The number of teeth extracted at an operation has varied from one to nineteen. The latter number was extracted by Mr. Canton on one occasion, and on two or three occasions, Mr. Arnold Rogers and Mr. Samuel Cartwright extracted seventeen at one sitting; but these gentlemen and others, as well as myself, have thought it better, as a general rule, to make more than one operation, when the number of teeth to be drawn exceeded ten, in order that the mouth might not contain too many wounds at one time, and that the loss of blood might not be very great. A great number of the operations have been for the extraction of the four first permanent molars, in children about thirteen, as these teeth are very apt to decay at an early period.
I have on 181 occasions, of which I have memoranda, given chloroform for the extraction of a single tooth. I exhibited it lately to a lady, aged eighty-six, whilst Mr. Bigg extracted an abortive wisdom tooth, which had recently come through the gum, and was giving pain. She awoke in about two minutes after the operation, and was quite cheerful and well.
The patients have been seated in an easy chair in all the operations on the teeth, except in a very few cases where a female patient was too ill to sit up. In many cases, and always if there was any feeling of faintness, the patient has been placed on a sofa, after the operation, for twenty minutes or half an hour. I am not aware of any inconvenience from the chloroform, in any of the cases of tooth-drawing, excepting sickness and vomiting, which in a very few of the cases have been troublesome for some time.
It is necessary in tooth-drawing to make the patient unconscious, and to continue the chloroform a little while after unconsciousness is induced, till the sensibility of the edge of the eyelid is very much diminished, or almost altogether suspended, otherwise the patient will probably make a resistance that will interfere with the operation, or scream out and alarm his or her friends. I nearly always take about four minutes in the inhalation. It is not desirable to take longer than five or six minutes, as the patient would be slower than is desirable in recovering completely from the effects of the vapour.
The patient is usually in the third degree of narcotism when the operation is performed, and, in this degree, as was previously stated, there is not unfrequently a contracted and rigid state of the muscles. This state often affects the muscles of the jaws, and interferes with the opening of the mouth, if it be closed. I generally tell the patient to keep his mouth open whilst inhaling, and by that means it often remains open when he is insensible. Not unfrequently, however, he closes it on becoming insensible. One can generally open it by pressing on the chin; but as the chin does not afford a very favourable hold, there are a very few cases in which the mouth cannot be opened easily in this way, at least not unless the effects of the chloroform are carried further than is desirable for these operations. I therefore carry with me a little instrument of two blades, made to open by means of a screw. The ends of the blades are covered with leather, and, if introduced between the teeth, at the corner of the mouth on the side opposite to that on which the dentist is about to operate, the mouth can easily be opened.[[149]] The power of the instrument is only such that I can scarcely open it with one hand, when I hold the blades with the other. It would not enable one to open the mouth of an adult if he were closing it by voluntary power; but the spasm caused by chloroform is very much less powerful than the action of the muscles when influenced by the will. I never use the instrument for opening the mouth when the patient is closing it voluntarily under the influence of a disordered consciousness, but always wait till consciousness and volition are entirely suspended. When the mouth is once opened, it can generally be kept open with the fingers, and the instrument may be withdrawn.
The bleeding during tooth-drawing is never so free as to interfere with the breathing; but when more than two or three teeth are extracted, and especially if they be in the back part of the mouth, some of the blood which escapes nearly always flows into the stomach; it flows down the fauces and œsophagus usually without any act of deglutition; but the evidence of its having gone into the stomach is obtained in those cases where the patient vomits. In consequence of the blood flowing into the stomach, vomiting cannot so generally be prevented by the precaution of not taking a meal before the operation in tooth-drawing as in other operations; but the sickness usually subsides as soon as the patient has emptied his stomach.
The chloroform has occasionally to be repeated in tooth-drawing before the operation is completed, especially in cases where several teeth require to be extracted. When this is the case, I always reapply it as soon as the patient begins to show signs of feeling the operation, without waiting till he recovers his consciousness. In many cases, however, a number of teeth are extracted without any repetition of the chloroform; and in the instances in which as many as fifteen, seventeen, or nineteen teeth were extracted at one operation, it was chiefly because the first application of the vapour enabled the dentist to take out such a number, otherwise, in most of these cases, a number of the teeth would have been left for a succeeding operation. It has occasionally happened, however, that the chloroform has required to be repeated, once or twice even, for the extraction of a single stump. When the chloroform is repeated once or twice, it is generally a longer time before the patient is able to leave the dentist’s house. I always request the patients who are operated on at the dentist’s, to drive home, as it is not advisable to walk, or use any exertion for an hour or two after the action of chloroform. Indeed, the patient is usually disinclined for any exertion for twenty minutes or half an hour after the influence of this agent, and sometimes for much longer; although I have seen a patient mount the box of a sort of dog-cart, and drive himself away, within five minutes after having several teeth extracted whilst he was in a state of complete insensibility from chloroform.
I have administered chloroform in a great number of cases for the destruction of the nerves of the teeth. The patient requires to be made as insensible in this operation as in tooth-drawing.
Secondary Hæmorrhage after Operations. The hæmorrhage which occasionally comes on several days after an operation, from sloughing, ulceration, or the non-formation of a coagulum in an artery, is probably as liable to occur now as formerly; but I believe that hæmorrhage, a few hours after an operation, is much less frequent since the practice of narcotism by inhalation. Before this practice, it was extremely common for the patient to faint during an operation, when the bleeding of the smaller arteries stopped, and they escaped the ligature, to break out in hæmorrhage occasionally afterwards; but under the influence of narcotic vapours it is unusual for the patient to faint, and consequently every vessel which is capable of bleeding is tied during the operation.