contraindicated. Occasionally endodontic treatment
is required to retain periodontally questionable teeth, as when
an apparent periodontal lesion is caused by pulpal involvement.
Further guidance in making this periodontal evaluation will
appear in Chapter 2.

Canal Instrumentation Not Practical.

This problem may be satisfactorily solved with surgical
treatment. Three types of canal conditions are encountered that
may contraindicate endodontic therapy.

Instruments broken within the canal can rarely be recovered or

bypassed. In a study by Crump and Natkin, there was a relatively
good prognosis if the broken instruments were within the apical
third of vital teeth with normal periapical tissue (see Figure 1-4).

A second type of inoperable canal occurs when irregular dentinal

sclerosis closes portions of the canal so as to make the passage of
the smallest enlarging instrument impossible. Because this
dystrophic calcification rarely completely obliterates the canal,
careful exploring procedures often enable the apex to be
reached. If the apex is not attainable, particularly when a
periapical radiolucency is present, treatment is contraindicated.

The third type of inoperable canal occurs when the canal

anatomy is such that a sharp dilaceration or a series of
dilacerations makes enlargement impossible. Recent advances in
specialized canal preparation procedures (Chapter 5) have
enabled many such teeth that were formerly extracted to be
saved.

Interestingly, two of the endodontic contraindications—sharp

dilaceration and a calcified canal—frequently lead to the other
contraindication mentioned, a broken instrument. In some of
these cases the tooth may heal anyway, or it may be saved by
surgical intervention; however, when that is impossible or
impractical, extraction becomes inevitable.

Nonrestorable Tooth.
Because the objective of endodontics is to return the treated
tooth to good form and function, it is necessary to place a proper
restoration after completion of the root canal filling. The best
canal filling is useless if it is impossible to place a restoration.
With alveoloplasty, gingivoplasty, improved dowel procedures,
and other techniques, many more teeth are now restorable than
with the limited techniques that were formerly available;
however, some teeth still remain for which proper restoration is
not possible. Among these are teeth with severe root caries,
furcation caries, poor crown-root ratio, and internally weakened
root (Figure 1-5).

FIGURE 1-5 Severe furcation caries in mandibular first

molar and root caries in second bicuspid necessitated
extractions.

Massive Resorption.
Resorption may be of either internal or external variety; if the
resorption is of extremely large dimension, with perforations,
therapy for the tooth is contraindicated. The resorptive process
occurs because of phagocytic cells that destroy dentin. Unless all
these cells are removed, either by surgery or by intracanal
instrumentation, the process will continue. A large resorptive
defect that is found on only one portion of the tooth may be
surgically (Chapter 9) or nonsurgically (Chapter 14) correctable.
Defects that have not perforated may respond to nonsurgical
treatment. It is the severe defect involving large portions of the
tooth structure that makes successful treatment impractical.

Nonstrategic Tooth.
At the time that treatment is considered, a tooth may not appear
to have great strategic value. However, before condemnation to
extraction, thought should be given to possible future needs for
the tooth. A good example for consideration would be an
involved third molar in a patient with multiple missing teeth and
a high caries incidence. Although the patient still retains other
posterior abutments, the tooth probably should be retained if
treatable because of possible further tooth loss. On the other
hand, a pulpally involved third molar in a patient with full dental
complement in a well-cared-for mouth is obviously better
extracted than retained.

Vertical Fractures.
Vertical fractures through root structure have an almost hopeless
prognosis (Figure 1-6). Many exotic treatments have been
suggested, including circumferential root wiring, "zipper"
amalgam implants, and removal of the smaller fragment.
Experience shows, however, that in only the rarest instance does
any measure of success result. A related condition that often has
symptomatology similar to that of teeth requiring endodontic
treatment, but may have a hopeless prognosis, is the cracked-
tooth syndrome (Chapter 2).

FIGURE 1-6

Vertical fracture of maxillary cuspid. Area did not heal after

routine endodontic therapy, and periapical surgery was suggested.
When flap was raised, a defect to the apex was seen.

Indications
Any teeth not contraindicated are excellent candidates for
successful endodontic therapy. Many of the supposed
contraindications of the past have been proved false. These
include the presence of severe disease, the number of previously
treated teeth, advanced age of the patient, or large size of the
radiolucency. A brief discussion of a few of these false
contraindications follows. In the presence of serious illnesses
(e.g., rheumatic fever, malignancies, coronary artery disease),
endodontic treatment is definitely preferable to extraction.
Bender and Seltzer have demonstrated that there is a lower
incidence of bacteremia after endodontic treatment than after
extraction. For patients with heart problems, endodontics
requires no alteration of existing anticoagulant administration.
Patients with malignancies may be undergoing radiation therapy
that makes extraction sites conducive to osteoradionecrosis.

Some time ago it was contended that no patient should have

more than five treated teeth and that extraction was indicated
for any beyond that number having pulpal involvement. Of all
the supposed contraindications to endodontic therapy, this is
probably the most ridiculous. Many patients have two or three
times that many successfully treated teeth; some reports show
patients with all their teeth treated. In fact, if any patient has
multiple successful cases, the prognosis for additional teeth is
excellent. On the other hand, a patient with a history of
endodontic failures should be evaluated cautiously if another
tooth requires treatment because this patient may have poor
recuperative ability, unusual canal anatomy, or some rarely
found condition that militates against successful treatment.

PROGNOSIS FOR ENDODONTIC THERAPY

One of the first questions asked by patients concerning treatment
deals with the anticipated degree of success. Endodontics is
extremely fortunate in that the degree of success enjoyed is
probably the best found in any phase of dentistry, much higher
than that in periodontics and other phases of reconstructive
dentistry. This degree of predictability has been the factor most
responsible for the acceptance of endodontics by the general
practitioner, who is acutely aware that a treated tooth may be
counted on to perform any function in the oral cavity that an
untreated tooth performs in a tremendous preponderance of
cases. Some of the factors that affect prognosis in endodontics
will now be discussed.

Studies Dealing with Success Ratios

Many studies have investigated the degree of success in
endodontics, using certain variables for comparison. One of the
most interesting was reported by Ingle and Beveridge, indicating
that undergraduate students at the University of Washington
were capable of obtaining 95% success. The significance of this
study points out that when a carefully followed course of therapy
is instituted, results are strongly in favor of success.
Undergraduate students treating their initial cases have close
supervision and little opportunity to deviate from predetermined
patterns of therapy. The advisability of remaining within a
regimen of this type is affirmed by the results.
 FIGURE 1-7

Healing ability of elderly patients. A, Large periapical lesions

around mandibular cuspid and bicuspid of a 73-year-old patient. B,
Canal fillings with laterally condensed gutta-percha. C, Perfect
healing 18 months later, teeth are serving as partial denture
abutments. D, Perfect healing still demonstrated 18 years after
original treatment. (Restoration by Dr. Robert Wheeler, Chicago.)

Strindberg reported on degree of success, basing his criteria on

the point to which the canal was filled—whether past the
radiographic apex, exactly to it, or short of it. All types, even
those teeth grossly overfilled, responded with success more than
90% of the time, although teeth that were filled slightly short of
the apex had the highest ratio of success.

Prognosis for Older Patients

The prognosis for older patients is actually better than that for
the younger age group on a statistical basis. This is probably
because of the tighter apical foramina, lack of completely patent
auxiliary canals, dense periapical bone, and because the teeth of
patients who have reached advanced age usually are healthier
specimens than those of patients whose teeth succumb at earlier
ages.

Elderly patients rarely have painful exacerbations during

treatment, with a tendency toward a chronic type of problem
rather than acute fulmination. This means that intratreatment
visits to relieve pain, which disturb the normal day's scheduling
of patients, are infrequent. Although healing for older patients
might be somewhat retarded, particularly if certain systemic
problems are present, in general they heal satisfactorily (Figure
1-7). In fact, reports of healing in many septuagenarians and
octogenarians are included in this text without specific
comments because of their good healing potential (see Fig. 11-1
and Fig. 11-2, A and B, in particular).

Significance of Large or Long-standing

Radiolucencies
Large radiolucencies will usually heal extremely well, often
without surgery (Figure 1-8). Studies have been published to
indicate that the success ratio for teeth with radiolucencies is
lower than that for teeth with normal periapical bone. This is
contrary to my clinical observation and certain unpublished
findings of groups at Loyola University and Indiana University.
Pulpless teeth are usually easier to treat than those that have
vital tissue because no anesthetic is required, and the solvents
used as intracanal irrigants are not resisted by vital tissue; the
necrotic material that remains is highly susceptible to the solvent
action.

The longer a periapical lesion is present, the better the chance

that it will undergo cystic degeneration and convert from a
granuloma, with excellent healing potential, to an apical
periodontal cyst. There is considerable evidence that this type of
cyst will heal after nonsurgical endodontic treatment, although
in some cases surgery does become necessary. Even when a
periapical lesion is known to have been present for a long time
and there are the classic cystic appearances for a very
radiolucent lesion with a sclerotic border, routine treatment
should be undertaken with equanimity. An observation period
should follow, during which radiographs are taken at 6-month
intervals. Generally, healing will occur (Figure 1-9). If the lesion
persists or becomes larger, surgery may be performed (see
Figure 9-3).
Although the percentage is quite low, in some cases surgery must
be utilized in order to achieve a successful result. Many such
examples are presented in Chapter 9. Generally, a suitable
observation period has indicated lack of healing before any
attempt at surgical intervention.

In some instances, however, surgery must be instituted early in

the treatment plan. Some radiolucent lesions may exhibit an
aggressive or suspicious appearance. In these cases, the canal
preparation and filling are performed in a minimal number of
appointments. Periapical surgery follows at the same
appointment, or at a subsequent sitting soon thereafter, to gain
information from the biopsy. Depending upon the histologic
diagnosis, the treatment is continued accordingly (Figure 1-10).

The quality of healing of some radiolucencies might surprise

even the operator on occasion. Figure 1-11 illustrates a case in
which it was not certain if the lesion was of endodontic origin.
However, because any subsequent surgery probably would
jeopardize the vitality of the involved tooth, the canal was
prepared and filled. The result was quite gratifying, but not
entirely expected.

Significance of Large, Rapidly Growing

Radiolucencies
If large radiolucencies of a long-standing nature have healing
ability, what is the reaction to treatment of large, rapidly
growing lesions? Rapidly growing lesions that are not of
endodontic origin may be very serious, and concern about a
malignancy in such instances is justifiable. If, however, the lesion
is definitely of endodontic origin, the prognosis is quite good for
nonsurgical treatment.

Generally, if a lesion of endodontic origin grows very rapidly, it

will heal very rapidly with proper treatment. Figure 1-12
demonstrates such a case, in which a large, diffuse lesion was
known to be less than 6 months in development. After correct
therapy, it healed perfectly in that amount of time.

Significance of Periodontal Disease

The periodontal condition of the involved tooth has an important
bearing on the prognosis. As will be discussed in Chapter 11,
necrotic teeth that simulate periodontal disease, but are not in
fact periodontally involved, respond well to endodontic therapy.
On the other hand, if a periodontal condition is present but
untreated on an endodontically involved tooth, the prognosis is
poor. Because the periapical area remains within the confines of
the periodontal ligament space, the disease process from the
periodontal condition will retard or prevent proper healing if
endodontic treatment alone is performed.
Reaching the Apex
Ability to reach the apical foramen has definite implications.
Because the objective of filling is to seal this foramen, inability to
debride and fill this area may alter the prognosis. There are
various reasons why an apical foramen may not be reachable,
even by the most expert operator. Severe curvatures, broken
instruments, miscalculation of canal length, development of
ledges, and inadequate instrumentation are among the most
common reasons. A preoperative radiograph can often indicate if
the apex will be difficult to reach. If so, the patient should be
informed about the chance of failure. When the pulp is vital and
the periapical tissue normal before treatment, a good prognosis
persists even if the root canal filling must be terminated a few
millimeters short of the apex.

However, when a preoperative radiolucency is present, unless

the apical portion of the canal is reachable with the cleansing
instruments and the irritants responsible for apical
inflammation can be removed, the prognosis is poor. In these
cases, apical surgery should be instituted when possible;
otherwise, extraction is necessary.

Many teeth have apical foramina located some distance short of

the radiographic apex (Figure 1-13; see also many cases in
Chapter 6). Often this is revealed by the preoperative radiograph
Exploring the Variety of Random
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prádéskocsisnak: nyalka vót meg özvegy is, szeretőnek alkalmasabb;
avval adta magát össze az a disznó. Az én uram arra, hogy hát így
megutálta; bevádolta, kiturta a szolgálatbul. Énnekem meg
mindenkép kedvem kereste osztán, szidta, gyalázta a másikat,
elmondta mindennek előttem. Anyám is aszondta: „Te meg most
mán ne fancsalogj, hé; – vágd el, míg meleg! Most kapasd
magadho’, többet el se engedd!“ Hát hajlottam én is a gyerekekre
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ágyúszó; nyitott szájjal, dult idegekkel rólunk álmodnak a szalmán.

IX.

Az első tavaszias este ránehezült a világra súlyos illataival,

epesztő igéreteivel. Egy gyászoló asszonytól jöttem, akinek ura
meghalt mint orosz fogoly tifuszban, egy moszkvai kórházban. „Lám,
túl lehet élni, – gondoltam, – ő túlélte!“ A két gyászruhás gyereke
közt ült és olvasta nekik a mesét az engedelmes asszonyról, aki jó
bolondistók urának minden ügyetlenségét helybehagyta, balgaságait
megdicsérte, – míg egyszer meg is áldotta érte az Isten. „Te, anyám,
épilyen voltál!“ – kiált a kisfia. „Hagyd, ne beszélj, dehogy voltam
ilyen jó!“ „De igen, mindég ilyen voltál apához, én tudom, – ne

É
nyakaskodj, hanem hidd el! Érted?“… Bementem a halott ember
szobájába; az íróasztalán minden rendben; a jegyzetei, a legutóbb
olvasott könyve, félbenhagyott munkája… És dermesztően éreztem
meg egy különös dolgot: ez az asszony nem hiszi, hogy az ura
meghalt. Érzésben nem hiszi, nem ment át a vérébe, az idegeibe, –
noha szörnyű, okmányi bizonyságai vannak. Egészségesen, virulón
látta utoljára, napokkal ezelőtt kapta kártyáját, noha két hónapja
halott. És egyre rajtakapom, úgy emlegeti, mint élőt, jelen időben;
élénken, bizalmasan beszél róla, apró szokásairól, terveiről,
munkájáról – s folyton a leveleit olvassa. Őrület!
Most hova menjek?… Féltem az üres lakástól, – a kis fiam pár
napra látogatóban. Itt kinn tavaszi zsongás, szépruhás nők, sok civil,
katonák; finom szivarok füstje, virágszagu fuvalmak és mesterkélt
illatok szédülete. Mint más évben ilyenkor, mint más tavasszal!
E z e k n e k épolyan! Akár a fáknak, a felhőknek, úgy n i n c s
k ö z ü k a ma rettenetéhez, akiket egészen közelről nem érint.
Emlékszem, mikor szomszédos országok voltak véres és kegyetlen
háborúban; – milyen derüs közönnyel futottuk végig egy ujságlap
címeit; s aki elolvasta, milyen jót reggelizett hozzá. Akár a Marson
történne mindez! S így, csaknem így vannak most is; – úgyszólva
csak etikettből szomorkodnak az emberek sokezrei, a
„nélkülözhetetlenek“, az „alkalmatlanok“, a „jól elhelyezettek“
családjai. Milyen távol van egymástól ember és ember!
Fullasztó, mély keserűség csapott fel bennem; utána dacos
elidegenedés. Elzárkózni, igen, – ővele vagy egyedül, – külön lenni
nem erőlködni többé udvariasan, mint eddig, hogy magamévá
tegyem formáikat, életemre, lelkemre alkalmazzam kicsinységüket.
Szegény, vak állat ez, függő és gondolattalan csordalény, rászedhető
néhány frázis kolompszavával, megrészegíthető egy tarka és cifra
figurával, amit mellére tűzhet és jár vele, mint a gyerek. Ki kiváncsi
tettei, szavai, szenvedelmei és szenvedései okára, értelmére ma?
S z a v a k a t tudnak feleletül, pukkanó és üres szókat, zavarba
jönnek, elfordulnak csudálkozva és rosszalón. Én vagyok-e őrült,
hogy nem érthetem őket? Ma biztosan látom: n e m ! Ketten
vitatkoznak, egyik nem győzi érvvel, – akkor arculüti az ellenfelét…
Ez ők! S ami m a v a n , hozzájuk illő, rájuk hasonlít, bírják, élik,
játszódnak vele és benne; s feledni tudják kurta időn. Rászolgáltak,
nem jobbak nála, törvénye törvényük, – nincs mit szánni őket! Mit is
akarnék velük? – Ó, csöndes hely, eldugott kis tanya, fák, állatok,
könyvek, ártatlan dolgok s az ő szép bölcsessége, lelke tisztasága!…
Nem lesz soha! Nem érdemlem meg én, ki eddig köztük éltem és
játékaik játékaim voltak, kacér önáltatásaik komoly ügyem. Kultura,
humanitások, szépségek! Most lerántódott a lepel s alatta vigyorog a
vérivó, parázna állat. – Ó, csak magamom kell kétségbeesni, – csak
magunkon.
Lábam sok utcán vitt át, kimerülve, félig öntudatlanul jártam az
emberek közt és gyülöletem fojtó ködében láttam a mosolyokat; a
sok buta, gondolattalan, állati mosolyt. Utálatos, ártó, szirupos gőze
a tavasznak, szinte látható volt a kábult fejek körül! egymásra
néznek, az ajkuk mozog, hogy oktalan, negédes kis szavaikkal
elburkolják az egyetlen, vak, akarattalan tendenciát, mely rajtuk
hatalmaskodik; míg ajk ajkot keres. Hogy lehessenek húsz év mulva
is egymást pusztító milliók! A véráradás enyhébb véletlenei most
partravetik itt-ott a sebzetteket, váltják, cserélik, frissítik, fokozzák
így a kába szerelem esélyeit, – s az emberek mosolyognak.
Fegyverrel és új nővel az oldalukon járnak e csömörletes tavaszban
és boldogok, hogy nem kell gondolkodniok!
… Nem bírtam tovább! Irtózatos volt, hogy éreztem: nincs
bennem egy hajszálnyi szánalom. Nem szabad így néznem őket, kik
alakra hozzám hasonlók! El közülük a magányba, – nincs jogom í g y
elfogadni tőlük még ezt se, e kétes szórakozást, a düh erejét, mely
összefogja lelkemet az őrület ellen. El, haza!…
A kapuban elébem sietnek egy távirattal. Most érkezett. –
Betegen hozták az ismerős, kedves városba megint… kórházban
fekszik és vár engem!
Mikor hozták?… Hány óra? A menetrendet! Igen… ma még
utazhatom! Milyen boldogság, – milyen jó, hogy hazasiettem! Dehát
 i g a z e z ?… Mi baja lehet? Mindegy, mindegy, – hisz él! Az utolsó
levél egy héttel ezelőttről. Meg is hallhatott volna! Utitáskába néhány
rongyot, akármit; de nem, jó ruhát is, hátha kérnem kell az
érdekében? Hogy hazaengedjék feküdni. A cseléd, a házmesterné
mind segít, – a szomszédném felhozza a vasalt ruhát szivességből, a
vice kocsiért szalad. Milyen jók hozzám! Még telefonálok gyorsan
egy-két barátomnak, egy ujsághoz. Kórházat ajánlanak,
utánanéznek, helyet csinálnak neki. Milyen jók hozzám az
emberek!…

X.

S a hamvas reggelben ott jártam már a dóm elegáns terén,

számláltam a boltok korai nyilását s az óraütést; csodálatosan friss
lélekkel vártam az időt, hogy hozzá mehessek. Fekete Péter fogadott
az állomáson és elmondta, miről van szó. Megkönnyebbültem; tehát
hosszabb tartamú betegség, haza jöhet!… Pár sort küldtem hozzá a
legénnyel, pár boldog sort és ibolyát. Engem csak tízkor engednek
hozzá.
De már nem voltam türelmetlen. Hadd pihenjen csak! gondoltam
és élveztem a reggel üdeségét, a levegőt, a biztosságot, a nem
remélt örömet. Ott, egy távoli utcasarkon látszik az épület orma,
ahol őt tudom biztos helyen, nyugodtan, veszélyen kivül. Ő is tudja,
hogy közelben járok. Milyen szépek ez órák!
Orosz foglyokat láttam, párosával mentek munkára, ásóval,
gereblyével a vállukon, csevegtek vidáman, egyszerü szemük kék
mosolyával rám néztek s a tág világra, – frissen, mint a tavaszi ég.
Egy altiszt ment utánuk fegyvertelenül, – az is mosolygott. Istenem,
tavasznak ura!… Fehéren csillant meg a napfény a templom nemes
ormán. Holnap husvét van! Krisztos voskres! – mondják akkor az ő
hazájokban, testvéri csókot vált úr és szolga, szomszéd és haragos,
mindenki; – „Krisztus feltámadt!“ szól hangosan az, aki csókol s a
másiknak hittel kell ráfelelnie: „Valóban feltámadt!“… Milyen szép ez!
A szívem feldobog érettük, egyszerű hymnusok csendülnek bennem.
Milyen jó, hogy ezek mindnyájan haza fognak kerülni téres földjeikre,
a szellős jurtákba, hol apró muzsikok várnak rájuk a szérüs, kietlen
udvarokon. Az ő vérük nem száll ránk és maradékainkra! Halleluja!
Gyakorlatra menő ujonccsapat jön, barna legények. A szívem
összébbszorul; – sejtéssel, babonásan szálalom őket, mint a deli
erdőt. Hány fog elesni, melyik?… Elgondolom őket; az arcukat
egyenkint a rombolás tébolyában, a vész őrületében, kidülledt
szemekkel és állati ajkakkal, fogvicsorgatva, vért áhítva, hajadont
gyalázva; – é s e l g o n d o l h a t o m ! Aztán akarom látni, sorban az
arcokat mind, – otthoni portól lepetten, munka után, harangszós,
teljes nyári estében, ha jönnek haza a nyájjal vagy kaszával a vállon,
ráncos ingujjban, pörge kalappal, fáradságtól gyöngéd arcvonásokkal
– s a rozmarinos kapuban egy-egy leány várja őket; és ezt is l á t n i
t u d o m ! Mindent, – ugyanez arcokkal; ó rettentő janusfejek! Ó,
százlelkű ember!
Elhaladnak s szememmel a napfényt keresem, a színeket, a
vigasztaló életet. Népesül a tér, kofák jönnek, megtelepülnek,
kirakják a falvak zsenge gyümölcsét, halovány parajt, sóskát, tavalyi
almát, friss tojást. Észreveszem, hogy a szemem egy zsömlyés
kosárra mered; odább szalámik lógnak, megcsap az erős hússzag és
beleszédülök; Uristen, hogy kivánom! Reggeli előtt vagyok és tegnap
nem vacsoráztam, az izgalomban rá se értem; – hónapok óta nem
evés az, mit úgy hívok; a konyhalány fejcsóválva hordja ki a teli
tálat. – De most, most csend és öröm van bennem, most lehet enni!
Még ráérek. Szép, tiszta kávéház a szomszéd sarkon, – milyen
pompás, nagy szaga van a kávénak! Enni!… (Egy csokoládé három
zsömlyével; két tojás vajaskenyérrel; két szepesi virstli tormával;
édes sütemény).
Szép lassan, nyugodt deliciával fogyasztom. Az ujság itt, – még a
tegnapi. S tegnap már olvastam ugyanezeket a harctéri híreket, –
szorongó, tompa érzéssel, nehéz lélekzettel – s kerestem az
általános szavakban valami vonatkozást vele, az eggyel, a tömegbe-
veszettel, ki szivemhez tartozik. S most, – ó milyen máskép olvasom,
mások a szók, a betűk! Közönyös zsurnalisztastílben értesítnek
bizonyos messzi hadállásokról, hol bizonyos politikai szempontoknak
kell majd tisztázódniok… Ó, de hisz e sivár szók mögött halál van,
vér, rettegés, romok, sebek, anyák könnyei, feleségek jajja!… De én
nem tudom ezt érezni most. Elfárasztott a részvét vagy megrontott
az öröm. Ő tiszta ágyon pihen, mellette a virág, mit én küldtem ma
már, hozzá sietek, c s a k e z t érzem. (Hát én is rosz vagyok?)… A
kávéház, az utca, a piac csupa napfény!

XI.

Kórházi ágyak pedáns, tiszta rendei egy festett padlójú, tág

iskolateremben. Pesti, kültelki iskola ez; most egy éve apró,
polgárista fiúk drukkoltak itt a tintafoltos padokban. A kathedrán, –
hol most borogatóruhák, karbolvizes üvegek, vatták, – e komoly,
tanári asztalon osztálykönyv állott és noteszmumus. A falitábla itt
maradt; most láztabellákat írnak rá a krétával.
Egy sarokágy mellett ülök naphosszat és most e két
négyszögméternyi hely: az otthonunk. Az éjjeli asztalon fénykép,
virágok a kis firenzei vázánkban; az ablakpárkány teli könyvekkel.
Suttogva beszélünk; egy külön, halk sziget a sarokban; a szoba többi
lakója, mintha mögöttünk volna, távolabb kissé, – a derüs szemlélet
vonalában. Szinte kedvesek így.
Csupa férfiak, harctérről jött tisztek, nagyobbrészt könnyű vagy
gyógyuló betegek; hangosan beszélnek, töméntelen sokat
kártyáznak; azt hiszem, többnyire unják magukat. A fennjáró fiatalok
az első sarokablaknál tolongnak, egymásnak adják, felváltva őrzik
naphosszat; mert a szemközti házból két világosblúzos nőszemély
könyököl nekik fáradhatatlanul, délutánhosszat s még tovább a
terhes, májusi alkonyatban. Milyen élményteljes órák, ó – mennyi
idegen férfi; messziről jött, fiatal katona! Szegény, nélkülöző
nőszivek itt a Ferencvárosban, a szűk utcán, a harmadik emeleten!
Két testvérkisasszony, érettek, férjetlenek, – a papájuk szenzál vagy
ócskabútoros, diplomás férjet akart venni nekik, dolgozott, gyüjtött,
– s most itt a háború; – s a mindeneslányuk már a harmadik szép
„diner“-szeretőt keríti odaátról a kórházból. De ők regényt olvasnak
az ablakban; összesúgnak „érdekes“ profilt mutatva; csipkeujjas,
telt, fehér karjukat kivánatos mozdulattal emelik a frizurájukhoz
gyakran… Jaj, ha hallanák, ha tudnák, micsoda beszédekkel
fűszerezik idebenn a játékot; hogy m i l y e n szórakozás tárgyai
lettek!…
Valami tréfás, könnyű könyvet olvasunk itt a sarokban; csak
színből, hogy odaneszelhessünk néha a többire; – mint
utazásainkban a vonaton beszélgetőkre: ágáló, hangos, furcsa,
idegen utitársakra. Milyen jól tudunk így együtt figyelgetni;
szemecskélve felszedni idegen dolgokat, szókat, jeleneteket! Mi „két
cinkostársak a világgal szemben!“
… „Ajaj, de sok repülőgépre lődöztem én odakinn, urak, – tizet,
istenucscse nyolcat legalább is eltaláltam!“ A beteg főorvos
fogadkozik így! Hihetetlenül naiv tódító; – mondják, tegnap egy
szerb zászlót emlegetett, mit az ellen kezéből neki adatott
kicsavarnia; – sőt tegnapelőtt, (ha a hallgatósága nem nagyit
viszont) a kilencszáztizenkettes mozgósítási érmet valami nagyon
ritkán nyerhető orvosi, hadi-medálnak mutogatta. – Ah, igen, persze,
– gonoszkododik sunyin a fiatal medicíner, – nálunk is a legtöbb
repülőgépet a vitéz doktor urak puffogtatták le!“ Néhányan halkan
kuncognak a paplan alatt; a doktor hirtelen áttér három darab
tízezreket érő, régi olajfestmény leírására, melyeket egy lengyel,
főúri kastély lovagtermében vágott ki a rámáikból. Most a
keretezőnél vannak; milyen kár, szeretné megmutatni!
A fiatal csúfolódó azalatt öltözni kezd; szép, elegáns, ezüstös
toalettkészletben kotorász, finom parfőmszag árad az ágya felől. Ma
urlaubja van, nagy vacsorára hivatalos. Borotvaszappant kenve
módját leli, – immár harmadszor, hogy kiejtse a nevet, egy
exminiszter kegyelmes úrét, kihez ma estélyre megy. Két lány van a
háznál, az egyiket szeretnék neki elsózni; de akkora orrhoz, –
mondja az elegáns ifjú, – több pénzt kellene adniok.
Az öreg, sovány, fizetéses ápolónő a leghűbb publikuma; az ágy
fejére könyököl és kopott, nagy fejével élénken bólogat. Majd ő is
belemelegszik, gyorsan beszél, nem győz várni a lélekzettel, befelé is
szívja a szókat. Mily tájékozott a „társaság“ legbensőbb pletykáiban!
A negyedik kerület szereplőit, a bálkirálynékat bizalmasan a
keresztnevükön emlegeti; s ó, mennyit, mennyit tud felőlük, – mily
hivatott kárhoztatója hibáiknak, mily szuverénül oszt elismerést! Mert
hiszen ő is, – ó Istenem, ha a boldogult férje nem oly könnyelmű, ha
nem játszott volna el mindent lóversenyen s a kaszinóban!… (És
mindez igaz! Valaha csakugyan szerepelt s az álláshoz, presztizshez
nyilván illő modora is volt, biztos, sőt méltóságos föllépése… De
ennyire külsőség ez, – csak a helyzettől függő?…) Most oly félszeg,
túlserény, ügyetlenül buzgó, alázatos e hivatalban, – egyre sürögne,
ki akarná érdemelni a havi nyolcvan koronát.
Hogy összeretten, mikor az öreg, címzetes őrnagy szólítja. „Jöjjön
csak maga! Már megint összetört valamit, az én jó kis szipkámat,
milyen ügyetlen!“ A hangja lassú, kenetes, nyögdécselő; a
többiekhez fordul bizonykodni. „Ké-érem! Ez a szipka, tudják-e,
milyen régen van ez nekem? Most harmincöt esztendeje vettem
Bécsben, hadnagykoromban, negyven krajcárért. Aj, de sajnálom!
Éjnye, éjnye!“ – Ez a „kedves jó öreg úr“ nem volt a harctéren, ez
helyi szolgálatban betegedett meg; ennek van egy kis háza Cinkotán,
kétezer korona kapitányi nyugdijból szerezte, abból élt a családjával
a háborúig, – s a szipkái harmincöt esztendeig tartanak. De a
harctéri helyzet mérhetetlenül izgatja, soha még nem volt
megelégedve a tábornokok taktikájával, a vezérek stratégiai
tehetségével. „A lelemény hiányzik belőlük, a lelemény!“ Ezt
panaszolja most is nagy sóhajok közt az ulánus hadnagynak.
Ó, az ulánus! Osztrák báró, ötvenkétéves, önként jelentkezett a
háború elején. Donkihotét így szokták fösteni, ilyen horgas, bús-
humoros figurának a szegény, lógó karvalyorral, a mély bánatú,
merev szemekkel. A leggazdagabb osztrák hercegcsalád oldalági
rokona; kis évjáradékot húz kegyelemből a majorescotól, de abból
nevelteti két unokahugát. Itt keveset beszél; ideges, szenvedő és
közönyös; gőgös és félszegen bizonytalan egyszerre. Éjszaka nem
tud aludni, jár-kél, botorkál az ágyak közt, s ha sikerült az uramat
felébresztenie, odaül hozzá, hirtelen generozitásból kitünteti a
közléseivel.
„Tudod, én vagyok az utolsó a családomban. Agglegény. A
testvéreim mind elhaltak, magunkra maradtunk a mamával. Nem
volt szinte semmink már, csak az ócska bagolyfészek a hegyen; – de
ő olyan ügyeske volt, szegény muti, úgy tipegett,
gazdasszonykodott, mindég kiteremtette, ami kellett. Gondold csak,
kilencvenkétéves volt; én voltam az utolsó gyereke. Már egészen
összeszáradt; de milyen helyeske volt; s milyen okoska. Könyv nélkül
tudta mind az ősőket, a kihalt ágakkal s a házasságokkal
ezernégyszázhatvantól kezdve; téli estéken mindig erről
beszélgettünk. Te nem tudod mi az, így összeszokni ilyen öreg
korban. És egyszerre meghalt, sohse hittem volna; tavaly meghalt.
Én megbolondultam volna, ha nem jön szerencsére ez a háború. Mi
lesz velem, ha élve maradok! Mindig egyedül az üres házban; nincs,
akivel a családról beszélgetne az ember!“… Szegény, bús, öreg
túzok, a szívszakadásig igaza van neki. A harcoló seregnek csupa
ilyen emberekből kellene állni, – pont ilyenekből!
Nagy kardcsörtetés a folyosón; a főhadnagy sántít be; a korzón
volt, naponta kijár a csúzos lábával; sohase láttam ilyen élénk, szinte
heves bicegést. Most mellén a signum laudis. „Hát megkaptad?“ „Na,
végre!“ „Grratulálok örregem!“ Körülveszik, tapogatják; mindenki
tudja, mennyire várta már; hogy bosszankodott, amiért késett; előre
megvette, hónapok óta hordja a zsebében. Most ragyog a képe,
hevült és liheg az örömtől, – de közönyös arcot vág, legyint
megvetőn: „Á, semmi! Marhaság az egész! Bizonyisten, nem adok rá
semmit!“…
Be kell zárnom e portrék sorát! Nyolc óra van, vacsorát hoznak.
Ilyenkor fel kell szedődnöm; indulni haza, egyedül, – míg itt
idegenek mérik meg a lázát, vetik fel az ágyát éjtszakára.
 XII.

Itthon végre, – itthon és együtt!… És milyen szörnyű rossz írás

volna, ha erről írnék!
Az ember gyáva, gyáva, hunyászkodó állat! Nemcsak a hatalom
és intézményes önkény vághat fát meggörbített hátán; – de a
sorssal szemben is alázkodóvá, kezessé teszik a rettegések, kinok,
kiszolgáltatottságok. Hová lett világnézetünkből a fölény, kissé
kesernyés gőgünk biztossága, az „én“-ek excluzivitása, a magány, a
finomság, az elkülönültség s az irónia?… Korbács alatt szükülő
állatok vagyunk; a templomok tömve vannak és sok értékesebb
veszteséggel együtt elvesztettük a s t í l u s u n k . A gyerek, aki verés
alatt lett szófogadó, – nagyon szégyelli magát; és az Úristen most
nem jó pedagógus. A nagy brutalitás, ami lelkiéletünkkel történt,
majdnem minden esetben sülyesztette azt. Ha máshol nem: az izlés
irányában.
Mert itt látszik, hogy a primitivitás mily sokszor nem erény! A
közelmultban, mondják, „túlkomplikáltak“ voltunk finom
disszonánciákkal, megkülönböztetett voltunkkal, nagyon-belső
történeteinkkel, „csendes válságainkkal“. – (Most örüljenek, akiknek
botránykövei voltunk!) Most lelkünk állapota nagy, nyers, százmázsás
e s e m é n y e k e n mulik, külső dolgokon, melyeknek nincs több
közük belső vonásaink karakteréhez, mint egy redves, otromba
szikladarab ránkzuhanásának. Sorsunk kalapácsa kiesett dolgos két
kezünkből, – naiv imára vagy a „görcsös tördelés“ vásári vagy
theátrális gesztusára kell kulcsolnunk e kezeket. – Érzéseink arányai
frescoszerüek; a nagy arányokhoz nem szokott kifejezés ezért téved
könnyen a torzba, még könnyebben az émelyítőbe.
Elválás, búcsú, halálhír, életért-rettegés, sebek, elnyomorodások,
özvegység vagy boldogság, várás, viszontlátás; halál;… Gigászokká
váljunk-é egycsapásra, hogy e torz-ballonokkal „művészi“ játékhoz
értsünk? Amit érzünk, rettegésünk, gyászunk, áhításunk mindenkié;
– s ami ennél sokkal rosszabb: „akárkié“. – Ki óv meg a trivialitástól:
s az elemi iskolás olvasókönyvek; a „Jézus szive“ cimű igen
tiszteletreméltó, kolostorokba járatos ifjusági hetilap; vagy a kései
„negyvennyolcas tárgyú“ novellák reminiscenciáitól? E g y m á r
agyonkopott, – de még nem patinás modor kísért!
Az intimitás segítne tán! Apró dolgok: ahogy a hosszú, harctéri
betegségből lábbadozó ember végigmegy először a régnemlátott
szobán; lehajol és kicsit félszegen, nagyon kedvesen megtapogatja a
szőnyeg csücskét. (Milyen is egy s z ő n y e g ? Milyen a fogása?
Igazán v a n -e, – valóság?) – Vagy ahogy leszedi a polcról,
kinyitogatja sorba a könyveit, csak nézni, – és végigsimít a lapokon
gyöngéden, szerető kezekkel. Vagy ahogy bezárkózik és titokban,
tükör előtt sorra próbálja mind a civilruháit!… Ó, és a legkedvesebb,
hogy egy nyári este, hidegvacsorra után esztétikai kérdésekről
lehetett beszélni v e l e , a másmunkájuval, más érdeklődésűvel – és
milyen furcsa, merész dolgok jöttek ki ebből!… „Szép az, ami érdek
nélkül születik!“
Aztán feküdni készült, kivette az órát, ami apjáé volt még, szép
rendesen felhúzta és a szekrény márványára tette… És ez a
mozdulat a szívemig ért, ahogy semmi egyéb! Ez az egyszerű,
mindennapi, szinte reflexes kis cselekvés, e nyárspolgári, lefekvés-
előtti, mely száz és száz e g y f o r m a , eseménytelen napot szokott
befejezni s a m a igénytelenségével a h o l n a p biztos bíztatása van
benne. Ó, egyhangú, szürke életidőimben, hogy kivántam néha
felrázó változást, nagy kockavetést, akár nagy fájdalmakat is bolond
fiatalságomban; és most mit nem tennék érte, ha tudnám, hogy
leszünk még egyszer együtt a szelíd egyhanguság poézisében, –
robotos, biztos, csendes hétköznapok estéinek tiktakkos
harmóniájában.
Egy hét mulva vissza kell mennie a harctérre.
 Javítások.
Az eredeti szöveg helyesírásán nem változtattunk.
A nyomdai hibákat javítottuk. Ezek listája:

6 gazdssszony gazdasszony
7 jódedvében jókedvében
15 luha ruha
15 felajánrott felajánlott
19 leánynak ís leánynak is
21 Otthagytam „Otthagytam
22 jók vele! jók vele!“
27 Le a villanyt! „Le a villanyt!
31 az apja! az apja!“
32 segíteni?… segíteni?…“
32 kocsi! kocsi!“
34 temetkezva temetkezve
36 leszünkl“ leszünk!“
36 tavasz is! tavasz is!“
44 falusi! falusi!“
45 a nő?… a nő?…“
48 uvalamit? valamit?
50 kihúzottt kihúzott
63 Elsápsdt Elsápadt
82 hogz tetszik hogy tetszik
87 hálistennek!… hálistennek!…“
90 igáskocsísné igáskocsisné
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