Treatment

Because of the marked anxiety it is of great importance to reassure the patient. In the excitement stage an ice-bag to the head and whisky or large doses of bromides may be supplied, or even inhalations of ether. In the collapse stage the treatment is for collapse, especial attention being paid to the respiratory center. C. C. Lieb has repeatedly checked cocaine heart-block in isolated turtle hearts by caffeine; but caffeine increases the poisoning of the central nervous system and is ordinarily contraindicated.

Cocaine Habit

The cocaine habit is quite common, especially among nurses, physicians, and druggists, who have easy access to the drug, among prostitutes, and among the negroes of the South. The drug is taken as snuff, or is rubbed into the gums, swallowed, or injected hypodermatically. The habit may be diagnosed by the nervousness and twitching in the absence of the dose, by the marks of a hypodermatic needle, by ulceration in the nose, with epistaxis, if the snuff is taken, and by the effects of a "fake" dose of some other drug. Blue atrophy of the skin at the site of the injections has been reported by Gottheil (1912).

When without his usual dose the habitue feels irritable, depressed, and restless, and cannot concentrate his attention; on getting the dose his spirits brighten and he experiences a return of his mental and physical energies. By degrees he passes into a state of poor nutrition, wasting, and anemia, with loss of appetite, deranged digestion, constipation, and insomnia. He gradually reaches a state of mental and moral weakness without self-control, far beyond those of the morphine or heroine habitue, is easily depressed, develops careless and debasing habits, and lacks the inclination to work. He may develop various mental and nervous symptoms, such as tremor of hands and lips, irregular twitching of the shoulder and other muscles, queer sensations in the skin, and hallucinations and delusions. The delusions cause great viciousness, and perhaps attempts to harm others. Mania and chronic dementia and other forms of insanity as results of the habit are reported.

Treatment

Isolation, the rapid or even the immediate withdrawal of the drug, with the substitution of atropine or hyoscine, and attention to nutrition, digestion, bowels, and sleep.

Therapeutics

The wine of cooa is employed to some extent as a tonic and appetizer in run-down conditions, or in convalescence from acute illnesses. Since it has the taste of wine and contains 1/6 grain or more of cocaine and allied alkaloids in each ounce, it is not surprising that a number of cases of cocaine habit have resulted from its use. It is not now Pharmacopaeial.

Cocaine hydrochloride is employed very extensively as an anesthetic, either by application to mucous membranes in 2 to 10 per cent. solution, by hypodermatic injection in 0.2 to 4 per cent. solution, or by injection of 1/2 grain (0.03 gm.) in solution into the spinal canal.

In the nose, besides its use as an anesthetic, it is employed to shrink the tissues so as to favor the passage of instruments, to increase the view, to stop hemorrhage, or to free the nasal passages and to lessen engorgement in rhinitis and hay-fever. It is inferior to adrenaline for these purposes. Many cases of cocaine habit can be traced to the use of sprays and powders in hay-fever, and not a few to the use of proprietary asthma cures and catarrh snuffs.

In the throat it may be sprayed over a hypersensitive pharynx before examination with a laryngoscope, or to check a distressing dry cough, or in tuberculous laryngitis to abolish pain and permit the swallowing of food.

In affections of the esophagus (ulcer, cancer, esophagitis, spasm, cardiospasm) cocaine solution may be swallowed just before eating, to lessen the pain and spasmodic contraction which results from the passage of food. A 10 per cent. solution is applied to the pharynx and larynx in direct laryngoscopy or esophagoscopy to prevent pain and shock.

In the stomach it is employed to allay pain, nausea and vomiting; in the eye, as anesthetic for operations and the removal of foreign bodies, and as a transient pupil dilator to facilitate examination of the internal eye; in the urethra, to allay spasm and permit the passage of instruments; at the anus, in ulcer or fissure, to allow a painless examination or painless defecation; on the vulva, to overcome intractable itching, and in the entrance to the vagina in vaginismus. In irritable rectum or anus it may be employed in ointment or suppository form.

In the external ear the aqueous solution is not absorbed, but some anesthesia may be obtained from the pure alkaloid dissolved in aniline oil. It is reported that a 10 per cent. solution in ether will be absorbed.

When cocaine is used hypodermatically, it is not injected deeply like other drugs to hasten absorption, but is placed immediately beneath the epidermis. The addition of epinephrine lessens the systemic and prolongs the local effects, and checks hemorrhage; so in this admixture it has recently come into extensive use for quite large operations, as amputation of a limb or laparotomy. It does not, however, abolish the perception of the patient or produce full muscular relaxation. In major operations under general anesthesia Crile and others are attempting to lessen shock by cocainizing the operative area in advance of cutting. Allen Starr uses cocaine hypodermatically as a diagnostic agent in painful tic, the drug being injected at the site of that branch of the fifth nerve which supplies the painful area. If the pain disappears, the lesion is peripheral; if not, it is central.

Spinal analgesia with cocaine or one of its relatives, especially novocaine and stovaine, may be employed for operations about the perineum and lower extremities when a general anesthetic is contraindicated, as in severe diabetes and severe nephritis. It has also been used to a slight extent in obstetrics. A very important use of it is to prevent shock in severe traumatism of the lower extremities. Its value for operations is limited for the following reasons: (1) The extent of the anesthesia is beyond the control of the anesthetist, in some cases the whole body, even the head and face, being affected. (2) There is frequently vomiting and diarrhea and excitement, effects which may persist for hours. (3) The patient remains conscious, and is made keenly alert by the drug. (4) There is little or no muscular relaxation. (5) Cocaine collapse sometimes occurs. A number of deaths are reported.

Systemically, cocaine is not ordinarily employed at all, but, if other remedies are not at hand, it may be used as a central stimulant in collapse from narcotic drugs.

Intravenous Injection Of Cocaine

A method of producing local anesthesia by injecting cocaine into the veins has been more or less used (Bier's vein anesthesia), a tourniquet above and below the area to be anesthetized preventing the loss of cocaine and causing the localized action. A danger is clotting in the vein.

Ritter's (1909) experiments with dogs, in which he produced general anesthesia by an intravenous of a 1 to 5 per cent. solution, and Meyer's similar results with cats have not been followed by any extensive use in man. Harrison (1911) reports the effects on himself of 5 grains (0.3 gm.) of cocaine hydrochloride in 2 per cent. solution introduced intravenously. Cerebration was normal except for a restless inability to keep the mind long on one subject. Motor power was unimpaired. There were dizziness and palpitation. There was marked analgesia everywhere, though slight twinges of pain were felt on making a 3/4-inch incision through the skin. Two hours later there was still a slight impairment of feeling. The experimenter says that the results are not good enough to justify this use of cocaine.