Chloral Hydrate has been extensively employed as an hypnotic in simple insomnia and delirium tremens. It is perhaps the most efficacious soporific which we possess when pain is not present. It is open, however, to two objections; these are the dangers of establishing a chloral habit, and the depressing influence which the drug exerts upon the heart. It directly affects the cardiac muscle, dilates the arterioles, and may in juriously affect respiration. Generally sleep is profound and refreshing, and the after ill-consequences are trivial. It acts rapidly, and the slumber may be prolonged to ten or twelve hours. Its depressant action should prevent its use in cardiac disease, in emphysema, and bronchitis. and in the late stages of typhus and typhoid insomnia, and in the sleeplessness following influenza, when the cardiac muscle is always weakened; it is likewise a dangerous hypnotic in ordinary senile insomnia for the same reason. In the insomnia of insanity its soporific virtues are so uniformly experienced that it is employed in a routine fashion in many asylums. Though patients have taken it without any ill-effects in these diseased conditions for many months, there is always a remote possibility of a lethal action upon the heart.
Whilst the victim of the opium habit may increase enormously with safety to life the dose of his narcotic, gauging its amount by the effects which he can measure by his own sensations, when he attempts a similar practice with chloral he may have no warning till fatal paralysis of the cardiac muscle ensues. This is the explanation of the many deaths " by misadventure " in medical men who have become victims of the chloral habit. It is useless to combine it with digitalis with the view of lessening its evil action of the heart, as is often advised. The digitalis has no cardiac tonic action for some hours after being swallowed, whilst the chloral may act injuriously within a short time.
Chloral acts rapidly, and should be given immediately before retiring to rest, and as some patients are very susceptible to its influence it is wise never to begin with a larger dose than 20 grs.
It has been combined with Morphia or bromides with advantage, and the writer believes that I or 2 oz. of whiskey given at the same time greatly increase its efficacy, and materially diminish its power of depressing the heart. Some authorities strongly condemn the combination of chloral and morphia as the most dangerous of hypnotics. The writer cannot confirm this judgment. The value of the bromides when given with chloral is above dispute, as a smaller dose suffices.
The following combination is very efficacious: Chloral Hydratis gr. xxx. Potassii Bromidi gr. xxxx.
Lig. Illorphime Bintecon. min. xxx.
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liromidia and Liquor Bromo-Chloral Co. contain hyoscyamus and Indian hemp in combination with chloral and bromides; they may be given in teaspoonful doses.
I3utyl-Chloral Hydrate possesses many of the good qualities of chloral and is less dangerous, but it is a much weaker hypnotic. Chlorctone a derivative—is given in zo-gr. doses in cachets, but has feeble hypnotic powers.
Chloralamide, now official as Chloral Formamide, may be given in 30-45 gr. doses. Sleep comes on in less than one hour. It seems less powerfully hypnotic than chloral, but there is no dilatation of the arterioles or fall of blood-pressure. It is indicated in the same class of cases as chloral in simple insomnia, and has been used as an hypnotic in heart diseases and bronchial affections. It is claimed for this drug that it is safe and that for very long periods the dose need not be increased, and that it tends to establish a habit of sleeping after its administration has been suspended.
Chloralosc has given excellent results in doses of 4 to so grs., and it is claimed for it that it causes no digestive derangement, and that it is less dangerous than chloral, but it is decidedly less reliable as an hypnotic.
Hypnal or monochloral-antipyrine is vaunted, but it is heir to all the objections raised against chloral in the ordinary hypnotic dose of zo grs.; it is perhaps the most depressant of the chloral compounds.
Isopral or trichlor-isopropyl-alcohol is another chloral product suitable for administration in the enema form, in 30-60 gr. doses, when there is gastric irritability or as a preliminary to chloroform narcosis.
Sulphonal may be given in (loses of 3o grs.; it is the type of a pure hypnotic, possessing nu analgesic properties. In insomnia uncomplicated with pain it acts with tolerable certainty, and it is free from any depressant action on the heart, and does not tend towards the formation of a habit. It is very slow in its action ; sometimes three or four hours elapse before the soporific effect begins to manifest itself. It has a prolonged deferred action,which sometimes causes a drowsiness, which may last for a consider able part of the day following its administration. It has been very often noticed that this drowsiness extends into the following night, and some patients who use the drug constantly find that it produces better effects upon the second night without taking any more of the drug in the mean time. It is especially suitable in the insomnia of individuals which shows itself by a waking up after a brief period of sleep on first retiring to rest. Ataxia or muscular inco-ordination, vertigo, giddiness and confusion of thought have sometimes been noticed after its prolonged administration, and hmatoporphyrinuria and albuminuria have occasionally resulted. It is a good hypnotic for children, and it is tasteless and inodorous. 3o grs. partially dissolved in a little warm beef tea or hot water may be given about an hour before retiring to rest. When some alcohol is combined with it the dose should be given as the patient retires to bed, and its effects are very rapid when it is dissolved in hot punch.