result of individual peculiarity, single doses or medicinal doses
continued for brief periods of time have occasionally caused
erythematous, urticarious, papular, vesicular, and pustular eruptions.
Of these, the first named is of most frequent occurrence. The habitual
abuse of chloral causes in many individuals chronic congestion of the
face, neck, and ears. This redness is often very striking. It is
increased by the use of alcohol. Erythematous patches upon the chest,
in the neighborhood of the larger articulations, and upon the backs of
the hands and feet, also occasionally occur. They are often associated
with urticaria. General eruptions resembling measles, scarlatina, and
even mild variola, are said to have been observed after large doses of
chloral. Purpura is by no means rare in old cases, and falling of the
hair and atrophy and loss of the nails occur.
The nervous system bears the blunt of the disturbance, and the more
significant symptoms relate directly to it.
The hypnotic effect is usually preserved. Hence the chloral habitué is
dull, apathetic, somnolent, disposed to neglect his ordinary duties
and affairs. He passes much of his time in a state of dreamy lethargy
or in deep and prolonged sleep, from which he awakes unrefreshed and
in pain. In one of my cases, however, even larger doses than usual at
length failed to induce more than fitful slumber, and the insomnia
which led to the formation of the habit finally reasserted itself,
reinforced by the unutterable miseries of chloralism.
Headache is a frequent symptom. It is usually general, sometimes
frontal, often referred to the top of the head. It is commonly severe,
not rarely agonizing, and is described as a pressure, weight, or a
constricting band. It is associated with injection of the eyes,
flushing of the face, confusion of thought, inability to converse
intelligently or to articulate distinctly, and other evidences of
cerebral congestion. Vertigo is common.
{664} Sensory disturbances are frequently present. They consist in
local areas of hyperæsthesia, more frequently of anæsthesia, numbness
of the hands and fingers or of the feet, formication of the surface of
the body and limbs, and burning or neuralgic pains in the face, chest,
and extremities. The pains in the limbs are almost characteristic.
They are acute and persistent, neuralgic in character, but not
localized to particular nerve-tracts. They are more common in the legs
than in the arms, and occupy by preference the calves of the legs and
the flexor muscles between the elbows and the wrists. They do not
implicate the joints, are not aggravated to any grave extent by
movement, and are often temporarily relieved by gentle frictions. The
pains of chloralism have been described as like encircling bands above
the wrists and ankles.
Sensations of chilliness alternating with flashes of heat are
experienced. The temperature is, in the absence of complications,
normal. Excessive doses are followed by a reduction of one or more
degrees Fahrenheit, lasting several hours.
Among the motor disturbances are the following:
Tremor.—This symptom is not common. It is neither so pronounced nor so
distinctly rhythmical as that of alcoholism or the opium habit. It is
increased upon voluntary effort. It affects chiefly the hands and arms
and the tongue.
Palsy.—Loss of power in the lower extremities has been observed in a
number of instances. It varies in degree from paresis to complete
paraplegia. Its occurrence may be gradual or sudden. It passes away
upon the discontinuance of the habit. In many respects this condition
resembles alcoholic paraplegia.
Impairment of Co-ordinating Power.—Ataxic phenomena are sometimes
present. The patient has difficulty in walking in the dark, cannot
stand with his eyes closed, has trouble in buttoning his clothes, and
the like.
Impairment or Abolition of the Knee-jerk.—In a man aged fifty, who had
taken thirty to sixty grains of chloral hydrate at night for eighteen
months, the writer observed complete loss of the knee-jerk, which,
however, reappeared in the course of a few weeks after the
discontinuance of the drug.
In rare cases epileptiform seizures have occurred.
Chloral produces in certain individuals, even as the result of a
single dose, congestion and irritation of the conjunctiva. Apart from
this idiosyncrasy, its habitual use not infrequently causes
conjunctivitis. This affection is occasionally of a severe grade and
accompanied by œdema of the eyelids and great photophobia. Retinal
congestion has been noted by several observers. Amblyopia,
disappearing upon the cessation of the habit, has also been observed.
Psychical Derangements.—The mental and moral perversion caused by
immoderate chloral-taking shows itself rapidly. The transient
stimulating effects of the dose of opium or morphine in those
accustomed to these drugs are seen not at all or to a very slight
extent in chloralism. Hence the mental state is characterized by
dulness, apathy, confusion, and uncertainty. These conditions
alternate with periods of irritability and peevishness. The physical
sufferings of the chloral-taker in the daily intervals of abstinence
are greater than those of the {665} morphine-taker; his mental
depression less. The one is tormented by the agony of pain, the other
by the anguish of craving. To the former repetition of the dose brings
stupor and sleep, to the latter exhilaration and activity. In certain
respects, however, the effects of these drugs upon the mind are
similar. They alike produce intellectual enfeeblement, inability to
concentrate the mind, habitual timidity, and impairment of memory. In
the worse cases of chloralism hallucinations, delusions, and delirium
occur. Acute mania may occur, and dementia constitutes a terminal
state.
II. Symptoms Due to Abstinence from Chloral.—The symptoms occasioned
by the abrupt discontinuance of even large habitual doses of chloral
are not, as a rule, severe. In this respect the difference between
this drug and opium and its derivatives is very marked. The
chloral-taker not infrequently substitutes some other narcotic, as
alcohol or opium, for his usual doses without discomfort, and in many
instances voluntarily abstains from the drug, without replacing it by
others for periods of weeks or months.
The more important of the symptoms induced by sudden discontinuance
relate to the nervous system. Insomnia is usual. It is not always
readily controlled, and constitutes one of the principal difficulties
in the management of these cases. Headache is rarely absent; it is in
many cases accompanied by vertigo. Occipital neuralgia frequently
occurs, and is often severe. Neuralgias of the fifth pair also occur.
Darting pains in the limbs are usual, and the fixed aching pains
already described as peculiar to habitual chloral excess are present,
and often persist for a long time after the withdrawal of the drug.
Irregular flushes of heat, nervousness, restlessness, inability to fix
the attention, formication, burning sensations in various regions of
the surface of the body, are unimportant but annoying symptoms.
In a considerable proportion of the cases delirium occurs. It is
commonly associated with tremor, great prostration, complete insomnia,
sweating, inability to take food, and vomiting, and resembles in every
particular the delirium tremens of alcoholic subjects. In the absence
of this condition gastric derangements are not of a grave kind. The
nausea, vomiting, epigastric pain, and diarrhœa which are induced by
the discontinuance of opium are absent, or if present at all only to a
slight degree. As a matter of fact, the functions of the digestive
system are in a very short time much more perfectly performed than
before. Hemorrhage from the stomach, bowel, or urinary tract may also
occur.
The conjunctivitis and cutaneous eruptions usually disappear with
promptness as soon as the influence of the habitual chloral excesses
passes away.
DIAGNOSIS.—The diagnosis of the chloral habit is attended with much
less difficulty than that of the morphine habit. In the first place,
there is general and often serious derangement of health without
adequate discoverable cause. The appetite is poor and capricious, the
digestion imperfect and slowly performed; jaundice of variable
intensity, often slight, sometimes severe, occurs in many cases; the
bowels are not, as a rule, constipated. Dyspnœa upon slight exertion
is, in the absence of pulmonary, cardiac, or renal cause, of
diagnostic importance. The circulation is, as a rule, feeble.
Disorders of the skin, persistent or easily provoked conjunctivitis,
puffiness about the eyelids, and a tendency to hemorrhage {666} from
mucous surfaces also occur. When with these symptoms, irregularly
grouped as they are, we find a tendency to recurring attacks of
cerebral congestion, persistent or frequently recurring headaches, and
the characteristic pains in the legs, the abuse of chloral must be
suspected. This suspicion becomes the more probable if there be a
history of protracted painful illness or of prolonged insomnia in the
past. The adroitness of these patients in concealing their vice, and
the astonishing persistency with which they deny it, are remarkable.
In the absence of the characteristic association of pains,
conjunctivitis, and affections of the skin the diagnosis is attended
with considerable difficulty. It becomes probable from the association
of chronic ill-health, not otherwise explicable, with perversion of
the moral nature, enfeeblement of the will and of the intellectual
forces. It is rendered positive, notwithstanding the denials of the
patient, by the discovery of the drug or the prescription by means of
which it is procured.
PROGNOSIS.—If the confirmed chloral habitué be left to himself, the
prognosis, after excessive doses or the stage of periodical debauches
has been reached, is highly unfavorable. The condition of mind and
body alike is abject. There is danger of sudden death from cerebral
congestion or heart-failure—a mode of termination by no means rare.
On the other hand, the prognosis under treatment may be said to be
favorable. The habit is much more readily broken up, and the danger of
relapse is far less, than in cases of confirmed opium or morphine
addiction. Nevertheless, the underlying vice of organization which
impels so many individuals to the abuse of narcotics precludes a
permanent cure in a certain proportion of the cases of chloralism.
Sooner or later relapse occurs—if not relapse to chloral, relapse to
opium, morphine, or alcohol, or into that wretched condition in which
any narcotic capable of producing excitement and stupor is taken in
excess as occasion permits.
Paraldehyde.
The use of this hypnotic is not unattended with danger. In a single
case afterward under the observation of the writer paraldehyde was
used in large and increasing doses for the sake of its narcotic
properties. The patient, a young married woman whose family history
was bad, her mother having died insane, contracted the chloral habit
after an acute illness. After some months a cure was effected without
great difficulty. She relapsed into chloralism after a second sickness
which was attended with distressing insomnia. The habit was again
broken up. In consequence of over-exertion in social life during a
winter of unusual gayety insomnia recurred. For the relief of this
condition paraldehyde was prescribed with success. Notwithstanding its
disagreeable and persistent ethereal odor, and the precautions taken
by the physician, this lady managed to secure paraldehyde at first in
small quantities, afterward in half-pound bottles from a wholesale
druggist, and took it in enormous amounts, with the result of
producing aggravated nervous and psychical disturbances corresponding
to those produced by chloral, but without the disturbances of
nutrition attendant upon the abuse of the latter drug. The patient
remained well nourished, retained her appetite and digestion, and was
free {667} from disorders of the skin and the intense neuralgia which
had been present during both periods of chloral abuse. She suffered,
however, from a persistent binding headache, disturbances of
accommodation, phosphenes, and brow-pains. Under the influence of
moderate doses she was enabled to take part in social life with some
of her old interest and vivacity. The brief intervals of abstinence
which occasionally occurred were characterized by distressing
indifference to her friends and surroundings and by apathy and
depression. At frequently-recurring intervals the indulgence in
excessive doses, constituting actual paraldehyde-debauches, was
followed at first by maniacal excitement of some hours' duration,
later by profound comatose sleep lasting from one to three days. Upon
the complete withdrawal of the drug this patient manifested the
symptoms produced by complete abstinence in the confirmed morphine
habit—yawning, anorexia, epigastric pains, vomiting, diarrhœa,
absolute sleeplessness, extending over several days, heart-failure,
collapse, colliquative sweating, and finally well-characterized
delirium tremens. At the end of a week, under the influence of
repeated small doses of codeine, sleep was secured, and within a month
convalescence was complete. This person now continues free from
addiction to any narcotic, in good health, and able to sleep fairly
well, after the lapse of several months since the complete
discontinuance of paraldehyde.
Cannabis Indica, Ether, Chloroform, and Cocaine.
These drugs are habitually used as narcotic stimulants by a limited
number of individuals. Cannabis indica, or Indian hemp, the hashhish
of the Arabians, is said to be largely used in India and Egypt. It is
occasionally taken by medical students and other youths of an
experimental turn of mind, but no case of habitual hashhish addiction
has come under the observation of the writer.
The use of ether as a narcotic stimulant is occasionally observed
among druggists, nurses, and other hospital attendants, but does not
give rise to clinical phenomena sufficiently marked or distinctive to
demand extended consideration in this article. The same remark may be
made of chloroform, which is also used in the same way to a
considerable extent among women suffering from neuralgia and other
painful or distressing affections of the nervous system. The fact that
individuals are every now and then found dead in bed with an empty
chloroform-bottle by their side serves to indicate the extreme danger
attending the vicious use of this substance.
Cocaine, within the short time that has elapsed since its introduction
into therapeutics, has unquestionably been largely abused, both within
the ranks of the profession and among the people. Highly sensational
accounts of the disastrous effects resulting from its habitual use in
excessive doses have appeared in the newspapers and in certain of the
medical journals. No case of this kind has fallen under the
observation of the writer, and it would appear premature to formulate
definite conclusions concerning the effects of cocaine upon the data
thus far available.
{668} Treatment.
The treatment of the opium habit and kindred affections is a subject
which derives its importance from the following facts: First, the
gravity of the disease, as regards the functions both of the body and
of the mind; second, the enormous suffering and misfortune, alike on
the part of the patient himself and on the part of those interested in
him, which these affections entail; third, the fact that they are not
self-limited, and therefore cannot be treated with indifference or
upon the expectant plan, but are, on the other hand, progressive and
gradually destructive of all that makes life worth living, and at last
of life itself; and finally, because they are capable at the hands of
skilful and experienced physicians of a cure which in a considerable
proportion of the cases may be made permanent.
The treatment of these affections naturally arranges itself under two
headings: (_a_) the prophylactic, (_b_) the curative treatment.
_a_. Prophylaxis.—It is impossible to overrate the importance of a
true conception of the duty of practitioners of medicine in regard to
the prophylaxis of the opium habit and associated affections. In
communities constituted as are those in which the physicians practise
into whose hands this volume is likely to fall, a large—I may say an
enormous—proportion of the cases of habitual vicious narcotism is due
to the amiable weakness or thoughtlessness of medical men. A majority
of the cases occur either in chronic painful affections attended or
not by insomnia, or as a result of acute illness in which narcotics
have been employed to relieve pain or induce sleep. The chronic
affections constitute two classes: First, those manifestly incurable,
as visceral and external cancer, certain cases of advanced phthisis,
confirmed saccharine diabetes, and tabes dorsalis. In such cases the
use of morphine in large and often-repeated doses, although attended
with evils and likely to shorten life, amounts to a positive boon. It
is neither practicable, nor would it be desirable, to interfere with
it. To this class may be added those cases of grave valvular or
degenerative disease of the heart where the patient has become
addicted to the habitual use of narcotics. Here, notwithstanding the
evils resulting from these habits, among which the likelihood of
shortening the period of life must unquestionably be counted, the
dangers of the withdrawal of the drug are so great that it must be
looked upon as neither desirable nor feasible. Attention must, at this
point, be called to the fact that great caution is required in the
management of pregnant women addicted to narcotics. Incautious
attempts to withdraw the habitual drug are almost certain to be
followed by speedy loss of the fœtus; and it is to my mind
questionable whether anything more than the most guarded reduction of
the daily dose should be attempted while the pregnancy continues.
The second class of chronic cases includes individuals suffering from
diseases which are remediable or capable of decided or prolonged
amelioration. Among these affections are painful diseases curable by
surgical procedures, such as certain obstinate and intractable
localized neuralgias, painful neuromas, irritable cicatrices, pelvic
and abdominal tumors, and surgical affections of the joints and
extremities. Here, either before or after radical surgical treatment,
an effort to relieve the patient from the bondage of habitual
narcotism should be made. For reasons that are {669} obvious, measures
having this end in view should be instituted by preference
subsequently to surgical treatment. To this class also belong certain
painful affections occupying the border-region between surgery and
medicine. These are floating kidney, renal and hepatic abscess,
calculous pyelitis, cystitis, impacted gall-stones, and thoracic and
abdominal aneurism. In these cases the possibility of a cure renders
it in the highest degree desirable that the opium habit should be
stopped. Whether this attempt should be made while the patient is
under treatment for the original affection, or deferred until relief
has been obtained, is a question to be decided by the circumstances of
the particular case under consideration. Finally, we encounter a large
group of chronic painful affections coming properly under the care of
the physician in which the opium habit is frequently developed. This
group includes curable neuralgias of superficial nerves, as the
trigeminal, occipital, brachial, intercostal, crural, and sciatic, and
visceral neuralgias, as the pain of angina, gastralgia, enteralgia,
and the pelvic and reflex neuralgias of women. Here also are to be
mentioned the pains of neurasthenia, hypochondriasis, and hysteria. In
this group of affections the original disease constitutes no obstacle
to the attempt to break up the habit to which it has given rise.
The practice of using narcotics, especially the preparations of opium,
in large and increasing doses for the relief of frequently-recurring
pains, especially in neurotic individuals, is a dangerous one. When
necessary at all, the use of these drugs should be guarded with every
possible precaution. In the first place, in so far as is practicable,
the patient should be kept in ignorance of the character of the
anodyne used and of the dose. In the second place, the physician
should personally supervise and control, in so far as is possible, the
use of such drugs and the frequency of their administration, taking
care that the minimum amount capable of producing the desired effect
is employed. In the third place, the occasional alternation of anodyne
medicaments is desirable. Fourthly, an effort—which, unfortunately, is
too often likely to be unsuccessful—should be made to prevent repeated
renewals of the prescription without the direct sanction, or indeed
without the written order, of the physician himself. Finally, the
danger of yielding to the temptation to allow a merely palliative
treatment to assume too great importance in the management of painful
affections must be sedulously shunned. Too often these precautions are
neglected, and the patient, betrayed by a dangerous knowledge of the
drug and the dose by which he may relieve not only physical pain, but
also mental depression, and tempted by the facility with which the
coveted narcotic may be obtained, falls an easy victim to habitual
excesses. The lowered moral tone of convalescence from severe illness
and of habitual invalidism increases these dangers. Yet more
reprehensible than the neglect of many physicians in these matters is
the folly of the few who do not hesitate to fully inform the patient
in regard to the medicines given to relieve pain or induce sleep, and
to place in his hands designedly the means of procuring them without
restriction for an indefinite period of time. Almost criminal is the
course of those who entrust to the patient himself or to those in
attendance upon him the hypodermic syringe. No trouble or
inconvenience on the part of the physician, no reasonable expense in
procuring continuous medical attendance on the part of the patient for
the sake of relief from pain, can ever offset, save in cases of the
final stages {670} of hopelessly incurable painful affections, the
dangers which attend self-administered hypodermic injections.
The uniform and efficient regulation of the sale of narcotic drugs by
law would constitute an important prophylaxis against habitual
narcotism. Unfortunately, the existing laws relating to this subject
are a dead letter. They are neither adequate to control the evil nor
is their enforcement practicable. Nostrums containing narcotics, and
particularly opium and morphine, in proportions that occasionally
produce fatal results are freely dispensed at the shops to all comers.
Prescriptions calling for large amounts of opium, morphine, codeia,
chloral, cannabis indica, etc. are dispensed to the same individuals
at short intervals over the counters of apothecaries for months or
years after the illness in which they were originally prescribed is
over. Yet more, occasional cases come to light which serve to indicate
the appalling frequency with which opium, its tincture, morphine, and
solutions of chloral are directly sold to unauthorized individuals. If
the evil thus accomplished were better understood, the paltry profit
realized from such nefarious trading would rarely tempt men to the
commission of the crime which these practices constitute.