“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.