Acute Poisoning. - The symptoms of poisoning from lethal doses are those of profound alcoholic narcosis plus the specific chlorine action. The patient is comatose. The pulse is feeble, thready, and irregular; the temperature is below normal; respiration is slow; the skin, particularly that of the forehead and extremities, may be covered with cold sweat and is pallid or cyanotic; the pupil is moderately contracted. There is great muscular relaxation, together with abolition of reflexes. Death is caused by paralysis of the respiratory center with pronounced cardiac weakness.

Autopsies have revealed inflammation of the mucosa of the mouth, esophagus, and stomach. In the latter organ ecchymoses may be present. Blood-changes are not constant but agglutination of the red blood-cells occur, and hyaline thromboses are present. Beginning fatty degeneration is also present in many of the organs, particularly the liver and kidneys.

Treatment of Poisoning. - It is of primary importance to maintain or restore the temperature by means of artificial heat - warm blankets, hot bottles, friction, massage, or other resources at command.

In order to arrest respiratory failure and stimulate the circulation, hypodermic injections of strychnine or atropine or the administration of other physiological antidotes, the inhalation of oxygen, and artificial respiration, may prove advantageous. Coffee as a hot rectal infusion is of value, and intravenous salt infusion may be demanded in severe cases. Naturally all alcoholic forms of stimulation are to be avoided.

Chronic Poisoning. - Chloral toxemia, or chloralism, is a well-recognized development of simple dosage.

The skin as in alcoholism may be subject to erythematous eruption, either persistent or temporarily excited by trivial causes. Respiration is embarrassed by the presence of dyspnea, which, however slight, is manifested after meals or is stimulated by physical exertion. Finally, the gravest complications may occur in the circulatory system, resulting in high fever, pyemia, and ultimate collapse.

The simplest treatment in these extreme cases is primarily the gradual withdrawal of the toxic agent, although delirium tremens is recorded as a result of abstention. The diet should be carefully regulated with a view to restoring, if possible, the decreased vitality. Change of scene, abundant air and exercise, chalybeate tonics, calmatives, and nerve-stimulants undoubtedly contribute to re-establish functional activity and normal circulation, and occasional purgatives may assist in eliminating from the body the toxic elements which the pathological cells are constantly forming.

Therapeutics. - Externally and Locally. - An injection of a 10 per cent. solution of chloral into the sac has been highly recommended by Marc See in the treatment of hydrocele. One ounce of this solution is injected, being followed in two or three days by a copious effusion, which is soon absorbed.

The antiseptic properties of chloral are utilized as a wash or dressing in cancer of the uterus, foul ulcers, etc. For these purposes the strength should be from 5 to 10 grains (0.3 to 0.6 Gm.) to I ounce (30.0 Cc).

Spohn recommends the continued application of a solution of 1 drachm (4.0 Gm.) of chloral in 4 drachms (16.0 Cc), each, of glycerin and water in cases of furuncle.

Bromidrosis and hyperidrosis have yielded to local applications of from 2 to 5 per cent. aqueous solutions of chloral.

Camphorated chloral is often an efficient remedy for toothache, and, when mixed with petrolatum or simple ointment in the proportion of 1 to 7, makes an excellent application in pruritus and other itching diseases where the skin is unbroken. This preparation undiluted has been used in neuralgia, painted over the affected nerves.

Cregny employs a 20 per cent. solution of chloral in anal fissure, and a 1 per cent. solution is used in cracked nipples.

Chloral is frequently used to preserve urine for microscopical examination, though it should not be added to urine reserved for chemical analysis intended to detect the supposed presence of sugar.

Solutions of chloral are used for embalming purposes and the preservation of anatomical specimens.

Internally. - The principal use of chloral internally is to depress the psychic mechanism and produce sleep. It is also employed to depress the reflexes and motor apparatus, and thereby diminish convulsions, and is sometimes useful in diminishing the activities of the sensory nerves.

As a hypnotic it is especially valuable in conditions characterized by excessive cerebral activity, such as insomnia resulting from overwork or worry, and in the wakefulness of many acute diseases - typhoid, typhus, and other fevers, delirium tremens, and puerperal mania - it is a remedy of well-known efficacy. Its depressing effects should always be guarded against during the active course of disease, as well as in delirium tremens where great cardiac weakness already exists. The insomnia of convalescence would usually indicate its use.

On account of its powerful depression upon the motor mechanism it is a valuable drug in treating the various convulsions and spasmodic disorders of childhood, such as whooping cough, laryngismus stridulus, status epilepticus, and myoclonus.

In asthma, tetanus, uremic convulsions, hiccough, strychnine-poisoning, and hysteria chloral has proved a useful remedy.

Chloral is useful in relieving the pains of carcinoma of the stomach; it is extremely valuable in restraining chordee, and in painful contractions of hollow viscera it is valuable, as in colic, in gall-stone, in cystitis, etc.

Certain forms of epilepsy, particularly the nocturnal variety, are benefited by this drug.

The reflex vomiting in pregnancy is sometimes relieved by either the internal administration of chloral or by enemas. It has also been used to depress the reflexes in sea-sickness.

It has given excellent results, used in rectal enemata, in the treatment of puerperal eclampsia.

Spasmodic rigidity of the os uteri is greatly reduced by a medicinal dose of this remedy, and, while its action on the sensory mechanism is feeble, it is nevertheless frequently efficient in modifying the pains of labor and in quieting the alarm and allaying the nervous excitement of the mother.

There are certain other pains of moderate intensity, especially those of neuralgia, which are temporarily more or less relieved by chloral. Its anodyne effect, however, is too transient to render chloral very popular as an analgesic.

A combination of morphine and chloral is a very efficient anodyne and hypnotic in sleeplessness due to pain, which is palliated by this combination with less digestive disturbance than if the former drug had been used alone, and less cardiac depression than if the latter had been the sole remedy, the medicines thus aiding each other and serving the twofold purposes of mitigating pain and inducing sleep.

In sthenic fevers chloral is an admirable remedy, not only as an antipyretic, but in allaying nervous irritability, restlessness, and excessive cardiac action. It dilates the blood-vessels, causes diaphoresis, and sleep is often of great service.

Contraindications. - Fatty heart; marked respiratory weakness, whether due to acute or chronic diseases of the lungs; atheromatous degeneration of the blood-vessels.

The drug should be administered cautiously, the patient being uninformed as to its nature in certain nervous diseases, lest he acquire the chloral habit.

Administration. - As is recommended in the case of all drugs, only the purest article should be prescribed. Frequently the untoward symptoms of chloral are due more to the impure article than to any idiosyncrasy against it. The recrystallized form alone should be used, the first dose administered not exceeding from 15 to 20 grains (1.0 to 1.2 Gm.), repeated as occasion may demand. Ordinarily a maximum dose should not be given oftener than once in forty-eight hours.

Children bear chloral well, and, as a rule, 1 grain (0.06 Gm.) may be prescribed for each year of the child's age.

Enemas of chloral may be rendered less irritating by mixing the drug with the yolk of an egg and milk. Chloral should always be well diluted when given internally, especially when combined with sodium or potassium bromide. Its disagreeable taste may be partially disguised by mixing the solution with peppermint water and elixir or syrup of orange. It should not be given in strong alcoholic solutions.