Drugs that enslave

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:—

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

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:—

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.