CONTENTS. ORIGINAL COMMUNICATIONS. PAGE Chloral Hydrate. A lecture delivered during the Session, 1870-71. By W. Fatal case of Measles. By Dr. Sheriff, Huntingdon, P.Q..... 405 407 409 410 416 Proceedings of the Medico Chirurgical Society of Montreal... CORRESPONDENCE. MEDICINE. The Trinity Medical School, Toronto...... PERISCOPIC DEPARTMENT. SURGERY. A specific in Erysipelas. By D. J. E. Garretson.... MATERIA MEDICA AND CHEMISTRY. The Treatment of Ulcers and other granulating surfaces by transplantation of skin MIDWIFERY. 431 432 434 Bloodletting in Obstertic Practice. By Fordyce Barker, M.D...... .... 437 .......... EDITORIAL. The Canadian Medical Association........ 440 CANADA MEDICAL JOURNAL. ORIGINAL COMMUNICATIONS. Chloral Hydrate. A lecture delivered during the session, 1870-71. By WILLIAM WRIGHT, M.D., L.R.C.S.E., Professor Materia Medica, McGill University. The chief steps for making chloral, C, HCl,, by Liebig's plan, arc to pass chlorine gas through absolute alcohol to saturation, to treat the mixture with concentrated sulphuric acid and collect the product. Thus got, it is a limpid fluid, sp. gr. 1-502, boils at 201. When mixed with water it developes much heat and becomes a white, crystalline hydrate. It is commonly seen as a solid, in irregular fragments, made up of fine acicular pieces aggregated together. At first they are transparent, but they soon become opaque and have a tendency to effloresce They sublime unchanged by a slight heat, are easily soluble in water and exhale an odour something like that of melons. The taste is pungent and approaches to that of a bad bitter orange. The watery solution when acted on by free alkalies, grows opaque and milky-looking, and is transformed into a formiate of the base and chloroform. Chloral comes to us with a great flourish of trumpets; from what we hear of it, almost in every medical paper we take up, we would expect to find it a safer, surer, and quicker hypnotic than any other hitherto used. Firstly. It is SAFER. Opiates, as you know, after they are taken leave behind a faulty state of the digestive system and of secretion. It is not so with chloral. One of its great advantages is, that it leaves after its action no dryness of the mouth, furred tongue, bitter taste, thirst, nausea, loss of appetite, constipation, &c.; nor does it cause dry skin, scanty urine, &c. On the contrary, after chloral, the appetite is often more keen and indigestion unheard of. Other narcotics tend to increase the destructive powers from the injury they cause in weakening the stomach. It is the reverse with chloral, it rather raises up the formative processes by promoting assimilation. The difficulty hitherto felt in chronic wasting diseases, as phthisis, cancer, &c., of giving sleep so as not to impair the general tone is now removed. Again, opiates are apt to leave a feeling of depression and other marks of disordered innervation. The only symptom of the kind after chloral, in proper doses, has been headache. Where the patient has his sleep out it does not occur; and, under any circumstances, it has not happened in more than ten per cent. of those who have taken the drug, and it has not lasted more than an hour. The very cases where opiates are likely to be injurious are those where chloral may be employed beneficially; for example, certain brain affections where cerebral congestion threatens to be imminent, and especially cases of uremic poisoning; also in certain cardiac cases, where to stimulate the heart or embarrass the respiration would be detrimental, chloral may be safely given, as it induces neither of these effects. Secondly. Chloral is SURER than other agents of the same class. Its action is not so likely to be prevented by the conditions that oppose these others. It has a wider range of applicability. Usually it may be given wherever sleep is needed, be the cause almost what it may. It may be resorted to under circumstances quite opposite to one another, in insomnia attended with gastric disorder or nervous exhaustion-with fever or without—with delirium or not-with structural brain disease or mere anæmic disorder. It is not contra-indicated by any age; it is as appropriate in early or advanced life as during the intermediate periods. Chloral sleep is, again, more prolonged, more calm, more refreshing than sleep from other narcotics. Like other medicines, however, it may fail, but its failures are less frequent. In three cases where it was given under my directions, at the General Hospital, it failed. In one case ij was the dose, in each of the others 3 ss. In these it caused either a slight dizziness or drowsiness with more or less of a feeling of intoxication. One of these persons was in the habit taking an after dinner nap, and he blamed the chloral for keeping him out of it, as it had been given just before, and he continued wide awake afterwards. These three patients did not need it. They knew what was expected to happen, and the interest this aroused may have helped to defeat the end in view. In upwards of seventy persons to whom it was given in the Royal Infirmary, Edinburgh, no sleep is reported to have followed in thirty. In some rare instances its effect is postponed for twenty-four hours, as sometimes occurs with morphia, &c. The success of chloral depends upon the circumstances under which the patient is placed, his habits, the time of its administration, quality, &c. Much talking, or a bright light in the room, or moving about of the patient, will impede its action, as they do the action of other cerebro-spinants. Inebriates appear to resist its action or to require larger doses than the temperate. Administering a stimulant with chloral seems to weaken its effect. The worst time for exhibiting it is generally the morning, the best about half an hour before bedtime. Lastly. It is very important it should be pure. The chief impurities are alcohol and aldehyd. Instead of being an hydrate it may be an alcholate, alcohol taking the place of water with the base. It is then weaker, as it contains but 76.3 per cent. of real chloral instead of 90 per cent. To detect alcohol I would suggest the same tests as those mentioned yesterday, when lecturing upon chloroform. Aldehyd is less common, as an addition, than spirit. It arises from acetic acid present in the material of which chloral is made. Thirdly. Chloral is QUICKER than many older sleep producers. Its celerity in medicinal doses is often equal to that of other narcotics in fatal doses. Sleep begins in from ten to twenty minutes, and lasts from half an hour to five hours or more. I have seen it act, however, more quickly than this. A common expression with patients is, they fell asleep soon after, or just after, taking the medicine. The usual dose advised is ij. I think it unnecessarily large as a rule. If good, and the conditions favorable, j or 3 ss, will suffice. In one case where I gave it, ss was enough. It was that of C. W., æt. 19 years, who had been admitted after her first confinement, for sub-acute rheumatism. The dose was repeated thrice daily, and each time sent her asleep before many minutes were over. The largest amount I have prescribed has been 120 grains, in divided doses, during 24 hours. J. B., while in hospital with necrosis of the sternum, caught typhoid fever, which was ushered in by profuse diarrhoea. From night time to the visit hour, 10 a.m., he had about twenty stools. Chloral though given to the extent of 3 ij, as stated, was well borne, moderated the purging, and was followed by no worse effect than great drowsiness. Eighty grains is the largest single dose I have read of. Dr. Madden directed it to be given in a case of hysterical mania, where there was violent excitement, coming on suddenly. It caused sleep for several hours, from which the patient awoke more composed. There were no bad results. Larger daily doses have been given in tetanus, perhaps, than in any other disease,-chloral falling in with other remedies equally tolerated on as huge a scale. From 3 iss-iij have been taken in divided quantities in the day, without exciting any tonic symptom. The CHARACTERS OF THE SLEEP from chloral are these: it is like natural sleep, but more deep; it is sound, not broken by starts or dreams, the patient is easily awoke, and generally, if not much disturbed, soon drops off again, he may be wakened to take nourishment, &c., in the mean while; the pupils as in natural sleep are contracted and dilate on awakening. The INFLUENCE of Chloral Hydrate ON ANIMAL HEAT has been variously stated. The conclusions arrived at from some experiments in th Royal Infirmary, Edinburgh, were, that it caused little or no reduction in the heat of fever: though in health it makes a decrease from a degree to 2 degrees. At my request Mr. W. G. Ross paid special attention to the first of these points, viz., the influence upon fever heat. The observations for more ready use he arranged in tables which are appended. They were taken from cases of typhoid fever; 8 from one, and 7 from another; any inconstancy or uniformity of action being more obvious from several consecutive observations on the same person than from 15 separate persons. They shew no change in 2. Decrease in 5; from one degree to 11 degrees; beginning in from 15 minutes to one hour after administration of medicine, and lasting an hour to 1 hour and 15 minutes. Decrease followed by an increase in 3. Increase in 7 (all in the one case, H. C.'s), from a degree to 1 degrees; beginning in from 15 minutes to of an hour after medicine ; lasting from forty-five minutes to one hour and fifteen minutes; and gravescent in three. After the decline of increase, heat lower than before chloral was taken in 2. No instance of increase, decrease and a second increase on the one day. The seven instances of increase were on seven successive days. In a case of the same disease where no chloral was given, the heat on seven successive days stood at the corresponding time at 101, 102, 101, 100, 101, 99, 102. To shew the relation of the heat to the pulse and respirations, their rate is also recorded on the same line in the table. From these additional observations it appears that after chloral, increase of heat was generally accompanied by increase of pulse and breathing, and decrease of heat by their decrease. Several exceptions to this rule were noted: 1. Increase of heat attend ed with higher pulse, and fewer respirations. 2. The same attended with a rise, a fall and a rise again in the respirations. 3. Increase of heat with marked fall in the pulse, respiration slower, and either quicker at first or not so. This last observation also noted when heat unchanged. When heat was the same after as before chloral, pulse and respiration have been found much more frequent than at first, but subsequently they fell below what they then were. |