The blood undergoes changes corresponding to the general disturbances of nutrition. What the special changes in its composition may be is not known. Many of the cases, even after the prolonged use of the drug in considerable doses, show few evidences of malnutrition or of anæmia. In the greater number, however, wasting is marked, and the physical signs and rational symptoms of profound anæmia are present. Deterioration in the composition of the blood is further indicated by petechiæ, hemorrhage from mucous surfaces, sponginess of the gums, and serous effusions.
The respiration is not permanently affected, save in grave cases. It is then slow, irregular, and shallow. Dyspnœa is common and easily provoked. It is usually accompanied by cough and abundant frothy expectoration. These symptoms vanish upon the discontinuance of the drug. In a fatal case of chloral-poisoning seen by the writer, in which the daily use of the narcotic in non-poisonous amounts had been for a long time varied at intervals of five or six weeks by doses sufficient to induce prolonged coma, death was preceded by Cheyne-Stokes respiration. This patient was a retired dentist, and kept the solution of chloral in a large unlabelled bottle. The actual doses taken were not ascertained.
The muscular system shares in the general malnutrition. The muscles become flabby and wasted. Persons addicted to chloral are very frequently of nervous organization and sedentary habits, and hence of poor muscular development prior to the use of the drug.
The kidneys show no constant derangement. In a certain proportion of the cases chloral acts as a diuretic, largely increasing the urinary excretion. Albumen is present in a certain proportion of the graver cases, when it is apt to be associated with anæmia, serous effusions, and a tendency to hemorrhages from mucous tracts. The occurrence of casts and the persistence of albuminuria after the discontinuance of chloral suggest an antecedent or coincidently developed nephritis. The reducing substance present in the urine after small doses of chloral is uro-chloralic acid (Mering and Musulus). It gives the reaction of sugar with the copper and bismuth tests, but is levogyrate. Glycosuria is occasionally encountered.
Vesical and urethral irritation occurs in a small proportion of the cases. When these symptoms vanish upon the discontinuance of the drug and recur upon its resumption, it may be fairly assumed that they are due to its action. A great number of morbid phenomena relating to the genito-urinary tract and to the urine, that have been ascribed to the action of chloral in those addicted to its use, are due to associated conditions rather than to the drug itself.
It has been claimed upon evidence that does not appear to the writer adequate that chloral sometimes acts upon the sexual system as an aphrodisiac, sometimes as the reverse. More or less complete impairment of sexual power and appetite is the rule in individuals addicted to great excesses in narcotics of all kinds. Menstruation is not arrested by chloral as by morphine, nor does it necessarily cause sterility in the female.
The skin undergoes nutritive disturbances of a marked kind. As a 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.