552 TRANSACTIONS OF SECTION I. 
heart arrested by inhibition, but it always failed in cases where the heart was 
irresponsive to stimuli, from excessive narcosis. In such cases as these, and 
in those in which the heart was pathologically impaired beforehand, was syncope 
fatal. 
The use of strychnine, atropine, ether, amyl nitrite, &c., is irrational. 
II. Excessive narcosis.—When the heart has ceased from this cause no 
remedy wili ‘restart it. Experimentally the tension of the anesthetic in the 
myocardium may be rapidly reduced, so as to admit of restoration of function, 
by the perfusion of isotonic salt solution through the coronary arteries; but 
this has no clinical value in consequence of the pulmonary cedema which ensues 
and the difficult surgical technique entailed. The indications for treatment 
are :—(1) Elimination of the anesthetic as rapidly as possible. (2) Raising the 
blood-pressure in the right cavities of the heart and in the adjacent veins. 
(1) Elimination.—In less severe intoxication, with respiration still continuing, 
it is only necessary to withdraw the anesthetic mask. Where respiration is 
feeble or has ceased, artificial respiration is demanded. This not only eliminates 
the anesthetic, but it oxygenates the blood and assists in raising the venous 
blood-pressure in the great veins at the right side of the heart. 
(2) Raising the venous pressure at the heart.—Inversion into the head-down 
position and artificial respiration, as for syncope. If the heart has not ceased, 
recovery is relatively rapid. Strychnine is not harmful, but it is not indicated. 
Amyl nitrite and ether are both harmful. Fatal excessive narcosis is often 
finally accompanied by cardiac inhibition. 
III. Shock.—The same indications exist for raising the blood-pressure in 
the right cavities of the heart and the veins adjacent as for I. and II. This 
is attained by inversion into the head-down position. The body-heat must be 
maintained and warm oxygen inhalations used. The employment of warm 
saline injections or infusions is not indicated unless in collapse from great loss 
of blood. Otherwise the rise of arterial and venous blood-pressure is soon lost 
in consequence of its rapid exudation into the surrounding tissues. Ergot and 
pituitary are of use in the mild forms, but where help is urgent they fail. 
Adrenalin and epinine, however, always raise both venous and arterial blood- 
pressure, but only temporarily unless it be given by continuous flow into the 
vein and not of greater concentration than one in 500,000, with the pulse used 
as a guide. The flow should be reduced if the pulse-rate falls to 60 per 
minute. The more severe the shock the greater is the care necessary to guard 
against vagus inhibition of the heart or against ventricular fibrillation from 
excess of adrenalin. 
TV.—In cases of drowning the patient should be inverted head-down, and, 
if the fluids have entered the bronchus from below, the sound side should be 
preserved from flooding by promptly turning it uppermost. When both sides 
are flooded a tube should be inserted through a laryngotomy opening and the 
blood or fluid aspirated by the mouth or other ready means. Laryngeal spasm 
or obstruction may be relieved by the finger or sponge cleaning out the glottis. 
An artificial cough, induced by sudden bilateral compression of the thorax, 
will often expel material or open a Jarynx closed by spasm. Respiratory failure 
in operations in cases of cerebral compression may be obviated by a preliminary 
injection of atropine, otherwise artificial respiration must be performed through 
the operation. Light narcosis is used throughout these operations. Cases of 
cedema of the glottis, retropharyngeal abscess, and Ludwig’s angina are very 
dangerous for general anesthesia, and should be operated under local anesthesia 
only. Reflex syncope cases are treated as syncope. Cases known to be liable 
to depressor reflexes should receive a preliminary injection of morphine and 
atropine, and be given ether 
(iv) Observations on a Case of Delayed Chloroform Poisoning. 
By Professor R. F. C. Lerrn. 
This form of poisoning denotes a persistent and generally fatal intoxication 
which comes on at varying intervals (from a few hours to many days) after the 
chloroform narcosis has passed off, and closely resembles the pyogenic forms. 
It is a rare condition, the number of cases recorded since its first recognition 
