ON ANAESTHETICS I51 
failure of the heart, a verdict in which the whole profession would probably 
have supported him, whether valvular disease or fatty fibres could or could 
not be discovered on post mortem inspection. The case, then, reads us another 
striking lesson on the paramount importance of taking the respiration as our 
guide, and shows how readily, if this be not done, a death due to the grossest 
mismanagement may be regarded as the inevitable result of constitutional 
peculiarity. 
The case also shows the necessity of keeping watch for a while after the 
administration has been discontinued. The last portions of the vapour inhaled 
seem to take some seconds at least before they produce their full effects on the 
nervous centres; and the patient should not be left till he has been seen to 
breathe calmly and freely for some minutes after the cloth has been removed. 
On one occasion only, so far as I remember, have I seen firm traction on 
the tongue fail to remove laryngeal obstruction. In that instance the chest 
continued to heave, but no air entered or escaped, although the tongue was 
well drawn out. Happily, however, the desired effect was instantly produced 
by slapping the face with a towel dipped in cold water, while the traction on 
the tongue was maintained. This fact is interesting, not only as a striking 
illustration of the value of the sudden application of cold under such circum- 
stances, but also because it confirms the explanation before given of the modus 
operandi of traction on the tongue, viz. that it operates not mechanically, but 
through the nervous system. For here the barrier to the entrance of air into 
the chest remained in spite of the clearing away of any obstacle which the tongue 
might be supposed to present, but that barrier was at once removed by a means 
which could not act in any other way than through the nerves. 
It is nevertheless true that the tongue does frequently fall back under 
chloroform, and so occasion a mechanical impediment to respiration. It recedes, 
no doubt, in consequence of relaxation of the lingual muscles ; and accordingly 
thick or obstructed breathing depending on this cause may be very simply 
cleared by pulling the beard or forcibly pushing up the chin, so as to draw for- 
ward the tongue through the medium of the muscular fibres which pass back 
to it from the maxilla. Turning the patient’s face well round to one side, so 
as to cause the weight of the relaxed organ to tell laterally rather than back- 
wards, is another way in which a needless puncture of the tongue may often 
be avoided. But it must always be borne in mind that neither of these means 
can be expected to succeed if the obstruction exists in the larynx, and if they 
do not answer their purpose, not a moment should be lost in applying the artery 
forceps. 
Whenever it is necessary to draw the tongue forward, it is of course equally 
