THE CONTINUED USE OF CHLORAL HYDRATE.
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:—
From 20 to 30 12
From 30 to 40 25
From 40 to 50 27
From 50 to 60 19
From 60 to 70 11
--
94
The sex was obtained in one hundred and thirteen cases, as follows:—
Males 77
Females 36
---
113
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:—
Nervous, 63
Sanguine, 1
Nervo-sanguine, 8
Melancholic, 21
--
93
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.