Chloralum hydratum

Volume I — Special Symptomatology

{Hydrate of Chloral.)

Pharmacology— Chloral itself is not used in medicine. It is an oily substance— a liquid. At ordinary temperatures it gives off pungent fumes. It is manufactured by the action of Chlorine on alcohol. United with water, this oily liquid is converted into a hydrate.

Chloral Hydrate is a volatile, crystaline solid, of a hot, burning taste ; insoluble in cold chloroform, but very soluble in water, ether, and alcohol It occurs generally as transparent, colorless tablets, but sometimes acicular, or even in rhomboidal crystals. The compound of alcohol and chloral— chloral alcoholate — which resembles closely the hydrate, can be distinguished at once by its solubility in cold chloroform.

If an alkali be added to a solution of Chloral Hydrate, it breaks up into foresnic acid and chloroform, which, when water has been the solvent, at once separates in the form of oily drops.

Officinal Preparations. — Tincture with strong alcohol; dilutions. (Watery solutions ; usually 20 gr. to 3 i.)

Analogues. — Ether, Chloroform, Bromides, Conium, Gelseminum, etc.

[When given to cause sleep or allay suffering, in material doses, it is best prescribed in Syrup of Tolu, 10 grs. to the dram. It should be administered largely diluted. 20 grs. is the average soporific dose for an adult.]

Mental Sphere.

Great excitement and intoxication, without sleep. Restlessness, with delirium and parched, dry skin.

Insanity. — The following results have been gained by giving

to insane persons a daily average quantity from twenty

to thirty grains: When patients are destructive and violent, the Chloral acts as

an excellent hypnotic by night, and soothing agent by

day.

Free from destructive habits, and gain in weight and strength.

Action of the bowels and bladder improves.

Appetite of the paralytic patients increased.

Those suffering from abnormal sensations are benefitted.

Cuts short the hallucinations in those predisposed.

Desire to maim and hurt themselves passes away.

Patients who suffer incessantly from hearing voices, some

benefitted. Melancholia has been benefitted.

That the greater the disorganization of the brain and the cord (as judged by the symptoms), the sooner does the system come under Chloral action.

Very easily irritated at trifles.

0 Puerperal mania, it causes sleep when all other remedies fail

Wandering of the mind; incoherent talking.

° Delirium tremens, when the brain is congested.

Head.

Congestion of the brain, with some mental excitement, (p.)

Cerebral congestion (fatal.) {Hammond?)

Pain which is excruciating in the occiput.

Great heaviness of the head/ he cannot lift it.

Head feels as if compressed in a vice.

u Cerebro-spinal congestion, in several cases. {Hale.)

Eyes.

Aching heaviness in the eyes.

The eyelids feel so heavy that he can hardly lift them. {Gels.)

• Intense itching of the inner canthi and edges of lids.

• Red, injected, and blood-shot eyes.

• Puffy swelling of the lids.

• Burning in the eye and eyelids.

Watery eyes, especially when looking at anything Eyeballs feel too large.

Congestion of the retina, (p.) Contraction of the vessels of the retina. (s.)

Sight.

Blindness, or great dimness of vision.

Disturbances of the power of accommodation. (Crabbe.)

Great hyperesthesia of the retina.

He cannot see small objects, such as printed letters, but a few

moments, when they gradually fade away. If one eye only is used until objects fade, the other sees objects

plainly for awhile. (Gelserninum.) Everything looks white (Coca)', color-blindness. Dark spots before the eyes, as in amaurosis. Gorgeous visions of arches, tapestry, of various vivid colors,

pass before the eyes when shut, or open in the dark. All colors are unusually bright.

Vibrations apparently in the eyes and head when lying down Great sensitiveness to light and noise.

Mouth and Tongue. Apparent swelling of the tongue, with sensations of stiffness,

vibrating, quivering, etc. Fears of suffocating from swelling of the tongue. A choking sensation at the root of the tongue. A black streak down the centre of the tongue. Foam at the mouth; a kind of salivation.

Face.

0 Neuralgia of the inferior dental branch of the fifth nerve.

(Itinger.)

° Neuralgia of the temporal region. (Ib.) Congested and livid face.

Teeth and Jaws. ° Neuralgia from decayed teeth, (a grain or two in the cavity

stops the pain quickly.) (Hale.) ° Odontalgia traumatica, from pressure of the filling; the pain unbearable ; worse when lying down. (Cured by ten grains. See New England Medical Gazette, March 1872.) (Hale.) Stomach.

Retching, lasting an hour, during a surgical operation. Does not usually disturb the stomach.

Sudden and violent vomiting.

Stool.

c Diarrhoea, worse at night, during dentition ; excessive nervous

excitement. Does not usually cause abdominal symptoms.

[In the very severe colic of children, when the pain threatens to cause spasms, 3 to 5 grs. will give prompt relief. (Hale.)]

Urine.

° Nocturnal incontinence of urine — in children.

Generative Organs. (Male.) Loss of sexual power, with absence of desire and

erections. Impotence.

° Chordee, during gonorrhoea, very severe.

(Female.) ° It quickly mitigates the pain of labor, of dysmenorrlio&a and uterine spasms, but should not be given when there is a tendency to haemorrhage, as it increases that tendency, even to the production of purpura. (Hale.) Heart and Circulation.

• Great dyspnoea, a sense of suffocation, oppression at the base of the chest (in front), and urgent thirst.

[The following case of poisoning from fifty grains illustrates its action on the circulatory system: Cold extremities, an excessively rapid, weak, irregular and intermittent pulse; jactitation of the limbs; an intolerable aense of sinking and oppression at the pit of the stomach; gasping breathing, aud confusion of thought. I observed at this time and for three-quarters of an hour subsequently that the radial, temporal, and tibial pulses were all of the character I now describe— frequent, weak, irregular in both force and rythm, and frequently intermittent, but that the heart was acting regularly, although with increased frequency and diminished force. Stimulants, with white of egg were administered freely, warmth was applied to the extremities, sinapisms placed on the cardiac region, fresh air was introduced plentifully into the room, and at the end of an hour from my first seeing the patient, the pulse had become much steadier, though still very frequent and very weak. The syncopal feeling had diminished; the feet were warm, and there was a tendency to sleep. This state of comparative freedom from urgently dangerous symptoms lasted for longer than an hour, when, without any apparent cause, they returned with increased severity. The patient now seemed in the greatest danger. The superficial pulses were almost imperceptible, and when they could be detected, presented the character I have described. Still the heart was regular in its beat, although feeble, and intensely rapid in its pulsations. The mind wandered much,

there was utter prostration of muscular strength, the limbs being extended, the head low, and the aspect was at times that of impending dissolution. There was great depression, a sense of suffocation, oppression at the base of the chest (in front), and urgent thirst. The treatment previously adopted was again pursued vigorously, and at the end of an hour and a half relief was obtained and sleep followed. The next morning I found the pulse quite regular) and of its normal frequency. The points of interest that occurred to me were: 1st, the dose; 2d, the time between its administration (one hour) and the appearance of symptoms; 3d, the recurrence of symptoms after their temporary cessation ; 4th, the curious effect on the muscles, which was obviously not due to effect on the heart; 5th, the relief by food and stimulants. I found that the albumen of two eggs was followed by a calming effect, and a tendency to sleep.]

Skin.

Purpura hemorrhagica, as the following cases show:

[M. A., female, aged 69, who had been an inmate of this asylum* for many years, and who was subject to periodical attacks of mania, occurring every six months, and ushered in by convulsions and coma, entered upon one of her wonted paroxysms on the 1st of March, 1870, and was ordered twenty grains of Chloral Hydrate three times a day. This produced sleep and cutaneous anesthesia, and on the 4th of March, a very unexpected result in the form of a bright red blush, erythematous in aspect but permanent under pressure, over the chest and shoulders. This blush on March 6th had pervaded the whole trunk and limbs, and had become mottled with livid patches and deep red spots. The lips and buccal mucous membrane had contemporaneously become red and raw-looking, the gums spongy, and the tongue blistered and ulcerated in several parts. The breath was foetid, the pulse 120, feeble and compressible, and the general condition that of great debility, with delirious excitement. On March 9th no material change had taken place, except that the ulcerations in the mouth had become more extensive and distressing; but on the 11th the petechial eruption showed signs of vanishing over the thorax and abdomen, where it had never been so severe as on the arms and legs, and where intervals of yellowish and white skin were now visible. The arms were of a red color, speckled with shreds of white, dead epidermis partially separated from the adjacent cutis, and the lips were covered with sordes and dried blood. On March loth a sort of general desquamation had set in, the cutis being raised in thick round patches, like blisters from which the scrum had been absorbed, the skin beneath being of a dull purple color^ and in some places yellow. After this a large bed-sore formed over the sacrum, and some superficial cracks and fissures presented themselves in the neighborhood of the joints. Convalescence was, however, steadily maintained, and the patient was soon restored to her usual health.]

CL. T., female, aged 46, laboring under heart disease, left hemiplegia,

♦West Riding Asylum. Cases reported by Dr. Crichton Browne. Monthly Homceoiathic Review, June 1871.

and dementia, with excitement, who was ordered, as a calmative, on February 24th, 1870, fifteen grains of Chloral thrice daily, and who seemed to derive benefit from the prescription until March 15th, when numerous reddish purple blotches were observed around the left elbow, which, on the following day, had enlarged and united with others of a similar kind which had come out on the shoulders and forearm. On March 17th several livid marks had broken out on the face, while the left arm had become swollen and indurated, and showed upon its red surface a mass of minute points or stigmata, of a much deeper red, and not disappearing under pressure. On the next day dull purple spots and discolorations — some small, round and circumscribed, others large and regular in shape — were seen on the legs, abdomen and back ; being restricted in the latter situation to a band two inches in breadth along each side of the vertebral column. Along with these petechias there was great prostration of strength, a tendency to somnolence, weakness and irritability of the pulse, a raw state of the lips, which were entirely denuded of epithelium, and a fissured and thicklycoated tongue. On the 19th of March the spots and discolorations had spread in every direction, and had lost their vividness of hue, having assumed a deep purple tinge. Symptoms of pulmonary congestion also appeared. Strength gradually ebbed ; and, after several slight attacks of syncope, death took place on the 22d of March. At the autopsy, thirty .one hours after death, the body was found covered with livid vibices and ecchymoses of various shapes and sizes, largest upon the limbs, smallest upon the abdomen. The ankles and feet were of a diffused purple color, and there was much sugillation of dependent parts. Rigor mortis was present. The outer layer of pericardium was adherent to the heart, which weighed seventeen ounces, had thin walls, dilated cavities filled with discolorized clots, and valves incompetent and enormously thickened and puckered. There was a sort of cartilaginous deposit cn the outside of the right auricle. The right lung was congested and cedematous ; the liver was fatty ; the capsules of the kidney were thickened and adherent, with wasting of the cortical substance. In the head a large arachnoid cyst was found coexistent with the right hemisphere, which was flattened beneath it. It presented a reddish-green appearance, and contained several ounces of a bilio-sanguineous looking fluid. The whole brain weighed forty ounces; the right half weighed eighteen ounces, the left half twenty-one and one-half ounces. There were the rusty-brown traces of an old clot in the right corpus striatum.]

[Note. — "Whether Chloral will prove a curative agent in this dreadful disease, must be shown by experience. The blood-disorganization may not be a dynamic effect of the drug, but due to its presence in the blood, and acting chemically. Hale.]

In several cases, and even several times in the same person, Chloral caused all the eruption and symptoms of an attack of scarlatina. (British Journal of Homoeopathy, April, 1872.)

Sleep.

Quiet sleep, apparently natural.

Comatose condition lasting for days, ending in fatal cerebral

congestion. Restless; screaming, noisy in sleep. * Night terrors, especially in teething children. Somnolence, during which he is conscious of all his actions, such as coughing, spitting, etc. [20 grs. usually causes quiet sleep for six hours, 40 grs. for 12 hours.]

Nervous System.

0 Traumatic tetanus (many cases).

° Puerperal convulsions in the last stages of labor. {Dr. F.

A. Lord.) ° Chorea (many severe cases).

0 Infantile tetanus; (two grs. at time of each spasm).

° Puerperal convulsions, arrested by 20 grs. {Dr. F. A. Lord, U. S. Med. & Surg. Jour., May, 1872.)

0 Tetanus, from various causes, and trismus.

° Neuralgic and rheumatic pains.

Pathological Effects.

Ocular and palpebral mucous membrane is injected.

Vascularity of the ears without increase of heat.

Pulseless, with contracted pupils; temperature 91-2.

Experiments on rabbits, they exhale the odor of Chloral through their nostrils, a fact which would lead one to think that it was not decomposed in the blood.

Congestion of the abdominal viscera; mesenteric vessels are turgid, all the mucous membranes are injected, particularly that of the trachea, if examined during the experimentation.

The brain, cerebellum, and their membranes show an intense vascularity.

The duration of its action is in proportion with the feebleness of the patient.

In two cases of delirium tremens, quiet sleep was induced. In a patient suffering from bronchitis with asthma, the Chloral gave relief.

Deep and prolonged narcotism can be produced by the Chloral.

During a portion of the period of narcotism there may be complete anaesthesia, with absence of reflex action; a condition, in short, in which every kind of operation fails to call forth consciousness.

In fatal cases the functions are destroyed in the following order: the cerebral; 5, the voluntary muscles; c, the respiratory; d, the heart.

The Chloral prevents in some small degree the coagulability of the blood, and in large quantities stops the process of coagulation altogether. In large quantities it also destroys the blood corpuscles, and produces general destruction of blood. But to produce deep insensibility, the dose administered need not be so large as to produce serious derangement of blood.

Hydrate of Chloral should be taken, to secure safe and satisfactory effects, on a neutral condition of the stomach.

If the stomach be acid, the Chloral is not taken into the circulation, and acts imperfectly.

If the stomach be alkaline, the Chloral is absorbed too rapidly.

An acid stomach should be neutralized before the Chloral is given.

Volume II — Special Therapeutics

The Hydrate of Chloral was discovered by M. Liebreich, and introduced by him as a therapeutic agent, before the Medical Society of Berlin, in June, 1869. It was a white solid, made up of needle-form crystals having the appearance of snow. It has an odor similar to ripe muskmelons. On exposure to the air it rapidly deliquesces, and after a time wholly disappears. It is soluble in water, alcohol, and ether.

The lower animals are readily affected by very small doses, two to five grains causing profound sleep. It is certain and rapid in its action. For an adult man twenty grains is the average dose. This generally causes the semblance of a normal, profound slumber, commencing in fifteen to twenty minutes after the drug is taken into the stomach, and lasting from six to ten hours. Certain persons, however, are so constituted that they require double this quantity to produce the same degree of somnolence. As a rule, the quantity may be safely graduated for a single soporific (sleepcausing) dose. Two grains can be given for each year of age until the patient is twenty. This dose may be repeated in an hour (or even thirty minutes if intense pain is present). If you give the Chloral hydrate to cause sleep and alleviate pain, you must administer the definite quantity known to cause the desired result. You can no more produce anesthesia with the attenuations than you can with the attenuations of Chloroform or Ether. It is only for symptoms and conditions simulating its primary effects, that you can give attenuated doses ; nor will it bear much attenuation, all theorists to the contrary notwithstanding.

Under a heavy dose the breathing is imperceptible; after a moderate one the breathing is soft and gentle. There is no sensibility during this sleep, not even upon the external applications of stimulants. They sleep on, while all the functions of life are apparently at rest, except one, the circulation. On a microscopic examination of the web of a frog’s foot, while under Chloral, the

circulation is found most perfect, confirming the theory of Liebreich, that the heart is the last to die.

One prominent and persistent effect is the decrease of animal temperature with contracted pupils. No excitement precedes the sleep. Patients can be aroused at any time to full consciousness, the natural functions are performed, there is no disturbance of the secretions, and waking is not attended by disagreeable symptoms.

In fatal cases the following symptoms occur : Stertorous respiration; eyes set and glassy, pupils contracted and insensible to light; conjunctiva congested ; motion of the heart quite rapid and so feeble as to be scarcely felt ; blood settles under the finger nails ; purple spots are on the side on which they lie ; extremities cold, and frothy mucus flows from the mouth ; insensibility of the skin, with occasional moments of hypersesthesia.

The functions are destroyed in the following order: (1) The cerebral ; (2) the involuntary muscles ; (3) the respiratory ; lastly, the heart.

It paralyzes the ganglionic cells of (1) the brain, (2) the spinal cord, (3) and last, the heart.

Its mode of action is quite analogous to Chloroform, but large doses should be avoided when the heart is weakened.

Its therapeutical uses in homoeopathic practice are similar, in one respect, to its use by the opposite school, viz., for the necessary alleviation of pain and the production of sleep. I do not hesitate to resort to it, after a fair trial of our most approved homoeopathic remedies; nor should any of you, after you have decided in your best judgment that your patient will be in better condition from its use than without it.

It is to the public one of the most fascinating of narcotics, if its taste is tolerated ; but its habitual use is attended by all the evils which follow the abuse of such agents. Attempts to break off the habit have resulted in a condition similar to delirium tremens, and other depressed and irritable mental states.

Its immediate effects on the mental sphere are always calming, soothing, and quieting. Its remote (secondary) effects, depressing and irritating.

It is, therefore, secondarily homoeopathic to many forms of insanity , idiocy, and dementia .

The records of insane asylums give the following pretty uniform results, the average dose being from 20 to 30 grs. : “ When patients are destructive and violent, it acts as an excellent hypnotic by night, and a soothing agent by day ; they become free from destructive habits, and gain in weight and strength ; the action of the bowels and bladder improves ; the appetite is increased ; it relieves abnormal sensations and hallucinations; it checks the desire for self-inj ury ; and melancholic patients become more cheerful.”

It has been observed that “ the greater the disorganization of the brain and cord, the sooner does the system come under its action.”

I have used it successfully in many cases of delirium tremens and 'puerperal mania, when the symptoms were like those I have just described.

The pathological condition which it induces in the brain in fatal cases is said to be ancemia. This I suppose to be the primary , direct result of a single fatal dose.

But cases are on record which go to show that an opposite condition results from longer use — of massive doses ending in death. In other words, secondary effects supervene. Thus Hammond relates a fatal case, where he gave it for a disease of the brain, and found congestion of the brain post-mortem. In other cases, the brain, cerebellum, and their membranes, showed an increased vascularity ; but these I believe were secondary effects.

Its purely homoeopathic applications in brain disorders are as follows :

In cerebral ancemia, suddenly appearing, simulating the usual effects of a dangerous single dose, you may prescribe it in the 3* or 6X dilution. In such cases it is analogous to the Bromides and Conium.

In cerebral congestion, occurring as a reaction from previous anaemia, the Chloral is one of the best remedies you can use, if you select it judiciously. It here rivals the Bromides.

This condition of the brain is that which is found in patients whose insanity takes the form I mentioned at the beginning of this lecture.

There is sometimes excruciating pain in the occiput and ternpies; great heaviness of the head, and a feeling of compression of the head, as if in a vice; also aching and redness of the eyes, illusions of vision, and photophobia.

I have cured congestion of the brain in children after cholera infantum, with the 1 * dilution.

It is useful for the night terrors of children when arising from worms, teething, and the result of cerebral irritation after colliquative discharges. Here it rivals Cuprum aceticum and the bromides, either of which are superior to Belladonna, which is so absurdly used in a routine way.

I can hardly give you the differential diagnosis between the Chloral and the Bromides in such cases; the line of distinction is very intangible. You will have to learn it by experience, or rely upon your intuitions, or wait until we have complete provings of these important drugs.

I believe it will prove useful in some cases of cerebrospinal congestion, but doubt its usefulness after inflammation has taken place. The pains in the occiput and head seem to indicate its relation to this disease.

When inhaled it causes intense irritation of the nasal and other surfaces of the respiratory mucous membrane. You may find it useful in cases of hay fever (catarrhus sestivus) if inhaled at the very outset of the malady, in a very dilute form. In my own case 10 grains taken at the outset of an influenza always arrests it.

Its effects on the eye and sense of vision are unique and peculiar. (You will find many hay-fever symptoms among its eye symptoms.)

It causes aching in the eyeballs, which feel too large. (Spig.) The lids feel so heavy he can hardly lift them. (Gels.) Intense itching of the inner canthi and edges of the lids ; the lids are puffy and swollen ; red, injected, and bloodshot eyes ; burning in the eye and eyelids; profuse irritating lachrymation.

You will find some interesting contributions to the therapeutics of Chloral in the “ British Journal,” for July, 1874, by Dr. D. Dyce Brown. Taking the above symptoms of the eye as the indications, he treated twelve cases of conjunctivitis with Chloral, and with uniform success. His doses were — “one grain of the pure salt, in water, three times a day, for adults, and fractional doses

for children.” In two cases, in my own practice, its curative effects were simply magical.

In addition to the symptoms already given, his cases presented others, namely, small ulcers on the cornea ; phlyctcence ; severe circum orbital pain ; chemosis ; loss of appetite , and sleeplessness.

It ought to be useful in abnormal conditions of the sense of vision, such as asthenopia, color-blindness, ocular hyper cesthesia, photophobia ; and perhaps, threatened paralysis of the optic nerve. Many of its eye-symptoms resemble those of Gelseminum, Coca, Calabar, and Cannabis indica.

Spasm of the glottis is imitated by the symptoms of the tongue and throat (primary).

I have made some very gratifying cures of traumatic odontalgia by means of Chloral, several of which have been reported in our journals. If the toothache is from the pressure of a filling, give the usual anodyne dose internally; if from substances which have gotten into a cavity, clean it out, and fill it with the crude salt, or cotton saturated with the mother tincture (one grain to each drop of water or alcohol).

It may be useful in the attenuations, in the severe flushings which occur at the critical age, for it has caused a “dark scarlet flushing and heat of the head and face, from roots of the hair to ramus of the lower jaw, including the eyes; it was persistent under pressure; was blotchy in places, and extended to the neck and chest. There was excited circulation and slight contraction of the pupils.”

Similar paroxysms occur premonitory to, and during tubercular meningitis, and I observed them last summer, after attacks of cholera infantum. In the latter it came on in the evening, and prevented sleep from the heat and itching.

I have used it in a few instances in the severe pains, vomiting and retching from passage of biliary or renal calculi ; but you must avoid its use in large doses in jaundice from arrest of secretion, for it has caused “ jaundice, with coma and stupefaction ,” and aggravated many cases.

It has also caused atrophy of the liver, but these facts need not deter you from trying it in just such cases, if you prescribe the

attenuations (1* to 3X). The law of Similia ought to hold good in relation to Chloral as well as to Mercury.

Chloral does not cause diarrhoea, nor do the Bromides, yet in those cases where the diarrhoea is the result of morbid nervous depression with irritation, it will remove the cause, thus indirectly curing that symptom.

For example, in cases of cholera infantum, where there is intense nervous erethism, severe pain, and threatening spasms, I have not hesitated to give Chloral in doses of 1 to 5 grains.

The Bromides and some other remedies may be equally well indicated by the symptoms; but no other drug acts as quickly, and in some cases a few minutes lost is fatal to the patient.

It has been suggested in cholera. It causes all the symptoms of cholera, except the purging and vomiting. But in some cases of cholera (cholera sicca) no discharges occur. The patient is stricken down suddenly, and dies from syncope induced by cerebral and cardiac paralysis. Chloral is homoeopathic to such cases.

No special observations have been made as to its pathogenetic action on the kidneys and bladder.

It has been used with good results in incontinence of urine. Dr. Leonards considers it the only reliable remedy to remove the spasmodic action of the detrusor vesicse, which overbalances the contraction of the sphincter. He gives children from 6 to 10 grains dissolved in water, just before going to bed; allows only small quantities of fluids at supper, which should be taken several hours before going to bed. He adds: “We must, in enuresis nocturna, strictly differentiate between spasm and atony of the vesical muscles, as in the latter case Iron and Quinine are indicated.” (Ferr. mur., Nux.)

It appears to have some diuretic action, either director indirect. In the case of anasarca where it was given by Dr. Swan, in 5, 10, and finally in 15 grains, every 2 or 3 hours, it alleviated the terrible sufferings ; and the action of the kidneys, which had been almost suspended for days, became active again under its use.

Chloral-eaters are said to lose their sexual desires and become impotent. I have not observed any such phenomena.

I have used it in many cases of painful and persistent chordee

during gonorrhoea. Ten or fifteen grains taken at bedtime, not only causes sleep, but actually prevents the painful erections.

In the diseases peculiar to women, Chloral is a useful palliative.

In dysmenorrhoea of unusual severity, it will give relief when specific remedies fail. It may require 5, 10, or 15 grains every hour, according to the intensity of the symptoms and the idiosyncrasy of the patient.

In a paper read before the Edinburgh Obstetrical Society, E. Lambert claimed that while Chloral could not supplant Chloroform, it can be used to advantage in the first stage of labor. He also claimed that it could be given “ under favorable circumstances ” all through labor, and that the woman could go through from commencement to termination without consciousness. 1 suppose he means by “ favorable circumstances,” that the patient has no tendency to licemorrhage, for if such exists, Chloral is not considered a safe remedy.

American accoucheurs rarely give Chloroform during labor, and then for a few moments only at the very termination. If the patient requires it for an hour, or for hours, Ether is the best and safest anaesthetic. I should hesitate to administer Chloral in large doses to a person with weak heart, or in whom I suspected a tendency to haemorrhage. I have, however, used Chloral in several cases of labor, when the intense nervous irritability led me to fear convulsions, and when Veratrum viride was not admissible. In all these cases it had the happiest effects. I agree with Dr. Lambert, that “ it does not suspend, but rather promotes uterine contraction, by suspending all reflex actions which tend to counteract the excitability of the centres of organic motion.” The dose of Chloral required will depend on many circumstances. I have given 10 to 15 grains every hour. Lambert advises gr. xv every quarter of an hour until the desired results are produced.

I have alluded to its power of preventing puerperal convulsions' I believe it has such power. The late Dr. F. A. Lord reported two cases where 20 grains arrested such convulsions promptly.

It causes pulmonary oedema, yet it has been found a valuable palliative in that condition, as well as in emphysema. In very

small doses it ought to cure the former, if the general state of the patient is not too much depressed.

It weakens the heart; it paralyzes the ganglionic life of that organ, yet true to the law of Similia, it has been found to restore force and motion to the heart when life was rapidly ebbing away.

In Drs. Swan and Helmuth’s case there was organic disease of the heart. The Chloral almost restored normal action to the seriously disorganized organ.

The symptoms it causes are: “Great dyspnoea, a sense of suffocation, oppression at the base of the chest, in front; tendency to fainting, intolerable sinking at the stomach, livid lips, cold extremities, respirations as low as four per minute, pulse imperceptible.”

I have given it in the threatened paralysis of the heart during pericarditis. The dyspnoea and distress were fearful, yet 5 grains every 15 minutes restored the action of the heart, and the patient made a good recovery.

The pulse of Chloral is frequent, weak, irregular, in both force and rhythm, frequently intermittent; but the heart at the same time acts regularly, but with increased frequency and diminished force.

I predict that in cardiac neuroses Chloral in properly graduated doses will prove one of our best remedies, not only palliative, but curative.

I am not as sanguine as Dr. Swan, who claims to have got heart-symptoms by taking the 200th dil., and that the 40th will cure cardiac neuroses. Such assumptions need be put to the test of positive experience before we accept them.

When brought in contact with blood, it stops the process of coagulation. It destroys the blood-corpuscles, and produces a general destruction of that fluid.

Its continued use internally has caused purpura hmnorrhagica , preceded by a “ bright red blush, erythematous in aspect, but permanent under pressure,” followed in two days by “deep red spots, mixed with mottled livid patches.” The buccal mucous membrane becomes red, raw, ulcerated, and blistered, breath fetid, pulse 120 and feeble. A desquamation ensued, but with bed-sores

in some places. In other cases it caused petechise, vibices, and ecchymoses.

If this action of Chloral is dynamic , it may prove a homoeopathic remedy in purpura and scurvy. If chemical , we need not expect curative effects from it.

Reference has been made to the peculiar flushings of the face and neck caused by Chloral. It causes anot her species of eruption, namely, of blotches of different shapes, raised above the surface, and of a deep-red color. These blotches nearly coalesced, nearly resembling measles. This was attended with high fever, thirst, coated tongue, loss of appetite, and intense irritation of the skin, preventing sleep at night. It has caused an eruption on the arms and legs exactly like nettlerash, in large raised wheals, with intense irritative itching. Another case so imitated scarlet fever that the person was supposed to be laboring under that disease. In this same case, “ A number of large, pale elevations, or wheals, showed themselves on the legs, shoulders, and waist, while similar ones could be produced on other parts by scratching. At the same time, burning and stinging sensations, and a feeling of tightness and hardness over the whole surface, with lassitude, headache, sharp pain in the eyeballs, wheezing respiration, etc.”

It is not improbable to suppose that it affects the mucous membrane in a similar manner.

These symptoms make Chloral an analogue of Apis, and this analogy may be closer than we now imagine ; it is also a congener of Urtica urens, Copaiva, and Arsenic.

Dr. Dyce Brown, believing that Chloral might be used with advantage, tried it in nine cases of urticaria, and with complete success. He gave from one to one-quarter grain every three hours. In another six cases the patients did not return and report, and he thinks they, too, were cured.

In one case of pruritus vulva it relieved after Collinsonia failed.

It will be a lucky thing for us if we have found a specific for nettlerash , for it has been a difficult matter to affiliate a remedy Some of the freaks of nettlerash resemble Chloral effects, namely, the sudden stupefaction, asthma, and cramp of internal organs, not to mention vomiting and purging, which latter is supposed to be due to its retrocession upon mucous surfaces. I have only had

the opportunity to try it in a few cases, one of which was quite satisfactory. A child, a year old, had suffered from severe summer complaint for several weeks, had become pale and weak, when a new symptom set in which deprived it of all rest aud sleep — an urticarious eruption, red, blotchy, and itching, on the face, neck, and shoulders, worse in the evening. Apis, Arsenicum, and Croton were tried unsuccessfully. Chloral, 5 grains in half a glass of water, a spoonful every hour, removed the trouble in two days.

There is a kind of nervous itching, a species of 'pruritus, affecting the whole body, coming on after undressing, especially at night; there is no visible eruption until the skin is scratched, and sometimes not then. Ignatia is recommended, and will sometimes relieve, but Chloral may prove a better remedy.

In certain spasmodic diseases Chloral has been of infinite service to the physicians and surgeons of all schools.

I have already alluded to its use in puerperal convulsions. In tetanus it has made some very brilliant cures. It is indicated for tetanic spasms from Strychnia poisoning ; trismus from traumatic causes; from cerebrospinal meningitis; and also in infantile tetanus.

You must not expect to cure such a terrible disease as tetanus with any but massive doses. You might as well attempt to propel a five-pound shot with ten grains of gunpowder.

The dose in cases of tetanus in strong adults ranges from 10 grains to 3 drachms, repeated every one, two, or three hours, as the case demands. One patient, with traumatic tetanus, reported by Dr. Vernuil, took the enormous quantity of 200 grams (3000 grains) in twenty-eight days, and made a good recovery. Dr. yEschenthal cured a case of trismus in a child seven days old. It had twenty-seven spasms, and took in all 25 grains.

In trismus and tetanic convulsions of very young infants, or in teething children, I have given it in many cases. I prefer it to any other remedy because it acts so quickly (in ten to fifteen minutes), as in some cases a few moments lost is a life lost.

In tetanus it rivals Calabar, Atropia, Gelseminum, Bromide of potassa, and Curare, all of which cure by virtue of their secondary action. I do not assert that remedies primarily indicated in tetanus, like Nux vomica, Strychnia, and Ignatia, will not cure,

for I know that cases have been cured by the latter class. I would advise you to use the latter in cases of less intensity, or when you think you have time to test their power. I need not inform you that primarily indicated remedies must be used in minute doses (from the 6th to the 30th attenuations).

Chorea in its severest forms has been treated by Chloral with success.

A severe case, in which the little child could neither lie nor stand, the head, limbs, and body being in constant motion, and each muscle apparently partaking of irregular action. She could not utter a syllable, and swallowed with difficulty. She would wake from disturbed rest, cry out, and scream until perfectly exhausted and in danger of general convulsions. She became anaemic and emaciated. Two grains of chloral put her to sleep. Its use was continued every night for a week. After that time improvement was so rapid that it was abandoned.

M. Bouchet says : “ Chloral is a most prompt and efficacious remedy in those cases of intense chorea where the constancy and severity of the spasmodic movements threaten the life of the patient.”

Dr. Russell relates a case of severe chorea during the fifth month of pregnancy cured by Chloral.

Dr. Strange cured an obstinate and long-continued case of chorea in nine days, with eight grains repeated every three hours.

No remedy, in my experience, will so quickly and permanently remove the uncontrollable nervous agitation of hysteria. A dose of 15 or 20 grains will quiet a fit of hysterics so suddenly as to astonish the patient and her friends. It is quite homoeopathic to a hysterico-cataleptic state, when the patient is conscious of all that transpires but cannot rouse herself.

A word as to the proper treatment of a case of Chloral poisoning. Nux vomica lx, Strychnia 3X, and Atropia 2X are the best antidotes, aided by Digitalis when the heart is failing ; electricity applied to the spinal cord ; and Ammonia by inhalation and internally. The sleep caused by Chloral is not always calm. Some patients seem to suffer from and complain of horrible dreams, frightful visions ; they scream and cry out, sit up in bed, and cannot be quieted. An adult who was taking it for rheumatism, after

sleeping a few hours, would jump out of bed trembling with fear, bathed in a cold, clammy sweat, and scream frightfully as if in mortal terror. Here we have a good picture of those conditions known as nightmare, night-terrors, and similar morbid conditions occurring premonitory of or during meningitis.

I usually give in such cases very small doses, y^th to 1 or 2 grains, according to age, and have been very successful in removing these abnormal symptoms.

In the 6th or 30th it may prove curative in “comatose conditions lasting for days, ending in cerebral congestion.”

The pleasantest vehicle in which to administer this drug, when given in appreciable doses, is the Syrup of tolu, to which you can add from 1 to 20 grains to each teaspoonful.

The dilutions from the mother tincture (1 grain to 1 drop) are made with water, alcohol, or syrup.

On the Use of Chloral-hydrate Enemata. — Dr. Starcke, of Berlin, has a paper on the employment of Chloral-hydrate enemata in the “Berliner Klinische Wochenschrift” (August 19th). He observes that there are great prejudices, especially in England, against the continued use of Chloral, occasioned, probably, by the not unfrequent misadventures occurring in connection with its use in habitual drunkards. Last year Dr. Starcke himself fell ill of a chronic gastric catarrh, with great acidity of the contents of the stomach, and considerable emaciation and prostration. The principal and most distressing symptom, however, was persistent insomnia, only half an hour to an hour’s sleep being obtained at night. At the suggestion of his colleagues Dr. Starcke resorted to the use of Chloral, but the irritable state of the stomach forbade its use by the mouth, and hence he determined to take it per rectum. An aqueous five per cent, solution of Chloral was warmed to about 95° Fahr., of which he first injected 10 grams, and after a quarter of an hour a further quantity of 10 grams, so that in all 1 gram (151 grains) of Chloral were thus taken. This was in a few minutes followed by a feeling of warmth, comfort, and repose, and lastly by sound sleep, which lasted uninterruptedly for five hours. In this manner Dr. Starcke continued the injection of Chloral for five months, taking in all 120 grams of the drug. Decided convalescence set in after almost the very first dose, which was followed every morning by a sense of vigor and a desire for food, without any headache or other discomfort. Nor did the efficacy of the dose of Chloral diminish, and latterly even half the quantity, i. e., .5 gram was sufficient. Frequently the attempt was made to obtain sleep without resorting to Chloral, but in vain, until within the last month, when Dr. Starcke found he could discontinue it altogether. This employment of Chloral per rectum has decided advantages in cases of gastric irritability. Dr. Starcke tried twice to take it by the mouth, and each time it was, after a lapse of a few minutes, completely rejected, and no sleep ensued. The absence of all unpleasant results when administered by the rectum is doubtless due to its undergoing no decomposition, as is generally the case when it comes into

contact with the contents of the stomach. Of course, the drug should he absolutely pure. The sensation of burning and tenesmus which at first follows an injection may be materially obviated by well oiling the nozzle of the syringe. And since the site of the tenesmus is chiefly in the region of the sphincter, contact of the chloral solution with this part of the gut should be avoided by passing the injection pipe as high up as possible. And if the injection is made by one’s self, the position on knees and elbows will be found the most convenient. It is also of consequence that the solution should be complete, and that it should be warmed to the temperature of the body ; also that the dose required is a moderate and even small one, as compared with that usually given by the mouth. Dr. Starcke has subsequently used Chloral in the same way in various cases and with the same uniformly safe and favorable results. It seems specially applicable in the case of aged people, and in no case need the dose exceed one gram (151 grains). — “ London Medical Record,” October 15th.

j Enemata of Chloral in Sick Headache. — Dr. J. Seure (“Bull. Gen. de Therap.” 1878, p. 385) recommends this treatment very highly. He says that a patient of his, a lady, who is subject to severe attacks of migraine after shopping, etc., is accustomed, on her return home, to take an enema consisting of a glass of warm water, with a tablespoonful of the following mixture: R. Chloral, gr. xlv; Aq. destillat., f^x. — M. She then reclines upon a sofa, with closed eyes. Within a few seconds she begins to taste the Chloral in her mouth, and at the same time she experiences a sensation of numbness. Little by little the headache disappears, nausea is allayed, and half an hour later nothing remains but a slight discomfort in the head, with a little torpor.

Within an hour and a half this lady finds herself able to sit down to dinner, and by the time the meal is over she has forgotten all about her headache and is able to entertain visitors during the evening. In this case twenty grains of the Chloral are enough, but in the case of men thirty to forty grains are required. Dr. Seure has noticed that the relief gained is more prompt if a tablespoonful of brandy or whiskey is added to the enema. The enema has one disadvantage, that is, the slight burning pain which it causes in the rectum. This may be avoided by the use of a glass of warm milk instead of water, or better by beating up the yolk of an egg in the water. In the case of individuals who retain enemata only with difficulty, a smaller amount may be injected, and a drop or two of Laudanum may be added. Dr. Seure regards this treatment as almost infallible for the arrest of an attack of sick headache, and as decidedly preferable to the administration of remedies by the mouth. It has the advantage of not disturbing the stomach. Chloral also acts very promptly, its absorption by the rectum being almost instantaneous, as is proved by the effects on the general system, and also by the exhalation of Chloroform by the lungs within a few seconds after the enema has been taken. — “ Philadelphia Medical Times.”