but as the advancing head encroached upon the perineum the sensation of pain revived. During the first stage of labor, in the after-pains, and in dysmenorrhoea, the organic nervous system is principally, if not mainly, involved. The satisfactory results obtained by the employment of chloral under the aforesaid circumstances would, seemingly, show that the hydrated chloral possessed an elective affinity for the organic nervous system. The failure of hydrated chloral to relieve the pain of facial and frontal neuralgia, notwithstanding sleep was induced, is strikingly illustrative alike of the said affinity, and of impotency of the chloral hydrate over pain existing or originating in the cerebro-spinal nerves. Should any one doubt the latter assertion, he may try it for himself; yet we would anticipate the result, as like that of the skeptical Hotspur, when he taunted the mystic Welchman to produce the spirits, which he boasted he could call from the vasty deep. Reasoning from cause to effect, may we not conclude that the virtue of hydrated chloral as a hypnotic, may be due to its influence upon the vaso-motor nerves of the brain. Such an influence would be in harmony with the accepted theory of sleep. From our observations, made thus far, we believe that hydrated chloral cannot be substituted for chloroform during the second stage of labor, in which the spinal nervous system becomes mainly implicated. We would be disposed to restrict the use of hydrated chloral when desirable to the initiatory stage of labor. Anstie* has asserted, after extended observation, that there are "certain portions of the skin and subcutaneous tissue which retain their sensibility with extraordinary tenacity. These are the matrix of the great toenail, the margin of the anus, and the whole skin of the organs of generation. It is impossible to obliterate their sensibility without pushing chloroformization to a degree which greatly surpasses that required for ordinary purposes." * On Stimulants; page 305. The anesthesia which chloroform thus so tardily induces cannot be expected of moderate or safe doses of the chloral hydrate. The following case exhibits the failure of the hydrated chloral to subdue the paroxysms of maniacal excitement; and also some manifestations counterfeiting alcoholism: M. P. M., vigorous for her age, being over seventy; long subject to attacks of mania, about once annually. Last attack began in January, with absence of sleep, followed by headache for several days, which culminated rapidly in mental excite ment. January 22d.-Ordered twenty grains of chloral hydrate at night; slept well; same dose repeated nightly. January 26th.-Sleeping at night, but growing daily more excited. Ordered ten grains of chloral hydrate morning and noon, and twenty grains at bedtime. January 27th.-Calmer, but cannot talk plainly; continued to sleep at night, but becoming more maniacal, till on the afternoon of February 1st, became wild with excitement. Exhibited twenty grains of chloral hydrate at 4 o'clock and 8 P. M. Slept, but the next day (February 2d) was worse; twenty grains three times during day; slept at night. February 3d.-More excited, tearing the clothes, etc.; ordered twenty grains four times during the day. February 4th.-Twenty grains in the morning and at noon; looked and acted like a person intoxicated; staggering, pronunciation imperfect, whooping, and tearing the clothes. Hydrated chloral was discontinued; she fell into a sound sleep. February 7th.-Quiet ever since the 4th inst.; has had no medicine. The following partial history is submitted as somewhat interesting: M. A. M., aged sixty, old maid; general health not good; melancholia. January 10th, administering fifty grains of hydrated chloral and half a grain morphia sulphas nightly; not sleeping well; had been taking chloral hydrate since December 11th. To ascertain whether a deficiency of an alkali in the blood had anything to do with the partial failure of the chloral hydrate to produce sleep, gave ten grains of the bicarbonate of potassa morning, noon, and evening, and exhibited the hydrated chloral at 8 o'clock P. M. Slept no better than usual. January 26th, administered at bedtime thirty grains of bichloride of potassium and thirty grains of hydrated chloral; slept worse than usual. Under the continued employment of the hydrated chloral the patient's condition has improved somewhat; still under treatment. The following cases are not without interest: F. D. J., aged thirty; exhaustion from work, poverty and child-bearing; maniacal. In this case hydrated chloral and morphia sulphas separately and combined had no satisfactory effect. Iron, whiskey, abundant food, and fresh air during several months were followed by improvement. L. J. J., young woman; primary dementia with excitement; strong hereditary predisposition. In the autumn of 1870 having become cachectic, manifested suicidal impulse, rejected all food, and slept none. Administered morphia sulphas for three nights in half, three-fourths, and one-grain doses; scarcely slept any, and looked worse. Hydrated chloral produced sound sleep at night; and together with tonics and stimulants, her physical health returned, and she lost her suicidal impulse. L. G., aged thirty-three, married, mother of eight children; has the appearance of being in good health. Suicidal melancholia; repeated attacks; sensation of burning heat in left side over region of the ovary always accompanied her mental disorder, and increases or diminishes with it. Morphia sulph. made her sick, and did not uniformly produce sleep. Hydrated chloral in doses of thirty to fifty grains secured sound sleep every night. Iron also was prescribed. Greatly improved. M. A. P., aged thirty-seven; no catamenia for three years; cachectic; religious melancholy. Iron and whiskey administered daily. August 19th.-Became noisy, with lamentations. Exhibited at night half a grain morphia sulphas, and repeated the dose next morning; vomited both. At 5 o'clock P. M. administered fifteen grains of hydrated chloral. Soon afterwards became hysterical; slept but little at night. Next day (21st) fifteen grains of chloral hydrate morning and night; another hysterical paroxysm after the night dose; chloral hydrate discontinued. September 8th.-Other remedies had been tried without benefit; agitation and distress very great; had five grains of hydrated chloral noon and evening without remarkable effect. Next day (9th) had seven and a half gains of chloral hydrate morning and at noon. An hour after noon dose she was found lying on the floor apparently unconscious, with eyes open and pupils somewhat dilated; muscles relaxed; on closing lids they reopened; on taking hold of the arm it seemed lifeless, and could be thrown about in any direction until it was directed towards the face, as if to strike it, when resistance was immediately felt. A short time afterwards she turned on her side, and slept for four hours. September 10th.-Administered seven and a half grains of chloral hydrate three times during the day. Two hours after exhibition of third dose another hysterical paroxysm occurred; medicine was continued. September 13th.-She was composed and much better. September 20th.-Discontinued the chloral hydrate, being composed and entirely rational. Soon recovered. R. J. L., young woman in fair health; mania; sleepless; noisy; incoherent and destructive. November 5th.-Morphia sulphas, one-third of a grain hypodermically. November 6th.-Noisy all last night; tongue dry; emesis. No food taken. November 8th.-Recovered from effects of morphia. Ten grains hydrated chloral with iron and whiskey three times · daily. Night dose of chloral was soon increased to twenty grains; did very well till November 11th; had been sleepless two nights. Morphia sulphas, half a grain added to evening dose of the chloral hydrate. November 19th.-No sleep last night; excitement greater; thirty grains of hydrated chloral and half a grain of sulphate of morphia night and morning. November 20th.-Vomiting; excitement unabated; morphia discontinued; continued to take chloral hydrate; sleeping, but not improving till the quantity reached 120 grains per diem, which she took from December 3d to 8th; looking well and experiencing no bad effects. All medicines were discontinued. December 29th.-Placed a blister upon the back of the neck, and sprinkled blistered surface with powdered opium at first; afterwards with morphia sulphas. Continued this till January 15th, 1871. Mentally improved; morphia upon blistered surface did not produce the disturbance which had previously followed its use by the mouth and hypodermically. Agreed to take the medicine which, up to this date, had been taken through a nose-tube. Chloral was resumed, twenty grains three times daily was not found to be sufficient; thirty grains three times daily seemed to produce too much drowsiness; twenty-five grains three times daily answered admirably. She is now (February 8, '71) convalescent. H. J., age not known, but menopausis occurred some time ago; subject to paroxysms of mania every year or two since puberty. November 23, '71.-Excitement setting in, and patient sleepless; gave twenty grains hydrated chloral. November 26th.-Dose had been increased to thirty grains. morning and night. November 30th.-Quiet and sleeping well; chloral hydrate discontinued. December 7th.-Excitement returning for two days; resumed chloral hydrate. December 14th.-Doing quite well; suspended the hydrated chloral. |