CHLORAL IN DELIRIUM TREMENS.

A painful case, which has recently occurred, of a fatal result following the use of chloral medicinally employed, has raised the question whether chloral is a safe hypnotic, and to what

extent it may with advantage be employed in the treatment of delirium tremens. Chloral seems at the present time to be as

popular a remedy with our profession as with the public ; and it is only when some sudden fatal result occurs that attention is called to the dangers which may attend its use ; and we are too

npt to imagine that some special want of precaution or excess

in dose has been contributory to the fatal issue. But a truer view would be that the doses habitually prescribed and sanctioned by eminent authority, and employed in our large hospital and asylums, are in many cases excessive, and that, especially in the case of delirium tremens and insanity, chloral is used to a need- less and dangerous extent. Particularly it is so with delirium tremens and the various grades of alcoholic poisoning which are included uuder that term. Chloral in large or repeated doses is the routine, and oftentimes the exclusive treatment to cut short

delirium, to produce quiet and sleep, and to prevent those sud? den outbursts of maniacal fury, which are sometimes so danger* ous to the patient and his attendants.

It is time, then, that the profession should face the question- Is chloral a necessary, or even a safe, narcotic in cases of alco- holic poisoning, acute or chronic ? Experience tends to the conviction that the practice of giving chloral ia all such cases, and pushing it till it produces hypnotic effects, is one attended by immediate dangers, injurious in its ultimate effects upon the path nt, and liable to great abuse on the part of nurses and attendants. The ca8es of alcoholism in which narcotics are employed

may, speaking roughly, be divided into three categories. A large number of cases occur in persons who, habitually moderate drinkers, or even abstemious, under the influence of excessive menial anxiety, or strain upon the nervous energies, or from some other cause, indulge in a prolonged drinking bout, which, with abstention from food, results in an acute attack of deli- rium tremens. In such cases the noisy violence of the delirium, the absence of sleep, and the general excitement of the whole system, seem to indicate the employment of sedatives, and, if combined with proptr nutriment, quiet, and the withdrawal of

stimulants, they 110 doubt conduce to a favourable issue. That such cases may be benefited by chloral we do not for a moment deuy, but the doses need not be large, and should not be too often repeated ; and we must add that the success of the treat- ment is proportioned to the amount of nourishment which can be given. Secondly, there are the cases of severe delirium

tremens, usually the sequel of prolonged excess, rarely the first attack, and often arising only as the result of combined disease or injury and alcoholism, in which the constant restlessness, tremor, delirium, and jactitation, seem to threaten life by ex- haustion, unless something be done to give temporary quiet and sleep to the patient; and in some cases, as, for example, of

fracture liable to become compound, the local conditions render quiet essential. In these circumstances narcotics may be em-

ployed, but with great caution, for too often the quiet of sleep only passes into that of coma and death, and, as we shall see, chloral is not the safest drug in such cases. In a third class of cases the condition is one which is rather the result of continued excess than its direct effect. The nervous, restless, irritable condition, with or without slight tremor, with loss of appetite, constipation, and a craving for drink, and drink only, exht during the day, and when night comes this condition passes into one of restlessness, slight delirium with hallucinations, or actual

violence. It is true that this state is rarely seen apart from the direct effects of alcohol. In most cases the passion for drink is

so strong, the craving for it so subtle and irresistible, that no sub- terfuge or artifice is left untried to get hold of drink, and, apart from physical impossibility, such people will and do drink. In these cases, especially at the present day, and amongst the better classes, there is often a combined indulgence in alcohol and

chloral, and chloral-drinking, first used to drive away the troubled dreams and hallucinations at night, is prolonged and increased, in order to permit of a freer indulgence in alcohol. Now, it is in such cases as these that the use of chloral, whether as a sedative or a hypnotic, is most injurious. As a sedative, in small and frequently-repeated doses, it may dull the senses and

quiet the craving, but it aggravates and prolongs the^ gastric catarrh, which is one of the existing causes of the craving, and it does nothing to restore the healthy tone and appetite. As a

hypnotic it is in some cases entirely ineffectual, even in large doses, and where it acts beneficially in this respect, the dose should never be maintained at a high level after one or two

nights, but with proper repeated nourishment may be rapidly diminished or entirely withdrawn. But chloral has some special dangers in the case of drinkers which should not be lost sight of.

Alcohol, as is well known, produces, when continuously em- ployed, fatty degeneration of all the organs, and, amongst others, the heart; this more especially in some cases of spirit diinking. Chloral, too, like its ally chloroform, probably gives rise to a fatty degeneration of muscular tissue, and in particular of the heart, closely analogous both in its mode of production and character to that due to alcohol. Again, as is well seen in some cases of delirium tremens, alcohol causes a fluid condition of the blood, in which the normal state of the blood-corpuscles and their relation to the liquor sanguinis, are altered ; and as a

physical condition evidencing this we see the defective coagula- tion of the blood and its tendency to transude too readily. We are not here entering into the intimate relations of these chang- es, and the effect they have on oxygenation and tissue nutrition; it is enough for our present purpose merely to indicate them. Chloral has a like effect, and similarly causes gradual destruction of red blood-corpuscles; so that in chronic chloral poisoning purpura is of frequent occurrence. In toxic doses chloral was formerly said to destroy, first the cerebral, then the muscular, thirdly the respiratory, and finally the cardiac functions. But this is certainly not true so far as concerns the usual result in suddenly fatal cases in the human subject, and modern research goes to disprove this view, and to show that cardiac paralysis, whether produced through the central nervous system or "by a direct action on the heart, is the usual mode of death. And

especially will this be the case when, from the effects of alcohol, or of continued chloral drinking, the cardiac muscle is already considerably degenerated, whilst at the same time the condition of the blood is such as to supply an imperfect stimulus to its contraction, and the impaired reaction between the blood and pulmonic capillaries affords an additional impediment to the circtilation. In such cases sudden cardiac paralysis or asystole may put an end to life before any cerebral symptoms or retarded respiration have given the warning note of danger. Nor can

any amount of negative evidence, derived from the absence of marked physical signs of organic disease, be sufficient to coun-

23 THE INDIAN MEDICAL GAZETTE. [January 1, 1878.

tcrbnlance the clear and decisive results of pathological investi- gation, which show how grave a degeneration may co-exist with apparent health. And, be it remarked, such fatal results do not of necessity occur only after a large dose. In healthy subjects death has occurred in this manner from so small a dose as thirty grains, and there is abundant evidence that the toxic effects of chloral are cumulative in a higher degree than the hypnotic, and that this does not depend solely upon accumulation of the poison itself in the blood.? The American Journal of Medical Sciences.

Treatment of Whooping-Cough.?Dr. Brynberg Porter observes that some members of the profession think it useless to treat whooping-coughs at all, considering that ordi-

nary cases do well of themselves, whilst fatal cases result from complications. These complications, however, he remarks, are best avoided by cutting short the disease at as early a period as possible, since all authorities agree that severe complications almost invariably occur after the affection has lasted some time, when it has reached its height and the paroxysms are of the greatest violence. Moreover, granting that pertussis does as a rule " get well of itself," is it not, he asks, better to save the little patient weeks and months of suffering, especially since a severe attack of this disease is always debilitating, lowering the vitality and rendering the system peculiarly sensitive to all influences which injuriously affect the health ? After a very extensive experience in whooping-cough he has found the most reliable and satisfactory agent he has employed to be chloral. It has the great advantage over quinine in solution (which he has also used with success) of not being unpleasant to the taste when given in syrup. Dr. Porter believes chloral to be a per- fectly safe remedy, and he has never known the slightest un- toward symptom to be occasioned by its use in the disease, if used with ordinary caution. lie advises commencing with only small doses, but the quantity can be increased with im-

punity. Ho gives the manner in which Professor Thomas now treats his cases with ether treatment. The nurse is instructed to wear a cotton glove on the right hand, and as soon as a paroxysm commences, to saturate it with ether, and put it over the mouth and nose of the child ; which, lie says, has the effect of cutting short the coughing spell. This procedure must be anything but agreeable to the patient, and in many cases Dr. Porter thinks would be impossible to carry out. Before using chloral lie was in the habit of prescribing belladonna in pertussis; but had to give it up on account of the unsatisfactory results which lie obtained. He is inclined to believe that the want of suc-

cess was clue to the fact of not using sufficiently large doses, for he has noticed Dr. Charles Kelly found that in the treat-

ment of whooping-congh, half an ounce of the tincture of

belladonna in twenty-four hours could be safely taken by child- ren of three or four years of age. Dr. Porter finds that his

observations tend to show that of the children suffering from the disease who are ill enough to cause their parents to seek medical advice, a considerable majority are girls, and that while only a trifle more than onc lialf of all the male cases treated can be classed as "severe," fully five-sixths of the female cases come under this category.?Practitioner.

Xiime water and Milk as Food and Medicine in Pregnancy.?Dr. E. N. Chapman, after pointing out that the use of milk has largely supplanted that of broths, and many farinaceous compounds for invalids and infants, as well as for those of riper years, refers to the serious objection that exists to it in consequence of the large solid curds formed in the

stomach by the action of the gastric juice being quite indigest- ible?a condition of things which is identical with that of

pieces of meat being swallowed entire. To remedy this the

addition of an alkali has been advised, particularly in the case of infants. Lime, potash, sodn, and ammonia have been select- ed indifferently, as the action of each is thought to be the same

the removal of acidity and the promotion of digestion. Now, an ounce and a half of lime water, containing less than a gra'in of the alkali, will, when added to a glass of milk, obviate its bad qualities and render it the best substance that can bo given even to those who never drink it plain without a sense of uneasiness and weight at the epigastrium, and that, too, though employed as the sole diet in typhoid eases. Dr.

Chapman notices the peculiar action of lime on oil and on

milk. An ounce of lime water and an ounce of olive oil when

shaken together become a thick houey-like mass that does not

change by keeping, a permanent emulsion in fact. There is, he thinks, a like reaction between the lime and the oil globules of milk intensifying the emulsion already existing. He also observes that 4 grains of pepsine will precipitate in the case of an ounce of plain milk almost immediately, but if lime water be first added, not for three or four hours. The first experi- ment yields dense adherent masses, but the second, fleecy broken curds, that are so soft and fine, as on agitation to blend again with the whey and restore the original white opaque colour. The emulsion formed by the reaction between the cream and lime is not disturbed by citric or hydrochloric acid, nor is a black precipitate thrown down by calomel. Dr. Chapman, therefore, concludes that the addition of about one ounce of lime water to eight ounces of milk renders it a perfect food by enabling it to resist the prompt action of the gastric juice, causing the precipitate eventually formed to be soft and flocculent and easily digestible, and thus allowing all the constituents properly elaborated to be presented to the lac- teals for absorption. For those who dislike the flavour of milk, he recommends that a thin gruel should be made of farina or ground barley, to which five or six parts of milk may be added. He does not And milk and lime water of much service in the sickness of pregnancy, but it has, in his hands, proved very useful in the debility that occurs after confinement; in cases of poverty of the lacteal secretion, in those of exhaustion after lactation, and in the dementia of the puerperal state. ?Practitioner.

Bromide of Potassium in Brig-ht's Disease.?M. Chauvet has studied the effects of bromide of potassium in Bright's disease. M. Bouchard had fixed the time for the elim- ination of the drug at nineteen days after its administration ; M. Chauvet, however, found bromide in the urine, on one occa- sion'on the thirtieth, on another on the thirty-fifth day. The iodides eliminate much more quickly ; in the healthy subject (M. Chauvet himself, for instance), the drug was completely eliminated at the end' of one or two days. In patients suffer- ing from Bright's disease, this elimination lasted once four days, once five days, once seven days, once twelve days. The same

thing occurs in the case of salicylic acid, which is also elimin- ated vefy quickly in the healthy condition, and much more

slowly in cases of renal disease. In these different cases of kidney-disease, the toxic phenomena soon appear, and do not disappear for a long time. All M. Chauvet's experiments go to corroborate M. Bouchard's proposition : that kidney diseases cause activo medicines to manifest toxic properties even when administered in small doses ; and it is thus that M. Bouchard

explains how in certain cases of heart disease the accumulation of digitalis produces toxic effects, which should be attributed to the condition of the kidneys, which are often secondarily affected.?Practitioner.

Treatment of Fissures of the Breast by Picric Acid M. Charrier utilises the hardening properties of picric acid in the treatment of mammary fissure. He paints the fissure once a day with a solution of thirty parts of picric acid to 1,000 of water, and also immerses the nipple in a little glass filled with a solution of picric of one part per 1,000 after each time of suckling.?Practitioner.

Podophyllin in Habitual Constipation and Haemorr- hoids. I)r. Bousselet gives the result of the employment of podophyllin in forty-seven cases. He finds the powder of

podophyllum superior in its action to the resin, which, as sold, is often inoperative. In habitual constipation the use of the

remedy must be continued for two or three months, and care should" be taken that the action of the bowels should be solicited with regularity at the same hour every morning. He com-

mences by prescribing about one-sixth of a grain, increasing the

quantity to a small extent day by day till the desired action is

obtained. The same quantity is then given daily for a fort-

night, when at first one day, then two and three days are allow- ed^to intervene between the doses. In cases of mechanical

occlusion of the alimentary canal, podophyllin possesses the

advantage that it may be used for a long period without harm. It is especially useful in hcemorrhoids, rendering the motior.s

pultaceous, and quickly causing the disappearance of the

swellings.?Practitioner.