Cocainism

Cocainism, the habitual use of cocaine for the purpose of achieving the peculiar state of heightened well-being (cocaine intoxication) that it provides. In the modern civilized world, cocainism is a relatively recent phenomenon, although among the natives of South America, the habit of chewing coca leaves existed even before the discovery of America by Europeans. The first reports of cases of pathological addiction to cocaine appeared in the medical press in the 1880s and referred to individuals to whom cocaine was injected subcutaneously for the purpose of facilitating withdrawal from morphine. Observations of such cases, which presented a very severe picture of one addiction complicating another, provoked a rapid reaction in medical circles and led to the abandonment of the use of cocaine in the treatment of morphinists. As a result, from the beginning of the 1890s, the number of morphine-cocaine addicts began to decrease sharply. In the first decade of the 20th century, cocainism was a relatively rare phenomenon; however, already in 1912–13, new reports appeared in the French medical press about the spread in Paris among the Montmartre bohemia and prostitutes of a new method of using cocaine—sniffing. At the same time, similar cases were noted in the American army. To a somewhat earlier period (1902) belongs the news of the spread of cocainism as a substitute for opiophagy; in India, cocaine was placed on the tongue, chewed with some additives, or taken internally. The World War brought with it a significant spread of the habit of sniffing cocaine; the latter spread almost epidemically, especially from 1916, in many states of Europe and America, both in armies and among the civilian population. The post-war economic depression favored cocainism, and 1918–23 were, in all civilized countries, especially in Germany, the era of the greatest flourishing of cocainism. In the USSR, it was observed as a mass phenomenon also in the second half of the war, predominantly among officers of the Tsarist army and speculators, and during the post-war devastation and the first years of the revolution, it spread strongly among the remnants of the bourgeoisie, especially the old nobility, the artistic bohemia, and also among various declassed elements of society, including homeless adolescents and children. The shortage or absence of alcohol had a certain significance for the development of cocainism, pushing lovers of intoxication precisely toward this easily obtainable, portable narcotic (many, however, combined the simultaneous use of both these poisons, and for a time, vodka mixed with cocaine was very popular in secret dens). The adoption of decisive measures against the trade in cocaine and, simultaneously with this, the lifting of the prohibition on alcoholic beverages deprived cocainism of its soil in the USSR, and from 1923 it began to decline sharply. There are no exact numerical data on the development of cocainism. According to the statistics of Bonhoeffer, per 1,000 admissions to the Berlin psychiatric clinic, there were the following numbers of cocaine addicts: in 1913—1.75, in 1914 and 1915—0, in 1916—1.25, in 1917—1.5, in 1918—3, in 1920—7.5, in 1921—10.0, in 1922–1923—6.25–7.0, in 1924—13.0. Similar figures are provided by the statistics of admissions to the Vienna clinic. In Paris, arrests were made for the secret trade in cocaine: in 1916—21, in 1917—52, in 1918—82, in 1919—69, in 1920—157, in 1921—212, in 1922 (only for 9 months)—187. In 1920, 70 kg of cocaine were confiscated there. Regarding the USSR, unfortunately, there is little even of such indirect data. The spread of cocainism among homeless children began in the USSR in 1919 and reached its apogee in 1924, when each of the special institutions for such children had at least 2% habitual cocaine addicts, while the number of casual users among them, according to various data, reached 8–15% of the total number of those interned. Then a rapid decline of this wave began, and in 1926–1927, child cocaine addicts were already a rare phenomenon (see also Intoxication Psychoses). Cocaine addicts usually sniff cocaine together: most often, for its consumption, they gather in tight groups in apartments, in night dens, and even (in 1920–23) in the ruins of houses. Usually, the powder is poured in small portions onto the nail bed and inhaled into the nose. The picture of acute cocaine intoxication in different individuals, depending on their personality as well as the method of use, is quite diverse, although a number of typical features can still be distinguished from it. Joel and Fraenkel divide the entire course of cocaine intoxication into 3 phases: 1) euphoric, 2) intoxication in the proper sense, and 3) depressive. The euphoric phase is characterized by increased activity, a feeling of an excess of strength, and an elevated, cheerful mood. In this phase, the cocaine addict feels the need to move and talk incessantly, and his excited behavior makes him at times very similar to someone who is tipsy. However, unlike alcoholic intoxication, here muscular strength, endurance, and work capacity appear objectively increased for some time, which can be explained by the weakening of unpleasant muscular sensations that usually signal the onset of fatigue. Some experience at this time a peculiar feeling of floating, of extraordinary lightness of their body, as if bodiless—a circumstance probably also connected with the weakening of the muscular sense. The course of intellectual processes is characterized by the elimination of inhibitions acting in the normal state; hence, on the one hand, the ease of the flow of thoughts, and on the other, the weakening of attention and increased distractibility; the speech and writing of cocaine addicts turn out to be incoherent, full of digressions and contradictions. Euphoria is intensified due to increased activity and imagination; visual images arising in the imagination easily take on a special brightness and convexity; this circumstance, in combination with increased excitability of hearing, gives the cocaine addict a sensation of the sharpening of all his senses. There is no sharp boundary separating euphoria from the phase of intoxication that follows it, and the change from one to the other occurs gradually. Decisive here are: 1) a change in mood and 2) the appearance of hallucinations. The mood becomes tense and is colored by a growing affect of fear, which is fed by the ever-increasing excitability of the sensory apparatus and a tendency to transform actual perceptions into illusory ones: a light creak turns into a roar, the horn of a passing car into military signals, a coat rack takes on human forms, etc. As a result, the entire affective attitude of the person intoxicated with cocaine toward the outside world changes: it seems to him that all eyes are turned on him, that people are whispering about him, that they are mocking him. While, when in euphoria, the cocaine addict strives to attract attention to himself, in the phase of intoxication, he tries in every way to escape from people's gazes. Hallucinations in cocaine addicts can develop in all sensory areas, but most often they are auditory in nature: sounds of footsteps, whistling, car horns, whispering, or loud voices uttering obscene words, threats, curses, etc. Visual hallucinations are also not uncommon, although they are not as frequent here as in delirium tremens. Erlenmeyer drew attention to the microscopic character and multiplicity often inherent in them; thus, for example, against a white background (for example, a sheet), cocaine addicts predominantly see numerous moving black dots, usually taking them for small insects. Sometimes, however, they also see large objects, most often those that excite horror or have a voluptuous character: dead heads, naked women, the act of coitus, etc. Pathognomonic for cocainism are considered the tactile hallucinations known among the French by the name of Magnan's sign: the sensation of foreign bodies located under the skin, sometimes moving. Occasionally, olfactory and gustatory hallucinations are also observed. Usually, all these heterogeneous sensory deceptions quickly unite into unified and all the more vivid and plastic perceptions, intensifying to the extreme limit the initially unaccountable and formless feeling of fear and filling the entire consciousness with a rapidly growing and systematizing delusion of persecution. The horror aroused by all these experiences and the continuous expectation of attack, arrest, etc., sometimes lead the cocaine addict to dangerous violent actions: he may start shooting at apparent pursuers, strike the first person he meets, etc. Of course, in this period, intellectual processes already suffer significantly (attention and memory weaken sharply, thinking becomes poor and incoherent, etc.); however, it is interesting that orientation in place and time rarely disappears completely, and traces of a critical attitude toward delusional experiences as something unreal, like a dream, almost always remain—something similar to schizophrenic double orientation. When the excitement is exhausted, the third and final phase of cocaine intoxication sets in—the depressive phase, according to Joel and Fraenkel (it would be more correct to call it the phase of exhaustion). It is characterized by a state of extreme fatigue and complete lack of will while being unable to fall asleep, and the decline of all activity can reach almost complete stupor: sometimes it is difficult for the cocaine addict even to drop the cigarette butt in his hand onto the floor.

Intellectually, this period corresponds to a complete absence of thoughts and an inability to think. Only after a long time does this paradoxical combination of extreme exhaustion and insomnia finally give way to sleep. The mood corresponding to this phase varies individually among different cocainists: for some it is rather indifferent, while for others it is deeply depressed—quite analogous to an alcoholic hangover—even to the point of attempted suicide. The symptoms of cocainism are quite diverse. On the part of the motor system, tremors and increased general muscular excitability are noted. Particularly characteristic are peculiar movements in the facial musculature, predominantly in the masticatory muscles; there is also a tendency toward twitching and choreiform movements in various parts of the body, and sometimes even true epileptiform convulsions. Small doses of cocaine increase tendon reflexes, while large ones weaken them; in chronic cocainists, they are usually increased. As for sensitivity, it usually turns out to be weakened in relation to painful stimuli, especially in individuals who inject cocaine—sometimes almost to the point of complete analgesia. Paresthesias are very frequent, especially burning, crawling, and itching, predominantly in the fingers, tip of the nose, ears, and back of the head. Cocaine apparently somewhat sharpens auditory sensations; in relation to visual ones, on the contrary, it reduces the clarity and distinctness of peripheral vision and perhaps increases the duration of afterimages. Of the divisions of the vegetative nervous system, cocaine excites the sympathetic nerve system, causing dilation of the pupils, an increase in the palpebral fissure, and some exophthalmos. A very characteristic and diagnostically valuable symptom of cocaine intoxication is profuse cold sweat. The sexual drive in women is intensified under the influence of cocaine; in men, however, with increased excitability, sexual potency is significantly reduced, even to the point of complete inability to achieve an erection. In many cocainists in a state of intoxication, there is a tendency toward sexual perversions, especially acts of homosexuality. It is unlikely that such a tendency is caused by cocaine itself; it is more probable that it simply removes the psychological inhibitions to the manifestation of previously existing but hidden urges. Among other somatic symptoms, necrotic changes of the mucous membrane and cartilaginous septum of the nose, even to the point of deviation and perforation of the latter, which are often noted in cocaine sniffers, have great diagnostic significance. Some connection can be made between this and the blunting of smell and taste observed in cocainists. Respiration and pulse in those poisoned by cocaine quicken somewhat; in some, palpitations develop, accompanied by a sensation of constriction in the chest; blood pressure increases due to vasoconstriction; for the same reason, the skin becomes anemic: the pale, sweat-covered face is particularly striking. In a state of intoxication, diarrhea is not uncommon, alternating with constipation in chronic cocainists. Salivation and gastric juice secretion are reduced, which leads to a decrease and even complete destruction of the feeling of hunger, not only in the state of intoxication but also for quite a long time after it. Finally, sleep is usually disturbed for a long time and is difficult to treat with anything but strong hypnotics. Among pathological-anatomical findings, one can note the rapid onset of rigor mortis, edema and hyperemia of most internal organs, hemorrhages and thromboses, predominantly small, in the vessels of the lungs and especially the brain; degenerative changes in the ganglion cells of the brain, nerve fibers, and parenchymal cells of the liver and kidneys have also been noted. Cocaine does not cause, like morphine, a chemical-physiological habituation of the organism to the poison, thanks to which abstinence from it is significantly easier than from morphine. The habit to cocaine is almost exclusively psychological and is caused, on the one hand, by a weakening of the will, and on the other, by an ever-increasing craving for the already many-times-tried stimulant. Nevertheless, chronic consumption of cocaine has an extremely pernicious effect on the cocainist and leads his psyche to rapid decline. The cocainist becomes emotionally dull and morally degrades, as a result of which he quickly sinks, forgets his social and family duties, steals and sells his own and others' things indiscriminately, and commits embezzlement just to get the desired powder. Following moral degradation comes intellectual degradation: interests disappear, memory weakens, creative abilities and even elementary reasoning decline. Sometimes true prolonged psychoses also develop: the mildest form is the persistence, even in the intervals between cocaine doses, of an undefined fear of people and thoughts of persecution; in some cocainists, acute hallucinatory states, characteristic of the above-described second phase, drag on for more or less long periods—up to 1-2 weeks; in individual cases, a full-blown, prolonged, more or less systematized delusion of persecution develops, usually accompanied by auditory hallucinations. Finally, occasionally, pictures resembling Korsakoff's psychosis or progressive paralysis (cocaine pseudoparalysis) are observed. The prognosis should be considered poor if the cocainist has any sharply expressed psychopathic features, especially if, in addition, cocaine consumption began long ago and occurs without interruptions. Occasional cocainists who began abusing the drug out of a desire for imitation and due to weakness of will often give up the habit, which has not yet had time to take root, without much difficulty. The fight against cocainism essentially boils down to the fight against drug addictions in general and must have a primarily social-preventive character. In addition to sanitary-educational measures, the absolute prohibition of the trade in cocaine, the fight against its smuggling and against dens used for sniffing, as well as against the unscrupulous use of the right to prescribe cocaine by prescription, must be placed first here. Treatment of individual cases must necessarily be carried out in closed medical institutions of a psychiatric type. Since withdrawal from cocaine does not produce severe symptoms of abstinence, it is always stopped immediately. Usually, after just a few days, the cocainist begins to feel relatively well and becomes accessible to psychotherapeutic influence. Since even in mild cases of cocainism, it is usually obliged in its origin to the presence of certain psychopathic properties in the patient, further treatment, requiring on average 2-3, and sometimes more months, must boil down to the systematic re-education of the cocainist's personality, the stimulation of his intellectual and aesthetic interests, the strengthening of his will, and the instillation of healthy social and labor habits.