Chloralum hydratum

Volume II — Main text

CHLORALUM.

Chloral; product of action of dry chlorine gas on absolute alcohol. Commonly employed as hydrate, CCl,CH (OH )2 . I. Provings.-1 . a. Dr. D. A. BABCOCK took 6x trit. in frequently repeated doses. Only effect noticed was that on 2nd d. he could not keep thread of sermon in church. b. Took 15 gr. of crude drug in one dose. After a few m. feeling as if hot band was drawn across forehead from temple to temple, directly over eyes, with sensation as of aburning ring around each eye ; also rush of blood and transient sensation of heat in face. Soon after,

severe pain in frontal region, right over supra-orbital ridge, which nothing relieves, aggravated by movement. After 1 h. sense of nausea and oppression in stomach, without inclination to vomit ; relieved by supper, but returning later in e. After 1 h. dull heavy headache in occiput, and in forehead over eyes ; there is sense of weight and soreness, seemingly wholly inside cranium, aggravated alike by lying down and by moving about, but somewhat relieved by going into open air. After 12 h. pupils contracted and insensible to light. Premature emission this n. and the next. c. Took repeated doses of Ix. After h. pulse (normally 72) 84, and headache in head extending to occiput. After 4 h. spells of feeling as though legs were asleep ; also dull aching pains in calves, at times running down into feet, and sense of fulness of skin there, with throbbing ; severity of pain lasted about 1 h., when it gave way to a dull, steady headache, not very severe ; it returned next d. more severely. On 2nd d. awoke in m. with feeling as of cold in head ; throat and posterior nares seem sensitive, raw, and burning. Dull and full feeling in head all d. d. Took 2 gr. of crude drug without effect, save some looseness and increased frequency of stools. (ALLEN, Encyclopædia, vol. iii .) 2. Same proved drug on G. A. T- [manner not stated) . After 5 m. belching of wind, lasting till after eating. After 2 h. headache over both eyes, running down into eyes, l. worst, with feeling as if eyes were constricted; within 2 h. it gradually passed away. ( Ibid.) 3. P. H. M- (as 2). After 1 h. dull, heavy, pressing headache over eyes, especially l., while at supper, lasting about I h., then gradually wearing away. On another occasion, after 2 h., similar headache, with nausea and sour eructations of liquid. After 7-9 h., two soft light yellowish stools, voided with some sharp pains in rectum. On 2nd d., loss of appetite ; slight throbbing pain in l. eyeball, aggravated by leaning forward. On 3rd d., stool in m. soft, but voided with great pain in rectum. Very sleepy in e., and retired early ; did not feel refreshed on waking next m. (Ibid.) 4. W. B- (as 2) . On 2nd d., woke at 8 a.m. with feeling of fulness and constriction of head ; all d. dull aching pain therein, aggravated by sudden motion, with inability to concentrate thought ; also pain in stomach and abdomen, with slight dyspnea. (Ibid.) 5. a. Took Dij in zss water and syrup. It produced for 45 m. a muscular and moral excitability similar to a slight champagne intoxication, whereby the proverver felt pleasant, smiled, and danced. Without any trouble he fell asleep as soon as he lay down. The sleep was quiet, natural ; not disturbed by any dreams or hallucinations. Forcibly awakened, clear consciousness returned easily, and he replied promptly to any question. Left again to himself, he fell immediately again into his natural sleep, which lasted for 10 h., a thing which had never happened to him during his whole life. He woke up refreshed in m. without any bad symptoms, but could not recollect the disturbance by which he was awakened, nor that he replied. The chloral sleep was therefore profound and lasting. b. Pulse 68, resp. 28, temp. 37.2° ; took Dij in mucilage. Imme

diately a pleasant excitation for h., pulse 88. At 10 a.m., quiet sleep ; pulse 74, resp. 28, temp. 36° ; both pupils somewhat dilated. 10.30 a.m., quiet sleep, although a good deal of noise in hospital (prover suffers from a slight bronchial attack) . II a.m., prover goes with another patient to the bath-room and takes a lukewarm bath. 11.45, returns from the bath, takes hearty meal, and at I p.m. goes to sleep again. 5.30p.m., wakes up refreshed, waiting for his supper ; pulse 72, resp. 32, temp. 37°. (Amer. Hom. Obs., vii, 293 ; from Wiener Med. Wochenschrift.) 6. Dr. Cavins took, Ist. n., 3j, 2nd n. zij, 3rd n. ziij. On each occasion symptoms were same in character but differed in degree. After largest dose, in 10 m. there was great confusion of mind ; a feeling of being in some distant place, with anxiety to get home ; consciousness of everything going on, with propensity to utter what was felt to be nonsense ; extreme restlessness ; violent palpitation ; panting respiration ; congested face ; bloodshot and staring eyes ; and profuse perspiration. These symptoms continued from II p.m. without intermission till 6 a.m., when he slept for 2 h. and awoke with violent headache. For 3 weeks thereafter there was painful sense of drowsiness ; eyes were inflamed and sensitive to light, and temper very irritable. (Ed. Med. Fourn. , xvi , 375.) 7. Dr. ANDREWS tested action ofChl. on pulse. a. Gr. x reduced pulse of healthy person 6 per m.; scarcely any drowsiness. Gr. xx ; after 5 m. pulse from 78 fallen to 72 ; 25 m . after, increased in volume, 66 ; in 50 m. volume increased, drowsy, 54. Gr. xxx ; in 10 m. pulse, which was before 84, fell to 72 ; 20 m. after increased in volume, 66 ; in 60 m., lessened in volume, 60. Gr. xl, during digestion ; pulse 78 ; 5 m. after, 78 ; 15 m., 72 ; 30 m., 66, no change in volume ; 90 m., 60, much reduced in volume for some h., drowsiness. Gr. xl ; pulse before taking, 66; 30 m. after, 60 ; 75 m., 54 ; 180 m., 54, greatly lessened force in heart's action for some h . b. Other effects : In 3 m. heat and burning in stomach, drowsiness, difficulty in keeping eyes open. In 15 m. sleep, in spite of resistance ; when aroused, talkative, tongue thick, speech indistinct (characteristic of intoxication) . After h., contraction of pupil as in natural sleep. After 1 h. fell asleep. Slept for 1 h.; awoke. After 3 h. again overcome with sleep for 1 h.; easily aroused, but went to sleep again. After 3 h. awoke and took a hearty meal. His gait was unsteady, as if somewhat intoxicated. In 5 h. after taking dose he went to sleep and slept for 10 h. c. Conclusions : (1) That the effect of Chl. is to reduce the number of pulsations. (2) That the primary action is to increase the force of the heart's action and arterial tension. (3) That in large doses, within safe limits, the pulsations are not reduced in number proportionately to the size of the dose, but the effect is more prolonged. (4) That the secondary effect is to diminish the force of the heart's action and the arterial tension. This will be apparent by comparing the number of pulsations, and the dicrotism of the first tracing with the last in the 4th experiment [tracings given.- EDS. ] . d. Order of effects is : sense of heaviness of head, a tingling of the

extremities ; feeling of weight, as if the part was asleep ; and gradually increasing drowsiness. There is inclination to talk, with thickness of tongue and inability to speak plainly, especially if the patient is talked to or otherwise disturbed. If he is quiet he yields readily to sleep, and this intoxicating stage will not be observed. Then occurs the profound sleep of Chl. On awakening, if the effects have not completely passed off, there may be a recurrence, in a mild degree, of the state of intoxication. (Amer. Fourn. of Insanity, xxviii, 35.) II. Poisonings.-1 . In a fit of insanity Mrs. J. S-, æt. 65, took about Zss in solution. She had taken several smaller doses within a few d. for the following symptoms : sleepiness at n. with restless irritability ; confusion in head ; melancholy ; inclined to wander away and hide herself ; avoided shrewdly the vigilance of her friends ; would then return, unable to give any account of where she had been. 12 h. after taking Chl. an emetic (zinc. sulph.) was given and vomiting ensued. Deep sleep, lasted 36 h., pulse normal, breathing easy, regular. On awaking was calmer, said she felt better, pain in head relieved, but could not get up. Sensation and motion paralysed in both legs. The following d. a smooth, bright scarlet eruption appeared over whole body (face, limbs, &c.). That on face was erysipelatous, and face was so much swollen that she could not see. Eruption disappeared after 4 d ., paralysis after I week ; since which (2 years) she has been free from headaches and mental symptoms. (J. H. SHERMAN, M.D., N. Eng. Med. Gaz., 1874, p. 412.) 2. Soon after experiments with Chl. were commenced in this asylum I noticed a singular flushing of the head and face in many of the patients taking the drug. Of 40 cases in which Chl. was tried in a certain period this blushing was remarked in 19 to a greater or less extent ; and it was not unusual to see a pale anæmic patient, to whom Chl. had been given, presenting at certain times a floridness of countenance resembling that of rude health. This was especially the case when alcohol in any form was given along with it, and it was rarely seen unless the drug had been given regularly for some little time. In one case, typical of many, h. after 15 gr. had been taken, the face up to the roots of the hair and down to the ramus ofthe lower jaw was of a dull scarlet colour, very persistent under pressure, most intense over the malar prominences and bridge of the nose, and thence shading off in every direction. The ears partook of the same colour, which was also scattered in blotches over the neck and chest, the lowest blotch being over middle of sternum, and the largest about the size of a florin . This condition was associated with slight contraction of the pupils, injection of conjunctivæ and excitement of the circulation ; lasted about an h. and then disappeared during a paroxysm of sneezing and emotional perturbation, to recur after the next dose. (CRICHTON BROWNE, Lancet, 1871, i, 440.) 3. E. R-, æt. 30, was noticed about an h. after a dose of Chl. to be much flushed and to present over her whole body a diffuse inflammatory redness, so closely resembling the smooth eruption of scarlet fever that it was thought prudent to isolate her in the hospital for contagious diseases. When these characteristic symptoms developed, a

number of long pale elevations or wheals showed themselves in the legs, shoulders, and waist, while similar ones could be produced on other parts of the body by scratching. At the same time burning, stinging sensations and a feeling of tightness and hardness over whole surface were complained of, along with wheezing respiration, sharp pains in the eyeballs, headache and lassitude. ( Ibid.) 4. M. A-, subject to periodic attacks of mania, entered on one of her wonted paroxysms on March 1st, 1870, and was ordered 20 gr. of Chl. ter die. This produced sleep and cutaneous anesthesia, and on March 4th an unexpected result, in the form of a bright red blush, erythematous in aspect but permanent under pressure, over the chest and shoulders . This blush had on the 6th pervaded the entire 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 fetid, pulse 120, feeble and compressible. On March 11th the symptoms began to abate. On the 15th a sort of general desquamation had set in, followed by convalescence. (Ibid.) 5. Woman, æt. 46, labouring under heart disease, 1. hemiplegia, and dementia with excitement, took 15 gr. ter die. from Feb. 24th to March 15th, when numerous reddish-purple blotches appeared round 1. elbow, on following d. enlarging and uniting with others on shoulder and forearm. Next d. dull purple spots and discolourations were seen on legs, abdomen and back, being restricted in last-named situation to a band 2 in. in breadth along each side of vertebral column. There was great prostration of strength, tendency to somnolence, weakness and irritability of pulse, raw state of lips, which were entirely denuded of epithelium, and fissured and thickly coated tongue. On 19th spots 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 attacks of syncope death took place on 22nd. (Ibid.)* 6. a. Dr. LUDWIG KIRN reports cases of chronic poisoning by Chl. A lady, prostrated by long suffering, had of late experienced attacks of severe dyspnea, which had increased to asphyxia ; at the same time the face was swollen, the facial muscles paralysed, and there were also signs of cerebral effusion . Every remedy had failed, and the patient seemed on the brink of the grave. The consulting physician ordered the daily dose of 45 gr. of Chl. to be stopped, and the symptoms vanished in an almost magical manner, the respiration becoming normal and the cerebral disturbance ceasing. The dyspnea may be anatomically explained by its analogy with the effects of Chl. on the skin and mucous membrane, hyperæmia of the lungs being produced through the vasomotor nerves . This confirms the assumption that Chl. operates upon the vaso-motor centre and the medulla oblongata, and that its paralysing influence extends thence to the peripheral branches of the affected nerves . * " The symptoms which these cases presented were ofan unique kind, and almost unparallelled in asylum practice at the present day."

b. The same author reports a case of blood-poisoning produced by Chl. in nightly doses of 45 to 75 gr. over a period of 10 weeks. A young, strong, previously healthy person, suffering from uncomplicated mania, developed in 9 d. a rash in groups of red spots which soon became confluent. On 20th d. temperature and pulse rapidly rose to febrile pitch. 3 d. later temperature had reached 106.7° ; large and repeated doses of quinine were given without effect, and baths only temporarily relieved. Edematous swelling of face, cheeks, eyelids and ears now set in. During the whole course of the disease the skin did not resume its natural condition but was the seat of now impetiginous, now moist, now scaly eczema, and now ichthyosis, so that desquamation occupied many weeks, during which great sheaths of epidermis were cast off from all parts of the body. There was shedding of the hair and a gradual falling off of all the nails. At the same time the mucous membranes were affected, first of the intestines, causing watery diarrhea, and then those of the conjunctivæ and bronchi. From the 6th week onwards a series of large abscesses formed on both arms, over the shoulders, and within the armpits, which secreted considerable quantities of pus. There was for 8 weeks continuous fever, occasionally remitting. This patient was thus continuously dosed with Chl. when it first came out, and it was not credited with producing severe constitutional symptoms. (Practitioner, x, 361.) 7. A child, æt. 8, was given 5 gr. ter die for hooping-cough . After a few d. an eruption appeared on arms, legs and face, and subsequently over whole body, in large blotches of different shapes raised above surface, and of a deep red colour. The conjunctivæ were injected, and the face had a puffed, swelled appearance, especially below the eyes. Gradually these blotches coalesced till the whole skin was in this red blotchy state, more nearly resembling measles than anything else. There was high fever, thirst, coated tongue, and loss of appetite, with intense irritation and itching of the skin, preventing sleep at n. (DYCE BROWN, Monthly Hom. Rev. , xv, 348.) 8. A stout, middle-aged woman was given 25 gr. in syrup, and after taking it was severely attacked with urticaria. Later, 10 gr. were given with same result. (S. W. FISHER, M.D., Brit. Med. Fourn., 1871, i, 331 .)* 9. Feb. 9th, 1870, J. S- was admitted, suffering from slight anasarca and bronchitis, connected with chronic Bright's disease. He was restless and nervous, and unable to sleep, and was ordered 30 gr. of Chl. at bedtime. Soon after taking it he jumped up in bed, clutched at his heart, and complained that medicine produced a sense of burning. In a few m. he became violently delirious, and after this had subsided was so much depressed that heart's action could with difficulty be sustained. Gradually pulse returned, and in a few h. he was out of danger. (On theory that an alkaline state of stomach might have converted Chl. into chloroform, a second dose was given later in combination with an acid, but same results followed.) (FULLER, Lancet, March 25th, 1871. ) * See also DYCE BROWN, in M. H. Rev., xv, 349 ; and LEWIN, op. cit., P. 170 .

1. A young lady, in fair health, but restless and nervous, was given 30gr. at 10 p.m. Almost immediately she became much excited, and complained of pain in chest. In about an h. excitement passed off, and she fell asleep and slept heavily all n. In m., still sleeping heavily and looking very pale, her medical attendant was summoned, and found deep sighing respiration, no pulse at wrist, extremities rather cold. It was impossible to rouse her in the slightest degree. Stimulants and warmth had little effect. Dr. Fuller saw her at 2 p.m., and found her in same state. Skin was dry ; pupils large, but sluggishly contractile under a strong light ; pulse scarcely perceptible, but heart beat regularly though feebly (120). Muscular system normal, and swallowing power intact. In spite of strongest stimulation she died at 9 next m., never having exhibited slightest consciousness or moved a muscle from time she first fell asleep. (Ibid.)* 11. a. The Committee appointed by the Clinical Society to investigatethe morbid effects of prolonged and continuous use of Chl. reported that over 70 replies had been received out of 1000 applications ; 29 stated that no ill effects had been observed. The other correspondents found morbid effects. Cerebral anæmia (Fothergill) with melancholia and impaired mental power ; muscular prostration, more especially affecting the legs, causing staggering and debility, almost amounting to paraplegia, and believed to be spinal in origin. With this are occasionally associated peculiar pains encircling the joints above and below, with great dryness of skin (Anstie), and several observers have noticed a singular affection of the fingers, consisting of erythematous inflammation, followed by desquamation of cuticle, superficial ulceration about edges of the nails, with great pain and tenderness to touch (Prof. Smith, of Baltimore) . Cardiac debility is alleged to follow in some cases the prolonged use of Chl.; and pharyngeal congestion, with a universally diffused red rash, resembling that of scarlet fever. Other skin affections are also recorded assuming the form of spots of roseola coalescing to form patches of erythema, or of deep flushing of the face and head following the use of stimulants (Crichton Browne and Kirn), or petechial and purpuric eruptions may appear (Cholmeley), and may even run into a species of pyæmic condition, in which the ulceration of the gums and great prostration simulate scurvy closely, abscesses and deep ulceration of the skin supervening, and even leading to a fatal result. b. Nervous system. Dr. Inglis, of the Royal Edinburgh Asylum, in a reprint records a case of Chl. eating, in which at last 180 gr. were taken daily, followed after seven years' indulgence by grave perversion of the moral sense, epileptiform convulsions, great mental enfeeblement, and general nervous debility, necessitating asylum treatment, under which recovery took place. Dr. Woodbury mentions a case in which nightly doses of 20 to 30 gr. during four months were * Dr. Crichton Browne says that Chl. in fatal doses acts by paralysing the heart through the inhibitory nerves. Like chloroform, it appears to have the power of reducing the natural force of action of the heart, and sometimes of stopping its play. Facts are not wanting to indicate that it exerts this power through the sympathetic system, operating through the inferior cervical ganglion. He relates several cases in which thepost-mortem signs resembled closely those caused by chloroform. (Loc. cit.)

followed by a violent attack resembling delirium tremens. Dr. Easton records the case of a lady who experienced ataxic symptoms with numbness and burning sensations, following the nightly use of 30 to 40 gr. during two years . Many other observers report similar results. c. Circulatory system. Dr. Langdon Down has noted failure of the 1. ventricle. d. Digestive system. Dr. Althaus reports a case of digestive derangement with loss of appetite and constipation. Dr. Carroll mentions the case of a lady in whom epigastric tenderness, dry brown tongue, vomiting and diarrhea followed 30 gr. nightly doses for two months . e. Cutaneous system.-Dr. J. Thompson mentions the case of a female, æt. 44, who took 20 gr. for three months, at the end of which time defective circulation of the hands was noted with a line of ulceration round each nail. Mr. Humphry sends a case of pompholyx (pemphigus) produced by Chl. Dr. Fothergill notes peripheral paralysis of arterioles with blueness of extremities. Dr. Langdon Down has observed liability to the production of facial erysipelas. Many others record skin eruptions. Dr. Buzzard and others have observed lachrymation and conjunctival irritation.* Dr. Sharpin reports two cases of troublesome itching of the legs . f. Urinary and other systems.-Dr. Longhurst mentions a case in which irritability and subsequently temporary paralysis of the bladder followed doses of from 10 to 20 gr. taken for some months. ( Trans. Clin. Soc. , xiii, 117.) 12. Dr. DABBS relates effects of overdose given for asthmatic breathing to a woman pregnant more than 7 months. She got, Sept. 28th, 8 p.m., 30 gr.; at midnight, 20 gr.; at 12.30 another dose. About 2 a.m. sat suddenly bolt upright in bed, complained of agonising cramps in legs, feeling of suffocation, of swimming in head, and of absolute inability to co- ordinate movements of lower extremities. She seemed in a peculiar state of consciousness, knew that she was very ill, and herself insisted on my being sent for. At 4.30 I found head bent upon chest, face intensely flushed, eyelids closed and with some little difficulty opened, and whole conjunctivæ injected. The odour of Chl. in the breath was something sickening. There was slight tendency to vomit ; a teaspoonful of last dose came back. The pulse was quick and bounding, 120, but gradually decreasing, till at 8 a.m. it was only 96. She was with difficulty roused either to speak or take food ; at 4 p.m. (Sept. 29) she tells me she does not remember a single circumstance after swallowing the second dose at midnight, but that the sensation had been one of unlimited rest, unbroken by anything, but quite different from sleep. The only symptom to which she could herself refer was to the cramps, which even now remain to a very slight extent. She says herself that the agonising pain in her legs was the only occasional * " Its habitual use is very apt to produce an injected and irritable condition of the eyes, which we have observed in the case of a lady who took from to to 20 gr. every m. for several months. This state did not disappear until several months after the medicine had been omitted " (STILLÉ).

break in her otherwise complete mental monotony. (Med. Times and Gaz., 1870, ii, 435. ) 13. Man, æt. 35, took 24 grm. of cryst. Chl. in order to destroy himself. Seen h. after, patient in deep sleep, face red, veins of neck fuller than normal, resp. deep, pulse 100. After h. (and cold applications to head) face, forehead, head to nape of neck flushed, with deep redness on lips and cheeks, livid colour. Pupils much dilated, veins in neck and head gorged, radial pulse hard, tense, 92. No abnormality at heart, temperature of skin 39.5°, respiration stertorous, intermittent. Employed artificial respiration, faradic current. After h. respiration ceased entirely, facies hippocratica, deadly pale, veins collapsed, mucous membr. became livid. Beat of apex and radial pulse imperceptible, in carotid scarcely to be felt. Heart's sounds hardly audible, pupils much contracted, body cold. Temp. 32.9° (a fall of 6.6° in h.) [Dr. L- then injected strychnia, with success.) (LEVINSTEIN, Viertelj. f. gerichtl. Med. , xx, 227.) 14. Lady, æt. 45, of slight but compact frame, keen intellect, suffering from sleeplessness and dyspepsia, for upwards of two years had taken Chl. up to 60-70 gr. in 24 h. Much reduced in morale and physique, unable to walk 100 yards without sinking from sheer exhaustion. Confusion of mind, inability to concentrate thoughts, impaired memory. Erythema of head and neck, with well-marked dark areolæ (much intensified after ingestion of smallest quantity of wine, beer, or spirits), with most distressing palpitations, for about 2 h., the hyperæmia disappearing last of all from the forehead in curiously welldefined patches. Partial paralysis of œsophagus with nervous disinclination to take food or drink, interfering with her nutrition. Dimness of sight with eyes bloodshot and overflowing with tears. Marked projection of eyeballs. Feeling of intense sickness (without vomiting) frequently for a few m. after taking drug. (MURPHY, Lancet, 1873, ii, 150, 191.) 15. Man, æt. 29, lightly but strongly built, remarkable for courage, suffering from sleeplessness from mental worry, took Chl. for eighteen months, repeated dose once or even twice if first was unsuccessful. Led open-air life, with violent exercise. Lost daily strength, nerve, and capacity for business. One m. awoke to find power of his lower limbs completely gone. Paralysis was transient. He found it necessary to increase dose. Sometimes large dose proved wholly ineffective, sleep fitful and restless. On awaking intense thirst with dryness of tongue and fauces, headache, vertigo, nausea, great nervous sensibility. Erythematous flush, intensified from beer or spirits. Violent palpitations forcing patient to lie down for 2 h. at a time. Completely prostrated. Eyes affected as in No. 14. Acute wandering pains in lower limbs, especially in calves of the legs, occurring during many weeks previous to cessation of Chl. Had a feeling at times, on putting his feet to the ground in m., " as if his legs were all in a mash," as if he could not distinguish clearly between one part and another. Finally, on rising one m. found his legs suddenly give way under him ; was unable to stand or walk, had to get into bed again. Passed off in course ofd., but left great nervous depression and bodily weakness, accompanied with a

feeling of utter vacuity of mind, and inability to concentrate the attention upon anything. (Ibid. ) 16. The symptoms of chronic Chl. poisoning, according to Richardson , are : sleeplessness, mental irritability, and muscular prostration ; uncertainty of movement, with tendency to fall forward ; caprice of appetite, nausea ; and injection or yellowishness of the conjunctivæ. The urine may be albuminous ; the bowels are constipated, and the stools pale and hard. All these symptoms we have met with, and also a state ofmental depression, irresolution, and gloom, which threatened to end in insanity. (STILLÉ, op. cit.) 17. a. According to Kirn, disturbances of the respiratory processes are excited in rare instances, which may increase from a feeling of anxiety, terror, and shortness of breath to attacks of dyspnea, and even ofasphyxia. Shaw also, after about I grm., observed spasmodic breathing, with irregular action of heart. Marsh states that after an ordinary dose he has found changes in the mucous membrane of the respiratory apparatus, as shown by the occurrence of acute bronchitis. b. Among other incidental effects, Curschmann reports swelling of epiglottis and false vocal cords, and Reimer the occurrence of bedsores under very slight external pressure, while epidermis is intact. Here and there cases are reported in which jaundice is said to have occurred after the use of this agent. Thus Wernich mentions the case of a drunkard, in whom a fresh icterus appeared after 4 grm. had been taken. Arndt also witnessed the occurrence of this condition in a paralytic after he had taken the drug for 14 d.; it passed off when medicine was stopped, and reappeared when itwas again used. (LEWIN, op. cit.) 18. Mrs. R-, æt. 24, took mixture of Chl. with tolu and pepper- *mint water. Suddenly sore-throat, swelling of parotid and submaxillary glands, face bloated out. Face, shoulder, chest intensely red, suggesting the appearance of scarlet fever, or a mild attack of erysipelas. Medicine was discontinued; on its being later resumed, was covered from head to foot with urticaria, with intense scalding pain in eyes, and a continual running of a semi-opaque fluid from them, as if from the intense heat ofthe surface. (CHAPMAN, Lancet, 1871 , i, 666. ) 19. a. Medical man, æt. 70, in habit of taking Chl. Desquamation of fingers of both hands, with superficial ulceration, especially about borders of nails ; pain and much sensibility to touch, acceleration of pulse, general malaise. 6. Young lady,taking Chl. for a month every n., had erythematous inflammation, desquamation, and ulceration around border of nails. (Bost. Med. and Surg. Fourn., 1871 , p. 33.) III. Experiments on animals.-1. Arabbit was given 30 gr. In 5 m. respirations 120, irregular ; sat quietly, ears semi erect ; in 10 m. moved about, but seemed very stupid, heavy, ears lying on its back ; 13 m., respirations 43, sat quietly, occasionally lifted its head smartly as if trying to shake off sleep, and gnawed at a box near it ; 15 m., appeared greatly excited,but was unable to keep itself steady ; 17 m., snuffing about; 18 m., has again settled down; 20 m., respirations 34, still moved when noise was made ; 22 m., was holding its nose on the ground, but raisedits head when noise was made ; 25 m., tried to move, but seemed paralysed in hind legs; 26 m., an unsuccessful attempt to " dress " scratched at floor with fore-feet ; 27 m., made VOL. II. II

itself, snuffed excitedly round about it ; 29 m., did not move when noise was made ; 36 m., again attempted to " dress " itself, moved its jaws as iftrying to eat, smelt its hind legs as if about to lick them, continued the movement of jaws ; 37 m., did not move when the glass globe over it was roughly shaken ; 38 m., respirations 34, free and full, abdominal, licked several parts of the body; 40 m., it snuffs slowly and lazily about, has complete command of its forelegs, but not of its hind legs, ears very warm and lying flat ; 50 m., ate oatcake eagerly, and quite recovered. (Edin. Med. Journ., Aug., 1872.) 2. a. In Liebreich's original experiments, gr. 1 administered hypodermically to a rabbit produced a lethargic sleep lasting 9 or 10 h., during which animal was thrown over.back of chair without its awaking. Similar results were obtained with dogs. Richardson, by internal administration to pigeons, produced sleep with 2 or 3 gr., during which respiration became slower and temperature fell. In frogs, I gr. caused almost instant insensibility, coma, and death, usually preceded by spasms or convul. sions. Experiments upon other creatures gave substantially the same results ; and in all it has been particularly noticed that the sleep produced by Chl. differs from that occasioned by other anæsthetics or narcotics in this, that it is less profound, is easily disturbed, and as easily renewed when the animal is left to itself. b. When animals are killed by large doses, the sinuses of the brain are found, after death, distended with dark fluid blood; the membranes are injected, but the brain itself is free from congestion, and is of a natural colour. The same appearances are presented by the spinal cord. The muscles are dark in colour, and filled with fluid blood, which flows freely from them when they are incised. The heart contains blood in both sides, preserving the distinctive arterial and venous characters. The lungs are pale, and contain blood, but are not congested. The blood coagulates with moderate firmness ; its red corpuscles are sometimes shrunken and crenate. (STILLÉ, op. cit.) 3. In conjunction with Professor Stricker, I found that when large doses are given, the temperature gradually falls until it can no longer be measured by the clinical thermometer. Animals which have received a dose that would certainly kill them if left exposed, recover from the effects if they are wrapped in cotton-wool. If dose be still further increased so as to kill the animal even when carefully so covered, it may still be kept alive by being put in a warm place. (BRUNTON, op. cit.) 4. The paralysis and loss of reflex excitability induced by chloral are not muscular in origin, for Labbée has found that after death the muscles respond perfectly to galvanism. Both Labbée and Rajewsky have found that the motor nerves are in no wise affected by large or even fatal doses of chloral, which must therefore act upon the spinal cord to produce the paralytic phenomena. The experiments of Rajewsky have afforded positive confirmation of the conclusion arrived at by this process of exclusion ; for he found that in the latter stages of Chl. poisoning direct irritation of the spinal cord gave rise to much less clonic spasm than in the unpoisoned animal. (H. C. WOOD, op. cit.)

Volume IV — Appendix

CHLORALUM.

(See vol. ii, p. I5».)

. 8. Effect of Chi. upon the circulation within the skull was

?~**^^rlained in two persons having a traumatic defect of the frontal

?***^C Its first cfFcct was found to be anaemia of the brain, probably

y^ cronsequence of vascular paralysis and dilatation at the periphery

'f'*^ i u, &c.) . The supervention of sleep coincides with hyperaemia of

"^^ brain from the gradual extension of the vascular paresis to its

^^Ssels. At the end of sleep and in the first portion of the waking

*^^tc a decrease in the volume of the brain occurs, as well as an increase

^ Vascular tonus that passes gradually into the normal. (CAPPELLiand

^RUGiA, Neurol. Ctntralbl.., 1866, No. 14.)

II. 20. In a case of aggravated dysmenorrhcea in a nervous (probably hysterical) subject, Dr. Bender gave 3j as a palliative. It produced a tingling warmth all over the body a few moments after ingestion j and soon the pains descended to the feet and disappeared. Nearly an hour's freedom from pain followed, simultaneously with hysterical feeling attended with immoderate laughing. Shortly afterwards "heavenly sleep/' in her own words, set in, lasting 5 h. No pain returned for 3 h. more ; there was loss of motor power, which hindered her from moving even a finger, and mental confusion. Throbbing headache of congestive type ensued with intolerance of light, for which she received bell. Headache increased spite of the medicine until 4 p.m., just 19 h. after the dose of chloral, when with the violent pains drowsiness supervened, preceding sleep for a few m., and then a wake up with a start, head so much worse that the patient would beg to be

kept awake. Objects and persons appeared distant and small, and the flowers on the wall-paper very red, luminous, and glaring. 'VVhefl addressed she would barely answer, and with difficulty, relapsing immediately afterwards into unconsciousness, to wake up quickly with a start, and a request that she should not be allowed to sleep. I prescribed lach., which quieted her within a short time, leading to fitful, successive naps. Till 31 h. afterwards she felt under the influence of the hypnotic, elated and inclined to laugh, although at the time very weak^the laughing tendency unusual. She also complained of the head feeling very large ; after two doses of lach., she asked her attendant if her head was not diminishing. [Hahn. Monthly^ vii, 506.)

ai. On May iSth, a lady set. 35, in 7th mo. of pregnancy, had » febrile attack with repeated vomitings j and next d. an eruption came out on neck, hands, and legs. When Dr. Pied v ache saw her on 17th this had extended all over body. It consisted of minute papules, like those of variola on md d., non-acuminated, of vivid redness, which disappeared under pressure. On forehead they were rather larger, and rest of face was slightly swollen. There was intense general pruritus j tongue, mouth and throat were coated, with salivation ; pulse 120, large and full ; temp. 39° ; skin very dry ; no headache. A cough which she had had for 4 weeks, but which had much diminished, w» now worse, with anguishing pain under sternum, and fine sub-crcpitaiii rales all over 1. side, here and there on r. } percussion normal. It was ascertained that she had had a short attack of same character, but of short duration, some 12 d. before; also that for the cough she had during three weeks past been taking a syrup of Chi. Not suspcaing this, Dr. Piedvache did not order its discontinuance and only prescribed aconite. She accordingly continued to take the syrup for 3 n. more. 18th. — General state worse; temp. 40*^; marked prostration; complete insomnia ; agitation and sub-delirium at n. ; dyspnoea and substernal anguish, incessant cough, expectoration slightly bloody, very Rne mucous rales in 1. lung, sibilus in r. Chills all m. Itching intolerable; papules much enlarged and gathered into groups, in some places resembling erythema papulata. Their colour is very deep, but disappears under pressure ; scratching does not whiten them. Face il more swelled, especially in eyelids, which are reddened, with injection also of ocular conjunctiva and some photophobia. Lips very swollen and hard, their free border much cracked. Abundant salivation. On buccal m.m. a discrete aphthous eruption here and there. Tongue somewhat enlarged, dry and cracked on dorsum. Slight oedema of velum palati, which is dark red ; much dysphagia, igth. — Papula larger and more numerous ; skin in face and extremities swollen as in variola ; intervals of healthy skin are of as dark a red as the papules ; eyes are closed, lips enormous and somewhat everted ; salivation abundant. In the labio-gingival fold the aphtha have become elongated ulcers, with grey base, extremely painful and making breath offensive. Aphtha; were seen in pharynx also; swallowing was nearly impossible ( there were momentary attacks of suffocation. Tongue was visibly swollen. Cough very frequent, and expectoration still sanguinolent { but rales were larger. Temp, early in m. was 38" only j but between

II and 12 a prolonged rigor took place, and thermometer at noon marked 40**} no sweating. (That e. grm. 075 of quinine were given.) 20th. — N. not quite so bad, and symptoms slightly less severe, but buccal ulcerations are larger. At noon, rigor recurred. Merc, corr., 2nd trit., was administered, with grm. i of quinine at n. The chloral was now suspected and stopped. N. was better } but there were attacks of dyspnoea, with acute pain under sternum. Other symptoms unchanged, save that febrile paroxysm was much weaker and later. Arsenicum was substituted for the mere, corr., and the quinine repeated. On 22nd all symptoms had begun to improve, which they continued to do henceforward. Prostration was very great for some d. The skin underwent desquamation repeatedly during days from 24th May to 4th June ; but skin remained somewhat discoloured. On this last d., patient ventured to take, for toothache^ a spoonful of the syrup at bedtime. During n. she felt poorly and suffered from itching } in m. she found whole surface of raspberry hue, with slight oedema of face and eyelids ; there was nausea, anorexia, and a febrile state. All this had gone off by next d. {Bull, dt la Soc. MM, Horn, de Franct^ xxvi, 163.)

1. Among the most striking features of chronic chloralism is muscular weakness, which is particularly manifested in the legs. There is such marked debility that on attempting to walk patient appears to be paralysed. There is no special group of muscles affected, but a general loss of power in the limbs. This paresis may also manifest itself in the upper extremities. There is feeble action of heart, with cold extremities and tendency to profuse sweating ; pulse is accelerated, but weak, arterial tension reduced. Active delirium, like d. tremens, has been observed from prolonged use in increasing doses j but more commonly patient becomes constantly dull and dreamy j will power seems completely wanting ; judgment and intellectual faculties are impaired. The vaso-motor centres lose to a certain extent their functional powers. This is partly shown bv the condition of the cutaneous circulation ; the extremities become cold and blue, and various inflammations of the skin occur. Sugar may appear in the urine, although it is not constant — at least I cannot say that I have found it so. (Da Costa, Med. Times and Gaz.^ 1883, li, 168, from Phil. Med. TtmeSy March 24th, 1883.)