CIIRONIC COCAINE POISONING, OR COCAINOMANIA.—The treatment of the cocaine habit, or chronic cocaine intoxi cation, is very much more difficult. It is more essential to have complete control of the cocainomaniac and his actions than even in chronic alcohol or naor phine mania. There is less to work upon in the brain- and nerve- centres of the chronic cocainist than in those of the chronic alcoholist or chronic mor phinist. There is less mental and moral elasticity, less desire to be freed from the narcotic bondage, less consciousness of the bondage itself, a more helpless and hopeless wreck being difficult to find. Cocainomaniacs, however, are, in a few cases, cured without seclusion. In these hopeful cases there generally has been a greater stock of inhibition from the first. Again, the indulgence having been peri odical and ordinarily provoked only by some recurrent neurotic pain or distress and leaving intervals of shorter or longer non-narcotic consumption between, in hibition has not been so paralyzed, and thus there has been more resisting power left. In the latter group of cases it is imperative to direct the treatment to the abolition or counteraction of the exciting influences.
In the mass of cases the main hope of cure rests in therapeutic seclusion. The patient must be treated as a dis eased person. Diet, at first simple and readily assimilable, should be carefully attended to. Milk, with soda- or lime water and efiervescents if nausea and emesis are present; arrowroot or other farinaceous or malted food, and other peptonized preparations are excellent. Gradually, broths and plain soups, oys sters, fish, poultry, and, lastly, mutton and red meat, with an ample supply of fruit and vegetables, may be given. But there are cases in which a non-fish-and flesh dietary agrees better with the pa tient. Each case must be carefully ob served to determine the most suitable dietetic instructions.
In the first week exercise and fresh air may usually be insisted on, with massRge to improve the wasted condition of the muscles. Meals should be regular, and exercise graduated.
Alcoholic beverages are best avoided; and, though in a few cases tobacco in limited quantities may be allowed to aid in staying the morbid impulse or crave, most cocainomaniacs would be better without it in any form. Tobacco is apt, in many patients, to impair digestion and depress the heart's action, the healthy state of both vital processes being points of the highest importance in the treatment of this mania.
To combat the wearing insomnia of most cases I know nothing better than the hot, wet pack. Of all the medicinal hypnotics, I have found phenacetin the most useful, in doses of 5 grains, re peated, if necessary,' every hour; no more than 3 doses (15 grains) to be taken in one night. Other physicians have found chloral and sulphonal serv iceable.
An important practical point is the method of complete withdrawal of the cocaine, which complete withdrawal is essential to cure. In most cases I have not felt justified in immediate with drawal, though I have done this where practicable. I spread the reduction period over from seven to nine days, be ginning, whatever the quantity which had been taken daily or how long, with a reduction of one-half. Dr. Welch Branthwaite informs me that in five cases he at once, after only one dose, stopped the cocaine, without trouble. These were cases in which morphine had also been freely used. In the cases in which I gradually reduced the dose of cocaine, morphine had not been habitually taken in large doses. Where morphine is also freely and regularly taken, it is easier to withhold the cocaine without delay.
The sudden removal of the drug is the first step, with sharp elimination through the skin, kidneys, and bowels. The con tinuous activity of the skin from hot air, sweating, and baths is essential, and this should be kept up for a long time. Nar cotics are dangerous and are seldom of any value. Infusion of cinchona-bark is very valuable, and can be used for a long time. Arsenic appears to be the best of all the mineral tonics, and acids are also excellent.