120 IMMEDIATE AND REMOTE 



involving some degree of shock, the depression of 

 the operation added to that of the chloroform may 

 lead to a fatal result which would not have occurred 

 with ether. This may to some extent be obviated if, 

 on account of bronchial complications, it is necessary 

 to trust mainly to chloroform, by giving an occa- 

 sional mask-full of ether to stimulate the great vital 

 centres in the medulla. 



If the surgical operation does not involve much 

 shock, but chloroform is carelessly pushed in spite 

 of dilating pupils and disappearance of the light 

 reflex, the breathing will fail, and in these circum- 

 stances the heart \vill be found still beating when 

 respiration ceases. 



DELAYED CHLOROFORM POISONING. 



The third danger is subtle and unexpected ; it has 

 been recognized only recently, and we do not know 

 how to treat its symptoms. 



In Chapter VII. reference is made to the remark- 

 able process of abnormal decomposition of fats which 

 may take place when the amount of glucose supplied 

 to the tissues by the blood is deficient. In 

 these circumstances, /3-oxybutyric acid, diacetic (or 

 aceto-acetic) acid, and acetone are produced, and 

 the patient is poisoned by the acids, while the acetone 

 imparts a sweet odour to the breath and urine. We 

 saw that starved patients and diabetics were par- 

 ticularly liable to this condition of " acidosis " or 

 " acetonaemia," as it is variously called. Fat chil- 

 dren and sufferers from peritonitis are frequently 

 the subjects of acidosis after operations in which 



