Stoppage of the heart may occur suddenly, and may take place while respiration is still going on. It is usually ascribed to the chloroform, and no doubt concentrated chloroform vapour inhaled into the lungs may arrest the heart. Very commonly, however, it is reflex, and when death occurs in such a case it is to be attributed to the want of chloroform rather than to its excess. It is worthy of note that in the greater number of the cases recorded as deaths from chloroform, the statement is made that the quantity administered was very small, and that anaesthesia was incomplete. Before anaesthetics were used at all, death from shock during operation was by no means uncommon, and no doubt it still occurs during imperfect anaesthesia, although complete anaesthesia tends to prevent it. The operations in which death during chloroform chiefly occurs are short and compara-tively slight, though painful, such as extraction of teeth, and evulsion of the toe-nail - operations in which the introduction of deep chloroform anaesthesia might be regarded as superfluous, and involving a waste of time. These operations appear to be dangerous during imperfect narcosis, and not so when either no anaesthetic at all has been given, or complete anaesthesia has been produced. The reason of this probably is that when no anaesthetic is given, irritation of the sensory nerves during the operation causes two effects - slowing or stoppage of the heart, and reflex contraction of the vessels. This contraction neutralises the result of cardiac weakness or stoppage, maintains the blood-pressure, and thus prevents syncope. During imperfect anaesthesia, the reflex contraction of the vessels is destroyed, whereas the effect on the heart may still persist, so that irritation of a sensory nerve may produce syncope by stopping the supply of arterial blood from the heart, while the blood still flows rapidly from the arterial system through the capillaries into the veins. When the anaesthesia is complete, both reflexes are paralysed, and the circulation remains unaffected by any impression made upon the sensory nerves. Even when chloroform anaesthesia appears perfectly complete, death from shock may still occur, at any rate in the case of animals. I have noticed this on two occasions when engaged in making a gastric fistula in a dog. The animal was completely anaesthetised, but in both instances, when drawing upon the stomach in the process of inserting a cannula, the animal died suddenly. On mentioning this to Professor Schiff, he informed me that he had had many similar experiences, so that he had entirely abandoned the use of chloroform in such operations, and substituted ether.

When the heart stops, the treatment to be adopted is to lay the patient's head lower than his body (p. 264), to keep up artificial respiration, and to administer nitrite of amyl by inhalation.

Instead of the plan of artificial respiration already mentioned, Sylvester's may be used. Howard's plan may be used for very strong patients, but is not suitable for delicate ones. Respiration may be assisted by stimulating the diaphragm by the application of a faradaic current to the phrenic nerve. One pole is applied to the epigastrium and the other to the side of the neck, and the current is made and broken during the time that the inspiratory movement is being made artificially.

Uses. - The vapour of chloroform may be applied to the eye in photophobia, to the os uteri in pruritus pudendi, neuralgia, ulceration, or cancer of the uterus, in order to relieve pain. A few drops held in the hand of the nurse and inhaled by a child when a paroxysm of whooping-cough comes on, will lessen its violence.

The power of chloroform to aid the absorption of vegetable alkaloids may be employed in order to assist their action when applied externally, but care must be taken not to apply them over too large a surface when using such drugs as aconite or veratrine in combination with chloroform or chloroform liniment. A pledget of cotton-wool dipped in chloroform is frequently employed as a remedy in toothache; but as the chloroform irritates the pulp, and may increase pain afterwards, Ringer recommends a piece of linen moistened with chloroform to be folded over the tooth, so that the vapour may act upon the pulp without irritating it. It relieves vomiting from gastric catarrh or sea-sickness, lessens flatulent distension of the stomach and intestines, and may be used in dyspepsia and diarrhoea after the irritant has been removed. In cases of dyspepsia and chronic gastritis with dilatation, washing out the stomach with chloroform water has proved useful, by lessening pain and irritability of the stomach, diminishing the dilatation, by preventing decomposition and the formation of gas, as well as by exciting movement and secretion in the stomach.

Chloroform, in combination with small doses of morphine, and with some adhesive vehicle such as glycerin, is a useful remedy in coughs, more especially the coughs of phthisis. When inhaled to an extent quite insufficient to produce even the earlier stages of anaesthesia it may relieve the paroxysms of asthma. The first stage of chloroform action, viz. partial anaesthesia and partial loss of consciousness, is useful in biliary and renal colic, and in other cases of very severe pain, such as intestinal colic, severe neuralgia, aneurism, and during labour. A most ingenious plan of administering chloroform in such cases has been devised by Mr. Image, of Bury St. Edmunds. A piece of blotting-paper or lint is put in the bottom of a tumbler, and moistened with chloroform. The patient then takes the tumbler in the hand and inhales the vapour. The shape of the tumbler prevents it from being brought too close to the face, so that the vapour is always inhaled with a free admixture of air. As soon as it begins to take effect, the patient's hand and the tumbler drop, so that the inhalation ceases. When the effect begins to pass off, the patient again raises the tumbler and inhales anew, and so the process may go on for a long time, without any further care on the part of the attendant than to keep the lint or blotting-paper in the tumbler moist with chloroform.

In severe cases of chorea with cerebral symptoms, the inhalation of chloroform may be necessary; care is, however, necessary if there be any cardiac disease. In the administra-tion of chloroform for surgical operations, the towel or napkin may be folded so as to form an imperfect cone, into the con-avity of which a little chloroform is poured. The towel is then held over the patient's face, a few inches from his nose, the apex of the cone touching the bridge of the nose, its base being directed downwards, and its margin a couple of inches from the ace. Care should be taken that no part of the towel which is wet with chloroform touches the face, on account of the burning sensation which it produces, and that a free admixture of air be allowed and the vapour not administered in too concentrated a state.

Another way of giving it is to spread a single fold of the napkin over the patient's face, and allow the chloroform to fall, a drop at a time, upon the napkin a little in front of the nose. The drug may be administered in a similar way upon a wire mask covered with a single layer of flannel. In order to avoid the possibility of the patient inhaling too concentrated a vapour, an apparatus has been devised by Mr. Clover, consisting of a bag of 10,000 cubic inches capacity, which is filled with air containing 4 per cent. of chloroform vapour, and from this the patient is allowed to inhale by means of a flexible tube and a mask. The apparatus is filled by pumping successive quantities of air from a bellows holding 1,000 cubic inches through a box heated by hot water, into which 32 1/2 minims of chloroform have been injected, a quantity just sufficient to charge the air with the proper amount of chloroform.

A mixture of 1 part of alcohol with 2 of chloroform and 3 of ether, known under the name of the 'A, C, E Mixture,' is sometimes used instead of chloroform. It is supposed to have the advantage of being more stimulant and less depressing to the heart than chloroform. One disadvantage of it is that the three constituents evaporate with unequal rapidity, so that at the end of an operation a patient may get a much larger proportion of chloroform than of the other two.