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.