Drugs that enslave

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:—

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.

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.