& CENEIAL 6URCERY 
 
 KNAPP 
 
 ** - «!. 
 
CORNELL UNIVERSITY. 
 
 THE 
 THE GIFT OF 
 
 ROSWELL P. FLOWER 
 
 FOR THE USE OF 
 
 THE N. Y. STATE VETERINARY COLLEGE. 
 
 1897 
 
Cornell University Library 
 RD 86.C6K67 
 
 Cocaine and its use In opiitlialmic and ge 
 
 3 1924 021 960 954 
 
Cornell University 
 Library 
 
 The original of tiiis book is in 
 tine Cornell University Library. 
 
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 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924021960954 
 
COCAINE 
 
 AND 
 
 ITS USE IN OPHTHALMIC AND 
 GENERAL SURGERY 
 
 H. KNAPP, M.D. 
 
 PROFESSOR OF OPHTHALMOLOGY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE 
 
 CITY OF NEW YORK 
 
 Reprinted from the Archives of Ophthalmology, December, 1 8S4 
 
 WITH SUPPLEMENTARY CONTRIBUTIONS BY 
 
 drs. f. h. bosworth, r. J. hall; e. l. keyes, 
 
 H., KNAPP, AND WM. M. POLK 
 
 NEW YORK & LONDON 
 
 G. P. PUTNAM'S SONS 
 
 SC^c |inttIi£ibDtkti grws 
 
 1885 
 
x^7 
 
 copyright;' Iv- 
 
 G: p. PUTNAM'S SONS 
 
 i88s 
 
 Press of 
 
 G P. Putnam's Sons, 
 
 New York 
 
CONTENTS. 
 
 PAGE 
 
 Translation of K. Roller's original paper . i 
 
 American Contributions. 
 
 Hy. D. Noyes . . 9 
 
 Agnew, Moore, Minor ... .10 
 
 / Roosa . .... II 
 
 Knapp . . .... .11 
 
 Experiments on the eye, 11 ; on other mucous membranes — ear, mouth, 13 ; 
 nose, larynx, and trachea, 14 ; urathra, 15 ; rectum. Application, 16. 
 
 Walker, Mittendorf, Claiborne • , • .... 16 
 
 Cocks, Peck, Polk ... .^ , 17 
 
 Griining, C. H. Williams, Bradford 18 
 
 Moore ..... . -19 
 
 Shakespeare, Bosworth . 20 
 
 Hepburn, Holt . . . 21 
 
 Squibij, C. S. Bull . . 22 
 
 F. M. Wilson, Hope, A. H. Smith . "22 
 
 Powell, Lyttle, Shaw, M. J. Roberts, von Ramdohr, B. Bettman, 
 
 J. Bettman, Clark 24 
 
 Ingal's, Lundy, Theobald, Michael, Chisolm, CabOt . 25 
 
 Knight, Burke, Jackson, TurnbuU, Lefferts .... 26 
 
 Dabney, Levis, Otis, Hall, Halsted ... -27 
 
 Castle, Croston, Jarvis . ... 28 
 
 Cocks, Knapp .... ... 29 
 
 Burrall, Weld, Shears, Uhler, Stickler, Doughty, Eug. Smith . 31 
 
 Riley, Da Costa, Squibb, Jurist, C. H. Williams . . 32 
 
 Wadsworth, Alt, Hunicke, J. Green . . -33 
 
 S. C. Ayers 34 
 
 European Contributions. 
 
 E. Meyer . . -34 
 
 Ad. Weber, Jelinek, Dworak • 35 
 
 Benson, Gunn, Nettleship . ... 36 
 
 Vulpian, KOnigstein, Hirschberg, Howe 37 
 
 General Remarks (H. Knapp). 
 
 A. — Pharmacological Notes • 38 
 
 B. — Physiological Action 40 
 
 C. — Therapeutical Application 41 
 
 Particular Use of Cocaine 
 
 In Ophthalmology. (H. Knapp) 42 
 
 " Otology. (H. Knapp) 49 
 
 " the Upper Air-Passages. (F. H. Bosworth) 52 
 
 " General Surgery. (R. J. Hall) . 71 
 
 " Genito-Urinary and Minor Surgery. (E. L. Keyes). 79 
 
 " Gynecology and Obstetrics. (W. M.-Polk) 82 
 
ON COCAINE AND ITS USE IN OPHTHALMIC 
 AND GENERAL SURGERY. 
 
 By H. KNAPP. 
 
 NO mbdern remedy has been received by the profession 
 with such general enthusiasm, none has become so 
 rapidly popular, and scarcely any one has shown so extensive 
 a field of useful application as cocaine, the local anaes- 
 thetic recently introduced by Dr. C. Koller, of Vienna. Con- 
 vinced that it will not only continue to prove as valuable as 
 it has hitherto been found, but that its properties will be 
 the subject of numerous scientific researches and clinical ob- 
 servations all over the globe for many years to come, I pur- 
 pose, as far as I am able, to collect in the following pages 
 "what knowledge has thus far been acquired on this highly 
 interesting and important drug. To help the reader in 
 gathering information is, however, not the only object of 
 this paper ; I would like it also to act as a stimulus for new 
 investigations. From this standpoint I consider a faithful, 
 unabridged translation of the original paper which Dr. 
 Koller read before the Medical Society of Vienna, and 
 published in the Wien. med. Wochenschr., Oct. 25, and Nov. 
 I, 1884, not only as an acknowledgment of a debt of grati- 
 tude we all owe to him, but also as an appropriate 
 introduction to the present article. The paper is as fol- 
 lows : , 
 On the Use of Cocaine to Anesthetize the Eye. 
 
 By Dr. Karl Koller, Assistant Physician to the General Hospital in Vienna- 
 (Translated by H. Knapp.) 
 
 I want to report on ~ some experiments which I have 
 made in regard to , anaesthetizing the eye. This is not my 
 
2 H. Knapp. 
 
 first communication on this subject— a previous, one, to se- 
 cure priority, having been directed to the meeting of German 
 oculists held at Heidelberg Sept. 15th and i6th of this 
 year. Dr. Brettauer, of Trieste, was kind enough to deliver 
 my paper to the Publishing Committee, and to exhibit be- 
 fore the Society my experiments, which have since been 
 repeated and confirmed in different places of Germany. 
 
 It is generally known that cocaine, the alkaloid separated 
 , from the leaves of erythroxylon coca, in 1859, by Niemann, 
 a pupil of Wohler, possesses the remarkable property of ren- 
 dering, on local application, the tip of the tongue anaes- 
 thetic. This property was discovered by Prof. Schroff, who 
 first, in 1862, mentioned it before this Society. It is further 
 known that cocaine, through the circulation, contracts the 
 peripheric arteries, and it is known also that it dilates the 
 pupil both through the circulation and on local application. 
 From the foregoing it is evident that cocaine has been in- 
 stilled into the eye in former years, but those phenomena 
 have been overlooked which will be the subject of my 
 present communication. 
 
 The internal application of cocaine, tried repeatedly, has 
 always been abandoned again. In 1880 Dr. von Anrep ' 
 published an elaborate experimental paper on cocaine, at the 
 end of which he points out that its local anaesthetic action 
 may become of importance. To us Viennese physicians 
 cocaine has been prominently brought to our notice by the 
 thorough compilation and the interesting therapeutic paper 
 of my colleague at the General Hospital, Dr. Sigmund Freud.* 
 Starting from the supposition that a substance paralyzing 
 the sensitive terminations of the mucous membrane of the 
 tongue could not greatly differ in its action on the cornea 
 and conjunctiva, I have made, in the laboratory of Prof. 
 Strieker, a number of experiments on animals, of which,, 
 in brief, the following were the results obtained : 
 
 A few drops of a watery solution of muriate of cocaine ; ° 
 
 ' Pfluger's Archiv f. d. ges. Physiol., 21. Bd. 
 
 " Centralbl. f. Therafie v. Heitler, August number, 1884. 
 Muriate of cocaine dissolves up to 5 ^ in water without addition of an acid, 
 but always opalescent. Addition of acids is to be avoided, as a very small quan- 
 tity of acid causes intense burning. The opalescent solution becomes as clear 
 as water by filtration. 
 
Cocaine in Ophthalmic and General Stirgery. 3 
 
 dropped on the cornea of a guinea-pig, rabbit, or dog, or in- 
 stilled into the conjunctival sac in the ordinary way, cause 
 for a short time winking of the eyelids, evidently in conse- 
 quence of a slight irritation. After one half to one minute 
 the animal again opens its eyes, which gradually assume a 
 staring look. If now the cornea is touched with a pin-head 
 (in which experiment we have carefully to avoid touching the 
 eyelashes), the lids are not closed by reflex, the eyeball does 
 not move, the head is not drawn back as usual, the animal 
 remains perfectly quiet, and on application of stronger irrita- 
 stion we can convince ourselves of the complete ancesthesia 
 of the cornea and conjunctiva. In this way I have scratched 
 and transfixed the cornese of my animals used for experi- 
 ment with needles, and have excited them with electric cur- 
 rents so strong as to cause pain in my fingers and become 
 quite intolerable in the tongue ; I have cauterized the 
 cornea with the nitrate-of-silver stick until it became milky- 
 white — during all this the animals did not move. The last 
 experiment convinced me that the anaesthesia involved 
 the whole thickness of the cornea, and did not affect the 
 surface only. But if I incised the cornea, the animals mani- 
 fested intense pain when the aqueous humor escaped and 
 the iris prolapsed. I have been unable, hitherto, to decide 
 by experiments on animals whether or not the iris could be 
 anaesthetized by dropping the, solution into the corneal 
 wound, or by prolonged instillations into the conjunctival 
 sac ; for experiments to test the sensibility of non-nar- 
 cotized animals are very complicated and difificult, and do 
 not yield unambiguous results. The last question which I 
 subjected to experimentation on animals, viz., whether or 
 not the inflamed cornea could be anaesthetized by cocaine, 
 was answered in the afifirmative. The cornea in which I 
 had incited a foreign-body keratitis became as insensible as 
 a healthy one. 
 
 Complete ansesthesia of the cornea from the use olz.2% 
 solution lasts ten minutes on an average. After such suc- 
 cessful experiments on animals I did not hesitate to apply 
 cocaine also to the human eye, trying it first on myself and 
 some of my friends, then on a great number of other 
 
4 H. Knapp. 
 
 persons, obtaining without exception the result of a perfect 
 anaesthesia of the cornea and conjunctiva. The course of 
 the phenomena is as follows : If some drops ol a. 2% solution 
 are instilled into the conjunctival sac, or better still, let run 
 over the cornea, first a slight burning (accompaiiied by some 
 lachrymation) is felt, which in one half to one minute disap- 
 pears, being followed by a dull sensation of dryness. The eye, 
 like that of the animals mentioned above, assumes a staring 
 look, owing to a considerable dilatation of the palpebral 
 fissure, a phenomenon to the explanation of which I shall 
 return later on. If now the corneals touched with the head 
 of a pin, no sensation of pain, or of contact is experienced, 
 and all reflexes are absent. The same holds of the ' con- 
 junctiva, in which the sensation of temperature is likewise 
 abolished. The scleral conjunctiva can be grasped with a 
 pair of toothed forceps, or a dimple can be made into the 
 cornea by pressure, without any unpleasant sensation or the 
 least reflex on the part of the person thus treated ; the only 
 thing he perceives is an indistinctness of objects, owing, of 
 course, to the change in the curvature of the cornea. This 
 complete anaesthesia lasts from seven to ten minutes, then 
 passes through a longer stage of reduced sensibility into the 
 normal condition. About fifteen or twenty minutes after 
 the instillation the pupil begins to dilate. The dilatation 
 reaches its highest degree within the first hour, decreases 
 considerably in the second hour, and disappears without a 
 trace in a few hours more. The pupil is never ad maximum 
 dilated, responds promptly to light and convergence during 
 the whole time, and for that reason the sensation of daz- 
 zling, connected with atropine mydriasis, is either totally 
 absent or only slightly pronounced. 
 
 A very insignificant paresis of accommodation appears 
 and disappears with the mydriasis ; the near point receded 
 y in myself and another person whom I examined on this 
 point. 
 
 Furthermore I have observed a marked ischcemia in the 
 normal, especially the palpebral, conjunctiva, on the dura- 
 tion of which I am unable to make any definite statement. 
 Other not perfectly ascertained observations, such, for in- 
 
Cocaine in Ophthalmic and General Surgery. 5 
 
 stance, as the ophthalmoscopic condition, I will pass by for 
 the present, yet I want to say that I have never noticed 
 any symptoms of irritation from the use of cocaine. 
 
 As to the dilatation of the palpebral fissure, this phenome- 
 non at all events precedes the action of cocaine on the 
 muscles of the iris and the ciliary ligament. On account of 
 its almost simultaneous occurrence with the anaesthesia of 
 the cornea and conjunctiva, I have thought it to be in con- 
 nection with this anaesthesia, accounting for it by the omis- 
 sion of the excitations which in the normal state act upon 
 cornea and conjunctiva, and upon which the ordinary width 
 of the palpebral fissure depends. 
 
 In regard to the anaesthesia I should not omit to mention 
 some points of practical interest. 
 
 1. The anaesthetic effect of cocaine may be cumulated up 
 to a certain limit, namely : if at the decrease of the anaesthe- 
 sia cocaine is instilled anew, a second anaesthesia is obtained 
 lasting longer than the first. In this way, by instillations 
 every five minutes for a longer time, I have produced com- 
 plete, anaesthesia of from fifteen to twenty minutes duration. 
 
 2. The anaesthesia is chiefly a local one, i. e., it is most in- 
 tense in those places which have been in contact with the 
 solution directly and longest. 
 
 3. As it can be demonstrated that cocaine is absorbed, and 
 that from each instillation a certain, though small, quantity 
 penetrates into the interior of the eye, first of all into the 
 anterior chamber, it could a priori be expected that the 
 deeper structures of the eye might be anaesthetized if they 
 could be reached by sufficient quantities of the remedy. 
 But as the absorption requires a certain time, and the an- 
 aesthesia of the cornea is of short duration, the anaesthe- 
 sia of the cornea will have disappeared before the iris and 
 ciliary body are acted upon. We must therefore anaesthe- 
 tize the cornea again. Both demands can be satisfied by 
 successive applications. By instillations oi a. $ % solution 
 made every five minutes and continued for about half an hour, 
 I have succeeded in ascertaining an action upon th,e deeper 
 parts of the globe, inasmuch as its sensibility on stronger 
 pressure was essentially diminished. 
 
6 H. Knapp. 
 
 I am indebted to the liberality of Dr. v. Reuss, acting 
 surgeon of the clinic of the late Professor v. Jager, for the 
 opportunity of testing, during the last two or three weeks, 
 the action of cocaine on diseased eyes. 
 
 From the beginning I have thought that therapeutically 
 cocaine might be used in two directions : first, as a nar- 
 cotic in painful affections, of the eye, and secondly, as an an- 
 cesthetic in operations on the eye. 
 
 In regard to the first category I have expected a good 
 deal of benefit from its action in diseases of the cornea and 
 conjunctiva accpmpanied by pain and photophobia. I have 
 used cocaine in a greater number of patients suffering from 
 lymphatic (phlyctenular) conjunctivitis with eruptions and 
 ulcers of the cornea, and a 2 ^ solution in one patient affected 
 with frenulum vasculare (from successive phlyctenulae). All 
 patients thus treated have said that a few minutes after the 
 instillations they hsivefelt materially better, pain and pho- 
 tophobia having considerably diminished. With the same 
 unanimity, however, they have complained that two or three 
 hours after the instillation pain and photophobia have re- 
 turned. It might therefore be expected that by applica- 
 tions repeated at such intervals pain and photophobia could 
 permanently be removed or at least abated. This mode of 
 application has not yet been tried. Under the conditions 
 to which I have limited my experiments I have not noticed 
 any influence on morbid processes either in the one or the 
 other direction. 
 
 With similar result I have used cocaine in a man with 
 painful erosion at the sclero-corneal junction. 
 
 I shou,ld think that cocaine might exert its influence also 
 on the pain in iritis, for I believe td have demonstrated 
 that its ansesthetic effect extends in a certain degree to the 
 iris and ciliary body. The mydriatic effect, on account of 
 its insignificance, would not merit great consideration, but 
 we may expect some influence from its property of con- 
 tracting the blood-vessels. The combination with atropine 
 treatment may, perhaps, be of advantage. I have not yet 
 had art opportunity to try it in this disease. 
 
 The sensation of pain from cauterizing the lids with ni- 
 
Cocaine in Ophthalmic and General Surgery. 7 
 
 trate of silver can, by previous instillation of cocaine, either 
 be entirely suppressed or at least materially weakened. 
 The majority of the patients in whom this treatment has 
 been tried, have alleged to have felt no pain at all ; in 
 others the pain, after a period of latency, has reappeared, 
 but could be suppressed again by a repeated instillation. 
 One patient said the pain had been much less severe, but 
 had lasted longer. 
 
 On the utility of cocaine in the bluestone treatment 
 my observations are few in number and contradictory; at 
 any rate it should here be used much more freely than in 
 touchings with nitrate of silver in solution. 
 
 I come to the second category of the use of cocaine, viz. : 
 as an anasthetic in operations on the eye. 
 
 It does excellent service in the removal of foreign bodies 
 from and out of the cornea, often a difficult task on account of 
 the restlessness of the patient. In a large number Of such 
 patients (about thirty) I produced the anaesthesia by letting 
 two drops of a two-per-cent. solution run over the cornea 
 while the patient was looking down. The instillation was 
 repeated in from three to five minutes. AH these patients 
 have asserted to have lost the sensation of a foreign body ; 
 they held their eyes entirely quiet while the foreign body was 
 dug out of the cornea with a needle, and, on being asked 
 what they had felt, all have answered they had felt nothing 
 at all. 
 
 With the same good result cocaine has been used in a case 
 . of tattooing corneal scars, and in an operation for pterygium. 
 
 Good results may be expected from cocaine in cauteriza- 
 tion of corneal ulcers with the glowing iron, in paracentesis 
 of the cornea, and in discision of cataract. Both the latter 
 operations, as I have noticed in experiments on animals, 
 and also in man, can be made absolutely without pain, for 
 they consist only in fixing the conjunctiva and puncturing 
 the cornea. 
 
 Dr. V. Reuss has performed staphyloma operation in a boy 
 of ten and a girl of seven years without narcosis, but only by 
 the use of cocaine after the method to be described pres- 
 ently. The children haye kept perfectly still, and, accord- 
 ing to their own statement, have experienced no pain. 
 
8 H. Knapp. 
 
 Dr. V. Reuss was further kind enough to allow me to use 
 cocaine in eyes on which he was to perform iridectomies 
 and extractions of cataract. On the whole, I would like to 
 say only that all these cases ran their course without irrita- 
 tion, a fact which certainly encourages to further trials. 
 The experinients yielded more or less favorable results, but 
 always corresponding to the intensity and manner in which 
 the remedy was applied. The most favorable, as to pain- 
 lessness during the operation, indeed almost entirely '•satis- 
 factory, results were obtained in those cases in which the 
 following method was strictly pursued : During half an hour 
 immediatelybefore the operation, two drops of a five-per- 
 cent solution were instilled every five minutes. The head 
 of the patient lies horizontal, and while he looks toward his 
 feet, his upper eyelid is raised and the solution dropped on 
 the upper part of the sclerotic. 
 
 One of the patients thus treated, a woman, on whom an ex- 
 traction of cataract wasperformed, stated, on being questioned 
 at the different steps of the operation, that she felt nothing 
 at all of the corneal section ; she did feel it when the iris was 
 seized and drawn out, but it pained her only a little. There 
 was no reaction during any of the steps of the operation ; 
 the same was the case with a weak-minded woman on whom 
 the same operation was performed, which Dr. v. Reuss had 
 dreaded on account of her great sensitiveness. 
 
 The following case seems to me remarkable on account 
 of its peculiar conditions: 
 
 A man with .seclusion of the pupil on both sides under- 
 went an iridectomy on the left eye after cocaine application. 
 There was not the least reaction during the operation, and 
 he said that he had not felt at all the corneo-scleral section 
 (witli the lance) ; he had felt the seizing and drawing out of 
 the iris, but it had not given him any pain. A week later 
 the same man was operated on the other eye, the cocaine 
 this time being omitted. He pressed and squeezed in such 
 a way that he rendered the operation quite difificult, as Dr. 
 v. Reuss told me afterward. 
 
 Even if the majority of the patients that have to undergo 
 such operations are torpid, persons who patiently bear their 
 
Cocaine in Ophthalmic and General Surgery. i g^ 
 
 pain, yet the last case seelns to demonstrate that also in 
 such cases an anaesthetic may be of great service. ' 
 
 AMERICAN CONTRIBUTIONS. 
 
 Two weeks before the original of Dr. Roller's paper was 
 published in Vienna, American physicians wene informed 
 of its substance. Merck's muriate of cocaine being in the 
 New York market, they without delay tried the new an- 
 aesthetic in every direction, finding for themselves a number 
 of important facts before Dr. Roller's or other European 
 publications reached them. This occurred in the following 
 way : 
 
 Dr. Hy. D. Noyes, of New York, travelling in Europe, 
 sent to the Med. Rec. a letter, published, in that journal 
 on Oct. II, 1884, under the title: "A few cursory notes- 
 on the proceedings of the meeting of the German 
 Ophthalmological Society, held at Heidelberg in the 
 middle of September of this year." , One of his notes at 
 once attracted the greatest attention among the oculists of 
 New York, and I dare say those of the whole country. It 
 was "the extraordinary ancesthetic power which a two-per- 
 cent, solution of muriate of cocaine has upon the cornea and 
 conjunctiva when it is dropped into the eye." The cornea 
 and conjunctiva can be touched and rubbed with a probe, 
 a speculum inserted, the conjunctiva grasped with a pair of 
 fixing forceps, and the eye pulled in different directions 
 without any unpleasant sensation. " The solution causes no 
 irritation of any kind, and its effect disappears in fifteen to 
 thirty minutes." Its remarkable anaesthetic property was 
 discovered by a young physician. Dr. Carl Roller, Secun- 
 dararzt at the General Hospital of Vienna, only a few weeks 
 before its presentation at the Heidelberg Ophthalmological 
 Congress through Dr. Brettauer. " Dr. Roller had made 
 but few trials with it. These he had been led to make from 
 his knowledge of the entirely similar effect which it has, for 
 some years or more, been shown to have over the sensibility 
 of the mucous membrane of the mouth, pharynx, and 
 larynx: The substance makes a clear solution, and is found- 
 in Merck's catalogue." 
 
lo H. Knapp. 
 
 A short communication on the same subject is published 
 in a report of the same meeting by the Ophthalmic Review 
 (London, October, 1884, p. 316). It adds to the account of 
 Dr. Noyes only the following statement : "The drug causes 
 a slight mydriasis, which lasts a couple of hours, and is 
 accompanied by some paresis of accommodation, but reaction to 
 light and e serine is not obliterated." 
 
 A third communication is found in No. 39 of the Wiener 
 med. Wochenschr., Sept. 29th, p. 1175, as follows: "Refer- 
 ring to Dr. Koller's communication to the Heidelberg 
 Ophthal. Congress, Dr. Edmund Jellinck informs us that 
 ■ he had noticed a similar anaesthetic and analgesic effect 
 when a cocaine solution was brushed over the mucous mem- 
 brane of the pharynx and larynx. A detailed account will 
 be given when both experiments are concluded." 
 
 The above is all that has come to my knowledge on 
 •cocaine, from European sources until Nov. 25th, when Dr. 
 Koller's original publication in the Wicn. med. Woch. of 
 •Oct. 25th reached me. 
 
 The first American contributions are short notes contained 
 in the Med. Record oi Oct. i8th, p. 438 by Drs. C. R. Agnew, 
 W. O. Moore, and J. L. Minor, concerning the application 
 -of cocaine to eye-patients. Agnew reports on two squint 
 operations that had been done without pain under cocaine ; 
 on a case of injury to the eye, where the remedy had in a 
 few minutes relieved great irritability and blepharospasm ; 
 and on another where the extreme sensitiveness to the 
 touch was so reduced by the remedy, that in two and a half 
 minutes the patient permitted his sclera to be touched with 
 the finger without wincing. MoORE used it in a case 
 of a corneal ulcer "which was touched and gently scraped 
 -without sensation " ; further in an operation for pterygium, 
 which was done with the utmost ease and without any pain- 
 ful sensation; then for squint in a boy, aet. seven, who 
 " made no complaint of pain, and simply said that the 
 speculum stretched the lids, but was painless." MINOR 
 used it to remove the sutures after a strabotomy which had 
 been done three days previously. The speculum was intro- 
 duced and the stitches taken off without pain. The patient 
 
Cocaine in Ophthalmic and General Surgery. 1 1 
 
 was a boy of ten years. He used it further in an exceed- 
 ingly excitable lady, who had a cataract extracted easily and 
 without pain. ^ She said that she had not been hurt. 
 
 The number of the Med. Rec. of Oct. 25th (issued 
 Oct. 24th) contains a paper on cocaine by myself, and one 
 by Dr. D. B. St. John Roosa. Roosa used it in four 
 operations of strabismus, the pain being greatly reduced ; 
 in a third case the patient experienced considerable 
 pain, and said she would take ether the next time. He 
 Used it locally upon the membrana tympani, in one case of 
 that rare disease, tympanic neuralgia. The patient said 
 the pain was relieved in ten minutes after two instillations. 
 
 In MY OWN paper I first gave some pharmacological notes 
 about cocaine, indicating the literary sources from which 
 they were taken. I will only mention here that the first 
 to isolate an alkaloid from the coca leaves was Gaedcke, 
 ■who gave it the name erythroxiline, in 1855. .Niemann and 
 Lossen investigated it more thoroughly in i860 and '62; 
 Lossen analyzed it and found for it the formula: C^,H2i 
 .NO4. I made experiments with cocaine on all accessible 
 mucous membranes, except that of the vagina and uterus. 
 In the eye I found that it produced neither pain nor any dis- 
 comfort. The movements of the globe and the ophthalmo- 
 scopic condition remain unchanged. The tension in healthy 
 ■eyes is either unchanged or slightly diminished. 
 
 " The diminution of sensibility in the cornea and conjunctiva 
 varies in different individuals. In most cases it becomes 
 manifest as early as two or three minutes after the first in- 
 stillation, increases for ten to twenty minutes, then decreases 
 and is over in about half an hour. When another instillation 
 is made, ten to twenty minutes after the first, the anaesthesia 
 is more intense, on superficial touching mostly absolute, and 
 lasts longer. In an hour after the first instillation jt becomes 
 very feeble and disappears in one hour and a half. 
 
 " The: pupil begins to dilate ten to twenty minutes after the 
 first instillation, increases slowly for ten to forty minutes, 
 scarcely ever becomes as large as with atropia {maximum dila- 
 tation^, feebly responds to changes of light, remains stationary 
 for about thirty minutes, and then the dilation slowly disap- 
 
12 H. Knapp. 
 
 pears. The last trace had disappeared on the next dajr 
 only." 
 
 [To try whether cocaine could produce a maximum dila- 
 tation, I have instilled a 3 ^ solution into the eye of a child 
 for one hour and loxty minutes every five to ten minutes, 
 and during the last ten minutes every two minutes. The 
 pupil became very large, but contracted to a certain degree,, 
 when exposed to light. The reaction was slow and limited, 
 but distinct and invariable during the time of experimenta- 
 tion, and some hours later.] , 
 
 " The range of accommodation is shortened by recession of 
 the near point from the eye, the far point not being appreci- 
 ably influenced. The shortening of the range of accommo- 
 dation in me and my son (15 years old) was equivalent to 
 -^ (iD) ; in a lady of thirty-two it was somewhat more. Co- 
 caine, therefore, reduces the accommodation, but does not 
 paralyze it. It may be preferable to other mydriatics if we 
 want to dilate the pupil for ophthalmoscopic examinations 
 of the interior of the eye, but it will probably not be pow- 
 erful enough for determinations of refraction. It is a 
 mydriatic which, even in producing a considerable dilatation 
 of the pupil, takes away only a fraction of the power of 
 accommodation. The accommodation is restored much 
 sooner than the normal size of the pupil. In \\ hours 
 to \\ hours we could read again as easily as before, though 
 our pupils were still enlarged. 
 
 " Cauterization of a ' cocainized ' conjunctiva. — The con- 
 junctiva of my right eye was a little congested, and at 10 :30 
 P.M., while writing this communication, I dropped a drop of 
 a four-per-cent. solution of hydrochlorate of cocaine on the 
 inner surface of the lower lid, Fiften minutes later I 
 noticed that this inner surface had become pale, paler than 
 that of tke left eye, which had been the paler before. I 
 dropped another drop in, holding my head back so that the 
 whole conjunctiva was moistened by it. Then I painted, 
 before a looking-glass, a good-sized camel's-hair brushful of 
 a two-per-cent. solution (gr. x. ad § j.) of nitrate of silver 
 into the eye, the lower lid being everted. I left the liquid 
 in place about twenty seconds, then it began slightly to 
 
Cocaine in Ophthalmic and General Surgery. 13 
 
 smart, whereas immediately after the application I only felt 
 the cold, no pain. I washed the nitrate of silver away with 
 ordinary water, and put another drop of cocaine in. This 
 relieved the smart for five minutes, then it returned, but 
 very slightly ; a serous liquid ran from my right nostril, 
 just as it does when a stronger solution of nitrate of silver 
 is put in the eye in the ordinary' way. I instilled another 
 drop of cocaine and continued writing. In a quarter of an 
 hour the eye felt hot and somewhat painful. The con- 
 junctiva of the lower lid was moderately, that of the adja- 
 cent scleral conjunctiva slightly, red, and along the whole 
 lower fornix lay a white streak of mucus. The cornea and 
 upper scleral and palpebral conjunctiva were white as if 
 nothing had been done. The pupil was wide, and the ac- 
 commodation somewhat weakened, not so much as to make 
 writing unpleasant, though the other eye had been ' cocai- 
 nized ' in the afternoon of the same day." 
 
 EXPERIMENTS ON THE EFFECT OF COCAINE ON OTHER 
 MUCOUS MEMBRANES. 
 
 " I. The ear.^I have made only one experiment in this 
 locality. It was an almost painless removal of polypoid 
 granulations. I do not doubt that the remedy will find 
 here a large field of application, both to allay pain and to 
 render the parts insensible during operations in this exceed- 
 ingly sensitive cavity. [In cases of perforation of the 
 drumhead I noticed that cocaine anaesthetizes the mucous 
 membrane of the drum cavity, but not the drumhead.] 
 
 " 2. The mouth. — I can confirm the former observations 
 that the tongue and the soft palate become numb. I 
 sprayed and brushed my soft palate ; in ten minuses I could 
 pass instruments over it without pain or reflex phenomena, 
 retching, etc. I brushed a four-per-cent. solution over the 
 right half of my tongue from the tip to the base, held 
 the tongue depressed with my finger and immovable as 
 long as I could endure it. In seven minutes I repeated 
 the manipulation ; five minutes later the right side of the 
 tongue and corresponding lip felt numb. Gentle touching 
 ■was not perceived, but quite well on the other side. Then 
 
14- H. Knopf. 
 
 I put, with a fine brush, some powdered sugar on the in- 
 sensible parts, successively from the tip to the neighborhood 
 of the palate. It was not perceived, whereas when put in 
 the same way on the corresponding places of the other half 
 of the tongue, it was at once tasted. The same was the 
 case when common salt and a one-per-cent. solution of sul- 
 phate of quinine were placed on the tongue. In half an 
 hour all was normal again. Conclusion : Cocaine tempo^ 
 rarily dnd locally destroys not only the sensibility and reflex 
 mobility of the tongue and pharynx, but also the faculty of 
 taste. In the endeavor to suspend the sense of taste alto- 
 gether, I sprayed my mouth and palate. The taste was 
 much reduced, but not abolished, evidently because the 
 remedy in this experiment had not sufificiently acted on 
 all the portions of surface from which impressions of taste 
 are received. 
 
 " 3. The nose. — I brushed and sprayed the nose to test 
 the action of the new remedy on the organ of smell. The 
 experiments required a good deal of time and material before 
 they were successful. The lower parts of the nose soon had 
 a numb feeling and were insensitive on touching, but the 
 power of smell was preserved. Bearing in mind that olfac- 
 tion is the function of the upper nasal passages, the recesses, 
 of which are very difficult of access, I bent my head down 
 so as to make the vertex its lowest part, and introduced the 
 bent nozzle of a Richardson atomizer in such away that the 
 spray was directed from the lower to the middle and upper 
 nasal passages, and the liquid flowed also in the same direc- 
 tion. This manoeuvre had to be repeated three times before 
 the faculty of smell was destroyed. Perfumes of rose and 
 heliotrope were not perceived. Tincture of iodine, concen- 
 trated nitric acid, etc., produced no peculiar sensation, 
 whereas on the other side they felt very unpleasant and pro- 
 duced coughing. Cocaine, therefore, temporarily renders the 
 mucous membrane of the nose insensible and destoys the sense 
 of smell. In less than half an hour the whole effect of the 
 remedy had vanished. 
 
 " 4. The larynx and trachea. — I am just suffering from 
 an attack of acute bronchitis, with fits of troublesome cough- 
 
\ \ 
 
 Cocaine in Ophthalmic- and General Surgery. 1 5, 
 
 ing in the morning and evening. When one of these fits 
 came in the evening, I sprayed my larynx with cocaine and. 
 inhaled it as well as I could by means of a Richardson jip- 
 paratus. The irritation was at once allayed, and soon sub- 
 sided. I had no cough, but half an hour later I threw 
 out, free from irritation, a large, compact, muco-puru- 
 lent sputum. If this experiment should be confirmed by 
 others, and the effect be the same or similar, cocaine will 
 prove a great boon to patients with pulmonary difificulties.. 
 The perfected methods of introducing medicated substances 
 by means of the ingenious apparatuses of Dr. Sass would re- 
 lieve the distress of coughing and its prejudicial conse- 
 quences. I may add, however, that the Richardson ap- 
 paratus, which seems inadequate for this purpose, relieved 
 me only partially in a second, and not at all in a third, at- 
 tack during the night. 
 
 , " 5. The urethra. — My urethra is very sensitive to the 
 introduction of instruments. I injected, by means of an 
 Eustachian catheter and a balloon, a four-per-cent. solution 
 of cocaine, and held it in for a few minutes. In ten minutes 
 the glanshad become pale and insensitive on touching. I 
 repeated the injection. Seven minutes later I introduced a 
 catheter and other instruments into the urethra. I did not 
 feel them at all as far as 3" ; when pushed farther I felt 
 them very unpleasantly painful. Evidently the cocaine had 
 not penetrated more deeply. Before the injection of cocaine 
 I felt the instruments very keenly from the- beginning of 
 the urethra. To test the loss of sensibility of the co- 
 cainized urethra in another direction, I injected a one-per- 
 cent, solution (gr. v. ad | j.) of arg. nitr. into the anterior- 
 part by means of an Anel's syringe, introduced as far as i^' . 
 I had no sensation from it at all. In about thirty seconds I 
 passed water, which caused a slight burning, disappearing in 
 about a minute. Since that time I have not felt any thing 
 from the treatment of my urethra. This experiment shows, 
 and I feel convinced, that cocaine will prove most beneficial 
 in uro-genital surgery. It not only destroys the sensibility 
 of the parts, and therefore admits of the easy performance 
 of many surgical procedures, but by being painless theses 
 
l6 H. Knapp. 
 
 'procedures will not incite reflex phenomena, spasm, and the 
 like. 
 
 " 6. The rectum. — For the sake of completeness I injected 
 cocaine also into the rectum. The sensibility, which was 
 not great anyhow, was reduced." 
 
 I have taken the liberty to reprint the above experiments 
 from the Medical Record i^oX. 25th), because some of them 
 were new — e. g., those on the urethra, the rectum, and the 
 upper nasal passages. 
 
 The remainder of my paper contains the description of 
 the application of cocaine in nine patients: squint, foreign 
 body, pterygium, cataract^extraction, tumor sacci lacry- 
 malis, polypi auris, in all of which the anaesthetic effect, of 
 cocaine was evident. In two cases of old trachoma the fol- 
 lowing is said : " Insensibility of cornea and 'conjunctiva ; 
 touched with sulphate of copper. No pain, no irritation, 
 scarcely any increased congestion after the application. No 
 discomfort as when touched before." 
 
 The A''. Y.Med. Journ. of Oct. 25th, pp. 459-461, con- 
 tains two papers on cocaine. The first is a short report of 
 Dr. Leroy P. Walker, resident surgeon of the N. Y. Eye and 
 Ear Infirmary, on fourteen cases treated with cocaine by Dr. 
 W. F. MiTTENDORF. These were : Three cases of squint, 
 operated on without pain; three cases of discision of cata- 
 ract, two primary, one secondary; all without pain. One 
 iridectomy ; no pain. Four cases of foreign body im- 
 bedded in th'e cornea; removed absolutely without pain. 
 One of burn of cornea and conjunctiva with hot metal; 
 pain of eye removed. One case of injury by a fragment 
 of metal. Great pain, photophobia, and lachrymation re- 
 moved by cocaine — ten drops insilled twice in five minutes. 
 One case of painful corneal ulcer after contusion; relief by 
 •cocaine during thirty-six hours. Ulcer healed by this time. 
 
 The paper concludes with saying: " In five cases of sensi- 
 tive throat I have been enabled not only to use the mirror, 
 but to prick the mucous membrane with a sharp-pointed 
 instrument without pain and with very little ' gagging.' " 
 
 The second paper is a report of cases from Dr. E. Grun- 
 ING's practice by Dr. J. H. Claiborne, Jr. In extraction of 
 
Cocaine in Ophthalmic and General Surgery, ly 
 
 cataract from both eyes at the same sitting, only the iridec- 
 tomy caused pain. In an iridectomy for degenerated glau- 
 £oma, the corneal section was attended with no pain, the 
 iridectomy -with paiii. A foreign body was removed from 
 the cornea without pain, and massage in a case of episcleritis 
 was less painful under cocaine than before. 
 
 Dr. D. C. Cocks, of New York, published in Med. News, 
 ■Oct. 25, 1884, p. 455, several cases in which he found cocaine 
 anaesthesia of use, viz.: 2 oi foreign bodies of the cornea ; 2 of 
 ^uint ; I of tattooing of the cornea. It allayed the pain in 
 a case in which the cornea was scratched by an infant's nail, 
 but not in another in which the cornea and conjunctiva 
 were burnt with a red-hot piece of iron. 
 
 Dr. E. S. Peck, New York, {Med. Rec, Nov. i, 1884, 
 p. 494,) used cocaine suceessfully in stitching a lacerated 
 wound of the eyetid, "cutting through the conjunctiva, the 
 tarsal margin, and the integument. A stitch in the con- 
 junctiva and two in the integument were taken after six 
 instillations of a 4 ^ solution, covering 25 minutes. Patient 
 experienced no pain, either from the forceps or needles, and 
 stated that the sensation had been as if something had been 
 pressed against the parts involved." 
 
 Dr. W. H. Polk, of New York, introduced the new 
 anaesthetic into operative gyncecology. November i, 1884, 
 he published {Med. Rec, p. 489) two cases of trachelor- 
 rhaphy. After thorough cleansing and drying of the parts, 
 a 4 ^ solution was painted over the cervix, in the canal, and 
 ■over the adjacent vaginal wall with a camel's-hair brush. 
 This was repeated twice at intervals of two to three min- 
 oites. Within three minutes of the last application the 
 operation was begun. It required the removal of extensive 
 pieces of cicatricial tissue. The operations lasted 40 minutes. 
 The patient suffered no pain until the last 10 minutes, then 
 she spoke of her discomfort as being a sense of soreness 
 rather than of pain. 
 
 In the second case no pain was felt till the lapse of about 
 20 minutes, then it was so acute as to require an application 
 of the solution of cocaine, making in her the fourth. It was 
 made directly to the cut surfaces, which had first been freed 
 
1 8 H. Knapp. 
 
 from blood. The operation was completed in three minutes 
 without any further pain. 
 
 The drug seemed not only to blunt sensibility, but retard 
 the first appearance of blood on the cut surfaces. 
 
 Dr. E. Gruning, of New York, communicates (iV. Y. Med. 
 Jour., Nov. 1st, p. 488), through the pen of Dr. Claiborne, 
 " more clinical facts regarding the hydrochlorate of cocaine," 
 from his hospital and private practice. They consist in two 
 iridectomies (for artificial ripening of cataract), one stra- 
 botomy, one pterygium operation, and the two following 
 cases : ^ 
 
 1. Advancement of the external rectus. " Exposure of 
 the" muscle, tenotomy, and insertion and tying of the 
 sutures were attended with considerable pain." 
 
 2. Hypertrophy of the mucous membrane covering the 
 inferior turbinated bone. " Eighteen drops oi a. 2 % solu- 
 tion were instilled into the inferior meatus, and as nearly 
 as possible on the mucous membrane of the inferior tur- 
 binated bone. Six drops were instilled every three min- 
 utes. A few minutes after the last instillation,' the actual 
 cautery was applied," and caused no pain. 
 
 The article ends with the following remark, which is of 
 interest : " Considering the high price of cocaine, it has been 
 suggested to the minds of many that its cheaper sister alka- 
 loids — caffeine, theine, theobromine, and guaranine — might 
 be possessed of similar anaesthetic properties. As there are 
 no stable single salts of these alkaloids, extensive experi^ 
 mentation has been made by Dr. Gruning with the double 
 salts, the salicylate of sodium {2^ %) and caffeine (4 ^, and 
 the benzoate of sodium and caffeine (4 fo each) in watery 
 solution. In no case, however, has he obtained any anses- 
 thetic effect with either." 
 
 The Boston Med. and Surg. Journal of Nov. 6, 1884, con- 
 tains two papers on cocaine ; the second, by C. H. Williams,. 
 confirming the anaesthetic effects of cocaine in several oper- 
 ations; the first, entitled "Rapid Cocainization," by H. W. 
 Bradford, containing a number of valuable new observa- 
 tions and suggestions. 
 
 In a case of incised wound in the ciliary region, the /r<7- 
 
Cocaine in Ophthalmic and General Surgery. 19 
 
 lapsed iris, after the third instillation, in the twelfth minute, 
 was seized with forceps and snipped with scissors, the 
 patient not feeling the slightest pain. 
 
 Traumatic ulcer of the cornea with hypopyon ; 2 % solution ; 
 1 2 minutes. Upon the introduction of the iris forceps to dilate 
 the opening into the anterior chamber, slight pain was com- 
 plained of, which was not experienced after placing a drop 
 along the line of incision. The usual pain due to evacuation 
 of the aqueous was not noticed. 
 
 In the following nine operations, Bradford used an 8 ^ solu- 
 tion, of which one drop was instilled every minute. The anaes- 
 thesia was complete in between two and five minutes. In 
 strabotomy the conjunctiva was seized with forceps at the 
 end of the secohd minute, cut and dissected up, and one 
 drop placed near the site of the muscle, which was then 
 divided. The patient said the operation was in no way 
 painful. 
 
 In a case of cataract, the speculum was inserted at the end 
 of the third minute. At the end of the fourth minute one 
 drop was placed upon the corneal incision, and half a minute 
 later the' iris was seized, drawn out, and divided, the patient 
 complaining only of a slight twinge of pain. The hemor- 
 rhage from the iridectomy was very slight and transient, 
 being in marked contrast to an iridectomy under ether. 
 
 "There has been thus far in this line of cases no bad 
 results noticed." Dr. Bradford thinks that there may be a 
 method of rapid cocainization, provided a sufficiently strong 
 solution is used and the intervals between the successive 
 instillations are sufficiently short. 
 
 Dr. W. O. Moore, Med. Rec, Nov. 8, 1884, p. 511, adds 
 some valuable observations to his former communication. 
 In a case of iridectomy for leucoma adhcerens, he injected, 
 after the section, two drops of a 2 ^ solution through the 
 corneal wound on the iris surface. The iris section proved 
 to be painless, and the operation did well. 
 
 After the slitting of the canaliculus in a case of stricture 
 of the tear duct, ^z conjunctiva having been anaesthetized 
 by cocaine, an Anel's syringe, charged with eight drops of 
 a 4^ cocaine solution was introduced into the cut canal, and 
 
20 H. Knapp. 
 
 the fluid forced into the nasal duct as far as it would go. 
 After waiting four minutes, the No. 8 probe was passed 
 without pain down to the roof of the mouth ; this was then 
 removed and a lead wire introduced, the patient all the 
 time having no sensation. In twenty minutes after the 
 injection, the lead wire, having been purposely left, was 
 felt for the first time. 
 
 In a case of syphilitic iritis, the pain, not influenced by 
 atropine, was relieved by cocaine. It returned in the night, 
 but not so severe. 
 
 In an irritable stump- he used some twenty drops, with 
 same benumbing influence, yet not sufiEicient to warrant the 
 removal of the eye, which, after two minutes, was removed 
 in the " old-fashioned " way. 
 
 In a strabotomy, he " dropped six to eight drops on the 
 conjunctiva and injected six drops under the conjunctiva, 
 over the site of the muscle. This procedure caused the 
 pain to be entirely abolished. No bad after-effect occurred." 
 
 Dr. E. O. Shakespeare, of Philadelphia, published {Med. 
 News, Nov. 8, 1884, p. 508) a number of experiments on 
 himself and patients — external inflammations, one iridec- 
 tomy — confirming the physiological, anaesthetic, and anal- 
 gesic action of cocaine. 
 
 Dr. F. H. BOSWORTH publishes a very important con- 
 tribution : " A New Therapeutic Use for Cocaine," in the 
 Med. Rec, Nov. 15, '84, p. 533. When a two-per-cent solu- 
 tion is applied to the mucous membrane of the nasal 
 cavity, by means of a pledget of cotton wrapped on a small 
 probe, it produces in twenty or thirty seconds a very nota- 
 ble contraction in the venous sinuses, covering the lower 
 and middle turbinated bones, expelling all the blood so that 
 the membrane clings closely to the bony structures, which 
 then become visible in absolute outline. Entire depletion 
 of the sinuses of the whole cavity is accomplished in about 
 three minutes, the production of anaesthesia, as a rule, re- 
 quiring a longer time. Dr. Bosworth has used this property 
 of cocaine to differentially distinguish venous turgescence, 
 which is eliminated by the remedy, from genuine hyperplasia, 
 which is not ; further, cauterizing the mucous membrane 
 
Cocaine in Ophthalmic and General Surgery. 2 1 
 
 was rendered comparatively painless by the drug ; in acute 
 coryza the venous sinuses were completely emptied, and the 
 nasal passages remained absolutely clear ; in the removal of 
 nasal polypi the swelling of the mucous membrane was re- 
 duced, a clear view into the upper regions of the nose was 
 obtained, so that it became comparatively easy to recognize 
 and remove even the smallest growths. In no case was 
 there other than the most trivial bleeding. In two cases of 
 autumnal catarrh there was complete relief from all the 
 symptoms. He thinks that cocaine will control epistaxis 
 from whatever cause. 
 
 Dr. N. J. Hepburn publishes the results of hypodermic 
 injections of cocaine, Med. Rec, Nov. 15, '84, p. 534. Six 
 minims of a two-per-cent. solution were injected under the 
 skin of the arm ; in four minutes complete anaesthesia of the 
 skin eight lines in every direction from the centre of 
 the injection. The injections were repeated- every five 
 minutes in adjacent spots until forty-eight minims had been 
 used. By this time the general effects had been so marked 
 that it was deemed unadvisable to continue the experiment. 
 There were acceleration of pulse and respiration, an agree- 
 able feeling of warmth, moderate mydriasis, slightly crossed 
 diplopia, agreeable hallucinations with closed eyes, disap- 
 pearing when the eyes were opened ; impairment of cutane- 
 ous sensibility, a feeling as if walking on cushions, a 
 tendency to walk on the heels, and a sensation, on grasping 
 an object, as if something spongy were interposed. Two 
 other experiments had the same results, but the number of 
 six- and eight-minim injections could be carried on to six- 
 teen before they had to be discontinued. 
 
 Dr. E. E. Holt, of Portland, Maine, {Boston Med. and 
 Surg. Jour., Nov. 20, '84,) instilled one drop of a one-per- 
 cent, solution into a cataractous eye thirteen times in the 
 course of two minutes, then removed the cataract. " The 
 eye was particularly unsound, since, when the counterpunc- 
 ture was made, vitreous was seen to present, but by 
 careful manipulation no vitreous was lost, and it is believed 
 that the use of the drug assisted materially in preventing 
 such a disaster. 
 
22 ' H. Knapp. 
 
 Dr. E. R. Squibb (i\^. Y. Med. Jour., Nov. 22, '84) 
 states that he had received a letter from Dr. Noyes before 
 the one which had appeared in the Med. Rec, and that he 
 had immediately sent some of the hydrofchlorate of cocaine 
 to Dr. C. S. Bull and another gentleman [Mathewson]. 
 Dr. Bull was probably the first man in this city [and coun- 
 try] to employ the drug, which was on Oct. 8, '84. Dr. 
 Bull has used it very extensively since. His first and, thus 
 far, only publication is a very well-written paper, read be- 
 fore the N. Y. State Medical Association, Nov. 19, '84, and 
 published in abstract in the Med. Rec. and the N. Y. Med. 
 Jour., of Nov. 22d, and in full in the N. Y. Med. Jour., 
 of Nov. 29th, p. 609. His physiological experiments con- 
 firm what has been made known by Koller and others. He 
 has used the drug in more than 150 cases, and has suc- 
 ceeded, in producing complete anaesthesia in all but three 
 cases, while in these three cases the sensibility was decided- 
 ly diminished. In no case has he seen the pupil become so 
 dilated as from atropine, even when a four-per-cent. solution 
 has been used. In one case no dilatation of the pupil was 
 produced after repeated instillation of the stronger solu- 
 tion, though atropine acted promptly on this patient. 
 
 As illustrations of the usefulness of cocaine in ophthalmic 
 surgery he reports ten cases. 
 
 Abscess of cornea ; cornea transversely split ; no pain. 
 
 Kerato-iritis with hypopyon ; broad paracentesis of cornea 
 with lance-knife; pus evacuated without pain. Squint; 
 conjunctiva opened, cocaine instilled beneath ; five minutes 
 later another instillation, then — ten minutes after opening 
 the conjunctiva — tenotomy without pain. Chronic glaucoma : 
 two drops of a two-per-cent. solution were dropped through 
 the corneal wound into the anterior chamber, and in ten 
 minutes a broad iridectomy was completed without the 
 slightest sensation of pain. 
 
 A cataract, after a preliminary iridectomyy had been pre- 
 viously done, was extracted (peripheral incision, quadri- 
 lateral capsulotomy) with ease and entire absence of pain. 
 
 Retention cyst of the ocular conjunctiva. A two-per-cent. 
 solution was instilled twice, and within ten minutes the cyst 
 
Cocaine in Ophthalmic and General Surgery. 23 
 
 was slit up, its contents evacuated with the spoon, and its 
 inner surface cauterized" with tincture of iodine — all pain- 
 lessly. 
 
 Mucocele, with stricture of nasal duct. Instillation of 
 cocaine four per cent, through lachrymal punctum, canal- 
 iculus slit, sac opened, contents evacuated ; solution 
 dropped into duct through opening in sac; in ten minutes 
 the stricture thoroughly divided with Stilling's knife, and a 
 large-sized Theobald's probe introduced^all painlessly. 
 
 " It may thus be seen that almost all the various opera- 
 tions on the eyeball and inner surface of the eyelids, and 
 on the tear-passages may be performed painlessly under the 
 anaesthetic influence of cocaine. The only operation in 
 which it may not answer its purpose is that of enucleation. 
 
 He adds that he has performed paracentesis of the mem- 
 brana tympani three times with entire absence of pain, has 
 removed exuberant granulations from the depth of the ear- 
 canal under cocaine without pain. He has used the solu- 
 tion in acute coryza, both nostrils being- almost completely 
 occluded, with such effect that in less than ten minutes 
 both nostrils were entirely free, and remained so for about 
 five hours. The swelling then returned, but to a less de- 
 gree. The application was made through the nostrils with 
 a probe and cotton, and through the mouth to the posterior 
 nares with a brush. 
 
 Dr. F. M. Wilson, of Bridgeport, Conn., relates (" Cocaine 
 Hydrochlorate in Minor Surgery," Med. Rec, Nov. 22, '84) 
 the painless removal of a small fatty tumor upon the fore- 
 head after subcutaneous injections of cocaine. 
 
 The N. Y. Med. Jour, of Nov. 22, '84, gives a report of 
 the meeting of the Clmical Society of the N. Y. Post-Grad- 
 uate Medical School and Hospital, held Nov. 8th. The 
 subject for discussion was hydrochlorate of cocaine. Dr. 
 Geo. B. Hope reported the case of a papilloma of the 
 larynx which had been made much easier by cocaine anaes- 
 thesia. Dr. A. H. Smith related a similar case. The 
 growth, twice the size of a coffee-bean, had resisted all 
 former attempts on account of spasmodic closure of the 
 glottis. Under cocaine a loop was introduced through the 
 
,24 H. Knapp. 
 
 glottis, passed around the neck of the tumor, and on draw- 
 ing the wire home the growth was readily separated from 
 its attachment and brought out entire. It would be diffi- 
 cult to imagine any thing more satisfactory than the effect 
 of the cocaine in this case. 
 
 Dr. S. D. Powell could dilate under cocaine a deep 
 urethral stricture where the sensitiveness was so great that 
 the introduction of even the softest instrument, without 
 anaesthesia, was impossible. 
 
 Dr. H. G. Lyttle reported a case of internal urethrotomy 
 under cocaine. The penis became quite small, cold, and 
 ansemic, especially the glans. No unpleasant after-effects 
 were noticed from the use of the drug. 
 
 Dr. A. H. Smith said that Dr. Shaw had used cocaine 
 in removing a toe-nail. He had wrapped the toe for a few 
 minutes in cotton saturated with cocaine solution, had ther» 
 divided the nail and removed it without pain. 
 
 Dr. M. J. Roberts reported that Dr. Eddy, a dentist, 
 had used it with success in cutting-operations upon the gums, 
 but had not found it of any benefit when applied in sensi- 
 tive teeth. 
 
 Dr. C. A. VON Ramdohr had succeeded in making an 
 examination in a case of vaginismus, which had always be- 
 fore resisted every attempt, by brushing the mucous mem- 
 brane with some of the solution. 
 
 Dr. B. Bettmann, of Chicago, (TV. F. Med. Jour., Nov. 22,. 
 '84, and Jour. Am. Med. Assoc, Nov. 22, '^4^ probed the tear- 
 duct, after having slit the canaliculus and injected cocaine. 
 
 In a case of severe earache from acute purulent otitis, a 
 few drops of the solution instilled into the ear caused almost 
 immediate cessation of pain, and the ear could be manipu- 
 lated without the slighest annoyance to the patient. 
 
 Dr. J. Bettmann, of Chicago, {ibidem,) reduced the swol- 
 len erectile tissue in the nose by galvano-cautery painlessly 
 under cocaine in a case of reflex asthma nervosum. 
 ■ Dr. C. F. Clark, of Philadelphia {Med. News, Nov. 22, 
 1884,) performed a tenotomy of each internal rectus virtu- 
 ally without pain by dropping cocaine in the wounds as he 
 proceeded. He noticed the ischaemia of the parts as a 
 striking feature. 
 
Cocaine in Ophthalmic and General Surgery. ' 25 
 
 Dr. E. F. INGALS, of Chicago, {Jour. Am. Med. Assoc, 
 Nov. 22, '84, p. 572,) reports a number of cases in which 
 cocaine was advantageously used for various affections of the 
 nose and throat, e. g., naso-pharyngeal fibroma, nasal polypi, 
 swelling of turbinated body, hypertrophic catarrh, cystic 
 tumor, etc. 
 
 Dr. C. J. LUNDY, of Detroit, publishes his experiments 
 and experience with cocaine in ^& Jour, of the Am. Med. 
 Assoc, Nov. 22, '84, p. 575, and the Nov. number of the 
 Phys. and Surg., Ann Arbor, Mich. He used it in the 
 ordinary operations on the eye, and besides in a case of 
 enucleation, but before the operation was completed the 
 patient complained of pain, and chloroform was given. 
 
 Dr. Samuel Theobald, of Baltimore, publishes among 
 others the following cases (Md. Med. Jour., Nov. 22, '84, p. 
 57). In an eye affected with inflammatory glaucoma the drug 
 was probably very imperfectly absorbed, and the anaesthesia 
 was incomplete. The operation nevertheless caused less- 
 pain than one performed previously on the other eye. 
 
 In a case of enucleation cocaine was instilled before and 
 during the operation, getting, to some extent, under th& 
 conjunctiva. The section of the muscles and the division 
 of the nerves of the eye were evidently attended by severe- 
 pain. 
 
 Dr. J. A. Michael, of Baltimore, {ibidem, p. 59,) com- 
 municates the successful employment of cocaine in venereal 
 surgery, e.g., removal of venereal warts with broad bases, 
 the operation of phimosis, incision of a contracted meatus 
 with chronic gbnorrhcea, of a suppurating bubo, cauteriza- 
 tion of small ulcers with chloride of zinc. In all these, 
 cocaine had materially lessened the pain. 
 
 Under the head, " Hospital Reports," the same issue of 
 the Md. Med. Jour, gives an enthusiastic account of the 
 manifold applications of cocaine at the Presbyterian Eye, 
 Ear, and Throat Hospital of Baltimore, by Dr. Chisolm, 
 without adding any thing new. 
 
 Dr. A. T. Cabot, of Boston, {Bost. Med. and Surg. Jour., 
 Nov. 27, '84, p. 515,) reports on the more or less painful op- 
 erations of congenital adhesions of the prepuce and urethral 
 
.26 * . H. Knapp. 
 
 stricture undef cocaine. Dr. F. I. Knight used the drug in 
 the form of spray in two operations for laryngeal papilloma' 
 without much effect on brushing a solution on the pharynx 
 of a phthisical patient. 
 
 Dr. W. C. Burke, of South Norwalk, Conn. {N. V. Med. 
 your., Nov. 29. '84), injected cocaine under the skin of the 
 hapd, which was swollen and painful from a shot, the ball 
 being situated near the first phalanx of the little finger. 
 Neither the cut nor the subsequent manipulation in the 
 removal of the ball gave any pain whatever. 
 
 Dr. G. T. Jackson, of New York, {N. Y. Med. Jour., Nov. 
 29, '84,) rubbed a four-per-cent. ointment of cocaine and oleic 
 .acid into the skin for about five minutes, and found that 
 ■epilation and the removal of superfluous hairs from the 
 upper lip and cheek of a female patient by electrolysis were 
 done with slight or no pain. 
 
 The report of a novel and very neat application of cocaine' 
 in a case of enucleation, by Dr. C. S. TURNBULL, oculist to the 
 German Hospital of Philadelphia, is contained in an editorial 
 of the Med. and Surg. Rep., Nov. 29, '84, p. 628. Two drops of 
 a fourTper-cent. solution of cocaine were instilled every three 
 minutes until eight had been used. When Tenon's capsule 
 was opened, one drop of the solution was allowed to flow 
 into the cut. As each tendon was caught up with the hook, 
 a drop fell upon it, and the successive tenotomies, each being 
 preceded by a drop, were made at deliberate intervals. The 
 -large blunt-ppinted scissors, curved on the flat, were next 
 introduced from the nasal side, and with these in position, 
 after thorough sponging, two or three large drops were so 
 instilled as to flow down the blades, one on each side of the 
 optic nerve' as a guide. After waiting a minute the optic, 
 -and with it the ciliary nerves, were severed at one stroke, 
 during which the patient remained entirely quiet. There 
 was less than the usual bleeding, and the healing was undis- 
 turbed. Cocaine maintained its claims as an ansesthetic 
 and haemostatic. 
 
 Dr. G. M. LeffertS, of New York, {Med. News Nov. 29, 
 '84, p. 597,) reports great relief of the terrible dysphagia in 
 advanced laryngeal phthisis by cocaine, The parts were 
 
Cocaine in Ophthalmic and General Surgery. 27 
 
 first carefully cleansed by spray-applications of an alkaline 
 solution, then immediately bathed gently, yet thoroughly, 
 with a four-per-cent. solution by means of a large laryngeal 
 brush. The effect was surprising. "A patient who was 
 slowly perishing more from hunger and thirst than from 
 •disease, one application so anaesthetized the acute sensibility, 
 that a full glass of milk -vl^as immediately drank with ease and 
 •entire comfort. Also the dyspnoea was notably relieved. 
 In a large series of cases the results have always been the 
 same." 
 
 Dr. W. C. Dabney, of Charlotteville, Va. {ibidem, p. 613). 
 Case of a boy who struck his eye against hot iron. Intense 
 pain relieved by cocaine. Examination showed upper part 
 of the cornea milky. Recovery. 
 
 Dr. R. J. Levis, of Philadelphia, publishes in the College 
 ■and Clinical Record, Dec. i, '84, p. 258, "notes on the use of 
 cocaine," of which the following may be quoted : " Prior to 
 the applying of nitric acid as a caustic to a syphilitic ulcer 
 ■of the tongue, the tongue was wiped dry, held protruding 
 between the teeth, and a four-per-cent. solution of cocaine 
 was brushed on. No pain was produced by the caustic on 
 the thoroughly anaesthetized tongue." 
 
 Dr. F. N. Otis, of New York, publishes his experience in 
 genito-urinary surgery in the N. Y. Med. Jour., Dec. 6, '84, 
 p. 635. He used it with the greatest advantage in cases of 
 stricture, enlargement of the prostate, irritability of the 
 urethra, stone in the bladder, and ulcer in the rectum. Co- 
 caine made not only the examination painless and easy, but 
 also operations and cauterizations. One remark may be of 
 use for probing the lachrymal duct. He says : "A four- 
 per-cent. solution of the hydrochlorate of cocaine in almond- 
 iDil makes an excellent lubricant for urethral instruments, 
 and I think may prove even better than the watery solution 
 for applications to the urethra. Its use in this way, in a few 
 cases, has been very satisfactory." 
 
 Dr. R. J. Hall, of New York, conlmunicates {ibidem, p. 
 €43) a number of very important experiments. He and Dr. 
 Halsted injected a four-per-cent. solution of cocaine near 
 or into several nerves, e. g., the ulnar, musculo-cutaneous of 
 
28 H. Knapp. 
 
 the leg, antero-superior dental, inferior dental, and linguaL 
 They injected from six to thirty-two minims, and found 
 that the tissues supplied by these nerves had become anss^^ 
 thetic. There was no diminution of muscular power. The 
 anaesthesia was complete until twenty-six minutes after the 
 injection, and sensibility was much diminished for ten or 
 fifteen minutes longer. The introduction of the needle 
 into the ulnar nerve caused quite severe pain, with tingling- 
 down the little finger, but the injection gave rise to no sen- 
 sation. From fifteen to thirty-two minims caused constitu- 
 tional symptoms. " About six minutes after the injection 
 there was giddiness, at first slight, then well-marked, so that 
 I could not walk without staggering ; and finally, there was- 
 quite severe nausea, the skin was covered with cold per- 
 spiration, and the pupils were dilated. The nausea passed 
 off with the local anaesthesia in about twenty minutes,, 
 leaving some dizziness for an iTour or so longer." 
 
 In a small congenital cyst over the outer third of the left 
 supra-orbital ridge, nineteen minims of a four-per-cent. solu- 
 tion were given hypodermically in divided doses, — one exter- 
 nal to the tumor, the others close to the supra-orbital notch. 
 In about five minutes the anaesthesia was complete. The 
 removal of the tumor, somewhat protracted, was connected 
 with pain only at the last minutes. 
 
 " We have used this mode of administration successfully 
 in a number of cases in the Roosevelt Hospital Out-Door 
 Department, and it is obvious that, when the limits of 
 safety have been determined, it may find a v£ry wide appli- 
 cation." 
 
 Dr. C. H. Castle of Cincinnati, reports {Med. News, 
 .Dec. 6, 1884, p. 662,) on Dr. Rob. Battler's (Cincinnati) 
 experience with cocaine, which is quite extensive and essen- 
 tially confirmative of what is stated in the previous reports. 
 
 Dr. J. F. Croston, of Haverhill, Mass., removed an epi- 
 thelioma (rodent ulcer) of the cheek under anjesthesia by 
 cocaine, which had been injected underneath.— j5oj?. Med. 
 and Surg. Jour., Dec. 11, '84, p. 573. 
 
 Dr. W. C. jARVis, of New York, {Med. Rec, Dec. 13, '84,. 
 p. 654,) describes several cases of successful intra-nasal opera- 
 
Cocaine in Ophthalmic and General Surgery. 29 
 
 tions under cocaine anaesthesia, e. g., removal of a horizon- 
 tal ledge of deviated cartilage ; firm, elastic, flesh-like masses 
 filling -the nostrils ; hypertrbphied turbinated tissue, and 
 polypi. In some cases he began the operation with co- 
 caine and ended it with freezing the parts by the spray of 
 rhigolene, a petroleum naphtha, proposed by H. J. Bigelow, 
 of Boston, as a local anaesthetic. (See " Dictionnaire de 
 M^decine," etc., Littrd and Robin.) 
 
 Dr. D. C. Cocks, of New York {Med. News, Dec. 13, 
 1884, p. 654), ancesthetizes the iris a.lter the corneal section 
 ■either by injecting the solution with a syringe, or let it run 
 along a spatula introduced into the wound. In a few 
 seconds the iris can be withdrawn and the cut painlessly 
 made. 
 
 In performing an enucleation (Nov. 29th) he first anaethe- 
 tized the cornea and conjunctiva in the ordinary way, then 
 incised the conjunctiva on the temporal side, separated the 
 -subconjunctival tissue as far back as possible, and with an 
 Anel's syringe injected a few drops of a 4 ^ solution over 
 the tendon of the external rectus. He then divided this 
 tendon, and introducing the point of the syringe as far 
 back as possible, keeping its point near the globe, he in- 
 jected a few more drops. This was done with each of the 
 recti. The globe was then dislocated forward, the nerve 
 severed, the obliques cut, and the conjunctival wound 
 loosely drawn together with a stitch. The patient occasion- 
 ally felt some pain, but not enough to interfere with the 
 operation. The operation had lasted about half an hour, 
 and during that time the solution was dropped on the eye, 
 or injected into the orbit, every 3-5 minutes. About 3 i ss., 
 i. e., 6 grammes, of a 4 $ solution was used. Recovery un- 
 disturbed. 
 
 The PRESENT WRITER {Med. Rev., p. 656) adds some new 
 observations to his previous communication. 
 
 I. Enucleation of an eyeball under ancssthesia from inject- 
 ing cocaine into the post-ocular connective tissue. The con- 
 junctiva was first anaesthetized by instilling the solution. 
 Then the globe was strongly drawn toward the nose by 
 means of a forceps, and six minims of a 4 ^ solution (pam- 
 
30 H. Knapp. 
 
 lessly) injected into the orbital tissue close to the posterior 
 part of the globe. Five minutes later the eyeball was re- 
 moved in the usual way. The divisions of the recti tendons 
 caused slight pain ; that of the optic nerve and the dissec- 
 tion of the posterior part of the globe, none or almost none. 
 When the ball was removed, the branches of the toothed 
 forceps were thrust an inch deep through the wound into 
 the orbital tissue, of which the patient felt nothing. The 
 bleeding was scant. Recovery undisturbed. 
 
 2. Ptosis operation after subcutaneous injection of cocaine ; 
 ancBsthetic effect not very satisfactory. The tissue was suf- 
 fused with blood along the track of the hypodermic needle, 
 and the anaesthesia did not reach the upper limit of the 
 region of the operation. 
 
 3. Perforation of the drumhead ; cocaine ancssthetizes the 
 walls of the drum-cavity , but not the drumhead. 
 
 4. Cocaine in cataract operations pre-em,inently useful. 
 Discisions are painless from beginning to end ; in extractions 
 only the grasping and drawing out of the iris are moder- 
 ately painful. The anaesthesia and the temporary anaemia 
 assist the operator in every step of the operation. No bad 
 effect of cocainization on the result of the operation has 
 been noticed ; fifteen extractions up to time of writing, 
 Dec. 2d, all doing well. 
 
 A week later the present writer injected five minims of a 
 three-per-cent solution underneath a sebaceous tumor the 
 size of a small walnut, situated in the centre of the upper 
 lid. The anesthesia was almost complete, and the some- 
 what laborious operation passed satisfactorily [and healed 
 by first intention], but during it the patient [a strong man 
 who never had fainted] became as pale as a corpse, felt 
 somewhat faint, asked repeatedly for drink, and was covered 
 with cold perspiration. In about fifteen minutes this con- 
 dition of distress, which was, however, in no way alarming, 
 disappeared. The writer sends this observation to the 
 editor of the Med. Record as a word of caution, and adds 
 that also the patient into whom he had injected cocaine 
 prior to enucleation had become quite pale,, but had 
 shown no other unpleasant .symptoms. The writer thinks 
 
Cocaine in Ophthalmic and General Surgery. 3 1 
 
 that injections into the orbit should be made with particu- 
 lar caution on account of the great vascularity of the tissue. 
 In future cases he would begin with injecting no more than 
 one or /two drops and gradually feel his way. — (Med. Rec, 
 Dec. 13, 1884, p. 662.) 
 
 Dr. F. A. BURRALL {ibidem) recommends an alkaline 
 ointment of cocaine hydrochlorate for piles. 
 
 Drs. G. W. Weld and C. H. Shears {ibidem, p. 657) 
 have successfully used cocaine anaesthesia in dental surgery 
 for removing tartar, extirpating exposed nerve-pulp, pre- 
 paring sensitive teeth for filling by using the dental engine, 
 etc., incising inflamed gums, and extracting teeth. 
 
 Dr. J. R. Uhler, of Baltimore, relates {ibidem) that 
 cocaine when freely used upon the rectum, besides benumb- 
 ing the parts, produced in two cases a rigid tome contraction- 
 of the sphincter ani and the longitudinal fibres of the gut,. 
 pulling up the mucous membrane which had previously 
 protruded. 
 
 Dr. J. W. Stickler, of Orange, N. J., («(5?^^»«,) publishes 
 ' the results of injections of cocaine on himself. » Once he 
 felt a slight muscular tremor, but no other systemic disturb- 
 ance. " It is interesting to observe that when the hypo- 
 dermic needle is made to traverse a direct source through 
 the skin and cellular tissue, the hydrochlorate of cocaine 
 does not diffuse itself equally in every direction, but follows 
 quite definitely the channel made for it by the needle, pro- 
 ducing anaesthesia .along this line, but only to a very limited 
 extent on either side of it." [The writer has found this con- 
 . firmed in the case of ptosis operation mentioned above.] 
 
 Dr. W. H. Doughty, Jr., of Augusta, Ga., reports {ibidem, 
 p. 658) a very successful performance of an operation for 
 vesico-vaginal fistula under cocaine. There was no tender- 
 ness and but slight oozing of blood. When the sensitive- 
 ness and the bleeding reappeared, they were dispelled by 
 new applications of cocaine. 
 
 Dr. Eugene Smith, of Detroit, Mich., {ibidem^ alleges- 
 that he obtains a more rapid effect from cocaine on the 
 conjunctiva by applying it in ^q form of spray with a hand 
 atomizer than by instillation. He produced total insensi- 
 
-2 2 II- Knapp. 
 
 bility of the iris in two cases of iridectomy by injecting with 
 a small lachrymal syringe two drops of a two-per-cent. solution 
 into the anterior chamber. Three minutes later the iris wa:s 
 seized and cut. No reAction followed the intra-ocular use of 
 
 cocaine. 
 
 Dr. F. C. Riley, of New York, {ibidem,) relates two cases 
 (granular lids with intense pannus, perforating ulcer of 
 cornea) in which repeated instillations of Merck's cocaine 
 ,: — which in other cases acted v^^W— failed to have any effect 
 . upon the sensibility of the conjunctiva and cornea. 
 
 Dr. J. M. Da Costa, of Philadelphia, delivered a lecture 
 before the Philadelphia College of Physicians, December 3d, 
 '(published in the Med. News, Dec. 13, 1884, p. 651) on 
 " Some observations on the use of hydrochlorate of cocaine, 
 especially its hypodermic use," which contains several state- 
 ments of importance. 
 
 A case of earache, which seemed to be neuralgic, was at 
 once i-elieved by instilling a few drops of a 4 ^ solution into 
 the meatus. A similar observation was made by the resi- 
 dent physician [name?] in the ward of his colleague. Dr. 
 Hutchinson. 
 
 In one instance of neuralgia of the face in which the 
 pain shot into the jaws, painting the gums of the upper 
 jaw with a 4 ^ solution gave very speedy relief. 
 
 Dr. Squibb and Dr. Jurist have found that the strength 
 of the solution, as we obtain it prepared, is less than in- 
 dicated by the druggists, e. g., a. 4% solution is in reality 
 no more than a 3 ^ solution, owing to impurities, especially 
 resinous substances, in the manufacture of Merck and others. 
 
 The most important result of hypodermic injections of 
 about 0.03 grm., is that the pulse invariably becomes fuller 
 and stronger. The vertical line of ascent in the sphygmo- 
 graphic tracing is twice as high as before the injection. 
 
 Dr. C. H. Williams, of Boston, {Bost. Med. and Surg. 
 Journ., Dec. 18, 1884, p. 585,) reports experiments on him- 
 self with cocaine subcutaneously, taking in the arm five one- 
 half-grain doses at half-hour intervals. Anaesthesia a short 
 distance up and down the arm and to a less distance around 
 lit was noticed. 
 
Cocaine in Ophthalmic and General Surgery. 33 
 
 Dr. O. F. Wadswortu, of Boston, {ibidem,) relates the 
 case of a young lady suffering from headache, the larger 
 part of which was referred to the eyes. In a few moments 
 after placing a drop or two of cocaine on the conjunctiva 
 of each eye, the pain in the eyes was wholly relieved and 
 the headache much lessened. 
 
 Dr. A. Alt, of St. Louis, {Amer. Jour, of Ophthal., Nov. 
 15, issued Dec. 20,' 84,) reports his experience after having 
 used cocaine for a month. In iridectomy, he has several 
 times dropped cocaine on the iris, which he had caused 
 to prolapse, and in a few minutes he found that the excision 
 was almost painless. He thinks that it has a direct influ- 
 ence on the nerves of the blood-vessels. He noticed that 
 it had a decidedly quieting effect on the oscillatory move- 
 ment of an eye not perfectly blind, and mentions, with great 
 emphasis, its benefit in a case of severe iritis after extrac- 
 tion, which terminated favorably by the benefit derived 
 from cocaine, the solution instilled every few hours having 
 removed pain and anxiety, and given the patient rest. 
 
 Dr. W. HUNICKE, of St. Louis, Mo., {ibidem, p. 229,) no- 
 ticed that after instillation of cocaine, the cornea appeared 
 •dry, and the reflection from it somewhat diminished. He 
 asks, why? 
 
 The paper of Dr. JOHN GREEN, of St. Louis, Mo., {ibidem, 
 p. 231,) contains some very valuable observations. In a case 
 of keratit. phlyct., in which the frequent instillation of a 
 one-half-per-cent. solution of atropia during two days had 
 produced only a half dilatation of the pupil, a single instil- 
 lation of the cocaine solution gave complete relief from 
 pain, and was followed within ten minutes by a dilatation 
 of the pupil nearly ad maximum. G. ascribes this to the 
 sedative action of the cocaine, permitting the atropia to 
 have its full effect. 
 
 In iritis no remedy approaches cocaine in giving full and 
 prompt relief from pain. It is especially efficient as an adju- 
 vant to atropia, in dilating the pupil and rupturing adhesions. 
 
 In two cases of nystagmus he could confirm Alt's obser- 
 vation, that the^ movements were considerably quieted by 
 cocaine ; in a third they were not. (The present writer 
 used it in four cases,— results negative.) 
 
34 H. Knapp. 
 
 In ''extraction of cataract the iridectomy can be rendered 
 painless by producing an artificial prolapse of the iris, and 
 applying a little of the solution to the prolapsed portion. 
 But regarding the safety of the procedure, the occurrence of 
 suppuration in the single case in which I have practised it 
 compels me, for the present, to suspend judgment." 
 
 Dr. S. C. Ayres, of Cincinnati, O., {ibidem, p. 238,) used 
 cocaine in a case of bullous keratitis. The removal of the 
 epithelium, and applying an almost saturated solution of 
 carbolic acid to the cornea on a line marking the boundary 
 of the bleb, produced scarcely any pain. In a case oi gran- 
 ular conjunctivitis with great photophobia, atropia did not 
 seem to have much influence on the pupil. After getting^ 
 the full influence of the cocaine, the pupil was widely 
 
 dilated, and remained so. 
 
 * 
 * * 
 
 The foregoing pages contain every thing on cocaine that 
 has appeared of interest in the American medical literature, 
 as far as it has reached me up to date, Dec. 24, 1884. No 
 doubt a number of valuable contributions have not come to 
 my notice, but the above extracts will give a faithful picture 
 of the enthusiasm, energy, and quickness with which the 
 American mind seizes upon every thing that is of practical 
 importance. I have arranged these extracts in chronological 
 order for two reasons : first, to secure each author the 
 right of literary priority to which he is entitled ; secondly, 
 to show the gradual growth of our knowledge on the phy- 
 siological and therapeutical action of cocaine. 
 
 European Contributions. 
 
 The abstracts from the European literature on the, sub- 
 ject, to which I now proceed, will be much shorter, for only 
 very little of it has thus far reached me. Future numbers of 
 the Archives will keep our readers informed of every thing- 
 that is new and important. 
 
 The Revue G^n^rale d'Opthalmologie, Oct. 31, '84, p. 433, 
 contains an article of Dr. E. Meyer, from which the follow- 
 ing extracts are of particular interest. " The instillation of 
 cocaine causes a certain pallor of the conjunctiva, and at the 
 
Cocaine in Ophthalmic and General Surgery. 35 
 
 same time a diminution of its normal secretion, and the 
 tension of the globe appears perceptibly (sensiblement) 
 diminished to the touch. These phenomena, and the dilata- 
 tion of the pupil, indicate a diniinution of the quantity of 
 blood in the ocular vessels, though I have not been able to 
 recognize the same with the ophthalmoscope in the back- 
 ground of the eye." 
 
 Dr. Ad. Weber, of Darmstadt, writes to Dr. M. " that 
 when the pupil is dilated by atropine, cocaine will enlarge it 
 considerably more, and that by the combination of the two 
 remedies he has seen adhesions of the pupillary border give 
 way that had resisted for weeks the action of atropia alone." 
 
 " Cocaine renders the inflamed conjunctiva as insensible as 
 the normal. It seems to exert no injurious influence on the 
 regular recovery of eyes operated on. The diminution of 
 the eyeball tension accounts for the flattening of the cornea 
 after the incision, which has surprised me, and made the 
 expulsion of cortical remnants a little more laborious, but I 
 have not noticed that it prevents a regular coaptation of the 
 wound at the end of the operation." 
 
 Dr. E. Jelinek, of Vienna, read a paper on " Cocaine a=; / 
 an Anaesthetic and Analgesic of the Pharynx and Larynx," 
 before the Vienna Med. Soc, Oct. 24, '84, and published it in 
 the Wien. med. Wochenschr., Nov. 8 and 15, '84. He says 
 that in Vienna, since Tiirk, concentrated solutions of mor- 
 phine had been brushed on the pharynx and larynx, but that 
 cocaine had been used — first by him, and almost simultane- 
 ously by Dr. Dworak — after Dr. Koller had informed them of 
 his experiments with this remedy on the eye. He had to in- 
 crease the strength of the hydrochlorate (Merck's) to 10 % 
 and 20 % (the latter especially for operations in the larynx), 
 which could be done only by adding alcohol to the water. 
 For the ten-per-cent. sol. he took: Cocain. mur., i.oo; aq. 
 dest., 8.00; alcohol, 2.00." For the twenty-per-cent. sol. the 
 relation is: coc, i.oo; aq. dest., 3.00; alcoh., 2.00. When 
 .1 concentrated solution or the powder is brought in con- 
 tact with the mucous membrane, we notice that the sensa- 
 tions of touch, temperature, taste, and pain are diminished, 
 as well as the tenderness on manipulation and. the reflex. 
 
36 H. Knapp. 
 
 excitability. He lays stress on the necessity of painting 
 the whole mucous membrane as far as it may come in con- 
 tact with instruments, for reflexes will be produced if the 
 smallest part has escaped the influence of the remedy. He 
 enters fully into the details of pharyngeal and laryngeal appli- 
 cations and operations, the extensive copying of which ' 
 would be out of place in THESE ARCHIVES. He praises, in 
 particular, the benefit derived from cocaine in dysphagia 
 accompanying perichondritis — mostly tuberculous^of the 
 epiglottis and larynx. The application of the remedy in one 
 of these cases, with dramatic effect, is related in full, and he 
 adds that in all such cases that had come under his care, thus 
 far, the result has been equally beneficial. His observations 
 are in perfect harmony with those of Dr. Lefferts, mentibned 
 above. For intra-laryngeal operations he uses a strong, hyper- 
 saturated watery solution, shaking it, of course, before the 
 application. He further states that two other properties of 
 cocaine will probably prove practically useful, viz.: its 
 haemostatic (ansemisirend) action in contracting swollen 
 portions of the mucous membrane (verified since by Bos- 
 worth and others), and its diminishing action on secretion. 
 He has found no injurious secondary effect from its appli- 
 ■cation. 
 
 The English reports on cocaine have been very cool at first, 
 ■but more appreciative later. Mr. A. Benson said at the meet- 
 ing of the Opthalmological Society of the United Kingdom, 
 "Oct. 9, '84 : " So far as his experience went the drug was of 
 no appreciable assistance in operations, the anasthaesia be- 
 ing too imperfect." Mr. M. GUNN had used cocaine in three 
 ■cases, and had come to the same conclusion. Mr. Nettle- 
 SHIP had tried it in two cases ; it had produced marked anaes- 
 thesia without any inconvenience, and he suggested that if 
 the drops were frequently instilled, so as to maintain the 
 effect, the drug might be practically us&iwl.— ^Ophthalmic 
 Review, Nov., 1884, p. 351. 
 
 The number of Dec. 6, '84, of the Brit. Med. Jour., has 
 seven articles on cocaine, all more or less appreciative, 
 but containing nothing new. It is characteristic of conser- 
 vative England that medical men were waked up to the re- 
 
Cocaine in Ophthalmic and General Surgery. 37 
 
 markable advantages of a new remedy fully six weeks later 
 than their American brethren, whereas with an equal spirit 
 of receptiveness and progressiveness they ought to have 
 been two weeks before them. 
 
 M. VULPIAN communicated his experiments to the Acad, 
 des Sciences, at its meeting on Nov. 18, '84 {Arch. Gdn. de 
 Mid., Dec, '84, p. 756, and Brit. Med. Jour., Dec. 6th, p. 
 1759). When cocaine is injected into the veins of the dog, 
 it is followed by symptoms similar to those produced by 
 electrifying the cervical branch of the sympathetic : protru- 
 sion of the eyeballs, dilatation of the pupils, insensibility of 
 the cornea, slight diminution of sensibility in the extremities, 
 and marked increase of the secretion of the submaxillary 
 salivary glands. 
 
 , Dr. KONIGSTEIN, of Vienna, {Wien. Med. Press., 1884, 
 Nos. 42 and 43 ; Centralbl. f. Augenh., Nov., '84, p. 345,) at the 
 requpst of Dr. Freud, experimented with cocaine simul- 
 taneously with, and independently of, Dr. KoUer, obtained 
 the same results, but had not yet arrived at final conclusions 
 when Dr. KoUer sent his communication to the Heidelberg 
 Congress. The drug does not seem to act on the peripheral 
 sensitive nerves alone, for many symptoms make it probable 
 that the sympathetic is also influenced. 
 
 Prof. J. HiRSCHBERG, of Berlin, {Centralbl., Nov., '84, p. 
 345,) has used cocaine in thirty-six operations. Among them 
 are seventeen extractions of senile cataract, all of which 
 passed normally and recovered "irreproachably." In one 
 case of tattooing a corneal leucoma, the bundle of needles 
 was introduced boldly and obliquely into the scar, and China 
 ink, of syrup consistence, was thoroughly rubbed in with the 
 finger." Pain slight. 
 
 Dr. L. Howe, of BufJalo, experimented with cocaine oh 
 animals, under the direction of Prof. Zuntz, in the Zoophy- 
 siological Laboratory of the Agricultural High-School at 
 Berlin. He published in Fortsch. d. Med., ii., No. 22, his 
 results as far as obtained Nov. 15th. The Centrabl. f.pr. 
 Augenh. gives them in abstract, of which we will mention 
 
 ' Hirschberg says that in this manner the largest leucoma can be blackened 
 in one sitting. The globe must be depressed by toothless fixing-forceps other- 
 wise the conjunctiva also will be colored. 
 
38 H.Kmpp. 
 
 the following : The action of a 4 ^ or 5 ^ solution seems to 
 surpass but little that oi a. 2 % solution. 
 
 After instillations into the conjunctival sac, a considerable 
 quantity of the alkaloid penetrates into the anterior cham- 
 ber. The aqueous humor drawn with an hypodermic syringe 
 out of the anterior chamber of an eye into which cocaine 
 has been repeatedly instilled, can be used to anaesthetize 
 another eye. 
 
 GENERAL REMARKS. 
 
 There is an extensive earlier literature on coca and its al- 
 kaloids, of which I shall give only brief extracts, supplement- 
 ing them by statements taken from the newest literature, so 
 as to give a kind of synopsis of our knowledge on this plant 
 as far as it concerns the physician. 
 
 A. — Pharmacological Notes. 
 
 The leaves of Erythroxylon coca (Lamarck) have for cen- 
 turies been used as a stimulant by the natives of Peru and 
 Bolivia, and they have been warmly recommended and ex- 
 tensively tried for almost all kinds of diseases, but without 
 satisfactory results. In the year 1855 Dr. F. GaedckE 
 separated from them, in the laboratory of Dr. Sonnenschein, 
 an alkaloid which he called erythroxiline. He had only 
 two ounces of leaves to work on, but he describes his pro- 
 cedure accurately in the Archiv der Pharmacie, vol. cxxxi., 
 pp. 141-150, Hannover, 1855 : "The peculiar action of the 
 coca leaves suggested to my mind the supposition that they 
 contained theine, or a body akin to it." He made watery 
 and alcoholic extracts from the leaves, but could not obtain 
 crystals from them by any kind of procedure and reagents, ' 
 until he subjected them to dry distillation, according to the 
 process which Steynhouse recommends for the discovery of 
 theine. He obtained in the neck of the retort small needle- 
 shaped crystals, distinctly recognizable with the naked 
 eye, made out clearly with a magnifier. The quantity was 
 too small to free a sufficient portion entirely from accom- 
 panying products of dry distillation. He could, therefore, 
 not ascertain whether they were identical with theine, nor 
 study their properties. He promised to do this as soon as 
 he rould obtain a larger quantity of coca leaves. 
 
Cocaine in Ophthalmic and General Surgery. 39 
 
 In the issue of ,the Medical Record oi Nov. 15, 1884, Dr. 
 Samuel R. Percy, of New York, claims priority of the dis- 
 covery of cocaine, or, as he calls it, erythroxyline. Nov. 4, 
 1857, he read an exhaustive paper on the leaf of erythroxy- 
 lon coca before the N. Y. Academy of Medicine. On 
 Dec. 2, 1857, he exhibited to the Academy a scruplfe of 
 the alkaloid, which he left with the librarian. He stated 
 that the hydrochlorate of erythroxyline had a peculiar but 
 not unpleasant benumbing and paralyzing effect upon the 
 tongue. " The librarian of the Academy has been unable 
 to find the paper or the alkaloid, but the fact of such a paper 
 having been read, is recorded on the books of the Academy." 
 
 A thorough and most instructive paper on coca and its 
 ■chemical analysis was published by Dr. A. NIEMANN, of 
 Goslar, Germany, in the Vierteljahresschr. fur practische 
 Fharmacie, vol. ix., pp. 48^524, Munich, i860. He received 
 a sufficient quantity of good coca leaves for examination 
 from Prof. Wohler, of Gottingen. On Wohler's request, Dr. 
 Scherzer had bought the leaves in Lima and brought them to 
 Vienna on the Austrian frigate " Novarra," which had made 
 a voyage round the world chiefly for scientific purposes. 
 Niemann investigated the coca leaf thoroughly, separated 
 the alkaloid, which he called cocaine, made several salts of 
 it, the hydrochlorate, sulphate, nitrate, and acetate, studied 
 its chemical reactions, determined its atomic weight, but 
 •did not investigate its physiological action, mentioning only 
 that a very diluted, probably too diluted a solution of the 
 hydrochlorate did not dilate his pupil. 
 
 M. LOSSEN, 1862, examined cocaine again, and published 
 his results in his Inaugural Dissertation, and in the Ann. 
 Chem. Pharm., 121, 374, and 133, 352. He gave it the 
 formula C17H21NO4 ; that of Niemann was CieH3oN04. 
 Lossen discovered in the coca leaves another volatile 
 alkaloid, hygrine, which is not yet suiificiently investigated. 
 
 A very good compilation of the most important literature 
 and the chemical and physiological action of erythroxylon 
 and its alkaloid is found in " Die Pflanzenstoffe" byHusemann 
 and Hilger, p^ 881, etc., Berlin, 1882. More or less extensive 
 abstracts from this work are found in some of our medical 
 journals. 
 
40 H.. Knapp. 
 
 An excellent description of coca, with illustrations, is con- 
 tained in the Pharmaseufiscke Rundschau, New York, Dec, 
 i8§4, p. 260, etc., by Dr. Fr. Hoffmann, and an interesting 
 paper is that of Dr. E. R. Squibb, "Cocaine," in his Epke- 
 meris of Nov., 1884, p. 685, etc. 
 
 The chief manufacturer of cocaine is Merck, in Darm- 
 stadt, from whom almost all that has been used thus far was 
 furnished. I have tried a sample given me by Messrs. 
 McKesson & Robbins, of New York, as their own make, 
 which acted as well as Merck's. Parke, Davis, & Co., of 
 Detroit, and others, manufacture it likewise, and their pro- 
 ducts have been found good. 
 
 B. — Physiological Action. 
 
 The foregoing pages contain so much of the physiological 
 action of cocaine that a repetition would be tiresome. Suf- 
 fice it to say that cocaine acts as an anaesthetic and analgesic 
 on all mucous membranes with which it is brought in contact, 
 the same on the skin and deeper tissues into which it has been 
 injected or to which it has been applied through incisions 
 and wounds. It paralyzes the sensory nerves and the pos. 
 terior columns of the spinal cord, but not the anterior 
 (Ott, " Cocaine, Veratrum, and Gelsemium," Philadelphia, 
 1874). The semicircular canals appear particularly affected 
 — disturbances of equilibrium, absence of co-ordination, ro- 
 tating spasms (v. Anrep^ Arch. ges. Physiol., 21, 38, 1880). 
 The pupil is dilated, not ad maximum, and remains respon- 
 sive to light, though less than normal. The power of ac- 
 commodation is diminished, not totally suspended. Mu- 
 colis membranes are bleached and thinned, their secretion is 
 lessened, the tension of the eyeball is diminished. It acts 
 locally on the peripheric sensitive and sympathetic nerve- 
 fibres, and when injected into or near the trunks of sensi- 
 tive nerves it paralyzes the whole distal part of those nerves 
 (Hall & Halsted, N. Y. Med. Jour., Dec. 6, 1884, p. 643). It 
 causes a diminution, of tactile, painful, and thermal impres- 
 sions, and abolishes reflex irritability. Its action is transient, 
 but can be- maintained for hours by repeated application. It 
 has no cumulative effect, and exerts no bad influence on the 
 nutrition of the parts subjected to its action, as far as we caa 
 
Cocaine in Ophthalmic and General Siirgery. 41 
 
 judge from the observations up to date. Constitutional symp- 
 toms after the injection of from five to thirty-five minims- 
 and more of a four-per-cent. solution once or several times 
 and even from instillations of a few drops into the con- 
 junctiva (T. R. Pooley) have been noticed. Thfey consisted 
 in headache, dizziness, nausea, unsteadiness of gate, deadly 
 pallor of skin, and cold perspiration. These symptoms were 
 transient, and riever had injurious after-effects. 
 
 It is easily understood that a substance with such a physi- 
 ological action will have a wide field of beneficial . 
 
 C. — Therapeutical Application. 
 
 This is owing to its action : 
 
 (1) As an ancesthetic and analgesic in a great number of pain- 
 ful diseases, irritative conditions, and inflammations of dif- 
 ferent kinds in many organs, unpleasant methods of exami- 
 nation, and painful operative procedures. The abolition of 
 reflex excitability, a consequence of the anzesthetic action of 
 the drug, is of the greatest service in many affections, such 
 as photophobia, blepharospasm, headache (reflex), dysphagia,, 
 asthma nervosum, and many other kinds of reflex spasms. 
 
 (2) As a vaso-constrictor (haemostatic) agent. It will bleach 
 the tissues, diminish hemorrhage, contract vascular (erectile)' 
 tissue in the nose, penis, ear, etc. ; thus by enlarging cavities 
 and canals facilitate the introduction of 'instruments and the: 
 inspection, cauterization, and operation of deep-seated 
 parts. It will dilate the pupil, and by its analgesic effect 
 favor and increase the action of other mydriatics. 
 
 The transient nature of its action makes it particularly 
 valuable when we desire its service only for a short time — 
 for instance, in ophthalmoscopic, rhinoscopic, laryngoscopic,. 
 and other examinations ; whereas, on the other hahd, its 
 action can be maintained at will by repeated applications 
 during operations of longer duration. Its diminishing effect 
 on secretions is mentioned by several observers, and will, if 
 confirmed, be of great benefit. 
 
 It is of decided advantage as an adjuvant to many re- 
 medial agents, operative procedures, and the vis medica- 
 trix naturae ; for instance, as an analgesic it will prevent in- 
 
42 H. Knapp. 
 
 flamed parts from dispelling sleep ; it will afford rest— the 
 chief requirement of obtaining primary union of wounds,,— 
 and in quieting the nerves of one part, quiet the nervous 
 •centres and the mind. 
 
 Thus far it has found a useful field of application in : 
 
 (i) Ophthalmology. 
 
 (2) Otology. 
 
 (3) Rhinology, pharyngology, and laryngology. 
 
 (4) Genito-urinary surgery. 
 
 (5) Gynaecology. 
 
 (6) General surgery. 
 
 Before concluding this communication I beg to review its 
 
 Particular Use in pphthalmology, 
 
 as shown in the preceding abstracts and verified by my own 
 •experience. 
 
 A . — Operations. 
 
 Cocaine is of the greatest benefit in catai-act -operations. 
 JDivisions of the capsule, primary and secondary, being abso- 
 lutely painless throughout; can be executed with the neces- 
 sary precision, without the liability of an accident by an 
 unforeseen movement of the patient. Prolapse of vitreous, 
 entrance of capsule or iris into the stitch canal when the 
 needle is withdrawn, are less likely to occur, on account of 
 the diminution of eyeball tension produced by the drug, 
 and the absence of reflex contraction of the ocular muscles. 
 
 The same holds good in extraction. The precision with 
 which every step of the operation Ought to be performed is 
 greatly assisted by the absence of pain and the diminution of 
 bleeding. The section, being painless throughout, can be 
 .accurately executed as to location, size, and direction. The 
 final cleansing and adaptation of the wound are exceedingly 
 facilitated by cocaine. The patient, having his full con- 
 ociousness, will turn his eye in every direction desired, while 
 the insensibility of the parts will permit the removal of clots 
 and portions of lens, the reduction of the iris from the corners 
 of the section, and the smoothing of the conjunctival flap 
 without any spasmodic flying off of the ball. The capsul- 
 ■otomy will also be rendered easier and surer by the anaes- 
 
Cocaine in ophthalmic and General Surgery. 43 
 
 thesia, but it is somewhat more difficult to introduce the 
 cystotome, as the wound does not gape so readily. Fre- 
 ■quently the point of the knife wounds the skin near the inner 
 commissure in the progress of the corneal incision. This is 
 felt as the f^rst pain by the patient, and sometimes causes 
 ^n involuntary movement. This movement may occur also 
 ■during the iridectomy, which is painful. Knowing the fact, 
 we can prepare the patient and ourselves for its consequences, 
 Avhich need not be of any account, as the pain is but slight. 
 I have not yet dropped cocaine into the wound, nor injected 
 it into the anterior chamber, for I dislike to protract the 
 •operation in any way.. Apart from all considerations of 
 mischievous bacteria, always and everywhere ready to 
 pounce upon a wound, we can easily believe that the less a 
 ;wound is exposed to the air, and the less it is manipulated, 
 the greater are its chances for primary union. This shows 
 us another advantage of cocaine ; it allows us to operate 
 quickly, yet with precision. Its advantage over ether is 
 immense. Ether anaesthesia, if complete, quiet, and unin- 
 terrupted during the operation, must in many cases be 
 allowed to pass, before remnants of lens can be removed, 
 -and the wound cleansed and adjusted. In many persons 
 the struggling, congestion, vomiting, and unmanageable- 
 ness when they awake from the etherization, are very un- 
 pleasant hindrances to a smooth operation. In cocainiza- 
 tion a marked diminution of eyeball tension is often noticed, 
 the cornea wrinkles, and in some cases, after the expulsion 
 of the lens, sinks in as if half the eye had been emptied. 
 The expulsion of the lens and of remnants requires more 
 'Outward pressure, but wards off accidents, for the eye is 
 insensible. A consequence of this diminution of pressure, 
 which I have noticed in the majority of cases, is the fact 
 that the iris rarely prolapses spontaneously. This I con- 
 sider to be an advantage, for we obtain a more regular, key- 
 hole-shaped pupil when we grasp the iris within the anterior 
 chamber than when it lies irregularly folded in the wound. 
 I have not noticed any injurious effect of cocaine on the 
 healing of the wound. I have made twenty-four extractions 
 lunder cocaine ; twenty-three recovered without disturbance, 
 
44 H. Knapp. 
 
 one suppurated. This was a case of chronic conjunctivaii 
 catarrh, with considerable discharge from both eyes the next 
 days after the operation ; the patient was a very restless, 
 woman, and the operation had not been quite free from 
 complications. I had repeated the capsulotomy, and during 
 an unexpected movement of the patient the cystotome had. 
 slightly grazed the iris. 
 
 In iridectomy for glaucoma cocaine is of advantage, but 
 requires particular caution at the moment of seizing the. 
 iris ; this being the first and only pain the patient experi- 
 ences, his eye is apt to make a sudden spasmodic upward 
 movement, which may bring the branches of the for- 
 ceps in contact with the anterior capsule and rupture it^ 
 The patient, as well as the assistant that steadies the eye,, 
 ought to be prepared for this emergency. The assistant, 
 who steadies the eye with the fixing forceps is liable to hold 
 it very loosely only, because the anesthetized eye does not 
 move, when on a sudden it feels the pain and flies up. I have, 
 made only five glaucoma iridectomies under cocaine, but 
 this movement occurred in two of them, and also in several 
 extractions. Another disadvantage of cocaine was noticed 
 in a case of chronic glaucoma, in which it dilated the pupil. 
 ad maximum, so much so that the whole iris was concealed 
 under the arcus senilis of the cornea. I had to make the 
 incision without the protection of the capsule by the iris and 
 without seeing either. After the incision the pupil remained 
 dilated, and I had to make the iris prolapse by pressing on 
 the posterior lip of the wound. In another case I made a. 
 good-sized corneal incision with a lance-knife, and when I 
 withdrew the instrument the anterior chamber did not 
 empty, the aqueous escaped only when I introduced the- 
 forceps. This shows more than any thing else the perfect 
 rest of the eye and its absence of reflex movements on the 
 part of recti and orbicular muscles. 
 
 The proper corrective of cocaine mydriasis is a drop 
 of eserine, instilled soon after the cocaine, which will pro- 
 duce a full contraction of the pupil (without diminishing the 
 anesthetic effect of cocaine), even if cocaine is repeatedly 
 dropped in after the eserine. The sensitiveness in iridecto- 
 
Cocaine in Ophthalmic and General Surgery. 45 
 
 my may be elimina,ted, as has been seen before, by dropping 
 •cocaine on the prolapse, or injecting it into the anterior 
 chamber, which can readily be done with E. Meyer's lachry- 
 mal syringe. I do not like injecting any fluid into the eye, 
 not even a perfectly fresh, pure solution of cocaine, or one 
 to which an antiseptic has been added. Before I recom- 
 mend this procedure, I want to have the support of further 
 •experience from those that have tried it. 
 
 Of a number of diverse operations on the cornea, paracen- 
 tesis, splitting according to Saemisch, abscission of partial 
 ■or total staphyloma, incising and scraping out pustules or 
 torpid infiltrations, tattooing, removal of deposit of lead or 
 ■chalky film, removal of foreign bodies, etc., I need not 
 speak in particular. They can all be done under cocaine 
 anaesthesia in the most satisfactory way. 
 
 Operations on the conjunctiva, extirpation of small tumors, 
 ■pterygium, symblepharon, and the like are much facilitated 
 by cocaine anaesthesia. It is recommendable in these opera- 
 tions to use a stronger solution, 8 %, — those over 5 fo require, 
 of course, a corresponding addition of alcohol, — and instil it 
 •on the wound during the progress of the operation. 
 
 The same rule ought to be followed in operations on 
 the muscles and the lids, e. g., simple tenotomy, advance- 
 ment, canthoplasty, tarsoraphy, uniting lacerated or incised 
 wounds, scraping or cutting out chalazia and denser tumgrs, 
 entropium, ptosis, etc. Subcutaneous injections, for appro- 
 priate cases, answer very well. 
 
 Enucleation •• of the globe can be done either by suc- 
 cessive instillations during the operation, according to C. 
 S. Turnbull, or by injecting a few drops into Tenon's 
 ■capsule along the recti musclps, as D. C. Cocks has done. 
 Both procedures will prolong the operation unduly. In- 
 jecting a few' drops directly into the orbit close behind 
 the globe has answered me well in two cases (see above), 
 and is as follows : when the conjunctiva is anaesthetized by 
 instillation, the eyeball is forcibly drawn toward the nose. 
 This will bring the posterior segment near the outer com- 
 missure, from where the hypodermic needle can be in- 
 troduced, and a few drops — one or two will probably be 
 .-sufificient— are injected where the ciliary nerves enter the 
 
46 H. Knapp\ 
 
 globe. All this is painless and in two or three minutes, 
 the operation can be begun. The division of the recti 
 muscles will be connected with some pain, but the re- 
 mainder of the operation will not, and there will be very 
 little hemorrhage from the orbit on account of the haemo- 
 static action of cocaine. From so small an amount of the 
 solution injected no general symptoms of any importance,, 
 should they occur at all, need be feared. If a drop or twa 
 anaesthetizes the cornea and conjunctival sac, then an equal 
 dose will be likely to produce the same effect on the ciliary- 
 nerves if injected into the loose cellular tissue of the orbit. 
 
 In removal of circumscribed orbital tumors injection of a 
 few drops behind them will probably anaesthetize the locality 
 so as to operate painlessly. 
 
 In lachrymal difficulties, cocaine may be instilled so as to- 
 reach the canaliculi, but the deeper parts, sac and nasal 
 duct, can only be anaesthetized by injections with the 
 syringe. Meyer's small syringe will answer best, admitting 
 of the injection being made without slitting the punctum. 
 
 In the removal of foreign bodies from the interior of the 
 eye, cocainization by repeated instillations into the conjunc- 
 tival sac is of the greatest advantage. The rest, the absence 
 of reflex motions, arid the diminution of eyeball tension pro- 
 duced by the drug, will render prolapse of iris and vitreous less 
 frequent and less extensive, and assist the operator in the 
 correct handling of his instruments. Only a few days ago I 
 saw the benefit of cocaine exemplified in a successful ex- 
 traction of a splinter of iron with an electro-magnet by Dr. 
 Geo. J. Stevens, in which operation I had the privilege of 
 assisting. , 
 
 From the above statements it follows that almost all 
 operations on the eye can be performed under cocaine 
 anaesthesia. The rules which I have given in the general 
 remarks are supported by actual experience of othervoculists 
 or my own, as will be seen by the abstracts from the current 
 literature in the first part of this paper. Whether that 
 which can be done is under all conditions the best to 
 do, is another question. In children and frightened peo- 
 ple, for obvious reasons, there always will be an indica- 
 tion for general anaesthesia. In rare cases the anesthesia 
 
Cocaine in Ophttuxlmic and General Surgery. 47 
 
 from cocaine instillations is so superficial that corneal inci- 
 sions are intensely painful, and ether has to be resorted to. 
 Dr. Jas. a. Spalding, of Portland, Maine, writes me, that 
 repeated instillations of a three-per-cent. solution, which 
 completely anaesthesized the conjunctiva and cornea for 
 speculum and forceps, in a case of absolute glaucoma, did 
 not prevent the patient from experiencing such intolerable 
 pain at the corneal incision as to make it necessary to com- 
 plete the operation under ether. 
 
 B. — 'Y\\.&,mode of applying cocaine will be by instillations, 
 painting the tissue before and during the operation as 
 the case may be, and by injections into the diseased part or 
 its surroundings. In particular cases injecting the solution in 
 or near a nerve-trunk when we want to operate in the region 
 of its peripheric distribution, may prove of advantage. As 
 to the doses we bu'ght to be cautious, for though i.oo grm. 
 taken internally, in an attempt at suicide, is reported not to 
 have been fatal, unpleasant symptoms have occurred after 
 injections of from six to thirty-six minims of a four-per- 
 cent, solution. Some persons seem to have an idiosyncrasy 
 against the remedy. Aside from my own experience I have 
 heard some of my friends say that injections of five or six 
 minims into the lids' produced unpleasant general symp- 
 toms. Dr. T. R. POOLEY noticed that two drops of a four- 
 per-cent. solution instilled into the conjunctiva produced 
 in ten minutes such extreme dizziness that the patient, a. 
 robust girl, feared to rise from the chair lest she should fall. 
 She did not lose color, nor was their any nausea, but her^ 
 pupil was widely dilated. She recovered quickly. None of 
 these cases showed alarming symptoms, but we are only at 
 the beginning of our acquaintance with the remedy, and it- 
 seems prudent to advance cautiously. 
 
 C. As regards the therapeutic action of cocaine, I have 
 
 nothing to add to what I have said above (p. 41). My experi- 
 ence and the publications on that point are too limited as yet 
 to deduct from them any general rules. In a number of cases, 
 of acute iritis, I have been able to confirm the benefit of a. 
 combined instillation of cocaine and atropine which KoUer, A. 
 Weber, J. Green, and others have recommended. The paim 
 was allayed and the course of the inflammation abridged. 
 
48 H. Knapp. 
 
 'The following note, kindly sent me by Dr. F. P. Kinnicutt, 
 
 of New York, is of interest : 
 
 During the past six weeks I have used cocaine in a number of 
 cases of facial neuralgia with very satisfactory results. My ex- 
 perience coincides with Dr. Murrel's of London, in regard to the 
 necessary strength of solutions for external application in this 
 affection ; a ten- to twenty-per-cent. solution is required. I have 
 
 •employed oleic acid as a solvent rather than the oil of cloves 
 recommended by Dr. Murrell. I rub in with the finger eight to 
 ten minims of the oleate along the course of the painful nerve, 
 with the effect of affording very speedy and marked relief. My 
 
 • experience is confined to cases of neuralgia of the ophthalmic 
 division of the trifacial nerve. 
 
 I have been able to compare the effect of cocaine used after the 
 
 . above method and given hypodermatically. The relief following 
 hypodermic injections is almost instantaneous, and thus far in my 
 
 ■ experience constant. In supra-orbital neuralgia, the injection has 
 been made in the loose supra-orbital tissue, near the point of exit 
 of the nerve. The only objection to this method is the slight 
 pain caused by the injection. In my own judgment it is to be 
 
 -preferred to the external application of the salt. Three to four 
 minims of a four-per-cent. solution has been found to be suf- 
 
 -'ficient. 
 
USE OF COCAINE IN OTOLOGY. 
 
 By H. KNAPP. 
 
 MY personal experience with hydrochlorate of cocaine 
 in aural surgery is limited, but encouraging. If I 
 supplement it by what has been published after so short a 
 time of trial, I may fairly ascribe to the remedy a consider- 
 able extent of useful application in this field. 
 
 Catheterization of the Eustachian tube through the nose is 
 ■greatly facilitated by previously applying cocaine to the 
 lower nasal passages and to the pharyngeal orifice of the 
 tube. This can be done with an atomizer, or a brush, or a 
 •cotton pad at the end of a probe. The mucous membrane 
 becomes insensible and thin ; the catheter glides over the 
 parts without pain, and is introduced more readily because 
 of the dilatation of the nasal passages. This remedy will ren- 
 der direct catheterization possible in certain cases, in which 
 otherwise it could only be effected through the mouth or the 
 nostril of the other side. Whether these methods are so 
 efficient as the introduction of the catheter through the nos- 
 tril of the same side, I know not, but I do know that 
 changing the classical bend of the catheter ^y making 
 it straighter in order to pass it through a narrow or 
 •crooked nasal passage, renders catheterizations, both for 
 purposes of inflation and injection, proportionately ineffi- 
 cient. It would be too troublesome had we to apply 
 cocaine often in the same case ; fortunately this is not 
 necessary, for when the remedy has helped the patient over 
 the discomfort of the first trials, the repeated introduction 
 and treatment have made the manipulation easy. 
 
 49 
 
50 H. Knapp. 
 
 Injections of cocaine into the Eustachian tube will, by their 
 contracting influence on the- blood-vessels, dilate the calibre 
 of the canal, facilitate inflation and injection of liquids into 
 the tube and the tympanic cavity. 
 
 It may be of advantage — though I am not aware that 
 it has ever been tried — to inject one or several drops of 
 cocaine, warm, through the E. tube into the drum cavity 
 for severe earache of inflammatory origin. It might also be 
 injected through the drumhead with a hypodermic syringe. 
 
 Instillations of cocaine into the external ear-canal in 
 cases of neuralgic earache have been found useful by Roosa 
 and Da Costa. 
 
 On the benefit derived from inflammatory earache, Dr. F. 
 P. KlNNICUTT writes me as follows : 
 
 I have very lately used a four-per-cent. watery solution in three 
 cases of acute " earache " in children. 
 
 By means of a speculum and " dropper," I have applied one or 
 two minims directly to the drum meuibrane, in each case with im- 
 mediate and complete relief ; there was no recurrence of the pain. 
 
 In tinnitus aurium I have not found any improvement 
 from instillations of cocaine, though I have made them re- 
 peatedly. 
 
 In all conditions that require manipulation, or the applica- 
 tion of remedies, or incision, scraping, torsion, avulsion, 
 ^crasement, etc., in the tympanic cavity, when the drum- 
 head is perforated, or in ulcers of the ear-canal and the auricle, 
 local anaesthesia can be easily and satisfactorily effected by 
 instillation of hydrochlorate of cocaine. The tissue-con- 
 tracting and haemostatic effect of the drug will greatly add 
 to its value in all operations on the middle ear. These 
 operations are particularly difficult on account of the nar- 
 rowness of the ear-canal and its obstruction by the slight- 
 est hemorrhage. In prolonged operations— for instance, 
 the removal of multiple polypi — the instillations should be 
 continued during the operation. I have -derived great 
 advantage from this procedure in several operations. 
 
 Also in cases of acute purulent otitis, accompanied by in- 
 tense pain, where the tenderness of the swollen walls of 
 
Cocaine in Otology. ■ 51 
 
 the meatus made cleansing both by syringing and the dry 
 method excessively distressing to the patient, have I no- 
 ticed great benefit from cocaine instillations. The manipu- 
 lations were made easy, the cleansing could be thoroughly 
 done, and the application of remedies — boric acid and weak 
 solutions of corrosive sublimate — caused no annoyance. 
 This treatment, because of its painlessness, was regularly 
 carried out, and the recovery was smooth and speedy. 
 
 The application of painful remedies in cases of chronic 
 purulent otitis — for instance, nitrate of silver, alcohol, etc. — 
 can be done, after cocainization, with great or entire relief 
 from pain. 
 
 The analgesic effect of cocaine has been noticed by J. 
 Bettman, other aurists, and myself, in cases of earache when 
 \h& perforation of the drumhead gives the remedy access to 
 the middle ear. 
 
 Dr. C. S. Bull reports that he has performed perforation 
 of the inembrana tympani in three cases with entire absence 
 of pain. In my experience instillation of cocaine upon the 
 healthy or inflamed non-perforated drumhead did not 
 diminish its sensitiveness to the touch of a probe, and an 
 incision in these cases could not have been painless. 
 
 Operations on the walls of the ear-canal, the auricle, and 
 its surroundings, such as removal of tumors, incisions into the 
 skin, etc., can be rendered painless by subcutaneous injec- 
 tions of cocaine, if the transient freezing with ether or 
 rhigolene spray is not preferred. A few days ago I enu- 
 cleated a cystic tumor, the size of a cherry, from the pos- 
 terior surface of the lobule. The lobule and the tumor were 
 held between the branches of an eye-lid clamp. Two drops 
 of a three-per-cent. solution of cocaine were injected under 
 the posterior side of the tumor, and two under the anterior. 
 The tumor was shelled out entirely without pain and 
 without loss of blood. 
 
COCAINE IN THE UPPER AIR-PASSAGES. 
 
 By F. H. BOSWORTH, M.D., 
 
 PROF. OF LARYNGOLOGY, BELLEVUE HOSPITAL MEDICAL COLLEGE. 
 
 COCAINE possesses two separate and distinct proper- 
 ties in its action upon the mucous membrane of the 
 upper air-tract. It not only acts as a local anaesthetic, but 
 also possesses properties of so singular and striking a char- 
 acter as to render it one of the most valuable, if not the 
 most valuable, single drug in our pharmacgpoeia as a local 
 therapeutic agent. The discussion of the subject would 
 then properly fall under two heads : ist, cocaine as a local 
 anaesthetic ; 2d, cocaine as a local therapeutic agent. 
 
 COCAINE AS A LOCAL ANESTHETIC. 
 
 In the Nasal Passages. All observers coincide in the state- 
 ment that a solution of cocaine when properly applied to 
 the nasal mucous membrane renders it absolutely insensible. 
 The method of application is very simple. A small pledget 
 of cotton is saturated with the solution and placed upon 
 the membrane, and allowed to remain for about eight 
 minutes. At the end of this time simple superficial cut- 
 ting operations may be accomplished, or the part cauter- 
 ized with the potential cautery or by means of any of the 
 chemical agents without sensation. The only care to be 
 exercised is that the part to be cut or cauterized shall be 
 thoroughly covered with the cocainized pledget. In us- 
 ing the snare for the removal of large masses of hyper- 
 trophied tissue, the cocaine very markedly mitigates the 
 pain, but that it completely eliminates it has not been my 
 
 52 
 
Cocaine in Rhino-Pharyngo-Laryngology. 53 
 
 own experience, or that of any other observer as far as I 
 know. 
 
 In operating upon a deflected septum, I have usually 
 allowed the cocainized pledget to remain over the part for 
 at least ten minutes, or even longer. In these cases the 
 operation was completed with very much diminished pain, 
 and in two, the patients, assured me that the pain was en- 
 tirely eliminated. The operations consisted in cutting off 
 the projecting angle of deflection. 
 
 In operating upon nasal polypi, the difficulty which pre- 
 sents is in applying the cocaine to the parts which it is 
 designed to render anaesthetic. In my own experience the 
 cocaine has not rendered the operation entirely painless. 
 ,The polypi so far occlude the cavity as to render access to 
 the membrane in many cases impossible. What the cocaine 
 does do in these cases is to render the mucous membrane, 
 which must be traversed by the instruments used in oper- 
 ating, so far insensible as to remove one of the most painful 
 features of the operation. As each lower growth is extir- 
 pated a fresh application may bei made, and the operation 
 made a comparatively painless affair. The strength which 
 is to be preferred for use in the nasal cavity is the four-per- 
 cent, solution, though I have frequently accomplished all that 
 could be desired with a two-per-cent. solution. The latter 
 strength, as a rule, requires a longer time to accomplish the 
 purpose. By far the best method of making the application is 
 by means of a pledget of cotton or a piece of sheet lint. By this 
 method the application can be confined to the part on which 
 it is designed to operate, for as a rule there is no especial 
 reason for anaesthetizing the whole nasal cavity. If it is 
 desired to anaesthetize a portion of the membrane where it is 
 not feasible to place a cocainized pledget, the part can be 
 rendered fairly anaesthetic by passing over it, at intervals of 
 two or three minutes, a pledget of cotton wrapped on a 
 probe and saturated with the cocaine solution. This is cer- 
 tainly far more efficient than making the application by the 
 atomizer or syringe, or dropping it into the cavity. 
 
 In the Vault of the Pharynx. The principal occasion 
 for rendering the vault of the pharynx insensible is for 
 
54 P- H. Boswortk. 
 
 the purpose of removing hypertrophied pharyngeal ton- 
 sils, the so-called adenoid growths. In my first experi- 
 ments in this region, I passed a cocainized pledget on 
 bent probe into the pharyngeal vault, passing the instru- 
 ment behind the palate. The palate was immediately 
 retracted in each case, the probe seized, and the cocaine dif- 
 fused over the upper surface of the soft palate, and in part 
 only upon the pharyngeal vault. In no case did I succeed 
 in rendering the vault insensible. I then commenced to use 
 a fine upward spray. In order to throw a spray into the 
 vault of the pharynx, it is necessary that the soft palate 
 shall be relaxed. Many patients will retract the soft palate 
 unconsciously when the attempt is made. A little training, 
 however, soon enables the operator to accomplish the ma- 
 nipulation at the first sitting. By using a cleansing solution 
 for the practice, the patient very soon gets accustomed to the 
 manipulation, and the cocaine solution may then be used. 
 The spray producer, being attached to a compressed-air 
 cylinder, is placed in position, and the pressure let on for an 
 instant, the result is that a momentary jet of spray is thrown 
 upon the part. This is repeated three or four times a*t in- 
 tervals of two minutes. At the end of this time the parts are 
 perfectly anaesthetized, and the growth can be removed pain- 
 lessly. In several cases of adenoids, I should state, I have 
 failed in making the application, on account of irritable 
 fauces, but in no case in which I have succeeded in spraying 
 the part with cocaine have I failed in rendering the opera- 
 tion painless. In these cases I used a two-per-cent. solution, 
 the soft spongy tissue of the pharyngeal tonsil seeming to 
 absorb the drug more thoroughly and deeply than the mu- 
 cous membrane proper of the upper air-tract. 
 
 In the Fauces. By this region I mean the lower pharynx, 
 soft palate, pillars of the fauces, faucial tonsils, etc. In cases 
 of irritable fauces, which resist attempts at making a laryngo- 
 scopic examination, we have a most valuable remedy in coca- 
 ine for rendering the parts tolerant of the laryngeal mirror. 
 In the few cases in which I have found myself balked in using 
 a laryngeal mirror, I have succeeded in accomplishing all that 
 was desired by spraying upon the parts a four-per-cent. solu- 
 
Cocaine in Rhino-Pharyngo-Laryngology. 5 5 
 
 tion of cocaine two or three times at intervals of three min- 
 utes. In this, as in all applications of cocaine by means of 
 an atomizer, it is important that the tubes shall have very 
 small openings, and that only sufficient of the solution shall 
 be thrown upon the parts to cover them without flowing. 
 When the compressed-air apparatus is not available I think 
 the little single-bulb hand-ball atomizer, sold in the drug 
 stores as Delano's atomizer, answers a most excellent pur- 
 pose. The tube openings are very small, and the spray a 
 very fine one. 
 
 In cutting the uvula, in a number of cases, I have com- 
 pletely anaesthetized the part by touching it with a four- 
 per-cent. solution of cocaine. In none of these cases, how- 
 ever, was the cut made into the fleshy portion of the organ, 
 elongation of the uvula very rarely indeed being due to 
 any thing more than a sagging down of the mucous mem- 
 brane. In removing the faucial .tonsils I have made a number 
 of attempts to render the operation painless by the applica- 
 tion of cocaine, but in no single-case have I succeeded. My 
 attempts consisted in brushing or spraying the organs with 
 a two-per-cent. solution and a four-per-cent. solution, repeat- 
 ing a number of times, and waiting from eight to twelve min- 
 utes, but in no case could I perceive that the drug had any 
 marked effect either in lessening pain or controlling hemor- 
 rhage. In a recent case, I made every effort to gain some 
 assistance from the application of cocaine in a nervous 
 young lady who came to me for the removal of very large 
 tonsils, but not only was the pain very severe, but I met with 
 the first case of troublesome hemorrhage I have had in over 
 a year. On the other hand, my friend. Dr. Camp, of 
 Springfield, Mo., tells me that in his experience the cocaine 
 has very marked effect in controlling the pain of the opera- 
 tion. His method of application is by means of a brush, 
 pencilling the organ repeatedly for ten minutes with a four- 
 per-cent. solution. 
 
 The faucial tonsil, as a rule, is a very hard, dense organ, 
 containing largely of well-organized connective-tissue, and 
 presents a consistency which is not well adapted for the 
 absorption of cocaine applied to the surface, and there- 
 
56 F. H. Bosworth. 
 
 fore it is easy to understand that there would naturally be 
 some difficulty in rendering it insensible. It has occurred 
 to me that a better plan of procedure might be in injecting 
 the cocaine into the base of the organ by means of a hypo- 
 dermic syringe. I regret that I cannot report on the result 
 of such a device at the present writing. 
 
 In one or two cases of chronic follicular pharyngitis I have 
 used cocaine for its anaesthetic effect, before destroying the 
 follicles with the actual cautery, but I am somewhat uncer- 
 tain as to the result. The use of the cautery in the affec- 
 tion is attended with so little pain that it is a question 
 whether the cocaine was of any practical value. 
 
 Dr. Lefferts, in a personal communication to me on the 
 use of cocaine, writes : " Such a disagreeable result may 
 follow its application to the pharynx for anaesthetic pur- 
 poses that I have practically given up its use here." This 
 result is " a paresis of the constrictor muscles of the phar- 
 ynx and total inability to swallow, with a feeling as if the 
 whole throat was filled with cotton. So alarming is this 
 condition, lasting a half hour or more, that nervous patients 
 will not endure it." 
 
 I have observed this sensation in experimenting on 
 myself, and have also had patients complain of the same 
 disagreeable feeling. I am disposed, however, to question 
 whether, it be a paresis of the constrictor muscles. The 
 fauces being completely anaesthetized, the effort at degluti- 
 tion necessarily will be extremely awkward. It is an at- 
 tempt at swallowing virtually an empty space. One cannot 
 go through the movements of deglutition unless there be 
 something to swallow, even if it be but a small portion of 
 saliva, the latter part of the act being completed by invol- 
 untary muscles whose contractions are excited by the pres- 
 ence of the bolus of food. Hence the attempt at deglu- 
 tition with the fauces anaesthetized, one can easily 
 perceive, might cause no little apprehension on the part 
 of a nervous patient, the experience being a somewhat 
 novel one. The point, however, which Dr. Lefferts raises is 
 an interesting one, and there is room for further investiga- 
 tion. In all my observations on the local action of cocaine, 
 
Cotaine in Rhino-Pharyngo-Laryngology. 57- 
 
 I have watched very carefully for any possible influence 
 upon striped muscular fibres, and I am very confident that 
 it has none. Its very remarkable effect upon unstriped 
 muscular fibres I will discuss in the second portion of my 
 paper. 
 
 In the Larynx.— \w no portion of the upper air-tract 
 would a perfect local anaesthetic be of such ineslimable 
 value as in the larynx. In the nasal passages and the 
 pharynx we are rarely, if ever, balked of success in. 
 our operations or manipulations for the lack of such 
 an aid ; in the larynx, however, we are not infrequently 
 compelled to subject our patients to a long and tedious 
 course of training before we can successfully introduce 
 the proper instrument for the removal of neoplasms.. 
 There still seems to be some question whether we possess 
 in cocaine so reliable and thorough an anaesthetic that we 
 can in all cases succeed in introducing a pair of forceps into 
 the larynx at the first sitting without producing spasmodic 
 closure of its cavity. 
 
 Dr. J. SoHs-Cohen,' in writing on the subject, states that, 
 while he succeeded easily in producing anaesthesia of the 
 pharynx, his experience in attempting to secure laryngeal 
 anaesthesia was very disappointing. He writes as follows :: 
 " On three separate occasions I applied as much as ten 
 minims of a four-per-cent. solution at a time, keeping the 
 brush within the larynx for at least five seconds, and re- 
 peating the application twice at intervals of five minutes.. 
 Although the patient stated that she was barely conscious 
 of the presence of the probe I subsequently placed upon 
 one of her vocal bands, the spasmodic, sphincter-like con- 
 tractions of the laryngeal muscles shut the interior of the 
 larynx out of view as completely as if no anaesthetic had 
 been used." This patient was a lady. Dr. Cohen also- 
 records a similar failure in the case of a man. 
 
 In a personal communication, dated Jan. 12, 1885, Dr., 
 Cohen writes as follows : 
 
 " To facilitate laryngoscopy in irritable or sensitive 
 throats, to relieve pain' in ulcerations, — as, for example, 
 
 ' Medical News, Phila., Nov. 15, 1884. 
 
58 F. H. Bosworth. 
 
 odynphagia in tuberculous laryngitis — I find cocaine an 
 extremely valuable agent. It has failed, in my hands, to 
 overcome spasm of the larynx sufficiently to enable me to 
 follow the instrument in the mirror, though obtunding the 
 sensation of contact. I have not, however, used a solution 
 stronger than ten per cent., though I see that they are 
 using a twenty-per-cent. solution abroad. Since cocaine 
 has been introduced, I have had but two cases of tumors in 
 the larynx. In one I used it without any advantage over 
 the ordinary manipulation with the forceps in the unanaes- 
 thetized larynx, which, by the by, is satisfactory enough. 
 In the other case I did not try it." Dr. Cohen writes me 
 further, on Jan. iSth: "Some weeks ago, I applied, on two 
 patients in succession, a five-per-cent. solution to the 
 larynx, and they both complained of a feeling as of a 
 foreign body obstructing respiration, though I could see 
 nothing to account for it. It was a nervous stricture, so to 
 speak, but neither patient was neurotic — one being a lawyer, 
 z. member of select councils ; the other, a very intelligent 
 lady. I see to-day, in a reprint sent by Jurasz, of Heidel- 
 berg, that he has observed the same phenomenon." 
 
 Dr. Lefferts writes to me as follows : " I have used five- 
 per-cent. and eight-per-cent. solution of cocaine with brush 
 to the larynx in the attempt to relieve a distressing reflex 
 laryngeal cough, there being no lesion of the larynx, except 
 hypersemia or slight acute laryngitis, but have failed in all 
 cases. I have had no experience in producing anaesthesia 
 prior to the removal of intra-laryngeal growths, but note that 
 others have failed to do so in some cases, and that, though 
 anaesthesia of the mucous membrane may be caused, reflex 
 laryngeal spasm is not prevented." Dr. Lefferts adds, in a 
 foot-note : " I may say that my drug and solutions are 
 reliable. I believe that many experiments published have 
 failed on account of an unreliable article having been used." 
 The point certainly deserves attention. ' 
 
 Dr. Lefferts' ' very important observation in regard to 
 the use of cocaine in laryngeal phthisis has already been 
 quoted by Dr. Knapp. My own observations fully confirm 
 
 ' Medical A^ews, Phila., Nov. 2g, 1884. 
 
Cocaine in Rhino-Pharyngo- Laryngology. 59 
 
 all that Dr. L. has stated. I have used it not only in 
 laryngeal tuberculosis, but also in a case of tuberculosis of 
 the pharynx, with signal relief to the terrible distress in 
 ■deglutition. Whether it possesses any power in retarding 
 the progress of tubercular ulcerations is very questionable, 
 but if we possess in it, as I think we do, an absolutely reli- 
 able palliative, its value in these cases cannot be over- 
 estimated. The relief usually lasts from twenty minutes to 
 a half hour, during which time the sufferer may eat a fairly 
 hearty meal without distress. 
 
 Dr. F. P. Kinnicutt, of New York, still further confirms 
 this view, in a personal communication, as follows : 
 
 "The good results which I have obtained from cocaine, in 
 cases of extensive tubercular ulceration of the larynx, have 
 far exceeded those, which I have ever produced by any 
 other method of treatment. The applications have been 
 made directly to the ulcerated surface, and instantaneous 
 relief from suffering, extending over a period of several 
 hours, has followed." 
 
 Dr. Elsberg writes me on January 9, 1885, as follows : 
 " The application of a four-per-cent. solution cocaine chlor- 
 ide in the larynx dulls in most persons the dolorous sensi- 
 bility ; but the annulling of the tactile sensibility — by which 
 temperature and pressure, are appreciated — requires a 
 stronger solution ; and that of the reflex sensibility — from 
 which result muscular contractions, as spasms, etc., as well 
 as intra-vascular and secretory phenomena — requires a still 
 stronger solution. For the latter purpose I have gradually 
 increased the strength until I now use a twenty-five-per- 
 cent, solution — i. e., 3 ii- | i. The quality of the preparation 
 may make some difference. I have had some of Merck's, 
 but most of what I have used, and use now, I have ob- 
 tained from Mariani & Co. Although on Oct. 30th I 
 removed, with a four-per^cent. or six-per-cent. solution, I 
 have forgotten which, a papilloma from the anterior com- 
 missure, in a throat exceedingly irritable previous to the 
 application, and the patient averred that he positively did 
 not feel the forceps at all, I am treating a case of tumor 
 now in which nothing short of the twenty-five-per-cent. 
 solution produces anaesthesia." 
 
6o K H. Bosworth. 
 
 Dr. F. I. Knight, of Boston, writes to me under the date 
 of January ii, 1885, as follows: "In brief, my experience 
 has been that operating in the larynx is facilitated very 
 much by the application of a strong solution of the cocaine 
 muriate, especially a twenty-per-cent. solution. The anaes- 
 thetic effect comes on almost immediately and continues for 
 a few minutes. The least effect has been produced on ' slob- 
 berers' in whom the excessive flow of mucus seemed to 
 wash the anaesthetic off. In some cases the reflex has been 
 wellnigh abolished, and operating made correspondingly 
 simple." 
 
 My own experience in the production of laryngeal anaes- 
 thesia adds nothing to the above. I hav6 made a number 
 of applications to the larynx for this purpose, only one of 
 which was in the case of a neoplasm. In this case, while 
 sensibility to the probe was very markedly diminished, I 
 failed entirely in controlling the spasmodic closure of the 
 laryngeal cavity. The same results followed in a number of 
 attempts to anaesthetize the larynx in health and in various 
 states of catarrhal inflammation. I used no solution stronger 
 than four per cent. In most of the cases I used a two-per- 
 cent, solution, and I could not see that the stronger solu- 
 tion differed from the weaker, either in the rapidity or the 
 thoroughness of its action. 
 
 In concluding this portion of the subject I think it may 
 be safely asserted that we possess in the cocaine a drug by 
 means of which the mucous membrane of any portion of 
 the upper air-tract may be rendered insensible to pain, or 
 to use Dr. Elsberg's admirable classification, that " dolorous 
 sensibility" may be completely annulled. Furthermore,, 
 this result can be best obtained by means of a four-per-cent. 
 solution, and in many, if not all cases by means of a two- 
 per-cent. solution. " Tactile sensibility " may also be an- 
 nulled, or so far reduced by the four-per-cent. solution as to 
 very markedly facilitate most of the minor cutting opera- 
 tions, such as operations on the nasal septum, removal of 
 polypi, amputation of the uvula, etc. If Dr. Elsberg's most 
 interesting observations be confirmed by further experi- 
 ence, and " reflex sensibility " can in all .cases be annulled 
 
Cocaine in RhinO'Pharyngo-Laryngology. 6 1 
 
 by his suggestion of a twenty-five-per-cent. solution, it 
 would seem that the new anaesthetic is a perfect remedy. 
 
 COCAINE AS A LOCAL THERAPEUTIC AGENT. 
 
 In a communication to the N. Y. Medical Record for Nov 
 15, '84 I called attention to a new therapeutic use for 
 ■cocaine. This observation I believe to be one of so great im- 
 portance that much of what was stfited in that article I re- 
 peat here with the additional light of a larger and longer 
 experience which fully confirms all that was then claimed and 
 more. 
 
 At that time I wrote : " In using a solution of cocaine in 
 the nasal cavity for its anaesthetic effect I have observed an 
 action which has not, as far as I know, been recorded. When 
 the solution is applied to the mucous membrane, it is 
 followed in about twenty or thirty seconds by a very notable 
 contraction in the venous sinuses underlying the part which 
 it reaches, and as the application is continued over the whole 
 membrane covering the lower and middle turbinated bones, 
 these sinuses become so rigidly contracted that all the blood 
 which they may have contained is absolutely expelled, and 
 the membrane clings closely to the bony structures which 
 then become visible in absolute outline. This action of the 
 cocaine was so entirely unexpected to me in the first case 
 in which I observed it that I continued my observations 
 in a number of cases, and in no single case, out of over 
 forty observed carefully, has it failed to produce the same 
 result. Every drop of blood was expelled from the erectile 
 tissue in each case. The strength used was a two-per-cent. 
 solution, and it was applied by means of a pledget of cotton 
 wrapped on a small probe. The effect was usually observed 
 in a few seconds, and the entire depletion of the Sinuses of 
 the whole cavity accomplished in about three minutes, the 
 production of anaesthesia, as a rule, requiring a longer 
 time." 
 
 Since writing the above my observations have been 
 continued into many hundreds of applications, and the 
 results are uniform, — the iriembrane is bleached almost. I 
 formerly laid especial emphasis on the action of the cocaine 
 
62 F. II. Bosworth. 
 
 on the venous sinuses of the nasal cavity ; a larger observa- 
 tion convinces me that the action is not only upon the ven- 
 ous sinuses but upon the capillaries and blood-vessels as well, 
 with which it comes in contact. 
 
 In watching its effect upon mucous membranes, it has. 
 seemed to me that the true explanation of its action is that 
 it produces rigid contraction in unstriped muscular fibres 
 wherever it comes in contact with them. In this way we 
 can understand how it completely empties the large venous 
 sinuses of the nose, while it only diminishes the calibre 
 of the capillaries and small blood-vessels, for in the intraven- 
 ous spaces of the nasal mucous membrane are found large 
 bundles of unstriped muscular fibres, which act in con- 
 traction not only on the periphery of the sinuses, but also 
 to contract the membrane itself, and draw it down upon the 
 turbinated bones. On the other hand, the contraction of the 
 muscular fibres in the coats of the capillaries and blood-ves- 
 sels, no matter how rigid, can only serve to diminish their 
 calibre, without obliterating them, as is really the case with 
 the erectile bodies. 
 
 That absolute contact with the muscle is necessary to "pro- 
 duce this effect, and that the cocaine does not act through 
 the nerve supply, is shown by the fact that the time required 
 for the cocaine to act upon the blood-vessels is exactly 
 proportionate to the absorptivity of the membrane, or, 
 in other words, by the rapidity with which the membrane is 
 penetrated by the solution. For it is a very noticeable fact 
 that in children, whose mucous membranes are exceedingly 
 delicate, and absorb remedies quickly, the action of the co- 
 caine is strikingly rapid. I have frequently observed the 
 venous sinuses in young children collapse in three or four 
 seconds, while in adults the time required to produce 
 the same result is often three or four minutes. Again, 
 the effect of cocaine on mucous membranes covered with 
 columnar epithelium is far more rapid than on those covered 
 with squamous epithelium. 
 
 We have, then, in the cocaine a remedy upon which we may rely 
 with absolute certainty of its action, that when applied in solu- 
 tion to the surface of a mucous membrane, it penetrates it^ 
 
Cocaine in Rhino-Pharyngo-Laryngology. 63. 
 
 epithelial coat and reaching the coats of the blood-vessels produces 
 rigid contraction of their muscular fibres, and thereby marked 
 diminution in the calibre of the blood-vessels themselves. In our 
 whole pharmacopoeia we possess no other remedy, I think, 
 which may be depended upon to accomplish this with cer- 
 tainty. We have used the various mineral and vegetable 
 astringents for years, as topical agents, but I often think 
 we do it in something of a tentative manner, and rarely 
 with any great confidence of securing the result we desire- 
 Certainly my own long and somewhat large experience in 
 the treatment of throat affections has served to diminish my 
 faith in the value of the ordinary local astringent applica- 
 tions to the mucous membrane of the upper air-passages. 
 
 If the prime factor or the first phenomenon of the inflam- 
 matory process be dilatation of the blood-vessels, from 
 paralysis of their muscular fibres, we possess in cocaine a 
 remedy which directly controls this feature of inflammation, 
 and herein I think lies largely one of the valuable properties 
 of the drug. Acting upon this view, that in cocaine we 
 possess a topical agent which, if properly applied, will con- 
 trol an inflammatory process in the mucous membrane of 
 the air-passages, I have made use of it in a very large num- 
 ber of cases — such as acute and chronic rhinitis, pharyngitis, 
 laryngitis, tracheitis, bronchitis, asthma, etc., — and in no 
 single case have I failed to secure the anticipated result, 
 provided that the drug was made to come in contact with 
 the diseased part. 
 
 I have observed a large number of cases with reference- 
 to the duration of this action of the cocaine, and find that 
 in the very large majority of cases the contraction of the- 
 venous sinuses persists about twelve hours, and oftener a 
 longer time than a shorter one. This is the case if the drug 
 has been thoroughly applied. In cases of acute inflamma- 
 tion of a mucous membrane the action on the capillaries, as 
 a rule, persists for the same length of time, though in a few 
 cases it has been only a few hours. 
 
 The contraction of the blood-vessels is always attended 
 by a diminution of the mucous secretion. 
 
 I might add here that it is of importance that every- 
 
»64 P- H. Bosworth. 
 
 watery solution which is applied to the mucous mem- 
 brane of the air-passages be of a decidedly alkaline reaction, 
 and, therefore, finding that the cocaine solution at times 
 seemed to cause irritation, I always add ten grains of 
 sodium chloride to each ounce of the solution; furthermore, 
 that in the clinical observations here recorded I have never 
 found it necessary to use a solution stronger than two per 
 '<:ent. to secure its full local action. 
 
 Dr. F. H. Hooper' has made some very interesting ob- 
 servations on this action of the cocaine, which confirms 
 fully the above noted views. 
 
 Dr. Cohen, however, writes me on Jan. 12, '85 : " The 
 effect on the turbinated mucous membrane I have 
 jioticed, but cannot accept your explanation. I hope, 
 however, that it will now lead some of our brethren to 
 recognize that these enlargements can be successfully 
 treated by milder measures than the snare or cautery." 
 I add some notes on the morbid conditions in which I 
 ■have found the local action of the cocaine valuable. 
 
 Hypertrophy of the nasal mucous membrane. — Perhaps no 
 one morbid condition is found in the nasal cavity which 
 demands treatment at our hands so frequently as this. The 
 only rational and radical method of treatment is by de- 
 :structive agents. Our usual experience has been that 
 immediately upon the application of a caustic, a violent 
 reaction sets in, the parts becoming actively turgescent, and 
 the patient suffers from three to six days with a most vio- 
 lent " cold in the head." Since using the cocaine this reac- 
 tion has been controlled in a large majority of cases, and 
 whereas formerly my patients often left my office in a far 
 worse condition than that in which they entered it, now it 
 is always with relief, even after violent cauterization. We 
 cannot only cauterize painlessly, but can do it without 
 reaction, and so do it far more effectually. 
 
 Another and notable value of this action of the cocaine is 
 
 as an aid to diagnosis in these cases of hypertrophy. As a 
 
 rule, when we examine one of these cases there is a notable 
 
 amount of turgescence of the sinuses, more or less completely 
 
 ' Boston Med. and Surg. Jour., Dec. 18, '84. 
 
Cocaine in Rhino-Pharyngo-Laryngology. 65 
 
 blocking up the passages. It is impossible to tell how much 
 of this swelling is due to venous turgescence, and how much 
 is due to hyperplasia. By means of the cocaine the ele- 
 ment of turgescence is entirely eliminated, and we c&nnot 
 only estimate the amount of hyperplasia, but can determine 
 the point where the cauterization should be made. 
 
 Acute coryza. — The first stage of an acute coryza is 
 turgescence of the blood-vessels, with diminution of secre- 
 tion from the membrane. I have had an opportunity of 
 making an application to two cases of this disease in the 
 first stage. The cocaine was very thoroughly applied over 
 the whole membrane, with the result of arresting or abort- 
 ing the attack. Sajous, ' writing on this subject, states that 
 in his own case the effect of the first application lasted but 
 twenty minutes. I have had no such experience,'and think 
 that he failed to thoroughly medicate the whole membrane. 
 In the second stage of a cold, or the stage of secretion, I have 
 treated quite a number of cases ; in inost pf these cases the 
 cold was broken up by a single application ; some of them, 
 however, required a second or third application. The re- 
 lief lasted usually from twelve to twenty-four hours. 
 When the trouble recurred it was always in a much milder 
 form. 
 
 Nasal polypus. — In operating upon nasal polypi, one of 
 the greatest difficulties that hampers the operation is the 
 turgescence of the venous sinuses blocking up the passage 
 and obstructing the view. This usually occurs as the re- 
 sult of the first introduction of an instrument into the 
 cavity. By the use of cocaine this troublesome feature of 
 . the operation is entirely eliminated. The congestion of 
 the blood-vessels is so thoroughly controlled that a clear 
 view into the upper regipn of the nasal cavity is obtained, 
 and even small growths recognized and removed. Further- 
 more, the troublesome hemorrhage which so pfter occurs 
 during the operation is very markedly controlled. The 
 bleeding is, I think, as a rule, from the venous sinuses, 
 and these being rigidly contracted, ithis trouble is much 
 diminished. 
 
 ^ Medical News, Phila., Dec. 20, '84. 
 
66 F. H. Bosworth. 
 
 Hay fever. — The morbid condition of the nasal mucous 
 membrane in an exacerbation of this disease consists in a 
 'turgescence of the venous sinuses and blood-vessels, prob- 
 ably from a paresis of the vaso-motor nerves which are dis- 
 tributed to their coats. I have not been able to observe 
 the action of the cocaine in an acute exacerbation of hay 
 fever, but I have applied it in several cases in which the 
 symptoms were present to a mild extent. In each case the 
 result was the same, there was complete relief. 
 
 Sub-acute laryngitis. — In a number of cases of this disease, 
 in which there was hoarseness or more or less complete loss 
 of voice, a single application has resulted in a marked im- 
 provement to the tone of voice, which only partially 
 relapsed at the end of twelve hours, or longer. In those 
 cases in which cough was present, this was entirely arrested 
 for from one to three hours. As is always the case in 
 catarrhal laryngitis, there was a diseased condition in the 
 nasal cavity, which was treated at the same time by the 
 cocaine. 
 
 Acute bronchitis. — I have used the cocaine in several cases 
 of acute bronchitis, or ordinary winter cold. In these cases 
 there was a mild acute inflammation of the whole upper air- 
 tract, extending from the nasal cavities to the pharynx, 
 larynx, trachea, and larger bronchi. There was cough of a 
 more or less distressing and persistent character, and a 
 muco-purulent expectoration. 
 
 The only internal medication given in any of these cases 
 was cubebs, either in the form of lozenges or mixed with 
 glycerine. The plan of treatment was to make daily applica- 
 tions of a two-per-cent. solution to the nasal passages by the 
 probe and cotton pellet, and to the pharynx and larynx by 
 spray. In addition to this, inhalations of the cocaine were 
 also given daily. A very fine atomizer was used (Delano's), 
 and the spray thrown into a large glass-globe inhaler (Sass'), 
 from which the patient inhaled deeply for about two 
 minutes. In this way the coarser particles of the spray 
 fell into the globe, while only the finer ones were carried 
 intp the trachea and large bronchi. I usually sprayqd 
 from four to six drachms of the solution, all of which except 
 
Cocame in Rhino-Pharyngo-Laryngology . 67 
 
 from thirty to forty minims was subsequently poured back 
 from the globe into my bottle. After the cocaine inhalation a 
 short inhalation of fluid vaseline (the " Cosmoline," of E. F. 
 Houghton & Co.) was given to allay any irritation which 
 might be caused by the cocaine. The result was that in 
 each case the cough was usually arrested for from one to 
 three hours, and markedly relieved for the rest of the day. 
 The colds were broken up in four or five days. It may be 
 that these patients might have gotten well in as short a 
 time by an ordinary cough mixture, but certainly at the 
 time there could be no question as to the effect of the in- 
 halations. 
 
 The following cases are added as affording many points 
 of interest, and I think illustrating in a striking manner the 
 local action of the cocaine. 
 
 A Case of Senile Bronchitis — Cure. 
 
 I was called on Nov. 30th to see Mrs. P., set. seventy-seven, 
 who had been suffering for a month with a violent cough. She 
 had been taking various remedies with no relief. The cough was 
 of a very harsh, racking character, coming on in paroxysms which 
 lasted oftentimes a half hour or longer, and gave her little rest 
 night or day. When I first saw her she seemed to be much worn 
 and exhausted from loss of sleep and the violence of the cough. 
 There was considerable wheezing with shortness of breath. An 
 examination of her chest revealed the lower portion of each lung 
 full of moist rales. There was also more or less sibilant and 
 sonorous rales. The expectoration was of a bright yellow color 
 and large in amount. The heart's action was weak, and the pulse 
 intermittent and 100 to no. She was of remarkably fine physique 
 and had also a superior constitution, but her bronchial disorder 
 •was evidently telling very much on her. I determined to use the 
 cocaine and therefore gave no medicine whatever. I feared some- 
 what to go too rapidly with her, being ignorant as to how much 
 of the drug might be administered at her age and in her condi- 
 tion. Commencing with light applications to the nasal cavity^ 
 pharynx, and larynx, I found the action of the remedy to be abso- 
 lutely neutral. It did neither harm nor good. On the fourth, 
 day I began giving inhalations in the manner described for acute 
 bronchitis. I found that the relief given was marked, and the re~ 
 
68 F. H. Bpsworth. 
 
 suit was a quiet night's rest without coughitjg. The cough, how- 
 ever, began again in the morning, — the inhalation havihg been 
 given at night. From that time I gave her inhalation night and 
 morning until Dec. 20th. During this time an examination of the 
 chest showed a marked and progressive improvement. The bron- 
 chial tubes cleared up, the shortness of breath improved, and the 
 riles disappeared. On Dec. 20th an examination of the chest re- 
 vealed no abnormal sign, and her cough had entirely disappeared. 
 
 It may be said in regard to this case that the inhalation 
 could not have carried the remedy dovsrn to the lower air- 
 passages. In inhaling she held the mouth-piece of the 
 globe in her mouth, and every breath she took was charged 
 with cocaine, which must have reached well down into the 
 bronchial tubes. I feel confident that she was cured by the 
 inhalations, and I think she could not have survived long 
 had she not gotten this relief, and soon. It should be 
 stated also that this was during the very trying weather 
 which we had through the month of December. 
 
 This case was of especial interest as showing the actions 
 of the cocaine in controlling the secretion of the bronchial 
 mucous membrane, for not only was the improvement 
 noted by ausculation, but the character of the expectora- 
 tion changed from a muco-purulent to a healthy mucous 
 discharge. The only explanation of this is in the action of 
 the drug in controlling the blood supply, diminishing the 
 calibre of the blood-vessels, and thereby lessening the 
 mucous secretion and cell-proliferation. 
 
 A Case of Spasmodic Asthma. 
 Mrs. K., age thirty-seven, married, consulted me November 18, 
 1884, giving the following history : Since the age of twenty-five 
 she had been a sufferer from asthma, with cough and expec- 
 toration ; the paroxysms coming on usually at night or toward 
 morning, and while they lasted being of a very severe character. 
 Her attacks finally became so distressing that in 1877 she went 
 to Colorado to live, where she was entirely well. Whenever she 
 came East, however, her attacks returned. She left Colprado 
 in October, and on her way her attacks commenced. She 
 arrived in New York November 17 th, and saw me on the follow- 
 ing morning. She was suffering at that time very severelyj the 
 
Cocaine in Rhino-Pharyngo-Laryngology. 69 
 
 attack having lasted eight days. On questioning her in regard to 
 a nasal disorder, she acknowledged having some catarrh, but 
 never associated it with her asthma, and was greatly surprised at 
 my suggestion of a connection between the two affections. In 
 Colorado she was free from asthma, but not from catarrh. She 
 also remembered that her attacks were preceded by cold in the 
 head, but had thought nothing of it. An examination showed 
 her chest full of loud sibilant and sonorous rales with some finer 
 moist mucous rales. In the nasal passages I found a marked de- 
 flection of the septum to the left, with enlarged right middle 
 turbinated bone. There was also notable turgescence of the 
 mucous membrane of the whole cavity, and as a result, marked 
 stenosis. 
 
 I applied cocaine freely to each nasal cavity, which, by the way, 
 was exceedingly sensitive, and in ten minutes her asthma had 
 completely disappeared, and no rale could be heard in the chest. 
 This relief lasted several hours, but at eleven o'clock the same 
 night I saw her at her room. She was feeling uncomfortably, 
 and feared her asthma was coming on. I applied the cocaine 
 and she was completely relieved and passed the night with entire 
 comfort. 
 
 I saw her daily from this time on, making applications of 
 the cocaine, and at the same time treating the nasal disorder, 
 which I was able to do without exciting any notable reaction, 
 using caustics, the snare, etc. The improvement was very marked 
 and most satisfactory. Occasionally she would feel somewhat 
 oppressed from a particularly bad day, but was always relieved by 
 the cocaine. After three weeks of treatment she was so well that 
 she considered herself cured of her asthma, and was entirely free 
 from it. Her nasal disorder, however, was not entirely cured, and 
 she was coming to my office but twice each week. Early in Jan- 
 uary, during one of our exceedingly bad-weather days, she caught 
 cold and had an attack of asthma. This was relieved, however, 
 and with this exception she has been made entirely comfortable 
 by the applications. 
 
 This case seems to present so many points of interest 
 that it is my excuse for repeating it. She is not entirely 
 cured of her liability to asthma, but the prognosis is very 
 favorable ; her nasal trouble, on which her asthma depends, 
 is a curable one, and when that is cured her asthma is 
 cured. Were nothing else accomplished than enabling her 
 
7o F. Hi Bosworth. 
 
 to remain in the East this winter, submitting to daily appli- 
 cations of cocaine, it would be a great gain. For were she 
 not relieved by the cocaine ; our pharmacopoeia furnishes us 
 with no remedy which could give relief. Opiates and 
 anodynes she had used, and numberless other remedies, with 
 most unsatisfactory results ; the cocaine gave her such relief 
 as she had never before experienced, quickly, safely, and 
 without disordering the digestive organs. 
 
 I have seen a very large number of cases of so-called ner- 
 vous or spasmodic asthma, and in none have I failed to find 
 some nasal disorder, the relief of which has given relief to 
 the asthmatic trouble. I, therefore, in the above case had 
 no hesitancy in assuring my patient that the temporary 
 relief to the nasal turgescence would result in relief to 
 her asthma, and hence, when I first saw her I made the ap- 
 plication of the cocaine to the nasal cavity rather than to the 
 bronchial tubes. The permanent cure of these cases can, of 
 course, only be accomplished by removing the organic 
 disease in the nasal passages. 
 
 Had the local application to the nares been ineffectual, I 
 should have made the attempt to give inhalations of the 
 cocaine, in the full faith of its giving relief,, with the view 
 that the morbid condition of her bronchial mucous mem- 
 brane was essentially the same as that of her nasal passages. 
 
 In closing, I have only to add that I have endeavored to 
 record my experiences with cocaine as a local therapeutic 
 agent with absolute candor, and that I do not believe I have 
 made a single claim for it which will not be confirmed 
 by careful observation. Scarcely a patient has been in my 
 ofiflce in the past two months and a half on whom the 
 cocaine has not been used. In no single case where the drug 
 was used to diminish the flood supply to a part, has it failed 
 to do so, and this so promptly and so patently that I think 
 I am fully justified in the assertion that our pharmacopoeia 
 contains no remedy so certain in its action, and few, if any, 
 so valuable as a topical agent. 
 
 In using the cocaine as freely as I have done in giving in- 
 halations, the question arose whether I might not be 
 in danger of administering too large an amount. A very 
 
Cocaine in Rhino-Pharyngo-Laryngology . 71 
 
 careful observation on this point has failed to detect 
 any symptoms whatever which would indicate that the.drug 
 had in any case acted upon the general system. I have also 
 watched with some care for evidence of a reaction following 
 the local use of cocaine. None has .been observed ; on the 
 contrary, its action seems to Joe that of a tonic to the 
 relaxed muscular fibres of the blood-vessels, for after the 
 drug has ceased its action, and the coats of the blood-vessels 
 relax, this relaxation does not, as a rule, reach to the extent 
 of the former dilatation. 
 
 In several instances I have placed in the hands of my pa- 
 
 , tients a two-per-cent. solution of the drug, with directions 
 to make daily application with the Delano atomizer; in no 
 instance have I discovered that it exercised any other than 
 a purely local action. In one of these cases the applications 
 have been made daily for six weeks. So far as our investi- 
 gations have gone, therefore, I think we may safely assert 
 that there is no danger of a " cocaine habit " being estab- 
 lished. 
 
 In two cases the use of cocaine seemed to be followed by 
 a violent headache. This came on about twelve hours after 
 the drug was applied, or just at the time when its action 
 was passing off. The headache lasted two or three hours, 
 .and was quite severe in character. My suspicion was 
 excited that the headache might be the result of the cocaine 
 application, but in no case did it occur from a second 
 application of the drug. Moreover, no such reaction was 
 observed in the very large number of other cases in which it 
 was used. 
 
COCAINE IN GENERAL SURGERY. 
 By R. J. HALL, M.D. 
 
 AS all the more-important published observations in this 
 department have been already noticed in a previous 
 portion of this paper, it only remains for me to add a few- 
 cases, not previously published, with some further experi- 
 ments of my own on the subject, and to indicate the cases 
 and the methods of using which promise the best results. 
 Wherever an operative procedure is limited to a mucous 
 membrane and the incisions required are superficial, it will 
 be sufficient to apply the cocaine by spray or brush, though 
 this may not be in all cases the speediest or most conven- 
 ient method. Where, however, the integument or the 
 deeper parts are involved, hypodermic injections must be 
 used, and my experience and observations, so far, indicate 
 strongly that the only way in which rapid and reliable results 
 can be obtained is by controlling the nerve supply of the 
 part in the way described in a previous communication by the 
 writer {N. Y. Med. Jour., Dec. 6, 1884). Thus, a number of 
 physicians have told me that that they found cocaine of no 
 value in the common and very painful operations upon the 
 hands, such as incising felons, opening palmar abscesses, etc., 
 yet these are among the very cases in which, properly applied, 
 it seems likely to be most useful. My experience in the 
 injection of the solution in the neighborhood of large nerve 
 trunks has been almost limited to the branches of the tri- 
 geminus and the nerves supplying the hand. In the latter^ 
 region I have succeeded, both in myself and in others, in 
 producing complete insensibility of the parts supplied by 
 the median, the radial, and the ulnar nerves. 
 
 72 
 
Cocaine in General Surgery. 73-, 
 
 The median can be found with great certainty as follows : 
 The needle should be introduced about one third of an 
 inc'h, at a level of about half an inch above the extremity of 
 the styloid process of the radius, and close to the radkl side 
 of the tendon of the palmaris longus, the point being 
 directed beneath this tendon ; or, if the palmaris longus is 
 absent, a quarter of an inch to the ulnar side of the flexor 
 carpi radialis. The ulnar can of course be injected at the 
 elbow between the olecranon and the internal condyle, but a 
 few experiments lead me to believe that unless a rather 
 large quantity is used, and the nerve actually pierced, the- 
 results are not very certain here, and it will probably be 
 better to make the injection near the wrist, close to the 
 radial side of the tendon of the flexor carpi ulnaris, anywhere 
 between the styloid process of the ulna and two inches 
 above it, introducing the needle about a third of an inch. 
 If it is desired to include the dorsal branch of the ulnar, the 
 hi'gher point must be taken. There might seem to be 
 some risk in making the injection here on account of the 
 proximity of the ulnar artery, but once the skin is pierced,, 
 the needle passes so readily that the force necessary would 
 not transfix the artery, and it can be further avoided by 
 keeping close to the tendon. I have succeeded in affecting 
 the radial by making the injection where it emerges from 
 beneath the tendon of the supinator longus and just above 
 the muscular belly of the extensor ossis metacarpi pollicis. 
 Success here, however, seems rather less certain than in- 
 the case of the other two. 
 
 In the domain of the trigeminus I have had the oppor- 
 tunity to use cocaine twice fdr Dr. Sands, in operations for 
 the removal of tumors of the floor of the mouth. 
 
 In the first case, which involved the removal of the right 
 sublingual gland through the mouth, ttl xvi. of a four-per- 
 cent, solution were injected, the needle being introduced 
 ^long the inner surface of the ramus of the inferior maxilla. 
 After eight minutes no effect had been produced except a 
 slight tingling along the side of the tongue. The needle, 
 as I ascertained by later experiments, had been passed too- 
 far back ; lU viii. injected by the side of the tongue had no- 
 
74 R- J- Hall. 
 
 ■effect, and a few minutes later ill xvi. were again injected 
 along the ramus, and in the usual time (three to six minutes) 
 -sensibility was almost abolished in the right half of the 
 tongue, the floor of the mouth, and the posterior surface of 
 the gums. Anaesthesia,- however, was not absolute. The 
 patient, a young man, then held his mouth open, and the 
 tip of the tongue against the palate, while the tumor was 
 excised by Dr. Sands with scissors and forceps, and the 
 bleeding poinsts secured. He winced occasionally during 
 the operation, and afterward said that it had hurt him, but 
 not very badly, — " not as much as pulling a tooth." Anae- 
 thesia was incomplete in this case obviously because the 
 ■needle was passed too deeply. 
 
 The second case was as follows : slowly-growing epithe- 
 lioma of the floor of the mouth occurring in a gentleman of 
 about sixty. The tumor has been removed four or five 
 times at irregular intervals, extending over a period of 
 about five years. It now occupies the right side of the 
 floor of the mouth, from the median line, extending along 
 the posterior surface of the gums, on which it slightly en- 
 croaches, and about one inch backward. Before I saw the 
 patient ni x. of a four-per-cent. solution had been injected 
 into the floor of the mouth, posterior to the growth, with- 
 out producing any effect ; fii viii. were injected along the 
 internal surface of the ramus of the jaw, passing the needle 
 one half inch, and drawing it out a very little as the injec- 
 tion was made. In six minutes there was complete-insensi- 
 bility of the right side of the anterior portion of the tongue 
 and floor of the mouth, with much diminished sensibility, 
 but not complete anaesthesia of the posterior surface of the 
 :gums ; Til X. were injected as before, but keeping a little 
 closer to the bone. In two minutes there was complete 
 -anaesthesia of the right half of the tongue, the floor of the 
 mouth, and posterior surface of the gums. (Whether the 
 lower lip was affected, as it should be, or not, I did not 
 ascertain in this case, but know from other experiments that 
 when the injection is successful it is completely anaesthe- 
 tized, exactly to the median line.) The epithelioma was 
 ithen freely excised by Dr. Sands with the knife, and several 
 
Cocaine in General Surgery. 75 
 
 bleeding points tied. The posterior surface of the gums 
 near the median line was scraped with a sharp spoon. .Dur- 
 ing the operation, which was completed in fifteen minutes, 
 the tongue was drawn up and to one side with sharp hooks. 
 No pain was felt at all, except when a suspicious point on the 
 ■upper surface of the gums, posteriorly, was scraped with a 
 sharp spoon. The patient stated afterward that this was 
 the only p'art of the operation which he felt. In this case, 
 a few hours after the operation, some hemorrhage occurred 
 from two small vessels, which had to be tied. The ques- 
 tion naturally arose whether the cocaine, which renders 
 mucous membranes anaemic, might not act as does the Es- 
 march bandage, and increase the oozing after the operation. 
 I do not think, however, that this is the case. There was 
 no general oozing, but hemorrhage from two distinct ves- 
 ■sels. Moreover, in this and in a number of operations which 
 I have performed with cocaine anaesthesia, the parts were 
 not rendered anaemic, the bleeding during the operation 
 was as free as would be expected, and there was never any 
 special subsequent oozing. 
 
 In my previous paper, I mentioned the use of cocaine in 
 Dental Surgery. Some additional practical points may be 
 of value. Dr. Nash, who first employed it, at my suggestion, 
 in this way, and has since used it quite extensively, thinks a 
 curved needle convenient for reaching the inferior dental. 
 Of course, when this is anaesthetized, all the lower teeth on 
 that side are insensitive. It is a rather remarkable fact that an 
 injection at the mental foramen will anaesthetize the two in- 
 ■cisors and the canine, with the corresponding portion of the 
 anterior surface of the gum, besides the half of the lower 
 lip. A corresponding effect is produced in the upper jaw 
 by an injection at the infra-orbital foramen ; and in two 
 ■cases a repetition of the injection here has caused 
 almost complete anaesthesia of the two bicuspids and the 
 •corresponding portion of the gum. Some only partially 
 successful experiments have convinced me that with a little 
 practice it will be easy to reach the infra-orbital nerve from 
 the mouth wKere it enters the infra-orbital canal. The 
 needle should be passed almost an inch along the tuberosity 
 
;6 R. y. Hall. 
 
 of the superior maxilla, the point being directed slightly- 
 backward and inward. Whether it will be found advisable 
 to make such deep injections in such a region, merely for 
 dental purposes, is of course doubtful, but it would un- 
 doubtedly be useful in operations on the superior maxilla, 
 and perhaps also in severe trigeminal neuralgia, should the 
 drug prove useful in these cases. In the few cases where I 
 have tried it no harm has resulted. The nerve could un- 
 doubtedly be reached more easily by passing the needle 
 along the external inferior angle of the orbit, but this would 
 appear much more alarming to the patient. Twelve to fif- 
 teen minims of a four-per-cent. solution seems to be the 
 amount generally necessary for a satisfactory result, unless 
 the nerve is very small. The anaesthesia is usually complete 
 in six minutes, and commences, to disappear about fourteen 
 minutes later. If the injection is repeated while the anaes- 
 thesia is at its height, the second result lasts longer, — in 
 some cases, thirty-five to forty minutes, — and appears to 
 last longer after each subsequent injection. In this way 
 I have kept up complete anaesthesia of one half of the lower 
 lip for over two hours, by the use of fifty minims in divided 
 doses. This will be of importance in plastic operations on 
 the face, and others which require some time. After these 
 repeated injections there is, at least sometimes, markedly 
 diminished sensibility of the part affected for from twenty- 
 four to forty-eight hours. In this way it may possibly be of 
 even permanent benefit in obstinate cases of neuralgia. 
 Before leaving this part of the subject, I would suggest that 
 it may be of value anatomically in mapping out areas of 
 nerve distribution. 
 
 Where no large nerve-trunk can be found supplying the 
 seat of operation, the principle can still be employed. It is 
 only necessary to more or less completely surround the 
 part, according to the directions from which its nerve sup- 
 ply is derived, by from three to five injections of about four 
 minims each very superficially beneath the skin. Using it 
 in this way. Dr. Halsted has operated successfully on four 
 cases of iistula in ano, where quite extensive sinuses were 
 opened up and scraped with the sharp spooij. In one case 
 
Cocaine in General Surgery. ' 27 
 
 sixty minims were injected in divided doses, with no other 
 constitutional effects than the production of marked pallor. 
 I have said nothing about the use of cocaine in general 
 surgery, by its mere application to mucous, ulcerated, or 
 raw surfaces, because in most cases the method suggests 
 itself. We have applied it in this way, in the Roosevelt 
 Hospital Out-door Department, to a number of cases of 
 chancroid, before cauterizing with nitric acid, and with per- 
 fect success. Dr. Halsted has performed internal urethro- 
 tomy, after injecting the urethra with an ounce of the four- 
 per-cent. solution. The patient stated that the operation 
 did not hurt him as much as the passage of an ordinary 
 sound. I have completely relieved the pain of an attack of 
 inflamed and prolapsed hemorrhoids, by the introduction 
 of a hollow suppository containing fifteen minims of the 
 solution, and after a second suppositary three hours la.ter 
 the pain did not recur. 
 
 It remains for me to consider the objections to the use 
 ■of cocaine. After an injection there remains for from 
 twenty-four to thirty-six hours a soreness at the point 
 where the needle was introduced, exactly like that of 
 a. rather severe bruise. This is not felt while the part is at 
 rest, but only on pressure or muscular movement, and it is 
 at worst but a trifling annoyance. The injection of fifteen 
 minims usually causes no constitutional symptoms, but 
 sometimes gives rise to dizziness, pallor, and dilatation of 
 the pupil. A second dose of fifteen minims within ten 
 minutes of the first generally produces slight symptoms if 
 the patient is standing or sitting, but, as mentioned in one 
 case above, much larger amounts are often borne, when the 
 patient is lying down, without any thing more being ob- 
 served than pallor and dilatation of the pupil. As Dr. Knapp 
 has shown, much smaller amounts may cause unpleasant 
 • symptoms if rapidly carried into the circulation. After 
 purposely producing dizziness and quite decided nausea in 
 myself, by the injection of fifty minims of the four-per-cent. 
 . solution in rapidly repeated doses, the dizziness was com- 
 pletely and immediately relieved, and the nausea almost 
 so, by inhaling amy! nitrite,— which suggested itself as a 
 
78 R. y. Hall. 
 
 probable physiological antidote, — until the face was slightly 
 flushed. This did not interfere with the anaesthetic effects 
 of the drug at all. Time and more extensive experience 
 can, of course, alone enable us to decide whether its use, 
 especially by the injection of nerve-trunks, is ever followed 
 by any more permanent ill effects than those mentioned 
 above. 
 
USE OF COCAINE IN GENITO-URINARY AND 
 MINOR SURGERY. 
 
 By E. L. KEYES, M.D., 
 
 PROF. AT THE BELLEVUE HOSPITAL MEDICAL COLLEGE. 
 
 MY personal experience in the use of the hydrochlor- 
 ate of cocaine relates to its employment in genito- 
 urinary cases, in dermatology, in minor surgery. I have 
 employed it in watery solution of two and four per cent., 
 and as a six-per-cent. oleate. In the urethra my experience 
 leads to the conclusion that the effect of the solution in 
 abolishing sensibility is mainly confined to the surface of 
 the canal, and that this effect is more marked in the an- 
 terior than in the deeper parts of the urethra. 
 
 If a four-per-cent. solution is painted several times over 
 the meatus and near it upon the glans penis, and assisted 
 by an injection of ten minims into the urethra, the latter 
 being retained by compressing the meatus for a few min- 
 utes, meatotomy and the division of a stricture near the 
 orifice with a straight bistoury may be accomplished some- 
 times without pain. Generally, if the cut is deep, a little 
 pain is complained of, yet so little that it is unimportant. 
 
 By injecting twenty minims and retaining it in the same 
 manner the instrument iox cutting strictures in the pendulous- 
 urethra may be adjusted without pain, but I have not 
 found, in several cases in which I have used the method,, 
 that the pain experienced during stretching the urethra 
 preparatory to the final cut could be abolished. It is 
 lessened undoubtedly, but not ovefcome, and the pain 
 caused by the knife in the final cut is undoubtedly also les- 
 sened but not destroyed. The deeper the stricture from the: 
 
 79 
 
:8o E. L. Keyes. 
 
 meatus the less positive has been the effect in my hands. 
 I have in this manner performed V,?^/ internal urethrotomy ; 
 but as I have already stated, the success is decidedly less 
 -satisfactory than for cutting in the anterior segment of the 
 canal. 
 
 I think it probable that this difference of result is due to 
 
 the fact that the injected fluid, unless the quantity thrown 
 
 in is considerable, naturally lies in the front part of the 
 
 •canal, being squeezed forward out of the deeper parts by 
 
 the contractile urethral walls. 
 
 In cases of irritable neck of the bladder, where exploration 
 was desirable I have not found as much advantage from the 
 remedy as has been claimed by Dr. Otis in his report. To 
 -introduce the solution I have used the Ultzmann syringe 
 and deposited about ten drops in the neck of the bladder 
 and along the prostatic and membranous urethra. The 
 -advantage derived from this manoeuvre has been in itiy 
 -bands very moderate. 
 
 One good effect in this region I can attest. In one 
 patient I had occasion, to inject the prostatic urethra with a 
 strong solution of the nitrate of silver, about half a drachm 
 to the ounce. I had done this several times, the effect 
 being that the pain on making the injection was considera- 
 ble and the frequency of urination and pain during the act 
 very great for twenty-four hours. In this case I tried the 
 cocaine, following it in five minutes with the nitrate-of- 
 silver instillation at the usual strength. The pain on intro- 
 ducing the deep urethral syringe was not materially altered, 
 the discomfort immediately attending the nitrate-bf-silver 
 application was as great as before, but no desire *to urinate 
 followed, and the subsequent urinary acts were not attended 
 -by the usual smarting pain. This result I considered satis- 
 factory. 
 
 I have not injected cocaine into the bladder, but I have 
 employed it in deep urethral injection for sub-acute ^^«^r- 
 rhoeal cystitis without any apparent effect. 
 , For the urethra, then, my experience leads me to con- 
 clude that the agent in question is valuable for catheteriza- 
 ^tion, sounding, explorations, etc., particularly in the front 
 
Cocaine in Genito-tlrinai^y and Minor Surgiry. 8l 
 
 parts of the urethra, less so as we progress more deeply in 
 the canal; but that some effect is obtained throughout. 
 Doubtless with stronger solutions used in larger quantity 
 more satisfactory results may be attained. 
 
 Preparatory to making cauterizations for mucous patches, 
 venereal ulcers, and the like, removing warts, excising chan- 
 cres and small growths upon the penis, the cocaine solution 
 is very valuable in relieving pain, but the effect is not uni- 
 formly great upon all subjects, yet it has been obvious in 
 all where I have tried it. 
 
 About the mouth, nose, and throat the same remark holds 
 good. 
 
 In spraying ten minims of a four-per-cent solution into 
 the throat of a gentleman on several occasions, I have 
 noticed that the patient sometimes complained of a sense 
 of constriction about the muscles of the throat, a choking 
 sensation with tendency to swallow and cough, quite disa- 
 greeable and lasting several minutes, attended by dizziness, 
 followed slowly by exhilaration and then a sensation of con- 
 siderable comfort, with anaesthesia. 
 
 Using the drug subcutaneously, ten to twenty minims of 
 the four-per-cent. solution, I have removed a great number 
 of wens, warts, moles, lipomata, fibromata, etc., with a uni- 
 form result. No pain was experienced in the cutting, tying 
 vessels, sponging the raw wound, applying the sutures, un- 
 less the operation was prolonged, in which case sensibility 
 gradually returned. 
 
 In one case I performed circumcision in an adult, injecting 
 twenty minims of a four-per-cent. solution into the redun- 
 dant prepuce, and when the cutaneous sensibility had been 
 abolished, cutting away the prepuce with its enclosed in- 
 jection. The result was not satisfactory. The injected 
 cellular tissue seemed redundant, and made accurate coap- 
 tation of the cut surfaces more troublesome than is usual, 
 and the effect of the injection was not maintained long 
 enough, so tliat the final application of the sutures was per- 
 haps as painful as if nothing had been used. The case did 
 
 well. 
 
 I was much gratified with the result obtained in cutting 
 
82 E. L. Keyes. 
 
 out a small ulcer which I believed to be an epithelioma at 
 the margin of the anus. I injected about ten minims of the 
 four-per-cent. solution under the ulcer, stretched the 
 sphincter with a speculum, distending to a circumference 
 of about six inches, and excised the ulcer and a few fibres 
 of the underlying muscle quickly — with pain, it is true, but 
 a pain easily tolerated, and not causing the patient to shrink 
 or pull away from the instruments either during the opera- 
 tion or the subsequent manipulations to arrest hemorrhage. 
 
 Two of my cases did badly : one, a broken-down hospital 
 patient, had considerable suppuration follow the removal of 
 a lipoma, as large as an almond in the shell, from his fore- 
 arm ; and in another case, that of a medical student appar- 
 ently healthy, diffuse suppuration of the forearm, with mild 
 lymphangitis and the subsequent formation of many small 
 cutaneous abscesses in the neighborhood, followed the ab- 
 latin of a small wart, a third of an inch in diameter, under 
 which I injected five minims of the four-per-cent. solution. 
 That the cocaine was at fault in this case I cannot affirm. 
 
 The six-per-cent. oleate I have used with temporary ad- 
 vantage (but no permanent effect) in relieving anal pruritus 
 and the itching of eczema. 
 
 I believe that in cocaine we have an agent of great pres- 
 ent value and of much future promise. 
 
 Appendix.— Dr. T. N. Otis kindly permitted me to in- 
 sert the following statement, taken from a letter, into this 
 pamphlet : 
 
 " I think that an important point is in the necessity 
 which I have found of waiting fully fifteen or twenty min- 
 utes after the introduction of the cocaine before attempting 
 operative procedures. To-day, in a rare case of spasm in 
 the penile urethra, at two and a half to four inches from 
 the orifice, the spasm did not give way until twenty min- 
 utes after the introduction of a four-per-cent. watery solu- 
 tion, and then only after the glans had become shrivelled 
 and cold. Up to that time only a No. 4 French bougie 
 could be passed ; after that a No. 28 was passed, and with- 
 drawn without holding. [H. K.] 
 
COCAINE IN GYNECOLOGY AND OBSTETRICS. 
 
 By W. M. polk, M.D., 
 
 PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE MEDICAL DEPARTMENT 
 OF THE UNIVERSITY OF THE CITY OF NEW YORK. 
 
 THAT this remedy may be of service in a number of the 
 operations upon the female genital tract is shown 
 by its action in the few in which it has been tried. 
 
 The results obtained in the operations upon the cervix 
 are quite satisfactory. The normal sensitiveness of this 
 portion of the uterus being less than that of most of the 
 tract, we have a tissue that can be readily influenced by the 
 drug. Consequently, trachelorrhaphy, incision of the cervix, 
 forcible dilatation, the application of caustics or the sharp 
 curette to the cervical surface, have all been satisfactorily 
 performed under the influence of cocaine. Even in cases of 
 commencing cancerous disease, we have been able to make 
 a free application of the actual cautery, causing but trivial 
 discomfort ; the well-known danger of the general anaes- 
 thetics — even ether — in advanced cancerous cachexia making 
 the use of this remedy in such cases peculiarly attractive. 
 The method of application that seems best in preparing the 
 cervix for operation, is to inject from three to five minims 
 of a four-per-cent. solution into the regions that are to be 
 cut, stretched, or scraped. 
 
 In all cases where, from the use of the Sims speculum, 
 prolonged stretching of the perineum is to be endured, the 
 whole of the posterior and lower half of the vagina should 
 be thoroughly painted. 
 
 In operations upon the vagina we meet with more diflS- 
 
 83 
 
84 W. M. Polk. 
 
 culty, owing to the greater sensitiveness of the tissue ; still 
 by careful injections into the region to be cut we have made 
 satisfactory operations. 
 
 The most striking results were obtained in small vesico- 
 vaginal fistulae. Here the remedy (four minim of a four- 
 per-cent. solution) was injected first on one side of the 
 fistula, — half an inch away, — then on the other. Next the 
 mucous membranes of the vagina and the bladder around 
 the opening were freely* painted with the solution. The 
 tissues were then cut without discomfort. Operations for 
 restoration of the perineum were less satisfactory, the sensi- 
 tiveness of this region being perhaps more pronounced than 
 in other regions of the tract. Our observations, however, 
 have led us to believe that in certain cases where the lesser 
 forms of perineal rupture are found, the remedy could be 
 made to answer a useful purpose. Certainly, in the removal 
 of wire stitches from the perineum, a procedure that is 
 usually very painful, the results have been satisfactory. 
 The best method of applying the remedy in all operations 
 about the perineum is to inject four or five minims of a 
 four-per-cent. solution into the two sides of the vagina, just 
 within the ostium, and then carefully rub the same solution 
 into the skin and pseudo-mucous membrane which covers, 
 first the perineal region and lower end of the labia 
 majora, the second, the faces of the torn perineum and the 
 inner faces of the labia ; lastly, freely applying it to the 
 whole of the lower third of the posterior and lateral vaginal 
 walls. In all of these surface applications the tissue should 
 iirst be carefully cleansed with soap and water and then 
 dried. 
 
 In the removal of urethral caruncles, bodies well-known 
 to be more than usually sensitive, we have operated with 
 the cautery without pain, first injecting into the tumor four 
 minims of a four-per-cent. solution. 
 
 In like manner we have cauterized painlessly chancroids 
 and chancres, securing the anaesthesia in such cases by 
 merely painting over the sore some half a dozen times with 
 the four-per-cent. solution. 
 
 In estimating the value of cocaine in gynecology, it . 
 
Cocaine in Gynecology and Obstetrics. 85 
 
 should be understood that its field is limited. There are 
 many women who are too sensitive, too apprehensive, to be 
 kept quiet during a protracted operation by any thing short 
 of general anaesthesia. 
 
 In general it may be stated that in the lesser operations, 
 and even in those that require time, when the subject is 
 phlegmatic and endowed with self-control, cocaine will 
 prove satisfactory. 
 
 IN OBSTETRICS. 
 
 Naturally attention was early directed to the possibilities 
 of the remedy in obstetrics. A good article of cocaine 
 was furnished Dr. Le Fevre, the House Physician of the 
 Second Medical Division, Bellevue Hospital, and he was 
 directed to try its efificacy in various stages of labor. Dur- 
 ing the first stage of labor injections of four minims of the 
 four-per-cent. solution were made into the anterior and 
 posterior lips, at the vaginal junction. Complete anaesthe- 
 sia of the cervix was obtained for an hour, during which 
 time the labor pains were so modified that the patients 
 complained only of discomfort above the symphysis pubis 
 and some dull pain over the sacrum. The cervix could be 
 stretched freely without causing pain, so that it was quite 
 evident that decided relief had been obtained. An eiTort 
 was made to secure the same result by merely painting the 
 solution over the cervix, but owing to the profuse mucous 
 discharge this application was difficult and the results un- 
 satisfactory. 
 
 To modify the pains of the second stage, injections were 
 made into the vaginal walls along the course of distribution 
 of the pudic nerves. In this the results were so far suc- 
 cessful that the child's head passed out of the vagina with 
 so little discomfort that the patient uttered no complaint. 
 Careful observation of all the children of these cases 
 showed no ill effect of the remedy. When rupture of the 
 perineum occurred, the remedy was injected into the torn 
 surfaces and rubbed on the skin. In this way sufificient 
 anaesthesia was obtained to permit of the easy passing of 
 
86 W. M. Polk. 
 
 sutures for repair. During labor cocaine seems to possess 
 no special advantages over chloroform, unless it be in those 
 cases where this remedy is contra-indicated. 
 
 In cases requiring dilatation of the cervix, as by Barnes 
 dilators, it may prove of great service. In one case of 
 troublesome nausea and vomiting of pregnancy. Dr. Le Fevre 
 found an eroded and sensitive os as the cause. Careful 
 painting of the surface with a four-per-cent. solution of co- 
 caine gave entire relief from the gastric disturbance. Ex- 
 cellent results were likewise obtained in cases of nursing 
 women who had painful and eroded nipples. The four- 
 per-cent. solution was freely applied to the nipples, fifteen 
 minutes before nursing, then washed off with warm water 
 just before applying the child. In all these cases the dread- 
 ful and wearing pain was either entirely relieved, or else so 
 modified as to be quite bearable. And here we may say 
 that if obstetrics derived no other benefit from cocaine than 
 this, we would have sufficient ground for hearty commen- 
 dation. 
 
 IN GENERAL SURGERY. 
 
 How far cocaine will prove beneficial here cannot be said, 
 but as a contribution to the subject we will give the results 
 obtained in a case of hepatotomy performed some weeks 
 ago. 
 
 The patient was a man of seventy-two years of age, who, for 
 four years, had been suffering from an hydatid tumor of the liver, 
 which touched the abdominal wall in the region of the gall blad- 
 der. Two months ago it began to suppurate, which led to such 
 enormous distension as to threaten the patient's life, as much from 
 pressure as from other causes inherent to it. It was evident that 
 the cyst must be evacuated, and that too by a free incision. 
 
 The condition of the patient was such that the effects of any 
 general anaesthetic were greatly feared. Therefore it was deter- 
 mined to perform the operation under the effects of cocaine. The 
 skin over the tumor was carefully cleansed with soap and water, 
 and then the four-per-cent. solution was rubbed in for half an 
 hour. Prof. J. Williston Wright, Dr. Stone, and Dr. Ashton assist- 
 ing, we then made the incision. The skin and subcutaneous fat 
 were passed with trivial pain. Reaching the muscles we found 
 
Cocaine in Gynecology and Obstetrics. 87 
 
 such sensitiveness as to necessitate the use of the cocaine. In five 
 minutes after a free application we passed without pain to the 
 peritoneum. This proved the most sensitive of all the tissue we 
 encountered, but a free application of the remedy speedily anes- 
 thetized it, so that we cut through it without pain. Contrary to 
 expectation, no adhesions were found between the tumor and the 
 abdominal wall, but its tissue was so little sensitive, a few minutes' 
 application of the cocaine prepared it for incision. Partially 
 emptying the sac with an aspirator, its walls were seized and held 
 against the abdominal incision while we made a free opening. 
 Passing in the fingers we stitched the edges of the cut in the tumor 
 to the wound in the abdominal wall. As many as eight sutures 
 were thus placed, each being passed through all the layers of the 
 abdominal wall, thence into the sac. This was done without the 
 slightest pain to the patient. Next the sac was emptied and 
 washed out, one gallon of pus and broken down hydatids being 
 removed. Then the usual dressing was applied. A careful ex- 
 amination of the patient, made by all the gentlemen present, 
 showed that his condition was much better than when the opera- 
 tion began. At no time did any symptom of shock occur, and 
 certainly the condition in which the completed operation found 
 him (it lasted nearly an hour) was far better than it would have 
 been had any general anaesthetic been used. To complete here 
 the record of the case, I will say that no peritonitis occurred. 
 Constant improvement marked its progress until about the tenth 
 day, when, with a normal pulse and temperature, he showed a dis- 
 taste for food. This increased, and finally on the twenty-second 
 day after the operation he died. The cause of death was appar- 
 ently pure inanition, due to failing digestion, consequent upon the 
 complete absence of bile from the alimentary canal. Soon after 
 eating, the flow of bile from the sac was very great, continuing for 
 about twenty minutes, then gradually ceasing. This continued so 
 long as he took food. The action of the bile as an antiseptic was 
 shown by the absence of odor and decomposition in the sac and 
 about the wound. 
 
 Autopsy showed no peritonitis, an atrophied left lobe of the 
 liver, and an old rupture of the bile duct, coming from the right 
 lobe, the point of division being just at the junction with the com- 
 mon duct, so that ninety-five per cent, of all the bile secreted was 
 poured out at the abdominal wound. Had the patient been 
 younger he might have combated this abnormality longer, but 
 his age rendered the defect speedily fatal. 
 
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