146 ON ANAESTHETICS 
Whether pulling the tongue operates by inducing or relaxing muscular 
contraction in the larynx may be matter for discussion, but the main con- 
clusion, that it does not act merely mechanically, but through the nervous 
system, appears satisfactorily established. I have not hesitated to give the 
evidence on which it rests in full, as it appears to me to be of the highest practical 
moment. For it shows at once how grievous a mistake is committed by those 
who content themselves with gently drawing the apex of the tongue a little 
beyond the teeth, or pushing forward its base with the finger, or perhaps ascer- 
taining that the epiglottis is not folded back. Such proceedings are instances 
of attention misapplied, and waste the golden opportunity for rescuing the 
patient from death. The proper treatment, like many other good things in 
medical practice, owes its origin to a false theory, but though the erroneous 
notion of obstruction by the tongue did good service in the first instance by 
suggesting the original method, it now tends to encourage supposed improve- 
ments upon it, which rob it entirely of its efficacy. 
If the above description is correct, if it is true that when the administration 
of chloroform with the cloth is carried too far, the first serious symptom is an ob- 
structed state of the respiration, which without watchful care mayoccur unnoticed, 
and, if allowed to continue, will endanger the life of the patient, but, if promptly 
treated, will harmlessly disappear—it follows that the attention of the adminis- 
trator ought to be concentrated on the breathing, instead of being, as it too 
often is, diverted by the pulse, the pupil, or other matters still less relevant. 
As an example of the risk that is run by want of close attention to the 
respiration I may mention the following case. A surgeon of considerable 
experience was giving chloroform to a patient on whom an operation was being 
performed, of which I was a mere spectator, but I noticed that stertorous 
breathing came on, and gradually passed into complete obstruction, at a time 
when the administrator was gazing with interest upon the proceedings of the 
operator. Seeing that the patient was in danger, I suggested to the giver of 
the chloroform the propriety of pulling forward the tongue. He replied that 
this was uncalled for, and pointed to the heavings of the chest as evidence that 
to the larynx of a patient. I find that it is not universally recognized.] This occurs in retching, 
and doubtless also in vomiting, when a folding back of the epiglottis, instead of protecting the larynx, 
would tend to direct into it the material passing from below upwards. Thirdly, an antero-posterior 
coaptation of the structures of the laryngeal aperture at a somewhat deeper level, without any change 
in the position or form of the epiglottis, towards which the folds of mucous membrane above the apices 
of the arytaenoid cartilages are carried forwards, till they are in contact with its base. This is seen 
in coughing, and also in laryngeal stertor; and it is probable that during sleep, when the respiration 
is so apt to become stertorous, there is but a very narrow chink between the epiglottis and these folds 
of mucous membrane, which would thus serve to protect the deeper parts of the air-passages from the 
introduction of foreign matters in the state of unconsciousness. Fourthly, the closure of the 71ma 
glottidis in the production of voice. The white chordae vocales form a beautiful contrast with the highly 
vascular structures in their vicinity. 
