K. C. Bose
1902 BMJ (Clinical Research Edition)  
these instances the stage of irritation of the centres had passed farther into that of paralysis. Similarly the temporary restoration to normal when at work of disturbed heart functions from prolonged work in compressed air must be due to hyperaemia of the deeper vessels together with inhiibition of the vasomotor centres and through the sympathetic nerve on the heart itself. Concerning the treatment, I found that nerve sedatives such as bromides, especially ammonium bromide, were better than
more » ... ates, and in a severe case of pain cannabis indica gave great relief. Potassium nitrate, potassium acetate, and ammonium acetate are good in the convalescent stage, or when the pain diminishes, but may be given from the first with good results. By far.the best treatment is the medical lock, into which, however, a purified air should be pumped till the pain goes, and then the pressure very gradually reduced. To effect this there should be attached to the medical lock an apparatus containing caustic soda in screens over which the air in passing would give up most of its C02. Similarly the prevention of the worst form of caisson disease would be effected by getting rid of the C02, where it collects in largest quantity, namely, in the shield where the men are working. This was done in the Greenwich Tunnel by running a blow-off tube down to the shield and blowing off the air every hour or oftener if necessary, if the analysis of the air in the tunnel and in the shield given above is examined it will be seen that the carbonic acid was reduced almost a half in volume by this expedient alone. Finally, all workmen about to be employed in compressed air should be subjected to a most searching medical examination, all new hands should be examined after work each day for a week, and the gang going off and that going oa twice each week, and those who are indisposed kept above ground till well; should the pulse have a high tension the man should be kept under observation every day, and should there be a booming sound in the heart or reduplication of the second sound he should be suspended altogether. This entails great labour on the part of the medical officer, but the responsibility of allowing men to work when unfit is infinitely greater, and the freedom of those under his care from a disease of such a distressing nature is a sufficient recompense. BESIDES the use of cocaine hydrochlorate as a therapeutic agent its consumption as a drug for intoxication is so great in Calcutta that unless stringent measures be adopted to control its sale, I have reason to fear that its demoralizing effects will soon spread amongst the juvenile members of respectable families, and that at no distant date special asylums will be required for the safety and treatment of cocaine inebriates. Fortunately, however, the cocaine habit is at present confined to people who are more or less addicted to opium, ganja, or alcohol, but we occasionally come across cases where the victims have contracted the habit de novo. We do not know how the people of Calcutta have obtained their knowledge of the intoxicating property of a costly drug which has hitherto been only handled by medical men, but facts tend to show that they have got it from, Bhagalpore. where cocaine has become a social necessity amongst the, less thoughtful. Inebriates say that the hilarity it produces is almost instantaneous, and is followed by no deleterious results. Novices as a rule take it quite secretly during the early hours of the night, whilst confirmed and veteran eaters consume it during all hours of the day. It is generally taken in the form of tablets or powder and chewed with betel leaves (Pan, piper betel) and slaked lime. Unlike ganja or bhang it requires no special preparation. The habit once acquired cannot be easily'given up. The first symptom experienced by the victim after he has taken a dose of cocaine is loss of sensation in the tongue and lips, followed by dryness of the mouth and fauces. A thermometer placed under the tongue does not indicate any rise of temperature. The approach of the so-called hilarity is announced by a feeling of heaviness of the head, throbbing of the arteries of the neck, and palpitation of the heart. The pulse becomes slightly full and quick, but never exceeds I io. At this stage the inebriate likes to be left alone; he firmly closes his lips and avoids talking, lest, in his attempt to do so, the saliva flows out of his mouth. His ears become hot and red, whilst his cheeks become pale; the tip of the nose becomes cold, perspiration soon breaks out on the forehead and neck, and the height of intoxication is marked by coldness of the finger ends and dilatation of the pupils. This stage lasts from 30 to 45 minutes, after which the victim longs for a fresh dose, and unless he gets it he feels lifeless and dejected. This depression of spirits is more imaginary than real, for I have not noticed any fall of temperature or slowness of the pulse, but the respiration becomes slightly hurried. The tongue and lips now become moist again, and perspiration on the forehead ceases altogether, but the pupils remain dilated. The physiological etfects of cocaine are most marked upon novices. The teeth and tongue of confirmed cocaine eaters turn jet black, and this is probably due to the chemical change produced by the action of lime and saliva upon cocaine. The craving for an increase of the dose becomes irresistibly great, and in one case the dose was raised from i gr. to 12 gr. within the short space of a month. Unlike opium, it brings on insomnia and anorexia, soon followed by dyspepsia and diarrhoea. The dyspepsia.of a cocaine inebriate is very obstinate and does not readily yield to treatment. Its prolonged use brings on some deafness. The quantity of urine is diminished, but in none of my cases was albumen detected. Delusions and hallucinations often occur, and cause dejection and dread. In some cases cocaine brings on acute mania, which is not amenable to treatment. Amongst numerous other cases I select the following in which the deleterious effects of cocaine upon the system were most marked. CASE I: Cocainism following the Use qf Opium and Bhang: Gradual Increase of 'Dose: Diarrhoea: Convulsions: Death.-L. B. M., a promising boy, aged 20, very respectably connected, fell into bad company and contracted the habit of taking opium and bhang in their various forms. His friends remonstrated with him, and he gave up the opium habit altogether and took a fancy to try the effects of cocaine. A friend of his offered him I gr., and its effect, as the young man said, was simply pleasant. He continued to take i gr. daily for some time with apparent benefit to his physical health. He then began to take 2 gr. twice daily, and he went on increasing the dose until it was raised to 30 gr. a day. The demoralizing effect of the drug was soon marked upon him: he now avoided society and became solitary. He was honest and truthful before, but now he became a liar and a pilferer. He was fair and strong, but he soon became weak and dark. He suffered very badly from insomnia, and hypnotics failed to give him rest and sleep. He would take nothing for his food except milk in very small quantities. His heart beat was strong, but his hands and feet were cold and clammy. His pupils were dilated, and the conjunctivae looked pale and bloodless ; his tongue and teeth were black. Obstinate diarrhoea supervened and carried him off. He had convulsions before death. CASE II: Confirmed Cocainism: Pluws Sulphonal: Ruined Life. -8, B., aged 45, a Sanscrit scholar, and versed in Hindu philosophy, consulted me for insomnia, the result of the cocaine habit. As a priest he said he had to fast at least three days in a week. About a year ago he had occasion to go to Bhagalpore, where he met a learned Pundit, who advised him to take cocaine, which possessed remarkable power of sustaining vigour and life without food, and enduring fatigue of all kinds. This induced him tn take cocaine. At the commencement he derived benefit from its use. Thinking he might further improve his health he raised the dose from I gr. to 3 gr. He felt weak and giddy, and consulted anotber cocaine eter, who advised him to take it twice daily and in pretty large doses. He raised the dose to q gr., which be took regularly for three months, when unpleasant symptoms began to make their appearance one after another. He soon felt himself dispnirited and miserable; he suffered from anorexia and obstinate insomnia; he lost his memory, and
doi:10.1136/bmj.1.2156.1020 fatcat:hz4yqyvgo5e7ppfyavb4lbjw4i