ART. I.-NOTES ON CHLORAL HYDRATE. By A. M. FAUNTLEROY, M. D., Staunton, Va.

This remedy appears, from clinical observation, to occupy the middle ground between an anæsthetic and narcotic agent; administered in doses which are not immoderate, its effects would not justify its assignment to either of the aforesaid classes. Hydrate chloral is pre-eminently a hypnotic. Its energy is mainly and primarily expended upon the brain structure in the production of sleep; from its great solubility and its power of extreme diffusibility, this result is attained with a readiness and celerity which surpasses in efficiency that of any other remedy known in the materia medica. For the correction of insomnia, occurring under the most varied circumstances, it appears to possess the most singular power and adaptability. In addition to the above, it presents yet higher claims to our favorable consideration and acceptance; all remedial agents present, more or less, their credit and debit aspect. The good and desirable effects produced may be assigned to the former, while the evils. incidentally incurred by the patient should be recorded on the debit side of the account.

Restorative sleep, rest, quietude, or anodyne effect may be secured, by the employment of hydrated chloral, without the disagreeable offset of headache, nausea, impaired digestion and appetite, and constipation, which analogous remedies occasion in one regard or several. In the integration of therapeutical results, where may the physician look for a more satisfactory and pleasing exhibition of maxima and minima? Hydrated chloral, it has been said, resembles chloroform in its action, yet observation has convinced us that its effects are not identical with those of chloroform, which suspends alike sensation and motion. In affirmation of this statement, we may refer to the notes of two cases, in which the typical effects of chloral hydrate were se cured:

We essayed to operate, in both instances, for the removal of hæmorrhoids by ligature, using the hydrate chloral. In these cases profound sleep was induced by the exhibition in one instance of sixty, and in the other of ninety grains. The very moment the tumors were pierced by the needle, the patients awoke to an acute apprehension of the circumstance and their surroundings, and it became necessary to resort to the inhalation of chloroform on both occasions, in order to render the operation painless. But little chloroform was required in either instance, in order to establish a satisfactory state of anæsthesia.

To one of the patients referred to, we had on a former occasion administered chloroform by inhalation, and it was fully three-quarters of an hour before chloroformization was established; but when we resorted to the chloroform, after the failure of the hydrated chloral to produce anæsthesia, the patient yielded quickly and quietly to the chloroform. From these cases we would infer, that the chloral hydrate cannot be substituted for chloroform in surgical procedures; that chloroform and hydrated chloral may be used conjointly with safety and utility; and that by the administration of hydrated chloral extremely nervous and excitable subjects may be prepared for a calm and speedy surrender to the influence of chloroform.

The following case is interesting in several points of view:

B. M. J., aged 24 years; acute puerperal insanity, with suicidal proclivity; before coming to Staunton, in one of her paroxysms of mania, she had seized the vial containing the following prescription, and hastily swallowed its contents, to-wit:

R.-Chlorali Hyd., 3 v.;

Tinc. Hyoscyami, 3 vi.;

Fluid Ext. Valerianæ, 3 x.

The result of this rash action was a profound sleep of ten hours' duration.

At a subsequent period we have ascertained that the bromide of potassium was exhibited in 100-grain doses, three times daily, during four days; aggregating 1200 grains; there was not the slightest manifestation of stupefaction during this administration.

August 6th.—Had forty grains of chloral hydrate at 8 P. M.; no sleep.

August 7th.-Fifty grains were ordered at bedtime; no sleep.

August 8th.-Half a grain of morphia sulphas was added to fifty grains of hydrated chloral; produced sound sleep.

During the progress of the case, the nightly dose of chloral hydrate was increased to a drachm, with one grain of morphia sulphas; patient recovered.

The history of this case is not given in detail, as our only object is to exhibit the failure of large doses of hydrated chloral alone to produce sleep, and the advantages secured by a combination with morphia sulphas. The 300 grains of hydrated chloral taken by the patient in her excitement, though it occasioned not even temporary disadvantage, secured, however, the sleep so much needed. No physician would order for a single dose as much as 300 grains of hydrated chloral; still the case shows that, under certain circumstances, exceedingly large doses may be employed with safety and advantage alike. Dr. Eshelman, of Philadelphia, has recorded, in the second number of the "Philadelphia Medical Times," an instance in which 460 grains of hydrated chloral were taken at once;

the largest quantity ever ingested at once by a human being. Recovery from the effects produced was attained by the immediate and active employment of means to counteract coma. Should an instance of the toxical effects of the chloral hydrate come within our observation, we should be disposed to employ small doses, hypodermically, of strychnia sulphas.

To Dr. Oscar Liebreich, of Berlin, the profession is indebted alike for a knowledge of the remedial virtues of chloral hydrate and the affirmed antidotal powers of strychnia.

The experiments of M. Rajerosky, upon rabbits, appear to have demonstrated that the hydrated chloral may correct the toxical effects of strychnia.* Hydrated chloral is a most remarkable agent in this regard; we have repeatedly administered it in cases of so-called neuralgic headache, in which the subjects have declared their consciousness of pain up to the last waking moment. Some have expressed themselves as going to sleep in despite of the headache.

We have, however, more than once witnessed its anodyne effects, when exhibited in doses which were neither sufficient nor designed to induce sleep. As for example, during the afterpains of labor, and in dysmenorrhoea. These results are in accordance with those attained by Dr. Weeden Cooke in that distressingly painful affection, cancer of the womb; ten-grain doses, ter die, produced effects which he has described as charming and persistent, freedom from pain, unimpaired appetite, no headache, sleeping well at night, and no morning sickness."

The following case illustrates the advantages of the combination with morphia sulph., and the failure of the latter agent. alone to meet the indication; and exhibits also the fact that the impressions made by the hydrated chloral are not as evanescent as they are generally thought to be:

G. H. A., aged 52; disease mental, with delusion and suicidal tendency; health much impaired. Treatment: Iron, codThe Journal of Psychological Medicine, July, 1870. †The London Lancet, April 20, 1870.

liver oil, and whiskey; morphia sulphas at night to produce sleep, beginning with half a grain, and gradually increasing to one and a half; sleep deficient.

February 25th.-Sleep still deficient; substituted twenty grains of chloral hydrate for the morphia.

February 27th.-Hydrated chloral increased to thirty grains. February 28th.-Sleep being still deficient, half a grain of morphia sulphas was given with the hydrated chloral; produced sound sleep.

March 1st.-Exhibited one and a half grains of morphia. sulphas alone; result, slept none.

March 2d.—Thirty grains of the bromide of potassium with morphia sulphas, grain i., ss.; produced sleep. Nightly dose the same up to March 16th, when the morphia sulphas was disassociated. The bromide of potassium alone made the patient sleep; and on April 6th it was withheld, the patient sleeping well.

June 1st.-Again became sleepless, and thirty grains of hydrated chloral ordered to be taken nightly, produced sleep.

August 10th-Condition improved mentally and physically; chloral hydrate discontinued.

August 25th.-Growing worse mentally; the chloral hydrate was again resumed in half-drachm doses at night. Result, sleep and mental improvement.

October 4th.—The satisfactory sleep and improvement secured seemed to justify the withdrawal of the chloral hydrate; still the patient slept.

November 8th.-The impression made seemed to be fading away, as in the previous intervals of the suspension of the chloral, and the remedy was resumed (thirty grains) without improvement or benefit.

We have administered the chloral hydrate during parturition, and procured an abatement of suffering without occasioning the slightest interference with the uterine contractions. Short naps and freedom from suffering have followed the occasional administration of ten-grain doses during the first stage of labor;