Like all other surgical operations, the extraction of teeth is at times attended with certain difficulties, complications and sequelÆ which for the sake of description will be considered under the following headings:

(1) Difficulties, complications and sequelÆ connected with the teeth themselves.

(2) Difficulties, complications and sequelÆ connected with the jaws.

(3) Difficulties, complications and sequelÆ connected with the soft parts.

(4) Difficulties, complications and sequelÆ arising during extraction under anÆsthetics.

(5) Miscellaneous complications, difficulties and sequelÆ.

(1) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE TEETH THEMSELVES.

(a) Undue Resistance of the tooth and alveolus.—Considerable resistance to our efforts to remove a tooth at times occurs. This is naturally most often, though by no means always, met with in those of strong physique. Teeth isolated are always firmer than those in series; this is accounted for by a consolidation of the bone around them. Experience will act as a guide, and it is to a certain extent possible, after a little observation, to gather from the general appearance of a tooth if it will give more than normal trouble in removal. Should undue resistance be met with, steady attempts to move the tooth slightly in different directions should be made and persevered with; if this precaution is not taken and too much force is used in any one direction, fracture of the tooth or alveolus is sure to result. It may, perhaps, be found impossible to remove the tooth; when this is the case it is best to dismiss the patient and to make a fresh attempt two or three days later; the tooth will then probably be loose, as a result of the inflammation which has been set up by the previous attempt at extraction, and can be easily removed.

The causes of undue resistance are:—

(i.) Abnormal density of the alveolar process.

(ii.) Divergent and twisted roots.

(iii.) Alteration in the shapes of the roots brought about by periodontal inflammation (exostosis).

(b) Fracture of the tooth.—The principal causes of this accident are:—

(i.) The use of badly fitting forceps.

(ii.) The use of unnecessary or wrongly applied force in attempting to loosen the tooth in its socket.

A tooth having been fractured, the patient should be made to rinse the mouth until the bleeding has ceased, the socket should be dried with cotton-wool, and the position and edge of the root defined with a probe before attempting to remove the fractured portion. It is neglect of these steps that so often leads to failure to remove the remaining portion of a fractured root. Too many attempts to remove a fractured root should not be made; if a second endeavour proves fruitless, the patient should be dismissed and a fresh attempt, if necessary, made after a period of one or two days, as the tooth will probably then be looser from inflammatory trouble, moreover, the hÆmorrhage having ceased, it will be possible to obtain a clearer view of the root. Before, however, dismissing the patient, an anodyne mouth wash should be prescribed, and the pulp if exposed touched with carbolic or nitric acid. The lower third of a root may generally be left without fear of unpleasant consequences; but it is always well to inform the patient when any portion of a tooth is allowed to remain in the jaw, as such knowledge may be of assistance should any trouble arise at a subsequent date.

(c) Crowded and irregular teeth.—The removal of these has already been referred to in Chapter III.

(d) The Removal of the wrong tooth.—The removal of the wrong tooth may occur and is naturally due to carelessness on the part of the operator. Should this accident arise, the tooth must be immediately replaced and if necessary secured with a ligature. If the pulp subsequently shows signs of degeneration or inflammation it should be removed and the canal treated and filled.

(e) Removal of a neighbouring tooth.—This may occur and is generally due to a crowded arrangement of the teeth. The accident seems to occur most frequently with the removal of the first permanent lower molar, the neighbouring tooth usually involved being the second bicuspid which is simultaneously dislocated from its socket. This accident can be avoided by placing the thumb on the tooth which shows a tendency to move, and exerting only as much force in the removal of the tooth which is being extracted as can be controlled by the thumb. If a neighbouring tooth is removed it must be replaced and treated in the same manner as described above.

(f) Removal of an unerupted bicuspid.—This may be an avoidable or an unavoidable accident. At times the developing bicuspid is so firmly embraced by the roots of the deciduous molar that during the extraction of the latter tooth the bicuspid is removed—such an accident cannot be avoided. It is an avoidable accident when it occurs during the extraction of the roots of a temporary molar and arises from using too much force. As previously pointed out it is best to leave the fractured roots of temporary molars alone unless they can be easily removed.

(g) Breaking one tooth in extracting another.—In the extraction of lower teeth with hawk’s-bill forceps the upper teeth may be fractured. This accident is most likely to occur to the inexperienced, and arises from the tooth leaving its socket suddenly, due frequently to the extracting force being used in an upward rather than an outward direction. It may, however, occur when a lower tooth has been more than normally resistant. In all such cases it is well for the operator to be on guard by keeping the thumb or a finger of the left hand over the joint of the forceps.

Also in using the elevator an adjacent tooth may be fractured.

(2) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE JAWS.

(a) Fracture.—The fracture and removal of a small piece of the alveolus is not an unfrequent accident which is fortunately by no means serious. It is sometimes unavoidable but at other times is due to getting the blades of the forceps on the outer sides of the alveolus instead of between the bone and the root of the tooth.

Extensive fracture is sometimes seen, for instance in a case that came under my notice at the Dental Hospital of London an unqualified person in removing the first lower right permanent molar fractured the bone in a horizontal direction so that the second and first bicuspids with the canine were completely separated from the body of the bone. Mr. Salter[5] gives an account of an extensive fracture of the jaw which occurred in a lady Æt. 35. The fracture occurred in connection with the removal of the superior central incisors. The right central incisor required some force for its removal, and when it came away the whole of the front of the alveolus was firmly attached to the root. In removing the left central incisor considerable force was required during the exertion of which the bone was fractured. On examination of the parts the mass of bone corresponding to the intermaxillary bone was found to be merely held in place by the soft tissues. “A vertical fracture extended from the side of the canine up to the root of the nose, then nearly horizontally across to the opposite side, being connected there with another vertical fracture. The lesion passed completely through the jaw from before backwards, and there was a wound in the palate three quarters of an inch from the alveolar border, through which was considerable hÆmorrhage.” A still more severe example of fracture during extraction of teeth is recorded by Mr. Cattlin,[6] where in an attempt to remove a third upper molar with an elevator the tuberosity of the maxilla, a portion of the floor of the antrum and part of the sphenoid were fractured.

Fracture of the maxilla tuberosity may occur during the removal of the third upper molar, and Mr. Nicol[7] records such an accident during the removal of the second upper permanent molar. In a case recorded by Mr. L. Matheson[8] a transverse fracture of the maxilla occurred in a line between the first and second permanent molars during the removal of the first-named tooth.

Direct transverse fracture of the horizontal ramus of the mandible due to extraction of the teeth has also been recorded.

Treatment.—In fracture of small portions of the alveolar process, no special treatment is called for except that all loose fragments should be removed. When the fracture is of a more extensive character, the fragments must be retained in position by a suitable form of splint, a description of which will be found in most works on dental surgery.

(b) Necrosis of the alveolus may result from extraction and is generally the result of undue violence or of some septic process occurring in the wound. The treatment to be followed consists of the use of antiseptic and deodorant mouth washes; the necrosed bone when quite separated from the living tissue should be removed with a pair of suitable forceps.

(c) Dislocation of the mandible.—The use of too much force in extracting a lower tooth and not at the same time counteracting the force by supporting the chin, may lead to unilateral or bilateral dislocation of the mandible. This accident may also be brought about by forcing the mouth open too much with a Mason’s gag during the administration of an anÆsthetic. It may likewise occur without the employment of undue force in those who have previously met with or are liable to dislocation.

Reduction may be brought about by placing the thumbs, carefully wrapped in a napkin, on the molar teeth and the palmar surfaces of the fingers below the chin. If downward pressure is then made with the thumbs, and upward pressure with the fingers, the condyles of the mandible will generally pass back easily into the glenoid cavity. In cases where more difficulty than this is experienced, the patient should be placed in a recumbent position, and corks should be inserted between the back teeth. Upward pressure should then be applied on the under surface of the chin. It is advisable, after reduction, for the patient to wear a four-tailed bandage for about a week.

(d) Forcing a root into the antrum.—This accident occurs mostly in connection with the extraction of the second upper bicuspid root and buccal roots of the first upper permanent molar. If a root has been so dislocated into the antral cavity as to still partly remain in its socket, the best course to pursue is to leave it alone and not to attempt removal as the attempt might only result in complete dislocation of the root into the antrum. The socket should be kept quite clean by the continual use of antiseptic washes. As a rule the root gives rise to no subsequent trouble.

When a root has been forced completely into the antrum, the latter should be enlarged and the antral cavity thoroughly syringed. For this purpose it is well to use an aural syringe of five or six ounce capacity. The rationale of this form of treatment is that the root may pass out with the return current from the antrum. If this treatment fails, an attempt may be made to remove the root with a little scoop of gutta-percha fixed on to a flexible wire. When it cannot be removed in this manner, the cavity should be thoroughly irrigated with an antiseptic solution and the root left alone, as it will in all probability become encysted and not give rise to any subsequent trouble. If, however, the patient has a history of epitheliomatous disease of the jaws further attempts should be made to remove it. A case where a tooth was forced into the antrum in a patient with a family history of epithelioma of the jaw is recorded in the Transactions of the Odontological Society, vol. ii., page 15, old series.

(e) Forcing a tooth into an abscess cavity.—This accident may occur; if it does, it requires similar treatment to the accident just described in connection with the antrum.

(f) Trismus.—Inability to open the mouth naturally renders extraction of the teeth more difficult than usual. When, however, the closure is the result of inflammatory trouble in connection with the lower molars, an anÆsthetic should be given and the mouth opened forcibly with a Mason’s gag. If the trismus is the result of tonic contraction of the muscles closing the jaw, ether should be used in order to overcome the resistance of the muscles, as nitrous oxide would not have the desired effect.

(3) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ IN CONNECTION WITH THE SOFT TISSUES.

(a) Extensive laceration of the gum.—In cases where a tooth has given rise to much trouble in removal, the soft tissues naturally suffer, but apart from this they may be severely lacerated when the gum is more than usually adherent to a tooth. This is most frequently seen in the removal of the lower third molar, but it is also sometimes met with in the removal of loose teeth. When the gum is found more than usually adherent the tooth should be left in the socket until the gum attachment has been divided with a pair of scissors or a lancet. Continued attempts to remove the tooth with the forceps before the gum has been divided will only lead to undue laceration.

In all cases where the gums have been badly lacerated, an anodyne mouth wash should be prescribed.

(b) Wounding the tongue.—This is most likely to occur under nitrous oxide, as the tongue during anÆsthesia is generally swollen, and is, moreover, not under the control of the patient. Wounding the tongue is nearly always due to carelessness, and arises generally in using the elevator. When the tongue is much lacerated, the overhanging portions should be trimmed off with scissors and the surface kept clean with antiseptic mouth washes. If the tongue is punctured and the wound does not involve a large branch of the lingual artery, but yet bleeds freely, the tongue should be drawn forward; if this does not prove successful the insertion of a stitch will generally cause the hÆmorrhage to cease. If the tongue is punctured and a large branch of the lingual artery is involved, the finger should be placed on the back of the tongue and the organ drawn forward; this compresses the lingual artery against the hyoid bone. The bleeding point must then be sought for and, if found, an attempt made to twist the wounded vessel. If this fails cauterisation may be tried, and as a last resource, if cauterisation does not stop the bleeding, the lingual artery must be tied.

(c) Bruising the lower lips.—This may occur in the removal of upper bicuspids and molars, and is due to having the mouth insufficiently opened, and using forceps of too straight a pattern.

(d) Injury of the mandibular nerve.—The mandibular nerve may be injured during the removal of the lower molars and bicuspids. Loss of sensation over the parts supplied by the nerve, with dribbling of saliva, generally follows the accident. Sensation is, however, usually restored, and in cases of laceration the nerve generally unites.

Mr. Sewill records a case in which “the roots of a lower wisdom tooth contained a groove and a foramen, through which the inferior dental nerve had evidently passed.”

(e) HÆmorrhage following tooth extraction is a most important complication, and one which needs prompt treatment. HÆmorrhage is predisposed to by a diathesis known as hÆmophylia. Of its pathology but little seems to be definitely known. The blood in this condition is said by Walsham to be deficient in fibrin. HÆmorrhage may occur in people not predisposed to the above-named diathesis; in some instances it is probably due to pathological changes in the artery supplying the tooth, these changes being frequently induced by inflammation around the apex of the root, and the vessel becoming adherent to its bony surrounding, and thus prevented from contracting. Another condition, which may or may not have any practical bearing, is the occurrence of hÆmorrhage during the menstrual period. I have, on two occasions, had under notice patients for whom teeth have been extracted during this period, and in whom hÆmorrhage followed, but ceased at the termination of the period. Teeth had been extracted for both these patients on previous occasions, without undue hÆmorrhage following.

HÆmorrhage is generally divided into three stages, viz.:—primary, intermediate and secondary. In the mouth we often find the primary running into the intermediate. The treatment of primary hÆmorrhage, or that occurring at the time of the operation, is not of serious import. If it is at all sharp a useful plan is to give the patient some tincture of hamamelis in the water used for rinsing the mouth. At the same time about fifteen grains of gallic acid[9] should be given, and the patient should be ordered to take a similar quantity every two or three hours until the hÆmorrhage ceases. The socket should also be loosely plugged with cotton-wool dipped in some styptic, such as gallic acid.

Intermediate and secondary hÆmorrhage is of a more serious nature, and generally sets in at night. When a case of intermediate hÆmorrhage is first seen, these two important points should be ascertained before treating it:—first, whether the bleeding is coming from the gums or the socket of the tooth; secondly, whether the blood shows a tendency to coagulation. The latter point will act as a guide in the choice of drugs for internal administration.

In hÆmorrhage from the gum search should be made for any small vessels that may be the cause of it, and if found they should be twisted or compressed. If the vessel is only partially divided it should be completely severed, as this will probably allow contraction to take place. If the bleeding is capillary in character, a pad of gutta-percha lined with lint dipped in some styptic and applied with firm pressure is usually sufficient to stop it.[10]

When the bleeding proceeds from the socket the following mode of procedure is adopted: some small cone-shaped pieces of non-absorbent cotton-wool are prepared (each about ? to ½ inch long and ¼ inch broad at the base), also a pad of lint and a four-tailed bandage; a syringe, a pair of conveying forceps, some cold water and the chosen styptic are likewise placed ready for use. The socket is first freed from clot, then syringed, then dried out with a pledget of cotton-wool, and directly afterwards one of the cone-shaped pieces of cotton-wool dipped in the styptic (the most useful being tannin) is placed in the socket and forced to the apex, with a fair amount of pressure; the hÆmorrhage is arrested far more by pressure than by the styptic. More pledgets of wool are inserted until the socket is quite full; a plug of lint is then placed over all and kept in position by antagonism with the upper teeth, a four-tailed bandage being used for this purpose. An excellent method of keeping the plug in the socket if the approximal teeth are standing is to wedge a piece of wood between them. Excellent as this plan is, however, if the hÆmorrhage is at all sharp it is better to use the four-tailed bandage to make more certain of retaining the plug in position. The number of pledgets of wool inserted in the socket should be counted.

The general directions to be given to the patient, though apparently trivial, are most important and should never be forgotten. He or she should be advised to go home very quietly, to avoid all forms of excitement, to assume the sitting position usual during the day, and to use a high pillow at night. The patient should be fed through a bent tube, and all fluids should be given cold.

In addition to plugging the socket, hÆmostatics should be administered internally.

In cases where there is a thin watery blood and no tendency to coagulation it may be fairly assumed that the cause of the hÆmorrhage lies in the blood, and such drugs as gallic acid[11] and perchloride of iron[12] are indicated, but when the blood shows a marked tendency to coagulate in the mouth, as often happens, and the bleeding still continues, such drugs as ergot[13] are indicated; in this latter condition it may be assumed that the cause of the hÆmorrhage lies in some want of contractility of the vessel wall, and ergot causes contraction of unstriped muscular tissue.

At the time of plugging the socket a dose of gallic acid, perchloride of iron or ergot should be given, and its administration continued at intervals until the bleeding ceases. Mr. Morton Smale prefers a hypodermic injection of ergotine.[14]

The patient should be seen within twenty-four hours after treatment, and if the bleeding has ceased the plugs may be removed and an antiseptic mouth wash prescribed. This course is not recommended when the hÆmorrhage has been severe; under such circumstances the plugs should be allowed to work themselves out. If the hÆmorrhage has not then ceased, the socket should be replugged tighter than before with a plug of wood wrapped in non-absorbent cotton-wool. Should this prove of no avail the actual cautery may be tried; if this fails, and the bleeding is from the mandible, the canal should be trephined and a plug of ivory inserted, so as to compress the artery against the inner plate of the bone. In uncontrollable hÆmorrhage from the maxilla digital pressure on the common carotid opposite the transverse process of the sixth cervical vertebra may be tried; should this fail to stop the hÆmorrhage, ligature of that vessel must be resorted to.

In one case of hÆmorrhage from the region of the third right lower molar Mr. Boyd[15] divided the lip in the median line and reflected the cheek from the jaw. The mandibular canal was then laid open by excising the outer plate of the bone, and the bleeding was arrested by plugging the mesial and distal ends of the canal.

In extreme cases, with sign of collapse, normal saline solution[16] must be infused into the median basilic vein.

In patients predisposed to hÆmorrhage extraction should be if possible avoided; but, if the removal of the tooth be absolutely necessary, prophylactic treatment should be pursued for three or four days previous to the operation by the administration of one or other of the remedies previously mentioned.

A new styptic, consisting of fibrin ferment 1 to 10 to which 1 per cent. of calcium chloride has been added, is said by Walsham to act only on the blood, not on the tissues, and to be perfectly aseptic. It was found to be effectual in arresting hÆmorrhage after the division of all the veins except the common jugular in a dog’s neck.

The tooth should be extracted in the early morning, as we then have the day before us should hÆmorrhage occur. Some hÆmostatic should be administered at the time of the operation and the socket plugged at once; for it is most important to remember that in these cases it is far easier to prevent the hÆmorrhage occurring than to arrest it when once it has commenced. The subsequent treatment will consist in the continued administration of hÆmostatic drugs.

(f) Injury of the arteries in the neighbourhood of the teeth.—Wound of the lingual artery has been referred to under the heading of injuries to the tongue. Laceration of the ranine, anterior and posterior palatine arteries may also occur. Such accidents are usually the result of the forceps slipping and are therefore avoidable. Treatment consists in pressure or in twisting or tying the divided vessel. In the case of the anterior or posterior palatine artery it may be found necessary to plug the foramina which give passage to these vessels.

(g) Pain following tooth extraction.—The causes giving rise to pain following the extraction of a tooth are:—

(1) Incomplete extraction of the tooth, more especially when the remaining portion contains an exposed pulp.

(2) Too rapid healing of the orifice of the socket.—It sometimes happens that the margins of the wound left after extraction unite very early, and when this occurs the discharges which naturally come away from the granulating surface at the base of the socket, have no exit; the consequence is that they are retained and set up a local traumatic inflammation, leading to swelling of the surrounding tissue.

(3) Suppuration in the tooth socket.—This may be due in the first instance to the use of dirty forceps, and under such circumstances it may be classed as a poisoned wound. An examination will reveal the presence of greenish putrid pus, while the tissue around will be much inflamed, and the portion immediately bordering the wound will have a tendency to slough. A condition of this kind is often seen in hospital nurses and medical students and is no doubt due to infection met with in their daily duties.

Suppuration in the socket may be due to a lowered vitality of the tissue, produced by some such local causes as acute or chronic inflammation, and is especially well seen in cases of extraction for the relief of periodontitis, or where the operation has been performed in patients suffering from general debility, syphilis, struma or in fact any of those systemic diseases which tend to lower the vitality of the organism.

(4) Extensive laceration of the hard and soft tissues in the neighbourhood of the socket; and

(5) Necrosis of the socket of the tooth are also fruitful sources of pain following tooth extraction.

(6) The presence in the wound of a foreign body.—A curious example of this came under notice a few years ago. A patient applied for the extraction of the left first permanent molar. During the operation a portion of one of the cusps disappeared; a search was made for it but, as it was not found, the natural supposition was that it had been removed in rinsing the mouth. The patient for the next three weeks complained of slight pain in the socket for which remedies were tried but proved of little use. Eventually the patient discovered the cusp on the top of the granulation tissue which had filled up the socket. In another case of the same character which came under notice, the offending material was a piece of an amalgam filling. A fractured blade of forceps may likewise act as the offending body.

(7) Injury to the nerve.—Direct injury to the trunk of the nerve is more likely to occur during extraction of the lower third molar than with any other tooth. It is more than probable that many obscure cases of pain following tooth extraction are due to exposure and irritation of the nerve at the apex of the socket. An interesting case of this character was lately reported by Mr. Storer Bennett.[17] The patient, a lady Æt. 23, had had the third upper molar dislocated through the use of a Wood’s gag, and, as it was considered hopeless to restore the dislocated tooth, it was extracted without difficulty. The socket in spite of treatment remained painful for the next twelve days, but in the meanwhile granulated healthily, except at its apex, where by the aid of a mirror and probe a spot about the size of a pin’s head was noticed which caused the greatest agony on being touched. Incision of the nerve produced permanent relief.

Treatment.—The treatment naturally depends very much upon the cause. A thorough examination of the socket should be made with probe and mirror. When due to incomplete extraction, another attempt, if considered advisable, may be made to remove the tooth. This proving unsuccessful, the socket should be swabbed with an anodyne drug and, if there is an exposed pulp in the remaining portion of the tooth, the pulp should be touched with fuming nitric acid or strong carbolic acid. The patient should also be advised to use some poppy head fomentation.[18]

In too rapid healing of the orifice of the socket, the freshly healed surface must be separated, the socket syringed out, and a small tent of lint allowed to remain in the orifice for about twelve hours. An antiseptic mouth wash should also be prescribed.

In those cases where the pus is putrid and there is reason to suspect infection, the socket should be thoroughly syringed with some antiseptic such as hyd. perchlor. 1 in 1,000, carbolic acid 1 in 40; following this the parts should be carefully dried with cotton-wool. A small piece of chloride of zinc should then be introduced and allowed to dissolve in the socket, which must be subsequently kept aseptic by constant irrigation with some antiseptic solution.

Suppuration is most frequently seen after extraction of the lower teeth owing to the fact that drainage is less easily effected than in the upper, owing to the dependent position of the socket. In many cases it will be found necessary to plug the socket tightly with non-absorbent cotton-wool dipped in an antiseptic solution; this prevents the accumulation of dÉbris which would act as an irritant. In cases of suppuration occurring in patients of diminished vitality a tonic form of treatment should be prescribed;[19] the dressing in the socket should be removed two or three times a day and the socket syringed.

Care must be exercised in applying escharotics to sockets to which the nerve may be in close proximity; this is especially necessary in dealing with impacted lower third molars. Two cases illustrating this point have come under my notice. In the first a second lower bicuspid with a long standing chronic abscess had been removed. The patient complained of pain, the socket was syringed out and a small piece of chloride of zinc inserted. Intense agonizing pain followed which all local anodynes failed to relieve. In the second case an impacted right lower third molar had been removed. The socket suppurated, and the pain although severe was not intense. Treatment similar to that used in the first case was adopted with similar results. Since then in all cases where it is possible that the trunk of the nerve may be in close proximity to the socket, I have used non-irritating antiseptic injections and plugged the socket with cotton-wool dipped in tincture of opium with much more satisfactory results.

It is advisable to inform the patient of the possibility of pain following the extraction of a tooth, especially after periodontitis, and in all cases where a large number of teeth have been extracted a mouth-wash[20] should be prescribed; for, even if there is no pain, it will prevent the discharge from the sockets of the teeth undergoing putrefactive changes.

In pain due to necrosis of the socket deodorant antiseptic injections must be used, while in extensive laceration of the soft and hard parts an anodyne mouth-wash[21] may be tried. In all obscure cases an application should be made to the socket of some local anodyne such as tincture of opium or cocaine, and a mouth wash having similar properties should at the same time be prescribed.

(4) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION UNDER ANÆSTHETICS.

(a) Tongue slipping back.—During extraction under anÆsthetics the tongue not being under control may slip over the larynx, or may be forcibly pushed back by the fingers of the operator. Symptoms of difficult breathing or even arrest of respiration will follow this accident. It is not enough to watch the chest walls, as respiratory movement may continue without air entering the lungs. Treatment consists in pulling the tongue forcibly forward with a suitable instrument and forcibly extending the head on the spinal column.

(b) Forcing out a tooth with a prop or a Mason’s gag.—With a prop this accident may arise from resting it upon teeth which are loose or from placing it in such a way that undue leverage is brought to bear on the teeth. It is an accident most likely to occur when the prop is fixed on the front teeth and the mouth opened to its widest extent. Under such conditions undue leverage at right angles to the long axis of the tooth is brought to bear upon the palatal surfaces of the upper teeth and they are consequently forced outwards. With a Mason’s gag the accident is due at times to clumsiness; great care should therefore be exercised when using this very powerful instrument. If a tooth is forced out it should if possible be immediately replaced.

(c) Passage of a foreign body through the isthmus of the fauces.—A foreign body, such as a tooth, a broken piece of forceps or a prop, passing through the isthmus of the fauces may become impacted in either the air or food passages.

In the air passages it may lodge (1) over the entrance of the larynx, (2) in the larynx, (3) in the trachea or bronchus.

In the food passages it may lodge (1) in the pharynx, (2) in the oesophagus, (3) at the pyloric opening of the stomach.

In the air passages.—Should the foreign body lodge over the entrance of or in the larynx the patient will be seized with a violent fit of coughing which may expel it; but, should this not happen, symptoms of asphyxia will supervene. With regard to treatment; the head should immediately be brought forward and the finger inserted along the side of the mouth into the pharynx, and then given a forward sweeping movement; by this means the foreign body, if lodged at the back of the tongue, will probably be removed. This failing, the patient must if possible be inverted and a forcible slap given on the back. If the foreign body is not dislodged by this method, laryngotomy should be immediately performed. There must be no hesitation about the performance of this operation and it must be carried out promptly, for the longer it is delayed the less becomes the chance of saving the life of the patient.

A foreign body in the trachea or bronchus may give rise to no immediate symptoms, but generally a violent fit of coughing, with signs of impending asphyxia, takes place at the time of the accident. These signs pass away, to be followed at intervals by fresh attacks of coughing and eventually by symptoms of collapse of the lung or lungs.

In a case recorded by Sir William MacCormac,[22] during the removal of an upper bicuspid the palatine blade of the forceps snapped off close to the joint and disappeared. The patient immediately suffered from great dyspnoea and appeared to be dying. The symptoms passed away, and for the following six weeks the patient’s condition gave no great cause for anxiety, although she suffered from a constant hacking cough accompanied by bloody expectoration. Seven weeks after the accident she was admitted into St. Thomas’s Hospital, the foreign body was with difficulty removed from the right bronchus, and the patient made an excellent recovery.

The diagnosis of a foreign body in one bronchus is made by an absence of signs of respiration over the whole or part of the lung on that side, with exaggerated sounds (puerile breathing) over the opposite side. Treatment consists in performing tracheotomy and removing the foreign body.

In the food passages.—A foreign body impacted in the pharynx will give rise to pain, symptoms of dysphagia and dyspnoea. A hacking cough is generally present.

Should a foreign body be suspected in the pharynx, its presence can usually be ascertained by digital exploration; this failing, the cavity should be examined by the aid of a laryngoscope.

An attempt should first be made to remove the body with the fingers, and if this is unsuccessful pharyngeal forceps must be called into use. In some cases where the impaction is very firm it may be necessary to perform pharyngotomy.

A foreign body in the oesophagus will cause dysphagia, and will probably give rise to constant pain; if it is situated in the upper part it will in all probability give rise to dyspnoea. On applying the stethoscope over the region of the oesophagus, a gurgling sound will be heard when the patient swallows fluids. The presence of a foreign body may be definitely ascertained by passing a bougie; this step will also enable the surgeon to determine the position in which the foreign body is lodged.

If impacted in the upper part of the oesophagus, an attempt may be made to remove the impacted body with forceps; this failing, oesophagotomy must be performed.

If lodged near the cardiac end of the oesophagus an attempt may be made with a bougie to push the foreign body into the stomach; this failing, gastrotomy should be performed.

If a foreign body becomes impacted at the pyloric opening of the stomach, it will give rise to gastric dilatation. Under such circumstances the stomach must be emptied of its contents, and gastrotomy then performed.

A foreign body going through the isthmus of the fauces will as a rule pass into the oesophagus, then into the stomach, and will give rise to no trouble.

The details of such operations as gastrotomy, oesophagotomy, &c., do not lie within the scope of this book, and should be sought for in works dealing with general surgery.

The necessity of being ready for such emergencies as the above cannot be too fully emphasised, and all who administer anÆsthetics should be provided with the instruments necessary to perform laryngotomy. These should be kept in a little case, and no anÆsthetic should be administered without the case being near at hand. Adherence to this rule is important.

(5) MISCELLANEOUS DIFFICULTIES, COMPLICATIONS AND SEQUELÆ.

(a) Uterine pain.—A case is quoted by Mr. Sercombe where extraction of a tooth was followed by paroxysmal uterine pain, followed by the cure of an obstinate leucorrhoea.[23]

(b) Shock.—The fact that tooth extraction is a surgical operation, and may be followed by shock, is often overlooked. The amount of shock which follows as a rule is practically nil, but at times, especially in the weak, it may be well marked. This is not taken sufficiently into account when a question arises as to the number of teeth to be extracted at one sitting, and it should be clearly borne in mind that what a strong, able-bodied person, can stand, one of weaker physique cannot bear. The wholesale extraction of teeth at one sitting which is carried out by some operators is not advisable, and the amount of prostration that follows is sometimes very severe.

Syncope at the time of the operation sometimes occurs. Should it supervene during the extraction of the tooth the operator should immediately desist until recovery ensues. Fainting is best treated by bending the head down towards the knees, at the same time loosening anything tight about the neck and applying ordinary salts of ammonia to the nose. In severe cases the patient should be removed from the chair and laid on the floor, and the chest should be exposed and flipped with a towel dipped in cold water. In more severe cases it may be necessary to inject ether or some other stimulant, such as brandy. Fatal syncope following tooth extraction has occurred, and a case which took place at Marseilles in 1881 is mentioned by Tomes.[24] The patient was a female, and an attempt was made to remove a tooth, but was desisted in owing to alarming syncope. A second attempt was made, or rather about to be made, when fatal syncope ensued. Post-mortem examination showed nothing beyond a slight amount of cerebral congestion.

(c) Epilepsy.—In those pre-disposed to epilepsy an attack often commences immediately after the extraction of a tooth. In the event of a fit occurring the patient should be removed from the chair and placed on the floor, the clothes being at the same time loosened, and a wedge of wood or some suitable material placed between the teeth to prevent injury to the tongue.

(d) Hysteria.—Manifestations of this disorder at times follow tooth extraction, but do not call for any special treatment beyond that usually adopted for this disorder.

(e) Septic and infective sequelÆ.—Scattered through dental literature will be found a large number of records of septic and infective diseases which have followed the extraction of teeth. In many of these cases it would be difficult to say that the infection was always the result of the operation; in a number of them the actual cause was due to the neglected condition of the tooth which called for extraction. Infection can, however, at times undoubtedly be traced to the operation, and once again attention cannot be too strongly drawn to the fact that antiseptic precautions should be carried out as far as possible.

Suppuration of the socket and its appropriate treatment has already been dwelt upon (page 82). Cases of syphilis having been acquired through the use of infected forceps are recorded, while septicÆmia, saprÆmia, cellulitis, osteitis, osteomyelitis, periostitis, pyÆmia, tetanus, have all been known to follow the removal of a tooth, but the treatment of these conditions hardly lies within the scope of this book.