Drugs that enslave

by H. H. Kane

THE CHLORAL HABIT.

CHAPTER VIII.
THE CONTINUED USE OF CHLORAL HYDRATE.

But little attention has been paid in this country to the habitual use of chloral. German and English literature is more abundant, but at best vague and unsatisfactory, and the professional mind does not seem to be at all settled upon the subject as to whether such a thing as a chloral habit does or does not exist.

A committee was appointed by the Clinical Society of London, a short time ago, to investigate this matter. The result was a failure, owing to the fact that the medical gentlemen who received circulars asking for information upon various points failed to answer in sufficient numbers or with sufficient explicitness to make the results valuable. There were but seventy replies from the thousand circulars sent out.

Not knowing until afterward of the work then undertaken by that society, I prepared and sent out some ten thousand circulars, containing a series of questions upon chloral, one of which related to the habitual use of the drug. To this circular I received over four hundred replies, one hundred and seven of which related to the chloral habit.

One hundred and seven physicians reported 135 cases where the long continued use of the drug had led to a more or less marked craving for it.

An analysis of these cases may prove of interest.

The ages of the patients were obtained in ninety-four instances, and show as follows:—

From 20 to 30	12
From 30 to 40	25
From 40 to 50	27
From 50 to 60	19
From 60 to 70	11
	94

The sex was obtained in one hundred and thirteen cases, as follows:—

Males	77
Females	36
	113

There were among the number clergymen, physicians, editors, clerks, prostitutes, mechanics, farmers and hospital nurses.

The majority of the females were married women, suffering from painful uterine complaints. The majority of the males, persons who had been or were addicted to the use of alcoholic stimulants. Some, both males and females, formed the habit through taking it for insomnia and mental depression, dependent on family troubles, business failures and the like. Some through hearing or reading of its magical effects and trying it to satisfy themselves.

In many important points the habitual or long continued use of chloral differs from that of opium or morphine, viz:

1. Many persons take it for years without any obvious ill effect.

2. Its continued use is not so liable to be followed by a morbid craving for it as for morphine or opium.

3. The habit once formed is, in the majority of instances, easily broken.

4. An abrupt change from chloral to some other narcotic is often made.

As regards the first and second propositions the following facts may be taken into account:—

Dr. W. M. Compton,[45] Medical Superintendent, Insane Asylum, Jackson, Miss., says that he has given twenty to thirty-grain doses of chloral hydrate nightly, for years, to noisy patients, without observing any ill effects. Dr. J. H. Nordlin,[46] of Rome, Ga., has given it in combination with bromide of potassium, capsicum and ammonia, in asthma, for a long time, without any ill effects.

A correspondent of the London Lancet,[47] a medical man, says that, for sleeplessness, he has been obliged to take twenty-grain doses of chloral at bedtime, for upward of four years, without any bad consequences whatever.

Dr. J. G. Thornley[48] has used chloral in the treatment of insane persons, continuing its use for from six months to two years, without any ill effects.

Dr. Schlaugenhausen, First Assistant Physician to the Lunatic Asylum, Hall, Tyrol, writes me that in a case of insanity he gave thirty grains of chloral every night, for six years, without any perceptible bad effect. He says that he has never seen a case where there was a morbid craving for chloral, such as is seen from opium or morphine. Dr. John Wirtinger, of Ybbs on the Danube; Dr. Reiman, of Kiev, Russia, and Dr. Fr. Akland, of Stockholm, Sweden, write the same.

Dr. A. Ady,[49] of West Liberty, Iowa, gave chloral in a case of chronic diffuse nephritis, for nearly a year and a half, without any bad results and with no tendency to the formation of a habit.

Bidlack[50] relates a case where this drug was used for a year, with no bad effects.

Lawrence Turnbull[51] gave chloral, in medicinal doses, for one year, as a sedative and narcotic. Its use was stopped at once, without any ill effects whatever. Dr. Blackwood[52] used thirty grains three times a day, in combination with bromide of potassium, for three months. No bad effects beyond slight conjunctivitis. No evil effects followed the withdrawal of the drug.

Dr. Carlos F. MacDonald[53] writes: “As regards the so-called ‘chloral habit,’ I can only say that I have used chloral very largely in my practice—commencing with its introduction to the notice of the profession in America—and I have yet to meet with a case.”

A physician, who does not wish his name used, took twenty grains at bedtime, for insomnia, for nearly two years and a half, without ill effect. Professor A. A. Smith, of Bellevue College, this city, writes me: “A lady of an extremely nervous temperament had it administered to her during an attack of typho-malarial fever. This was seven years ago, and she has taken it every night of her life since. Usually ten grains suffices, but sometimes she takes thirty grains. It has had no perceptible bad effect. She seems perfectly well. I have, time and again, tried to wean her from the habit, but to no purpose, and I am quite certain that the drug has never yet done her any harm.”

Dr. G. A. Shurtleff, Medical Superintendent State Insane Asylum, Stockton, California, writes me that he has seen a morbid desire for chloral produced by the taking of from twenty to forty grains regularly at bedtime, to procure sleep. It was easily broken, the desire passing away in a few days.

Dr. M. L. Holbrook, of this city, writes me of the case of a highly cultured lady, an authoress, now in Germany, who had taken thirty grains of chloral nearly every night, for eight years, without the production of a morbid craving or other ill effects.

Dr. Joseph Parrish, of Burlington, N. J., writes me of the following curious case:—

“I have known persons (and have one under treatment at this time) who are habituated to the use of narcotics, and who, to avoid being enslaved by either one, alternate between morphia, chloral, whiskey, and the bromides, with the result of rest and composure from each in its turn. They are not opium or chloral habituès, nor inebriates from alcohol, but they are habituated to artificial narcotism.

“In the case now under treatment, the chloral dose does not exceed fifteen grains at bedtime, and the morphia dose does not exceed half a grain, nor the whiskey dose more than a fluid ounce. I learn from the patient that his former physician employed these remedies for long-standing insomnia.

“Present condition fair; i. e., delicate constitution, but good appetite, and even temperament; functions not interfered with, though the habit of taking something to promote rest and sleep is of several years’ duration.”

The following is from a prominent physician, who does not care to have his name appear in connection with the case:—

“A lady patient of mine—now fifty-seven years of age—began to take fifteen grains of chloral about eight years ago, after very great family affliction, to procure sleep, and has kept up its use almost uninterruptedly ever since, without increasing the dose, though she occasionally (not very often) repeated the dose once during the night. During seven of these eight years she was subjected to the depressing influence of the care of a child with severe epilepsy and mental deterioration slowly progressing. During the last year she has gone several times, for a week at a time, without the drug, and I think that she could now dispense with it almost entirely were it not for constant anxiety about one of her children. She takes it only to procure sleep; and I cannot see that it has harmed her in any way.

“The above case cannot be called one of the chloral habit, as during a number of hours out of every twenty-four she is free from the influence of the drug; but I think the case may be of value as illustrating the length of time during which the drug may be taken, almost daily, without any increase of dose.”

Professor Henry M. Lyman, of Rush Medical College, Chicago, writes as follows:—

“I am acquainted with a clergyman, sixty-five years of age, whose mother died insane. He informs me that for ten years past he has been obliged, in order to procure sleep, to take ten grains on retiring, and ten grains more about 3 A.M. His health is otherwise good, and he is possessed of more than common intellectual power. He, however, though never in the habit of using alcoholic drinks, has the red eyes and rather ‘groggy’ appearance of a person who drinks too much. I have known of other cases where persons were in the habit of taking ten grains at bedtime, every night, for months together, with great benefit. I have never happened to make the acquaintance of a person who was addicted to its use as a simple instrument of pleasure.”

Some men, in the early history of this drug, and some at the present day likewise, lauded it highly as a substitute for opium, claiming for it perfect freedom from the danger of forming a habit and the non-production of ill effects when used for a long time.

Thus a correspondent of the Doctor[54] says:—

“Long-continued use does not impair the general health. I know persons who have taken it almost since its introduction, in the same dose and with the same success.”

Dr. Pollak[55] says: “The prolonged employment of chloral is not usually attended with any disagreeable effects, and if any such occur, they are of no consequence. It especially does not induce congestion of the brain or disturbance of the digestive organs.”

Dr. C. W. Cram,[56] of Columbus, Ohio, writes: “Its use is not followed by that craving for its continuance which so often attends the administration of preparations of opium, especially morphine, producing a multitude of opium-eaters.”

Others went to directly the opposite extreme.

Dr. Madison Marsh[57] says: “Its effects are so pleasant, its use so exquisitely fascinating, that, the habit once acquired, a person becomes a slave to its use, never to stop till death closes the scene. The enchantments of alcoholic stimulants, cannabis Indica, morphine or tobacco, bind with silken cords, compared to the bars and hooks of steel thrown around the unhappy victim of this popular drug and infatuating stimulant.”

The first to call attention to the possibility of the formation of a “chloral habit” was Dr. B. W. Richardson, of London, a part of whose most excellent paper[58] I cannot refrain from giving.

“It is a matter of deep regret to have to report that, since the name was given to the disease, chloralism has become widespread. It has not yet spread far among the female part of the community. It has not yet reached the poorer classes of either sex. Among the men of the middle class, among the most active of these in all its divisions—commercial, literary, medical, philosophical, artistic, clerical—chloralism, varying in intensity of evil, has appeared. In every one of these classes I have named, and in some others, I have seen the sufferers from it and have heard their testimony in relation to its effects on their organizations. Effects exceedingly uniform and, as a rule, exceedingly baneful.

“At the meeting of the British Association for the Advancement of Science, held in Edinburgh, in the year 1871, I drew earnest attention to this subject. I said, and the words were published in the reports of that year (p. 147), there is another subject of public interest connected with the employment of chloral hydrate. I refer to the increasing habitual use of it as a narcotic. As there are alcoholic intemperants and opium eaters, so, now, there are those who, beginning to take chloral hydrate to relieve pain or to procure sleep, get into the fixed habit of taking it several times daily, and in full doses. I would state from this public place, as earnestly and as forcibly as I can, that this growing practice is alike injurious to the mental, the moral, and the purely physical life, and that the confirmed habit of taking chloral hydrate leads to inevitable and confirmed disease. Under it the digestion, natural tendency to sleep, and natural sleep are impaired; the blood is changed in quality, its plastic properties and its capacity for oxidation being reduced; the secretions are depraved, and the nervous system losing its regulating, controlling power, the muscles become unsteady, the heart irregular and intermittent, and the mind excited, uncertain, and unstable. To crown the mischief, in not a few cases, already, the habitual dose has been the last; involuntary, or rather, unintentional suicide closing the scene. I press these facts on public attention not one moment too soon, and I add to them the further facts that hydrate of chloral is purely and absolutely a medicine, and that whenever its administration is not guided by medical science and experience, it ceases to be a boon and becomes a curse to mankind.

“This was stated within two years after the substance, chloral hydrate, came into medical use. If at that time the mind of the public had been as ripe as it is now for the acceptance of the truth, or if I could then have reached the ear of the public more plainly, much evil might have been nipped in the bud. As it was, the warning had little effect, except to expose me to adverse criticism as an alarmist, and the evil has gone on with increasing rapidity and mischief. There is, at the present time, a considerable community addicted to the habitual use of chloral hydrate, on one pretence or another, and a learned medical society has recently framed a series of written questions on the subject, which questions it has felt it expedient to address to members of the profession of medicine generally, for their replies.

“The persons who become habituated to chloral hydrate are of two or three classes, as a rule. Some have originally taken the narcotic to relieve pain, using it, in the earliest application of it, for a true medicinal and legitimate object, probably under medical direction. Finding that it gave relief and repose, they have continued the use of it, and at last have got so abnormally under its influence that they cannot get to sleep if they fail to resort to it. A second class of persons who take to chloral are alcoholic inebriates who have arrived at that stage of alcoholism where sleep is always disturbed, and often nearly impossible. These persons at first wake many times in the night, with coldness of the lower limbs, cold sweatings, startlings, and restless dreamings. In a little time they become nervous about submitting themselves to sleep, and before long habituate themselves to watchfulness and restlessness, until a confirmed insomnia is the result. Worn out with sleeplessness, and failing to find any relief that is satisfactory or safe, in their false friend, alcohol, they turn to chloral, and in it find for a season the oblivion which they desire, and which they call rest. It is a kind of rest, and is, no doubt, better than no rest at all, but it leads to the unhealthy state we are now conversant with, and it rather promotes than destroys the craving for alcohol. In short, the man who takes to chloral after alcohol enlists two cravings for a single craving, and is double shotted in the worst sense.

“A third class of men who become habituated to the use of chloral are men of extremely nervous and excitable temperament, who by nature, and often by labors in which they are occupied, become bad sleepers. A little thing in the course of their daily routine oppresses them. What to other men is passing annoyance, thrown off with the next step, is to these men a worry and anxiety of hours. They are over susceptible of what is said of them and of their work, however good the work may be. They are too elated when praised, or too depressed when not praised or dispraised. They fail to play character parts on the stage of this world, and as they lie down to rest they take all their cares and anxieties into bed with them, in the liveliest state of perturbation. Unable in this condition to sleep, and not knowing a more natural remedy, they resort to the use of such an instrument as chloral hydrate. They begin with a moderate dose, as occasion seems to demand, and at last, in what they consider a safe and moderate system of employing it, they depend on the narcotic for their falsified repose. Among these classes of men the use of chloral hydrate is on the increase. The use is essentially a bad business at the best, and while I do not wish in the least to exaggerate the danger springing from it, while, indeed, I am willing to state that I have never been able to trace out a series of fatal organic changes of a structural character from such use, I have certainly seen a great deal of temporary disturbance and enfeeblement from it, without any corresponding advantage that might be set forth as an exchange of some good for some harm. The conclusion I have been forced to arrive at is, in brief, to this effect, that if chloral hydrate cannot be kept for use within its legitimate sphere, as a medicine to be prescribed by the physician, according to his judgment, and by him as rarely as is possible, it were better for mankind not to have it at any price.”

A case showing the evil effects of the continued use of chloral in large doses, and aptly illustrating how readily some of these patients pass from the use of this drug to alcoholic stimulants and vice versa, is related by Dr. T. Inglis,[59] of the Royal Edinburgh Asylum. I here give an abstract of his very interesting article.

“F. S. P., shopkeeper, male, aged forty-seven. Patient’s father died of kidney disease, at an advanced age. Mother “nervous,” died of paralysis. Two sisters neurotic and eccentric. Brother a confirmed dipsomaniac, died of brain softening. Patient a man of average intelligence, neurotic temperament, previous general good health, but has had asthma. Habits teetotal for ten years, up to three weeks before admission.

“Seven years before was ordered chloral and bromide of potassium, for relief of spasmodic retention of urine. Of these he took about one drachm each, daily, for six years regularly, and during that time neither he nor his friends noticed any ill effects on either mind or body.

“At the end of this time he had an attack of bronchitis, for the dyspnœa attending which he was given chloral, without bromide. Recovery from bronchitis was rapid. Death in his family and other troubles, however, led him to the continued use of the chloral. Commencing with sixty grains daily, he came to use one hundred and eighty grains daily. This in ten-grain doses, often repeated. Effect not hypnotic, but calmative and soothing.

“No headache or vertigo were complained of, but there was lassitude, nervous debility and exhaustion; irritability of temper and peevishness. Anorexia, acidity, nausea and vomiting appeared. Piles became troublesome and the fæces white and hard.

“Intellectual enfeeblement and perversion of affective life and character. He became untruthful and deceitful, and manifested a dislike for home and family. Even threatened violence to his wife. Three weeks before admission he discontinued using chloral, and kept himself in a chronic state of muddle and confusion, by means of whiskey. In a day or two he became restless, excited and quite unmanageable. Diarrhœa set in, with great discharge of blood from the bowels. A state resembling delirium tremens came on. Imaginary voices mocked him; he saw loathsome animals, snakes, etc. What little sleep he had was broken by terrible dreams. This terminated in three severe and unmistakable epileptiform convulsions, at intervals of four hours. This was followed by stupor, and that by excitement.

ON ADMISSION.

“Man of average height and development, but seems to be prematurely old and broken down. Very weak and anæmic, can speak only in an undertone, and can hardly walk.

“Expression blank and vacant. Eyes dull and meaningless. Great enfeeblement of mind. Silly, childish, and almost imbecile. No excitement, but, rather, slight depression of mind. Would laugh and cry without adequate cause. No interest in surroundings. Replies to questions rambling, incoherent and disconnected, being unable to carry on a consecutive line of thought. Memory almost obliterated. Could not tell his age or where he came from. Had vague, fleeting delusions on various subjects.

“Persistent muscular tremulousness of upper and lower extremities, requiring assistance in walking, while the finer acts of coördinative power, as writing and whistling, could not be performed at all. Tongue furred in the centre, tremulous and with fibrillary twitching at the edges, and pointed markedly to the right side. Articulation thick and indistinct. Pupils equal, dilated, irregular at margins, and insensible to light. Right side of face partially paralyzed. Reflex action of cord much impaired. Common sensation acute, verging on hyperæsthesia. Complained of sleeplessness and exhaustion, but had no headache nor neuralgic pains.

“No cutaneous eruption. Muscles poor and flabby. Conjunctivæ yellow. Respiratory and circulatory system normal. Pulse 67, weak and thready. Temperature 97°. Urine, specific gravity, 1.005. Neither albumen, sugar, bile nor tube casts. Could only make water at night, when it was passed in large quantities, was clear and limpid, resembling that of hysteria. Bowels confined, fæces hard and of a white color.

“Neither narcotics nor alcoholic stimulants were used. Tonic mixture, containing strychnia, prescribed. Improvement in all the symptoms marked and rapid. Discharged, well, physically and mentally, in three months’ time.”

This case illustrates, also, the fact that the majority of those who become habituated to chloral, and in whom it works the most serious injury, are of the neurasthenic type, and manifest a morbid craving for some stimulus or narcotic.

Of the cases where I have been able to obtain information upon this point, I find the temperaments given as follows:—

Nervous,	63
Sanguine,	1
Nervo-sanguine,	8
Melancholic,	21
	93

In forty-one cases there is a history of either nervousness, nervous disease, insanity, alcoholism or opium addiction in the ancestors.

In many of these patients there is a “mixed” habit, as opium and chloral, alcohol and chloral, alcohol, chloral and morphine, chloral and chlorodyne, etc.

It is largely used[60] by the intemperate as a substitute for alcohol. On this point the testimony is abundant and positive.

As an example of hereditary tendency, etc., the following, sent me by Dr. N. Jasper Jones, of Blairstown, Iowa, is very interesting:—

“Alcoholism prevalent in the family, also the opium habit, but no insanity, although the mother, at times, under mental worry, becomes somewhat unreasonable, as though she might become insane. Father died of heart trouble while sitting at breakfast. The entire family are of the most intense nervous type, on the mother’s side, all the children taking after the mother; but the father was unusually reserved and cautious, probably because he had schooled himself to be so, on account of his wife’s and children’s excitable natures.”

It will be seen, from the foregoing cases, that while there is no doubt that in certain individuals a morbid craving for chloral may be established by the prolonged use of the drug, it is very different, as a habit, from that produced by opium or morphine. As an offset to this stands the fact that, in those cases where a habit is formed, it causes a more complete and rapid ruin of mind and body than either opium or morphine.

Persons addicted to the habitual use of this drug are usually of the educated class, as is the case with opium.

It has been denied by some authors that it is ever used as a stimulant to the mind. In one case now under my care, and in several reported to me by correspondents, this was the object for which it was first taken, and it was found to answer the purpose admirably, especially in the case of those doing continuous literary work. This effect was, however, short-lived and the reaction decided.

Dr. Quintius C. Smith, who has had a large professional experience among the prostitutes of the Pacific coast, writes me that the drug is or was used largely by this class, they finding it quite as efficient a stimulant, nerve sedative and sleep producer, as opium or alcohol, and having the advantage of leaving no ill after effects. One such patient, unless she previously took a dose of chloral, would have a severe epileptiform convulsion at each connection.

A clearer idea of the ill effects of the long-continued use of chloral in large doses is best studied on each system or apparatus separately. Unlike morphine, it not only shows its baneful effects on the nervous system, but it acts to directly undermine the health by disorganizing the blood.

CHAPTER IX.
EFFECTS OF CHLORAL ON THE DIFFERENT SYSTEMS AND APPARATUSES.

As I said in my last chapter, it is not every person who uses chloral for a lengthened period who becomes an habituè, and it is not every habituè who is affected in every way as fully or completely as in the manner about to be described. In each individual the organs chiefly affected and the length of time necessary to produce the effect vary according to idiosyncrasy, which simply means peculiar personal susceptibility. This same fact holds good with reference to opium and morphine, as well as chloral.

MIND.

The effect of the long continued use of this drug on the mind is, in the majority of instances, much more rapid and distinct than that of opium. At first there is a transient period of stimulation, followed by gradual weakness and cloudiness of intellect, mental hebetude, apathy to what is going on around. A low species of cunning is usually developed, that leads to the planning of plausible excuse and subterfuge to obtain a full supply of the drug. This condition is well illustrated by the following:—

Dr. Wm. Kirkpatrick Murphy[61] reports three cases of chloralism—

1. Lady, fifty-eight; spare but muscular, and of more than ordinary intelligence and strength of will. Took morphine for some time, to overcome sleeplessness due to painful affection of the bladder. Six months before Dr. M. saw her she had been taking chloral, twenty grains at night, to commence, finally one hundred and fifty grains in the twenty-four hours. At his first visit found her almost a skeleton, hard to rouse, maudlin and semi-narcotized. When questioned, answered wildly and disjointedly. State of mind closely bordering on imbecility. Pupils dilated. Pulse slow, feeble and intermittent. Face flushed and anxious. This had been her condition for many weeks. Her rare lucid intervals were spent in childish whining for more chloral, or in cunning attempts to deceive her attendants and obtain an extra dose surreptitiously. From having been a cheerful, upright, exceptionally intelligent and strong-willed woman, she had become morose, deceitful, and imbecile alike in intellect, memory and will.

Points of exceptional interest.

1. Marked decubitus, with not mere indisposition, but, at times, manifest incapacity for exertion.

2. Dark, erythematous flush over head and neck, with extraordinary twitching of facial muscles.

3. Partial paralysis of the œsophagus, not spasmodic stricture; but sluggish and incomplete contraction of the muscles of deglutition, with regard to both food and drink. This was well marked in Case 2, and in both recurred at intervals for many months; even after convalescence was established.

4. Dimness of sight; eyes bloodshot and constantly watering. Once, after total cessation of chloral, temporary loss of vision, lasting, with intervals, two days.

5. Dryness of the hair.

Case 2.—Lady, aged forty-five, good health and keen intellect. Insomnia from worry and from dyspepsia. Had taken chloral for two years. At first only at bedtime; after a time during the day also. Never above seventy grains in twenty-four hours. Both physical and mental exhaustion, morbid fear, confusion of mind, lack of concentration and impairment of memory. (She was, however, an authoress, apparently doing her regular literary work.—K.)

POINTS OF INTEREST.

1. Erythema of head and neck.

2. Excessive hyperæmia after smallest quantity of wine or beer.

3. Partial paralysis of the œsophagus, with nervous disinclination to take food or drink.

4. Dimness of sight, with eyes bloodshot and overflowing with tears. Marked projection of eyeballs.

5. Intense nausea, oftentimes, after taking chloral.

Intense melancholia, with suicidal tendencies, hallucinations and delusions, delirium. Acute and chronic mania, have resulted. A condition, seemingly a cross between idiocy and softening of the brain, sometimes occurs, the patients crying at the most trivial things, and bemoaning their persecution by what would to others appear to be but trifles. The moral nature is profoundly affected, but the tendency to lie does not seem to be so distinct as in the opium habit.

Delirium is not so often found while the patient is taking, as when he stops the drug. In some cases it does not even occur then, but when so happening, is usually very violent.

Convulsive seizures are rare, but do occur, as has been shown by the labors of the Clinical Society, of London. Two of my correspondents speak of such cases. In both, the character of the attack was epileptiform, and occurred in persons who had used large doses of the drug for a long time.

A mind greatly enfeebled by the continued use of chloral is sometimes thrown completely from its balance by the effects of an overdose, or the unusually intense action of an ordinary dose, an accident that is liable to take place at any time. Such a case is related by Dr. Willis P. King,[62] of Sedalia, Mo., as follows:—

“Mrs. S., aged forty years, first began to use chloral during an attack of rheumatism. Has now been taking it for some years. Dose about 32 grains, taken from three to five times a day. I was treating her for acute rheumatism, and allowed her, by her request, to take an occasional dose of a solution that she had been using for years. She begged for more than I was willing to allow, and, in the absence of the nurse, got up, and, from the amount missing, must have taken anywhere from 100 to 200 grains. I found her, three hours afterwards, in profound stupor, pulse small and 190 per minute, respiration rapid and stertorous, extremities cold. Under stimulation, etc., she recovered consciousness after a few hours, but was insane, and was sent to the Missouri Insane Asylum, where she was treated for acute mania. She was always ‘flighty’ before she went to the asylum; on her return from there her mental condition was greatly improved.”

The temper becomes irritable, peevishness is developed, friends and acquaintances are shunned, and the patient lives in a world of his own, built by the warped and distorted outcome of a diseased imagination. The delusions and hallucinations are more often terrifying than pleasant, varying, however, somewhat, with the mental peculiarities of the victim. The following interesting case is sent me by Dr. D. N. Kinsman, of Columbus, Ohio:—

“Patient’s age, twenty-four years. Had been surrounded by a set of vicious companions, and got to drinking excessively. Had an attack of delirium tremens, for which chloral, bromide of potassium and valerian had each been prescribed. In a fit of virtuous indignation at his oft-repeated falls, he signed a ‘Murphy pledge.’ Having learned the value of chloral for the horrors, now, in his abstinence from alcohol, he began the use of chloral. He would sit in the office and sleep in his chair, day after day. His speech became drawling and indistinct, and he could not remember what he read. At the end of two or three weeks he had an eruption appear on his face, neck, and shoulders, like acne. These pimples, at first hard and red, suppurated, being attended with much soreness and pain.

“After being in this condition for some weeks he began to hear voices at night, rose from his bed in great terror, and ran to his father’s room, saying burglars were in the house, on several occasions. His neighbors were in a conspiracy against him; living in a double house, could hear them planning against him, through the walls. On going home at night would go at full run, waiting till very late, to have the streets deserted; asserted he was often pursued by a ‘band of niggers’ who had been hired to injure him. Heard people talking about him, whom he passed, even when I was with him and knew nothing was said. He continued in this state for several weeks; finally became exhausted, had to take to his bed, where he remained several weeks. He had been removed to his father’s farm, several miles distant, at this time, hence, not at this period under my observation. Now, being obliged to abstain, he got better; but when he got better, relapsed into his old habit. Now, he was sent to Fort Hamilton, and there kept for, I think, six months. Perhaps a record of this case can be found there.

“He returned here, and has been fully restored. Though after his sojourn in Fort Hamilton he had another attack of his appetite for chloral, whiskey, etc., which lasted some months.

“His doses of chloral, daily, would amount to half an ounce, I estimate, for days together. The data are impossible to learn, because he never kept it all in one bottle, and he had a supply located at various points, for convenience.

“The eruption did not itch. It lasted during the time of taking the drug, and subsided after it was discontinued. There was also, at times, a use of valerian, in quantities unknown.”

Dr. Roswell Park, of Chicago, Ill., writes me of a young man “who established the chloral habit after a series of business reverses. He was nervous and excitable. I have no idea as to what amount he took. He finally developed a suicidal tendency, jumped from a fourth-story window, sustained a compound comminuted fracture of the elbow, and other injuries, and finally died, about the tenth day, from acute mania and exhaustion.”

Dr. James Bunting[63] had a patient who took large doses of chloral daily, with the effect of perverting the morals and producing a tendency to suicide.

Dr. Thos. Bond[64] relates the case of a friend, a young medical man, who died of acute mania, produced by continued and excessive use of chloral.

The memory, especially for words, is greatly impaired. I have seen one case of this kind, and one such was reported to me by a medical gentleman in Boston, who forgot to sign his name to his very interesting letter.

The patient whom I saw not only had an impaired memory for words, but would use one word for another, as “slippers” for “hat,” or “pen” for “coat.” He had been using the drug for nearly six years, and, although profoundly affected by it, would, at times, be decidedly better than at others.

Dr. G. W. Davis, of Chico, California, writes me of the case of a lady who had been using the drug for some time. She first took it for facial neuralgia. She takes from forty to sixty grains daily. Her present health is fair. “She complains, however, of a fullness about the head, confusion of ideas, and loss of memory.”

Drs. Norton Folsom, of Boston, and J. W. Parsons,[65] of Portsmouth, N. H., relate cases where the habitual use of this drug produced childishness, fretfulness, muscular tremor, and, in Dr. Parsons’ case, seemed to aggravate an existing attack of melancholia.

Dr. James Perrigo,[65] of Montreal, relates the case of an old lady, sixty years of age, who took chloral, forty-five grains at bedtime, and fifteen grains during the day. She was partially insane, but whether from the chloral or not, I have been unable to learn.

Maudsley[65] uses it but rarely in insanity. “Sometimes in melancholia. Rarely in mania, and then only when subacute.” Similar testimony was obtained from Drs. Maudsley, Clouston and Lindsay, by the Committee of the London Clinical Society.

Dr. A. P. Hayne, Medical Superintendent Inebriate Asylum, San Francisco, Cal., writes me: “There is no doubt but that its long continued use is one of the causes of insanity. I think I may safely say that several cases of this kind have fallen under my immediate observation, where chloral has been the remote or immediate cause of the disease.”

Dr. H. H. Doane,[66] of Litchfield, Ohio, reports a case where chloral produced, in an habituè, melancholia, with suicidal tendency.

The following interesting case history was sent me by Dr. Frank R. Fry, of St. Louis, Mo.:—

Patient, J. M., aged fifty-nine years. First used chloral eleven years ago. At that time he had been having some domestic troubles, had been drinking some—he says, not hard; he was unable to sleep, on account of these troubles and severe pains in the soles of his feet. His physician said they were not caused by rheumatism, but did not say by what. His physician prescribed him 15 grains of chloral in one ounce of water. Two teaspoonfuls of this solution, the prescribed dose, gave the patient some relief at first, but he immediately increased the dose to four teaspoonfuls. Does not remember exactly how soon, but very soon, he was taking from thirty-five to forty grains at a dose, every night, to obtain sleep. He increased the dose as fast as was necessary to obtain the continued desired effect, until he was taking eighty grains every night, and often a large dose during the daytime.

Six years ago he was in the City Insane Asylum, for three months. When he left there he felt very much better, and states positively that he used no chloral for a period of three years after that time.

He began the use of chloral again, subsequently, and for the last two and a half or three years he has been using it very steadily and in large doses. He does not take such large doses at present, but takes it much oftener than he did. Says the size and frequency of the dose are much of the time varied according to his means. He does not now pay any attention to the number of grains he is taking, as he used to, but he has a hard time, often, in getting enough to satisfy. He is also drinking to some extent now. Says he has tried to substitute alcohol and morphine for chloral, but has always fallen back to the latter.

He is now in bad health, suffers from dyspepsia and constipated bowels, and a generally debilitated condition. His father was a hard drinking man and his mother a very “nervous” person.

Dr. C. Pollock,[67] of Donnelsville, Ohio, reports the case of a physician, aged fifty. From twenty to sixty grains were used nightly for two years, with the result of producing loss of co-ordinating power, marked failure of memory, loquacity and intense despondency, and obstinate insomnia, only relieved by continued taking of the drug that had caused all his misfortune, and which brought on only a troubled slumber, laden with dreams horrible beyond description. The most prominent features of the case were his profound melancholia and extreme loquacity.

A somewhat similar case is reported by Dr. T. D. Crothers,[68] Superintendent Walnut Hill Inebriate Asylum, Hartford, Conn., the case ending fatally.

As in the opium and morphine habits, only more so, business is abandoned, friendship broken, family ties sundered, and unless relieved the victim sinks into a state of slobbering insanity or acute mania, finally ending in death through hemorrhage, exhaustion, or from the satisfaction of a suicidal tendency. Physical wrecks, guided by shattered mental rudders, they sink out of sight or go to pieces through accidents incident to their own self-produced restlessness.

Thirty-eight of my correspondents report the production of insanity by the habitual use of this drug, as follows:—

Acute mania,	8
Melancholia,	16
“Insanity,”	3
Silliness, childishness, etc.,	11
	38

In many cases where I wrote for more full and positive information I received no reply.

THE NERVOUS SYSTEM.

On the nervous system the effect of chloral, when habitually used, is quite as decided and injurious as upon the mind.

These symptoms may be classed as:—

(a) Those affecting the nerves themselves.

(b) Those affecting other organs, or systems, through the medium of the nervous apparatus supplying them.

To the first class belong anæsthesia and hyperæsthesia, usually of parts of the body only. These may and do extend to the mucous, as well as to the cutaneous surfaces, as evidenced by gastralgia, loss of taste, incontinence and irritability of the bladder and sexual organs, etc., to be more fully considered a little further on.

Neuralgic pains are felt here and there, more especially in the neighborhood of, but not in, the joints. Mattison[69] and others lay great stress upon this pain, which usually girdles the limb above or below the joint, as a diagnostic mark of the chloral habit. That it is not distinctive of this affection, and occurs in only a few cases, is proven by the fact that out of all the cases I have been able to collect, this symptom appears in but a few—nine—and in not all of these is the pain in the neighborhood of a joint. I have taken special pains to investigate this matter, for the value of a positive diagnostic sign in these affections cannot be underrated. In many of the cases, pains, resembling those of rheumatism or neuralgia, were present, but they did not girdle the limb or occur in the neighborhood of joints.

Dr. Mattison says that Dr. Lee and others have observed these pains in the wrists and elsewhere. I find a case reported by Dr. Benj. Lee,[70] of a very nervous woman, who had taken chloral in twenty-grain doses, nightly, for eighteen months. Conjunctivitis occurred, the dose was reduced, and the eye trouble disappeared. She again increased the dose, when pains appeared in the wrists, running along the course of the radial arteries. The chloral was stopped and the pains disappeared. I find no reference, in the place mentioned, to pain girdling the limbs. Unfortunately, Dr. Mattison makes no reference to the source of his information, so that it is impossible to say whether this is the Dr. Lee referred to or not.[71] Anstie, as quoted by Dr. Mattison, said that he was of the opinion that many cases of supposed rheumatic or neuralgic pains would be found, on careful investigation, to be due to chloral taking, and cited the following case, in which this symptom was prominent:—

“A. B., physician, began the use of chloral Feb. 1, 1873, in thirty-grain doses, to produce sleep, when kept awake by great anxieties. In two months noticed inflamed and weakened eyes, with scalding tears. Continued the drug, however, sometimes increasing the dose and repeating it. From April to August the usual amount was one drachm. In this latter month commenced using it during the day, one to three times. About Dec. 1st, began to realize the amount he was daily taking, and found it half an ounce, sometimes more. He now began to complain of severe general pains, especially about the joints, which grew worse in the moist air of London. There was no tenderness, and they were not increased by motion. Chloral did not relieve them, except when it put him to sleep. Soon after this he made a mistake in his dose, using from a strong solution, which brought on the pains with frightful severity, and Dr. Anstie was summoned. He found him with suffused eyes, haggard features, sleepless, peculiar, broken speech, lower extremities partially paralyzed, with loss of coördinating power, and excessive joint pains. An examination disclosed that he had taken more than an ounce of chloral the preceding day. It was at once withdrawn, cannabis Indica used to relieve the nervous disturbance, tonics ordered, and under this treatment he recovered.”

It is a well-known fact that rheumatism or rheumatic neuralgia, so called, is often aggravated by the administration of acids. It is barely possible that in this case, the drug being kept in a solution, probably with syrup, partial decomposition may have taken place, and through the large amount of chloral taken, a sufficient amount of hydrochloric acid has been ingested to produce the aggravation of pain. I offer this simply as a suggestion. Many chloral-takers, especially the English, use the drug in the form of the officinal syrup chloralis (B. P.), or in a syrupy solution, expose it to the air and light, and do not keep it in warm places. When a large amount of the drug is used, and decomposition has taken place, an appreciable amount of acid might be taken.

Pains in the limbs, face, chest, eyes, and about the heart are not uncommon, but in some cases never occur, although the person is taking large amounts (100 to 200 grains).

Flushing of the face and ears, and congestion of the eyes, the latter apparently bloodshot, is often seen, and is intensified by the use of a small amount of any alcoholic stimulant. A physician in the South, an habituè for years, writes me that his face became so very scarlet, and his eyes so bloodshot after drinking a glass of liquor, that people in the street would turn around and stare at him in amazement. It is of the same character, though less intense than that flushing of the face produced in some people, not chloral-takers, by the use of coffee. It is due to a more or less complete paralysis of the vaso-motor nerves. It is usually accompanied by dyspnœa and palpitation of the heart. It sometimes occurs on taking stimulants a week or ten days after the habit has been broken.

Nervous chills are also often found, and following them is sometimes felt numbness of one leg or arm, or the sensation of insects crawling on the skin of the trunk, less often of the limbs.

Paralysis sometimes occurs, and is usually confined to the legs. Dr. W. R. Upham, of Yonkers, N. Y., reports the following:—

“Had one case of a lady afflicted with cancer of the breast, who had taken about twenty-five to thirty grains, for one year. Soon after this she became partially paralyzed in the lower extremities; and, becoming very much frightened, she discontinued the use of the drug at once, and without much trouble. She afterwards took up the use of morphine, and has recently died from the original disease. She was of a very nervous temperament.”

Here is a similar case by Dr. William Kirkpatrick Murphy[72]:—

“Young man, twenty-nine years of age. Muscular athlete. Took chloral for insomnia. Amount taken not known, as it was taken loosely, without measure. Once nearly died from an overdose. Awoke one morning to find the power of his lower limbs completely gone. This was transient, but caused him to abandon the use of the drug.

POINTS OF INTEREST.

“1. The necessity often to use a large amount, in order to obtain any effect. When awakening, thirst, nausea, headache, irritability.

“2. Well-marked erythema, intensified by stimulants. Palpitation very severe.

“3. Acute pains in lower limbs, especially calves of legs. Some loss and perversion of sensibility in feet and legs in morning.

“4. Inability to use legs. Passed off in one day, leaving patient physically and mentally weak.”

Brown-Sequard[73] relates “two cases of mania, with obstinate insomnia, in which he gave five grains twice a day to one and double that to the other, followed by thirty to forty grains at night. After seven or eight weeks of this treatment the patients had become so feeble as to be unable to walk or to put one foot before the other. This rapidly disappeared when the chloral was withdrawn.”

Anstie (also quoted by Dr. Mattison), with his characteristic honesty, relates the following:—

“He was called in consultation, to a lady, aged thirty-eight years, with symptoms of partial paraplegia, of obscure origin. Reflex uterine irritation was mentioned as a cause, but the suggestion was not accepted. The regular medical attendant then suggested that the nightly doses of chloral, which the patient had for some time been taking, to procure sleep and allay mental anxiety, might be a factor in the paralytic trouble. This was also rejected, and, as some sedative seemed called for, the chloral was continued. The lady, however, failed to improve from the treatment recommended, and, after one or two consultations, a different physician was called. He accepted the chloral hypothesis, the sleeping draught was discontinued, and she speedily lost her paraplegia. Anstie observed that the case afforded him some practical but rather rueful reflections.”

Dr. Mattison says: “The loss of power in the lower extremities is sometimes very marked, and strongly suggestive of serious spinal lesion.” It would seem, from the rapidity with which the trouble disappears on the discontinuance of the drug, and its sudden appearance in some cases, to be due, more likely, to derangement of the circulation in the cord, dependent on vaso-motor paralysis.

Vertigo, trembling of the hands and body, and “inability to stand erect, with tendency to fall forward, as in ataxic trouble, lack of coördinating power, so as to be unable to write, whistle, button clothing, etc.” (Mattison), are often seen. The tongue, when protruded, trembles; paralysis of one side of the face and ptosis sometimes occur. Flashes of heat, followed by a cold sweat, on stumbling, “stubbing” the toe, or without any appreciable cause, is often noticeable.

CHAPTER X.
EFFECTS OF CHLORAL ON THE DIFFERENT SYSTEMS AND APPARATUSES.

THE DIGESTIVE APPARATUS.

The effect of chloral upon the organs of digestion is twofold. (a) That due to its local action, and (b) its effects produced through the medium of the nerves supplying the parts. Taking the throat first, we find that there is usually more or less irritation and congestion from the local action of the drug. In some cases there is paralysis of the muscles of deglutition. Dr. J. H. Arton, of Hamilton, Bermuda, writes me that in one case chloral, no matter how given, always produced irritation of the throat and difficulty in swallowing. No other drugs were being given at that time. It disappeared on stopping the chloral. This patient was not an habitual user of the drug. It only produced this effect when the drug was given in large quantity, or often.

Dr. R. C. Brandeis[74] relates the case of a lady who was an habitual user of chloral. For some nine months she had been taking from forty to sixty grains, three or four times a day. It produced great difficulty in swallowing, intense hyperæmia of the pharynx and larynx, and the return of fluid through the nostrils. There was occlusion of the œsophagus and paralysis of the muscles of the larynx. She fully recovered on strychnia, iron and quinine, finally stopping the chloral. The curious fact has been noted by some of my correspondents, that a rectal injection of chloral will, in some patients, immediately produce a peculiar sensation in the throat and a metallic taste in the mouth.

“Dyspepsia” is one of the earliest symptoms complained of by these patients. From simple loss of appetite to the gravest forms of gastric trouble may be produced. There is loss of sensitiveness, alternating with the most severe gastric pain. The tongue is coated, the breath foul, and not having the odor of chloroform. Circulation in the liver is disordered, gastro-duodenal catarrh results, with accompanying jaundice, that is sometimes intense. A sense of fullness and pain over the hepatic region is not uncommon. Small, brownish patches upon the skin, known to the laity as “liver spots,” are frequently seen. The bowels are constipated, the stools lacking in bile, and, consequently, clay-colored, hard, and sometimes coated with mucus, here and there streaked with blood. Hemorrhage from the bowels and stomach sometimes occurs. Diarrhœa alternates with constipation.

Some patients, taking the drug in large amounts and for a considerable time, are not troubled at all with affections of the digestive organs.

An habituè, a physician in the South, assured me that it always increased his appetite when taken before meals, and Dr. A. P. Hayne, of San Francisco, says that he has seen a number of these cases, in which there was no effect on these organs beyond a temporary stimulation.

THE URINARY ORGANS.

Upon the kidneys the effect of the long continued use of chloral is to produce congestion, dilatation of the vessels, and albuminuria. There is no positive evidence that chloral produces any organic change in these organs. Albumen is present in the urine, often in large amount, but its presence there is readily accounted for by the vaso-motor paralysis, and the impoverished condition of the blood, which is still further aggravated by this, its symptom. Casts are often found, but are usually small and medium sized light granular, and hyaline. Epithelial and fatty casts occasionally occur, but it is probable that, in these cases, renal disease had commenced before the chloral was used to excess. Hemorrhage from the kidneys and, indeed, from the whole urinary tract, is sometimes found. It is but a part of a general condition, usually, purpuric spots being found on the skin, and bleeding occurring from the mucous membrane of the throat, stomach, nose, or bowels.

Both before the albuminuria appears, and during its continuance, dropsy is not uncommon. Puffiness of the face and eyelids, dropsy of the feet and legs, and ascites occur in certain cases, not from suppression of urine, but from the condition of the vascular system and blood.

The albuminuria, unlike that of opium patients, is usually persistent.

Diabetes is found in some cases where large amounts of the drug have been used for a long time. In acute poisoning by this drug sugar has been found in the urine of man, by Bouchut[75] and Levenstein[76]. Labbée[77] failed to find it in the urine of chloralized rabbits and frogs, but Feltz and Ritter[78] found it in the urine of dogs into whose veins they had injected chloral. They proved its presence by both the fermentation and reduction tests. They also claim to have found an organic body, which was present in such small quantity that a determinative analysis was impossible. The same substance was probably found by Von Mering and Musculus, who named it uro-chloralic acid. They found that it reduced the copper and bismuth tests, and turned the polarization apparatus to the left. This from small doses, while large doses gave sugar, turning the polarization apparatus to the right.

Dr. John B. Roberts and Morris J. Lewis[79] found that the urine of patients taking chloral, and urine to which chloral had been added, gave a yellow precipitate, with Fehling’s test solution.

It is probable that in the urine of patients habitually using small doses of chloral, the reaction with the copper solution is due to the presence of uro-chloralic acid, while that of those taking large doses is due to both uro-chloralic acid and sugar; the preponderance of the latter masking or overcoming the reaction of the former, especially with the polarization test.

The functional activity of the kidneys varies greatly from day to day. At times the urine is very scanty and high colored, at others, passed in quantity and of a light straw color. Unlike the urine of opium takers, the gravity varies markedly from day to day (1.006 to 1.045).

On the mucous surface of the bladder and urethra the continued use of this drug sometimes produces decided irritation, and often congestion. Frequent desire to urinate, burning and cutting pain in the act, and a sensation as if the contents of the bladder had not been fully evacuated, are often found, more especially in women.

It has an action, also, on the muscular structure of the viscus, producing temporary paralysis, with retention.

Oxalate of lime, and numerous fibrillæ of mucus, occur as deposits. The reaction varies from intensely acid to distinctly alkaline.

Deposits of stellar phosphates are of frequent occurrence.

My correspondents report as follows:—

Irritability of the bladder, with tenesmus,	21	instances.
Hemorrhage from the urinary organs,	6	”
Retention of urine,	11	”
“Atony” and paralysis,	7	”
Albuminuria,	23	”
Reduction of copper test,	16	”
Casts in urine,	7	”

SEXUAL ORGANS.

The evidence as to the effect of the continued use of chloral on the sexual apparatus is meagre and conflicting. The sexual appetite seems to be at first decidedly increased, but finally greatly impaired or lost. Such an increase was observed in one case by Dr. J. A. Miller, of Williamsburg, Ky. (non-habituè). I have seen a decided increase in two cases from occasional small doses, where the effect could have been due to nothing but the chloral; and in one case, by Dr. John N. Upshur,[80] where it had been used for weeks, with large doses of the bromides, in a case of tetanus in a negro.

On the other hand, Dr. Edward Bradley, of this city, writes me that in ten cases he has found decided decrease in sexual appetite and inability to have an erection in patients taking chloral for a short time. It disappeared shortly after stopping the chloral. Dr. J. W. F. Webb,[81] of Liberty, Miss., has known it to diminish and temporarily destroy the sexual appetite, when taken only for a few days. Also in the case of a chloral eater.

Dr. Horatio C. Bigelow,[81] of Washington, D. C., saw “loss of erectile power follow the use for one month of ten grains of the drug, three times daily.” The person was a strong, healthy man, seemingly of good virile power, to whom it had been given for chronic dysentery. He was never so affected before. It was some months before there was any return of power.

Dr. J. H. Nordlin,[82] of Rome, Ga., has used it successfully as an anaphrodisiac, as also a correspondent of the Lancet.[83] Dr. O. F. Ham, of North Barnstead, N. H., writes me of a chloral taker, a lady, whom he has questioned closely. She avers that chloral has absolutely no effect on her sexual appetite, which was never marked.

Sensitiveness of the organs of generation, a kind of mucous membrane hyperæsthesia, has also been noted by Dr. H. H. Doane,[82] of Litchfield, Ohio, as follows:—

“Female, aged forty-two; used chloral for twelve years. Given for insomnia and nervousness of prolapsus uteri, with constipation. Bilious temperament. Dose, twenty grains, four or five times a day. Present condition, prolapsus uteri, obstinate constipation, great loss of flesh and muscular power, appetite poor, stomach weak and tender on pressure; also constant, dull, and sometimes sharp gastric pain. Headache, nervous prostration, loss of mind (general melancholia, with suicidal tendency, if chloral is withdrawn for a few days). No pain in neighborhood of joints, slight dimness of vision accompanying headache. No family history of morphine or opium habit or alcoholism. Extreme sensitiveness of sexual organs.”

Its effect on menstruation is slight. It sometimes causes too free flow, sometimes a slight, continuous flow. I can find no facts supporting the belief that it, like morphine or opium, produces sterility. As menstruation seems to be unaffected it is probable that it does not do so.

As bearing upon the effect of chloral on menstruation, the following letter is of interest. No replies seem to have been received.

To the Editor of the Lancet:—

Sir—Have any of your correspondents noticed one peculiarity in the action of hydrate of chloral—namely, its power entirely to check the catamenial discharge? I have three patients who are in the habit of taking the drug, for attacks of asthma, and who have assured me that its exhibition is attended with this one drawback, if taken at the onset of the monthly period. I have had no opportunity of verifying their statements, but imagine there must be some truth in them, as they are all three of them in different stations of life, do not know one another, and cannot have compared notes. Moreover, their statements were volunteered, and not elicited by leading questions.

Your obedient servant,

G. H. R. Dabbs, M.D.

Newport, I. W., Sept. 21st, 1872.

CIRCULATION AND COMPOSITION OF THE BLOOD.

Aberrations in circulation are due to derangement of the nerves governing the vessels; in other words, the vaso-motor system.

Flushing of the face, fullness of the head, redness of the ears, congestion of the eyes, alternating hyperæmia and anæmia of the various organs, is the result. From this cause we have the intense splitting headache one day, vertigo the next.

Palpitation of the heart, a weak, intermittent, irregular pulse, cough due to lung hyperæmia, accompanied by excess of secretion, often follow. Heart murmurs are sometimes heard, chiefly in very anæmic patients. Palpitation and irregular action of the heart is due to three causes, in the majority of cases—irregular nerve supply, impoverished blood, and atony of the cardiac muscles. This is not so in all cases, for we sometimes get these same symptoms from single doses of chloral, referable wholly then, I think, to disturbed nerve supply.

Upon the blood itself chloral acts as a disorganizer. That it does so we know. How it does so it is impossible to tell. This deterioration is evidenced by its action on the skin, to be noticed fully further on; by the tendency to hemorrhage from mucous membranes, purpuric spots beneath the skin, spongy gums, falling of the hair, loss of the finger and toe-nails, malnutrition of the muscles, brain, and nervous system, anæmia, dropsy, and the but too palpable evidences of a general breaking up of the whole system.

Ludwig Kirn,[84] who has contributed some very valuable observations on the long continued use of chloral, relates the following:—

“We come now to a fourth group of cases, in which both the quality of the symptoms and their greater or less extension in the organism indicate a distinct change in the composition of the blood.

“In this connection, the following cases, observed by Crichton Browne, may first be referred to; their interesting phenomena justify a detailed report.

“Case 1.—A woman, aged sixty-nine years, suffering from periodical mania, had twenty grains of chloral twice 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 fœtid. 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 neighborhood of the joints. From that time convalescence proceeded and ordinary health was restored.

“Case 2.—A woman, aged forty-six years, suffering from cardiac disease, hemiplegia, and dementia, took fifteen grains of chloral, three times a day, with calming effect. On the nineteenth day of the treatment numerous purple-red spots appeared in the neighborhood of the left elbow; on the next day many similar spots were seen on the shoulders and forearms, 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 surface appeared a multitude of minute points, of a much deeper color, which did not diminish on pressure. Next day there were dark purple spots and discolorations; some small, round, and circumscribed; others broad and irregularly shaped, on the legs and abdomen, and in stripes on either side of the vertebral column. Simultaneously with the petechia there was great prostration, tendency to somnolence, weakness and excitability of the pulse, sore lips, thickly coated tongue. On the twenty-third day the spots and discolored patches had extended in every direction, and the previously bright-red spots had assumed a deep-purple color. 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 œdematous; the heart dilated and its valves thickened; over the right central hemisphere there was a large arachnoid cyst, containing fluid blood.

“With the foregoing may be joined a case, related by Monkton, in which, after four days’ administration of sixty grains of chloral daily, a rash resembling slight variola, with hemorrhagic purpura, appeared, and death occurred on the sixth day, by syncope.

“Finally, may be mentioned two patients of Pelman, in whom, after treatment with chloral, there were larger and smaller petechia over the whole skin; in one which proved fatal numerous petechia were found on the mucous membrane of the larynx and under the endocardium, and a hæmatoma on the right side in the skull, reaching to the base, the fluid contents of which gave evidence of their recent origin.

“I shall now relate a case observed by myself, which is yet more striking, from the multiplicity of its phenomena, which are of a kind, perhaps, to give us some clearer understanding of their origin. The case was observed by me at a time when the evil effects of chloral hydrate were not yet known; the medicine was, therefore, continued, in spite of the most multiplied symptoms, because chloral was not for a long time recognized as their cause; the affection was, therefore, followed up further than we should dare to do now, that our increased knowledge would oblige us to stop at an earlier stage. [Here follows a detailed report of the case, which need not be given]. If we may sum up the weightier symptoms of this case, we find a young, strong, personally healthy person suffering from uncomplicated mania, in whom, on the ninth day of chloral treatment, a rash appeared in the form of groups of red spots, which soon became confluent. On the twentieth day the temperature and pulse rapidly rose to a febrile pitch; three days later the temperature had reached 106.7°; large and repeated doses of quinine were given without result, and baths had only a temporary effect. Œdematous swelling of the face, cheeks, eyelids and ears now set in. During the whole course of the disease the skin, so far from returning to its natural appearance, was the seat, now of impetiginous, now of moist, now of scaly eczema and ichthyoses, so that the process of desquamation, instead of being short, as in the acute exanthemata, occupied many weeks, during which great sheaths of epidermis were cast off from all parts of the body.

“The profound lesions of the skin nutrition were evidenced in the later stages by a remarkable shedding of the hair, and a gradual falling off of all the nails of the hands and feet. The affection of the skin was accompanied by a similar one of the mucous membranes, first of the intestines, which kept up watery diarrhœa in spite of medicine, and then by a similar affection of the conjunctiva and the bronchi. From the sixth week of the disease onward a series of large abscesses formed on both arms, over the shoulders and armpits, which secreted a considerable quantity of pus. While these phenomena were occurring there had been for eight weeks a continuous fever, occasionally remitting, and then again running up to a temperature beyond 104°.

“The symptoms which we have now collectively described must be defined as chronic blood poisoning. We cannot, however, place this in any of the known groups; we have not to do with a pyæmia or septicæmia, nor with a metallic or vegetable poisoning, since none of the causes have been at work which would lead to these affections, nor do we observe their characteristic phenomena; still less did the affection which the medicine produced in this patient resemble puerperal mania. In fact, there was no other external cause except the administration of the chloral; this medicine, which in even much larger single dose produces no such effect, was for ten weeks given in nightly doses of forty to sixty or even seventy-five grains; sometimes in two doses daily. The symptoms began after a certain saturation had been produced by accumulation, to spread further and further, and finally to assume the complete picture of a chronic blood poisoning.

“The origin of the disease leads us thus, by exclusion, to conclusions which have a high degree of probability, and we are also in a position to adduce positive facts. If a glance be cast at the symptoms observed by ourselves and others, after a more or less continued administration of chloral, we meet with the greater part of the phenomena observed in our last case, especially the very various affections of the skin and mucous membranes, the alterations in vascular action, and finally, the profound alterations of the blood, which in some cases remind us of the phenomena of scurvy.”

The characteristic feature in the morbid picture which we have given consists less in symptoms which in themselves are altogether new, than in the assemblage of the most heterogenous phenomena, which previously had only been observed singly, in one person, and in a most aggravated degree of intensity.

It is a peculiar fact, that such severe symptoms as are here related, comparatively common in the early history of the drug, are not now seen, save in very rare instances, even in persons using larger quantities of the drug for a much longer time. There must have been some impurity in the drug as then used. It might be supposed, also, that such effects would be more apt to occur in these insane patients, much below par mentally and physically, was it not well established that its prolonged use in like cases, at the present day, does not produce the same effects, save in occasional instances.[85] The ulceration of the skin about the finger and toe-nails, spoken of by so many observers. Thus, Professor Nathan R. Smith, of Baltimore,[86] reports two cases where this occurred. Twenty-six similar cases have been observed by Dr. James G. Kiernan,[86] former Assistant Physician at the New York City Asylum for the Insane.

From eighteen superintendents of insane and five physicians of inebriate asylums, from whom I have heard, not one mentions this condition of skin about the edges of the nails. The only case of the kind reported to me is by Dr. J. W. F. Webb, of Liberty, Miss., and consisted in simple elevation of the skin at these points, without ulceration.

I think we must conclude that there was some impurity of the drug used, although Dr. Kiernan avers that the drug was that furnished by Powers & Weightman.

Disordered condition of the blood manifests itself in other skin affections. Judging from its effects in single or small doses in certain persons who manifest an idiosyncrasy, would lead us to entertain the possibility of skin affections from the long continued use of the drug. An artificial idiosyncrasy seems to be developed.

Single doses, or the use of moderate doses for a short time, has been found to produce erythema, eczema, papular, pustular, or macular eruptions; also urticaria and herpes zoster. In a few well-authenticated instances, eruptions, exactly resembling and in some cases mistaken for those of measles and scarlatina, have been produced. They passed through regular gradations, finishing with the typical desquamation of the disease simulated. Further use of the chloral again produced the same disturbances.[87] It has been suggested that these effects are due to disorders of the digestion, as excessive acidity, etc., produced by chloral. This is disproved by the fact that in the majority of instances where they occur, the digestive organs are not disturbed.

Schüle[88] believes that the majority of these skin affections are due to nervous disturbance.

The following cases of hemorrhage are of interest in this connection:—

Dr. A. E. M’Rae (Edinburgh Medical Journal, Nov., 1871) relates a case of hysteria, where he gave chloral for months. Bleeding from the lungs became so frequent and violent that twice the patient’s life was despaired of, and he had to abandon the use of the drug entirely. He refers also to a case by Dr. Husband, where fatal hemorrhage from a fibrous tumor of the womb occurred in a patient who was taking chloral. Spencer Wells (Medical Times and Gazette, Sept. 18, 1869) has, however, given it in cases of cancer of the womb, without producing bleeding. Turnbull (Philadelphia Medical and Surgical Reporter, Aug. 31st, 1872) claims that it increases the menstrual flow. Dr. C. R. Cullen, of Richmond, Va., writes me that he has seen flooding follow its use. R. C. Shettle, Physician to the Royal Berkshire Hospital, believes that its use is dangerous in labor cases, owing to the likelihood of flooding afterwards. This is totally disproved by a mass of testimony sent me by my correspondents.[89]

Bleeding from the nose has been noted by Inglis (Edinburgh Medical Journal, Sept., 1877), by Mauriac, in three cases (Gazette des Hopitaux, 1870, p. 405) and Dr. F. Delmont, of San Buena Ventura, Cal. (by letter). This was a hysterical lady, who was using large quantities of chloral. After one of her spasms about an ounce of blood flowed from her mouth in a fine stream, as though thrown by a syringe.

MUSCULAR SYSTEM.

Upon this system the effects are decided, and are chiefly produced through the agency of the nervous system.[90] Trembling, spasm of isolated muscles and muscular fibres, convulsions, paralysis, loss of coördinative power, etc., have already been spoken of.

Certain symptoms, as flabbiness, paleness, atrophy and weakness, result from imperfect nutrition. By confining these patients to the house a great deal it still further lowers the tone of the general health.

RESPIRATION.

This vital function is very seriously affected in certain advanced cases. Dyspnœa is the most prominent symptom. This is more marked if alcoholic stimulants are taken. The trouble is undoubtedly of purely nervous origin. It is usually accompanied by a slight cough, and excessive secretion of mucus. Ludwig Kirn[91] says:—

“An important symptom which we have noticed in a series of cases of the long continued use of chloral is an interference with respiration, which may remain slight and scarcely troublesome to the patient, or may become positive dyspnœa.

“This symptom was experimentally produced by the Swede, Hammersten, who observed severe dyspnœa in a cat that had taken chloral, and was briefly noticed by Jastrowitz, one of whose patients, while taking chloral, suffered from severe dyspnœa, with occasional cessation of breathing; and it was finally completely described and explained by Schüle, who observed a patient who, after a long use of chloral, used regularly to suffer after meals from a sense of oppression, which made going up stairs extremely difficult, and even interfered with speech, although there was no chest disease to account for this. The symptoms persistently recurred in spite of all treatment, until the chloral was left off, when the oppression entirely disappeared. A similar chloral dyspnœa, though not so long continued, occurred in many cases observed by us, either with or without a rash, and a feeling of heaviness and anxiety. That the chloral dyspnœa does not always stop at the lower degrees, but may proceed to the most severe and dangerous developments, is shown by the following observation communicated to me by an eminent physician. This gentleman was summoned in consultation by a lady prostrated by long suffering, who had of late suffered from attacks of extreme dyspnœa, which had increased to asphyxia. At the same time the face was swollen, the facial muscles paralyzed, 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, therefore, recommended the discontinuance of a daily dose of forty-five grains of chloral which had been given as an 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. The dyspnœa may be anatomically explained by analogy with the effects of chloral upon the skin and mucous membrane, by hyperæmia of the lungs, which is produced through the channel of the vaso-motor nerves.

“We find here a further confirmation of the assumption that chloral operates upon the vaso-motor centre and the medulla oblongata, and that its paralyzing influence extends thence to the peripheral branches of the affected nerves. This might also lead to a practical contra-indication of chloral in all morbid conditions where there is a tendency to congestions or stases of blood in the lungs.”

In non-habituès it has been found by Fothergill[92] to produce dyspnœa where there is cardiac disease:—

“A patient was taken into the West London Hospital, with emphysema and aortic stenosis. In spite of rest, digitalis and ammonia, he was liable to attacks of dyspnœa, which had come on since his admission into the hospital. On searching for an explanation, it was found that the house-surgeon had benevolently prescribed chloral for the sleeplessness complained of. This was at once stopped, and the attacks of dyspnœa never returned, though the man gradually sank.”

Dyspnœa is reported by thirteen of my correspondents as a symptom of the continued use of chloral.

On the throat and larynx the effect is one of decided irritation, attended by congestion and sometimes ulceration. The uvula is congested and œdematous, the epiglottis red and swollen, and the vocal cords sometimes congested also. Cases of this kind are reported by Kirn[93] and Chapman[94].

THE EYES.

Upon the eyes the continued use of chloral produces a very decided and characteristic effect. Some persons not addicted to the use of chloral manifest a peculiar idiosyncrasy with reference to it. A single dose sometimes, more often a few doses, will produce severe conjunctivitis, occasionally accompanied by œdema of the subjacent parts, as also of the face. Photophobia is often marked. Abundant testimony as to this effect of chloral on the eyes may be found in my article upon that subject in the N. Y. Medical Record for 1881.

Conjunctivitis from the continued use of chloral is reported by forty-one of my correspondents, œdema by thirteen, and photophobia by thirteen.

Sixteen report “weakness of vision,” nine report “double sight,” one cataract, one sudden blindness disappearing on discontinuance of the drug, one ptosis, four amblyopia, and six asthenopia. Two cases of temporary blindness from chloral are also reported. This was in non-habituès. Keyser,[95] of Philadelphia, reported the case of a gentleman accustomed to sixty and eighty grain doses of chloral, who suddenly became blind. Opthalmoscopic examination revealed great retinal anæmia. The drug was discontinued, and in a few days sight was restored.

Schüle[96] demonstrated that in chloral takers the retina was congested. The same condition was observed by Bouchut[97] in the retina of children completely anæsthetized.

Burke Haywood,[98] of North Carolina, observed an elderly man, who, after some weeks’ use of chloral, began to complain of dimmed vision, which persisted and increased till the drug was withdrawn, when it gradually disappeared.

The case of ptosis is reported by Dr. H. C. Bigelow, of Washington, D. C., as follows:—

“Female, aged thirty years, married, spare build, nervous temperament, and active mind. Grains thirty to sixty, daily, for eighteen months. Emaciated, hysterical, constipated, flatulent. Temper irritable. Ptosis of the right eye, commencing iritis and photophobia. Ulceration of os uteri. Had an orgasm while being examined. Vaginismus; sexual appetite strong, but dislikes her husband and marital intercourse. Suffers from insomnia, loss of memory, mental unsteadiness. She ascribes all these symptoms to chloral.”

Dr. N. C. Husted, of Tarrytown, N. Y., reports to me the case of a lady who has used the drug in from ten to twenty-grain doses, for about eighteen months. She is troubled with partial amaurosis and excessive lachrymation.

Dr. Edward Bradley, of this city, reports to me the case of a lady who took twenty grains of chloral, three times a day, for some time. Eyesight gradually failed, and she was soon obliged to wear glasses. Her eyes were thoroughly examined, and nothing abnormal was found. On discontinuing the chloral the eye trouble speedily disappeared. The effects of the drug on the general system, especially the digestive apparatus, was very marked. The habit was broken without trouble.

For a full discussion of the subject here presented in outline, the reader is referred to my article in the Record, already spoken of.

CHAPTER XI.
SYMPTOMS OF ABSTINENCE FROM CHLORAL—DOSES AND DANGERS—TREATMENT.

The symptoms incident to the abrupt withdrawal of chloral from those who have used it for a long time are rarely severe; never so severe as those attending the same procedure in opium or morphine habituès. Many chloral takers voluntarily intermit the use of the drug for weeks at a time, themselves.

One of the most prominent symptoms that occurs occasionally is the supervention of severe delirium, very like that of delirium tremens. Such a case is reported by Dr. Geo. F. Elliot.[99] The patient, a man, aged thirty-five years, had, however, taken fifteen grains of opium, daily, for many years. He had for a few weeks substituted chloral, taking 200 grains of this drug daily. On withdrawing the chloral all the phenomena of delirium tremens appeared. It subsided on the use of large doses of tartar emetic and opium. Similar symptoms are reported by many of my correspondents.

Flashes of heat, nervous prostration, palpitation of the heart, dyspnœa, insomnia, sometimes persistent, intense headache with vertigo, and neuralgic pains in the occipital region, are likewise common.

Pains in the limbs are usually found, but are not so severe as those occurring after stopping the use of morphine. They are speedily relieved by large doses of gelseminum. This drug was first used for the pains occurring in the limbs of chloral eaters, during the continuance of the habit, by Mr. Herbert M. Morgan.[100] It acted well. Baths, electricity, the cold pack, and the measures recommended for the treatment of the morphia habituès, should be used. There should be no gradual reduction, unless the patient is very anæmic and much debilitated. Quinine in twenty-grain doses is an excellent sleep producer in these cases. The delirium tremens is best treated by digitalis and bromide of potassium. Stimulants should be freely used for the first three days, and strychnia and iron be given in large and frequently repeated doses. Cod-liver oil, extract of malt, and a generous diet should be prescribed. Pepsine should be given in fifteen to thirty grain doses after each meal. The bowels should be kept gently moving, by some mild laxative and cold water enemata. Hemorrhage from the bowels, stomach or urinary passages is readily controlled by the homœopathic tincture of witch-hazel, in ten-drop doses.

After the first ten days of treatment, strenuous efforts should be made to improve the patient’s health and mind by means of exercise, free diet, good reading, and pleasant conversation.

The conjunctivitis is best treated by mild astringent applications, as tea, or the following:—

℞.	Acid tannici,	gr. vj
	Sodæ biboratis,	gr. xv
	Vin. opii,	ʒ j
	Glycerinæ,	℥ j
	Aq.,	℥ ij.	M.

Sig.—Eye wash.

The eye troubles and the skin affections usually pass away, without interference, a few days or weeks after the discontinuance of the chloral.

Restraint, full control, and a thorough search of the patient are necessary with these as with opium or morphine takers.

The practice employed by some physicians, of “tapering off” chloral eaters on small doses of opium or morphine, I consider unnecessary, and extremely dangerous, for these patients, as is well established, are prone to go from one habit to another, and the use of these drugs is placing needless temptation in their way.

PROGNOSIS.

Cure may be assured if proper control of the patient is had. As much depends on proper after treatment of these cases as in that of the morphine habit.

Relapses less often occur in these than in opium habituès.

Finally, then, the prolonged use of chloral is not so likely to form a habit; is not so thoroughly enslaving when formed; is less prone to endanger life in small, more prone to destroy mind and body in large doses, and is easier broken, than the opium and morphine habits.

DANGERS.

There is a certain peculiar danger attending the use of chloral that is comparatively rare among opium habituès, viz: that of death from an overdose; death, also, from a dose that has previously been taken with safety.[101] Medical literature is filled with records of such cases, and instances where death almost occurred, the patient only being saved through the exertions of the physician called.

In some instances an overdose was accidentally taken; in others the person is found dead, it being probable that he took no more than his customary dose, which, however, acted with unusual strength upon a system surcharged with the drug.

Here, for instance, is, supposably, one of these cases. It is sent me by Dr. P. C. Remondino, of San Francisco, Cal.:—

“Isaac H., barrister, aged fifty-six; about four years ago began taking chloral for sleeplessness, due, he was told, to cerebral anæmia; was then a portly gentleman; hair and beard dark; beard slightly tinged with gray; feeling the need of stimulus, began to drink quite freely, and also to take morphia; then soon followed the habitual use of chloral. He now takes as much as one hundred and eighty grains per day, in three to four doses. Sometimes takes ten grains of morphia with one of the doses; is more than usually nervous; now is greatly emaciated; hair and beard a bleached white; skin itches and has a hard, dry feel; has small brownish spots, about the size of this ◯, that cast off a small scab of skin; suffers with pain in wrists and knees; also elbows and ankles, but not so severely as in the wrists and knees; insomnia and loss of appetite. Bowels regular; mental faculties are active; of course nothing like those he formerly possessed, as his physical debility makes him childish, but still he can use his mind and will, to a certain extent; acts perfectly gentlemanly, although he is as stated. His physical state is that of the debility and tottering of a man of ninety.”

A short time afterward the doctor writes: “The chloral eater died some few days ago, in Los Angelos. Was found dead in the water closet of his hotel. The despatch says, ‘supposed cause apoplexy.’ I think it was more likely cardiac asthenia.”

Dr. R. F. Lewis, of Lumberton, N. C., writes me: “A prominent physician of this place who was intemperate in the use of spirits, morphine, etc., began the use of chloral instead, and for weeks or months was more or less under its influence. He died suddenly after using it in increased quantities the day and night before. No autopsy.”

Dr. A. R. Kilpatrick, of Navasota, Texas, sends me the following curious note:—

“About four or five years ago there was a doctor living at Port Hudson, West Feliciana Parish, La., named (I think) Harris, who wrote several papers for the Med. and Surg. Reporter, of Philadelphia. He wrote one or two papers especially on the use of chloral and on the chloral habit, and very impressively warned people about its use and abuse, and in less than a year after the publication of those pieces I saw his death announced, and that he had been a habitual consumer of chloral, and that it killed him.”

Here is another case of death from an overdose, in an habituè, contributed by Dr. S. Henry Dessau, of this city:—

“The only case where I have known death to be in any way connected with the administration of chloral, was in a case of dipsomania in a hysterical female. I prescribed a combination of fifteen grains of chloral with thirty grains of bromide of potassium, to be repeated every two hours, until sleep was procured; the effect was obtained after three or four doses. About eight doses were given in the mixture. I ceased attending the case, and about a year after learned through the press that the patient had died from an overdose of chloral. On inquiring from the druggist who had prepared the prescription, I learned that the patient continued to use the medicine steadily after my visits ceased, and that for twenty-four hours before death she had used two bottles of the mixture, or in other words four ounces of chloral with one ounce of bromide of potassium.”

Two cases of chloral habituation in men past middle age are reported by Dr. C. A. Bryce of Richmond, Va., where death occurred from symptoms resembling apoplexy.