1032 
THE PHARMACEUTICAL JOURNAL AND TRANSACTIONS. 
[June 23, 187S. 
But the article deals more particularly with the morbid 
phenomena which appear sooner or later in the course of 
continuous employment of this hypnotic. The most 
prominent of these symptoms are connected with the skin, 
and consist of more or less extensive erythemata and pus¬ 
tular or papular exanthemata. Schide speaks of chloral 
producing a tendency to fluxionary hypersemias and in¬ 
creased heart action, early manifested in the head by an 
intense erythema, occurring first in spots, but afterwards 
more diffusely, and which in more pronounced cases ex¬ 
tends downwards to the trunk. This chloral-rash remains 
latent until set going by some stimulus to the vascular 
system, but then appears with an intensity proportionate 
to the extent of chloralization. This opinion is confirmed 
by the author, who states that he is acquainted with a 
series of patients in whom the chloral rash can be pro¬ 
duced with the certainty of an experiment. For instance, 
in a paralysed patient, who took 30 grains of chloral every 
night, ten minutes after she had drunk her beer there 
occurred increased action of the heart and spots of roseola 
upon the forehead, nose, cheeks, and neck, which quickly 
coalesced into a patchy erythema, with swelling and heat 
of the affected parts, which symptoms disappeared in 
about an hour. The same symptoms appeared still more 
strongly in a young and previously healthy woman 
affected with mania, who every night took 30 to 45 grains 
of chloral (although she had not previously suffered from 
congestion of the face). As soon as she took a glass of 
beer there was strong pulsation of the arteries, and the 
whole face was swollen and of such an alarmingly deep 
colour that the use of wine and beer was forbidden. At 
present the author but rarely allows alcoholic drinks 
to patients who are being treated with chloral. In an¬ 
other young woman suffering from mania, who took 30 
grains of chloral at night, four ounces of wine were suffi¬ 
cient to induce the chloral-rash. 
The effect is not always limited to congestion and ery¬ 
thema of the skin, but other skin affections are occasionally 
produced. Female patients, who had taken 60 grains of 
chloral daily, first had erythema of the face, and later a 
papular rash on the arms, with red bases. In some nettle- 
rash occurred. 
The swelling, accompanied or not by rash, which has 
been noticed in the face after continued use of chloral, 
may equally occur on extensive portions of the body. In 
several patients a swollen condition of almost the whole 
body was noticed, which might be ascribed to serous in¬ 
filtration of the skin from stasis of blood. With these 
affections of the skin must be associated affections of the 
mucous membranes. 
Reimer observed in a series of patients, especially after 
the use of morphia and chloral together, that after slight 
external pressure there was congestion in circumscribed 
spots with much lowered sensibility, which quickly dis¬ 
appeared if the pressure was soon removed. Under less 
favourable circumstances, the red spots swelled and 
assumed a darker colour; vesicles were soon developed 
which might even run on to sloughing. 
An important symptom noted in a series of cases of the 
long-continued use of chloral is an interference with 
respiration, which may remain slight and scarcely trouble¬ 
some to the patient, or may become positive dyspnoea. 
Schiile observed a patient who, after long use of chloral, 
used regularly to suffer after meals from a sense of op¬ 
pression which made going up stairs extremely difficult, 
and even interfered with speech, although there was no 
chest disease to account for this. The symptoms per¬ 
sistently recurred in spite of all treatment till the chloral 
was left off, when the oppression entirely disappeared. 
A lady, prostrated by long sufferings, suffered from attacks 
of extreme dyspnoea, which had increased to asphyxia; at 
the same time the face was swollen, the facial muscles 
paralysed, and there were also all the signs of cerebral 
effusion. Every remedy had failed, and the patient 
seemed on the brink of the grave. The physician there¬ 
fore recommended the discontinuance of a daily dose of 
45 grains of chloral which had been given as a hypnotic ; 
whereupon all these highly alarming symptoms vanished 
in an almost magical way, the cerebral disturbance ceased, 
and the respiration quickly resumed its normal type. 
In another group of cases both the quality of the symp¬ 
toms and their greater or less extension in the organism 
indicate a distinct change in the composition of the blood. 
Dr. Crichton Browne reports that a woman, aged 69, 
suffering from periodical mania, had 20 grains of chloral 
thrice daily. On the fourth day a redness was developed 
on the skin of the chest and shoulders, which did not 
vanish on pressure. On the sixth day the eruption had 
extended over the whole trunk and limbs, livid spots and 
deep red patches alternating; the lips and the mucous 
membrane of the mouth were excoriated, the gums 
spongy, the tongue blistered and ulcerated, the breath 
foetid. The general state was one of great depression,— 
pulse 120. On the eleventh day the ulceration of the 
mouth had extended further; the lips were covered with 
crusts; the petechial eruption was diminished on the 
chest and abdomen—the spots were yellowish with patches 
of white skin between them; the spots on the arm lost 
their redness later. On the fifteenth day there was a sort 
of general desquamation; fissures of the skin over the 
sacrum, and in the neighbourhood of the joints. From 
that time convalescence proceeded, and ordinary health 
was restored. 
A woman, aged 46, suffering from cardiac disease, 
hemiplegia, and dementia, took 15 grains of chloral three 
times a day with a calming effect. On the nineteenth 
day of the treatment numerous purple-red spots appeared 
in the neighbourhood of the left elbow; on the next day 
many similar spots were seen on the shoulders and fore¬ 
arms, which coalesced with the others. On the twenty- 
first day livid spots came on the face; the left arm 
swelled and became hard; on its reddened surface ap¬ 
peared a multitude of minute points of a much deeper 
colour, which did not diminish on pressure. Next day 
there were dark purple spots and discolorations—some 
small, round, and circumscribed, others broad and irregu¬ 
larly shaped—on the legs and abdomen, and in stripes on 
either side of the vertebral column. Simultaneously with 
the petechia; there were great prostration, tendency to 
somnolence, weakness and excitability of the pulse, sore 
lips, thickly-coated tongue. On the twenty-third day the 
spots and discoloured patches had extended in every 
direction, and the previously bright red spots had assumed 
a deep purple colour. Finally, signs of lung-congestion 
appeared, with gradual failure of power, and death, after 
several fainting fits, on the twenty-sixth day. At the 
autopsy numerous ecchymoses of every shape and size 
were observed more or less on all parts of the skin; the 
right lung was congested and oedematous, the heart dilated 
and its valves thickened; over the right central hemisphere 
there was a large arachnoid cyst containing fluid blood. 
Other cases are quoted by the author, and the article 
closes with a notice of a case which occurred before the 
effects of chloral hydrate were yet known, and in which 
the use of the medicine was continued much longer than 
it would be now the symptoms are recognized. It was 
that of a young man in whom, on the ninth day of chloral 
treatment, a rash of groups of red spots appeared which 
soon became confluent. This was followed by a rise of 
temperature (on the twenty-third day to 106'7°), oedema¬ 
tous swelling of the face, cheeks, ej 7 elids, and ears, ec¬ 
zema, shedding of the hair, and falling off of the nails 
of hands and feet. After the sixth week abscesses formed 
on the shoulders and armpits. The author considers that 
the symptoms described must be defined as those of chronic 
blood poisoning. There was, however, no other external 
cause than the administration of chloral, which for ten 
weeks had been given in nightly doses of 45 to 60, or 
even 75 grains. After a certain saturation had been pro¬ 
duced by accumulation the symptoms began to spread, 
and finally they assumed the complete picture of a chronic 
blood-poisonin g. 
