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 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 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.