SYNONYMS.—The Chloral habit, Chloralism.
ETIOLOGY.—A. Predisposing Influences.—Age exerts but little predisposing influence. Cases occur almost exclusively in adults, and the greater proportion of these are in middle life. The abuse of chloral is relatively somewhat more common among males than among females. Individuals addicted to this habit usually belong to the refined and educated classes of society; the fascinations of chloral remain thus far unknown to the great mass of the people. Professional men and those engaged in literary work form a very considerable proportion of the cases. Chloral is occasionally used by hospital nurses, and very frequently by prostitutes. Chronic alcoholism is an important predisposing element in the formation of the chloral habit; in fact, morbid conditions attended by insomnia from whatever cause tend to the formation of this habit.
B. The Exciting Cause.—Chloral is a powerful hypnotic, usually without unpleasant after-effects. In full doses it is a depressant to the nerve-centres at the base of the brain and to the spinal cord. It enfeebles the action of the heart, depresses respiration, and lessens reflex activity. It has no action on the secretions except that of the kidneys, which it frequently augments.
The habit has in some few instances been developed in consequence of the indulgence in a morbid desire to experience the effects of the drug. In a majority of instances it is due to the continuance of the medicine indefinitely after the sickness in which it was originally prescribed has ceased. I have known apothecaries to renew prescriptions of chloral often enough to supply a daily dose of from forty to sixty grains for years—in one instance for more than four years.
The dose taken by victims of the chloral habit varies greatly. Thirty or forty grains daily is a moderate amount. Not rarely this quantity is repeated twice or oftener within the space of twenty-four hours. The tolerance after a time exhibited by the organism for enormous doses of alcohol and opium is not established, as a rule, in regard to chloral. The victim of the latter after a little time discovers the average dose required to produce narcotic effects, and, while he may vary it within limits, he is liable to acute toxic effects if it be greatly exceeded. Death from such excesses is not uncommon.
SYMPTOMATOLOGY.—I. Symptoms Due to Habitual Excesses.—The habitual use of chloral, notwithstanding its ruinous consequences in a certain proportion of the cases, is less dangerous than that of opium or morphine. Many individuals take chloral in considerable doses for years without obvious ill effect. The craving for it is much less intense than that for opium or morphine, and is readily satisfied by other drugs. In point of fact, persons addicted to chloral very frequently exchange it for other narcotics. For these reasons the chloral habit is more easily cured.
Derangements of the digestive system are common, but by no means constant. They are (1) primary, and due to the direct irritant action of the drug upon the mucous tissues of the month and stomach; and (2) secondary, due to its effects upon the nervous system and the circulation. Irritation of the mucous membranes is very common. This not rarely amounts to gastro-duodenal catarrh with its characteristic symptoms. Jaundice is common, sometimes intense. A sense of fulness with pain and tenderness in the hepatic region is frequent. Constipation, with clay-colored stools, is the rule. It occasionally alternates with diarrhœa. The tongue is often coated and the breath foul. On the other hand, in a fair proportion of the cases the digestive organs are not affected. Chloral has been said to occasionally exert even a favorable influence upon appetite and digestion when taken before meals. The recent observations of Fiumi and Favrat11 in a man suffering from a gastric fistula and insomnia have shown that chloral hydrate in twenty- or forty-grain doses, administered before or at the beginning of a meal, retarded digestion by increasing the secretion of mucus in the stomach. The acidity of the gastric juice is diminished temporarily. The secretion of pepsin is not changed. Taken two hours after meals, doses not exceeding forty grains caused no derangement of gastric digestion.
11 Archives Ital. de Bioloqie, vol. vi. No. 3.
Persons not habituated to chloral usually experience a sense of constriction upon swallowing it, and a disagreeable after-taste.
The circulation is much affected. Chloral weakens, and finally paralyzes, the vaso-motor centre, and thus dilates the vessels; it at the same time weakens the action of the heart. Its habitual use is attended by flushing of the face, congestion of the eyes, and fulness of the head. The heart's action is weak, intermittent, irregular; palpitation occurs; the pulse is full and compressible or small and weak. It is usually slow.