Drugs that enslave

by H. H. Kane

“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.