The anesthetist watches _constantly_ the rhythm and quality of the breathing, the color of the ear and the character of the pulse. From time to time, only as occasion demands, he refers to the accessory signs for confirmation. Should he, at any time, be in doubt about the depth of the narcosis, the first step is always to desist from giving more of the anesthetic until he has regained his bearings or the signs of awakening are recognized. SOME IMPORTANT REFLEXES. [Sidenote: Pharyngeal Reflex] (1) _Pharyngeal reflex._ Coughing does not necessarily indicate awakening. It usually means that the vapor of the anesthetic is too concentrated and irritates the air passages. “Holding the breath” occurs even in fairly deep narcosis and has the same significance. The treatment is to dilute the anesthetic by admitting air. [Sidenote: Ano-respiratory Reflex] (2) _Ano-respiratory reflex._ The crowing inspiration heard during operation on the perineum or rectum, _does not indicate that the patient should have more anesthetic_. [Sidenote: Splanchnic Reflex] (3) The reflex produced by traction on the gall bladder or mesentery is similar in its significance to that of the ano-respiratory reflex. VOMITING DURING ANESTHESIA. [Sidenote: Vomiting] It may happen to the conscientious anesthetist, who desists from giving more of the anesthetic until he has regained his bearings, that the patient suddenly shows signs of awakening, and vomiting begins. This is a disagreeable, but generally not a serious interruption. The anesthetist is absolute master of the situation. Although the patient’s face turns somewhat blue during the vomiting efforts, the anesthetist _should not attempt to push the jaw forward or exert traction on the tongue_. The face is merely turned to the side and kept in position by placing the hand on the cheek. The mouth and pharynx are cleansed gently with a piece of gauze and the anesthetic is continued, drop by drop. It is often surprising in such cases how rapidly the patient can be brought back into the proper plane of anesthesia. There need be no fear that the patient will fully awake. OBSTRUCTED BREATHING. Many anesthesias are unsatisfactory because the breathing is obstructed. To my mind the prime cause of obstructed breathing is too great a concentration of the anesthetic. The importance of avoiding the _crowding of the anesthetic_ is the secret of a good narcosis. [Sidenote: Concentrated Anesthetic]