perience in its use, that cocaine is a very valuable agent in nose and throat surgery? •?*

DISCUSSION ON DR. DONALDSON'S PAPER

ON COCAINE.

DR. J. N. MACKENZIE in discussing Dr. Donaldson's paper said that he could confirm that doctor's experience with it. In regard to the galvano-cautery, however, it does not entirely stop the pain, though it greatly lessens it. In speaking of its effect on the throat he spoke of having extracted a large tumor from the sinus pyriformis. By means of the cocaine he not only entirely stopped the pain, but the operation was bloodless. He had also operated on laryngeal papilloma in a case where there was a great deal of reflex irritability and had found it of the greatest use. He does not consider it as of value as a hæmostatic. In regard to its use in pathological conditions, such as coryza, it is practically valueless. It will relieve the symptoms for a short time, but will not do so permanently, and after twelve hours the sensitiveness of the parts will be found to have greatly increased. The reason of this is that the cocaine produces tetanic spasm and this after a time leads to atony of the tissues and to a permanent puffy condition of the parts. Its injudicious use begets irritability, and it opens an avenue to quackery, as it relieves only for a time.

Cocaine does not deaden the sensation of heat and cold. This was observed first by Dr. Mactier Warfield on the eye and Dr. M. had verified it on the nose in six cases.

The proposition of some to treat chronic nasal catarrh or hay fever by its use, Dr. M. considered absurd.

*Since the reading of this Report, Dr. Mactier Warfield, of Baltimore, observed (Medical News, May 30, 1885) that while the sensibility of the cornea and conjunctiva was abolished by cocaine, the impact of the instruments was felt as a distinctly cold sensation. Subsequently, Mr. H. H. Donaldson experimented upon the eye, and Dr. J. N. Mackenzie upon the oro-pharyngeal cavities and nasal passages with results confirmatory of Dr. Warfield's observation. These observations are of great interest in their bearing upon the physiological question of the separation of the varieties of sensation. A comparatively weak solution (4 per cent.) was used in these experiments. The late Dr. Elsberg (quoted by Dr. Bosworth) noticed that the application of a 4 per cent. solution in the larynx dulled in most persons the dolorous sensibility but that the annulling of the tactile sensibility by which temperature and pressure are appreciated, required a stronger solution and also that reflex sensibility demanded a still stronger solution. He found that a 25 per cent. solution was necessary. The writer has frequently observed in producing local anesthesia by ether, by rhigolene, as well as by cocaine, that, although the dolorous sensibility was overcome, there remained some tactile sensibility. These contradictory experimental results must be further investigated before it can be positively concluded whether cocaine can annul all varieties of sensibility.

Dr. R. H. THOMAS said that his observation had been that cocaine muriate would entirely stop the pain caused by the use of the galvano-cautery, provided it was applied in the right way. If the parts were only brushed with the solution repeatedly, the pain would be lessened. If, however, the solution was kept in contact with the parts for some moments the pain would be almost altogether avoided.

In his hands, the drug had not yielded satisfactory results in less strength than a 5 p. c. solution. In regard to adenoid growths he had not been able to stop the pain of the operation for their removal entirely by means of the cocaine. Without taking up the time of the Faculty by repetition, he would emphasize the value of cocaine applications to the nose as a means of diagnosis. The parts become so shrunken that it is quite easy to examine the interior parts of the nostrils in cases where it was quite impossible before the application.

COCAINE IN OPHTHALMIC SURGERY.

BY HERBERT HARLAN, M.D.,

Surgeon to Presbyterian Eye, Ear and Throat Charity Hospital; Assistant Demonstrator of Anatomy, University of Maryland.

Since the last meeting of this Faculty, a long stride has been made in the onward march of medical science, in the discovery of the local anesthetic properties possessed by the muriate of cocaine.

And now that the first stage of excitement and enthusiasm has been passed, and we are in a better position to judge of its real merits, a brief consideration of its present status and applicability seems appropriate from the section of ophthalmology. For there is no doubt that in its adaptability to the delicate mucous membrane of the eye, lies its greatest sphere of usefulness.

Gadeke in 1860 first isolated an alkaloid from the leaves of the erythroxylon coca and gave it the name of cocain (Ann. Chem, and Phar., 114, 213). From this, muriate, sulphate, nitrate, tannate, and oxalate salts have been prepared. The physiological effects were studied by many careful observers, but as we are concerned only with the local anesthetic effects we may pass to 1880, when Von Anrep showed that the sensibility of the skin was abolished whenever it was hypodermically injected, and that of the tongue when touched with strong solutions. He also applied a solution to the conjunctiva and noticed the dilatation of the pupil, but seems not to have observed insensibility of this mucous membrane, or, if he did observe it, did not appreciate its practical significance.

During '83 and '84 the German laryngologists used a solution to lessen the sensibility of the larynx in manipulation and for the removal of growths. In the summer of 1884, Dr. Karl Koller of Vienna, seeing the action of the drug on the mucous membrane of the throat, began experiments on the conjunctiva, first of animals and then of men. In this way he established its local anesthetic properties. He gave a vial containing a 2 per cent. solution to Dr. Bret

tauer of Trieste, to exhibit its action at the Ophthalmological Congress at Heidelberg, in September, 1884. Dr. Henry D. Noyes was present at the Congress, and in a letter which appeared in the New York Medical Record of Oct. 11, 1884, gave an account of the experiments he there witnessed. The first that we in America heard of the drug was from this letter. Unqualified praise coming from so high an authority as Dr. Noyes, of course attracted universal attention, and as soon as a supply of the drug could be obtained all sorts of experiments were made, and week after week the medical journals were filled with favorable reports of cases in which the muriate of cocaine had been used. As an example of the absurd uses to which it was put, it may be mentioned that it was lauded as a remedy in typhoid fever. The few unfavorable reports were put down to the bad preparation of the drug used. Fortunately cocaine is practically harmless, thirty-two grains having been taken in one instance at a single dose without serious results.

That cocaine is a very valuable remedy in suitable cases, no one can for a moment doubt. Experience has convinced me that on the delicate mucous membranes where it can readily be absorbed, it causes complete anæsthesia so far as the parts are concerned with which it comes in contact. The cases where it has been reported to act so charmingly on the skin, and deep tissues, whether by hypodermic injection or not, I am inclined to attribute to enthusiasm in the experimenter.

In ophthalmic surgery, however, it is very nearly perfect. A solution varying in strength from 1 to 5 per cent. acts charmingly. I prefer the 4 per cent. as it requires few drops and acts promptly. To produce complete anæsthesia it is usually necessary to instill one or two drops at intervals of three to five minutes, several times. This having been done, at the end of ten or fifteen minutes, we find all sensation of the eye-ball gone. Deeply imbedded foreign bodies may be removed from the cornea, ugly squints may be corrected, cataract extractions may be painlessly performed, and so on through the whole list of eye operations. That the operation for cataract can be performed more safely under the influence of cocaine than in any other way I firmly believe, and it seems reasonable that it should be so. Without anæsthetic there is only a small percentage of patients who can bear the pain with sufficient equanimity not to seriously interfere with the surgeon by sudden uncontrollable movements of the eye-ball, and under any general anesthetic we all know the inconve

nience and often grave danger arising from sudden and violent movements during a partial return of consciousness, to say nothing of nausea and vomiting accompanying or following their administration. There is also the danger to life to be considered in the use of ether and chloroform, which can be entirely eliminated in the case of cocaine.

Since last November I have extracted ten senile cataracts and all have done well. In all these Knapp's modification of Von Græfe's operation was the one performed. In one or two cases a little pain was felt when section of the iris was made. In all other respects the anæsthesia was complete.

As an anaesthetic for squint operations, in my hands cocaine has proved perfectly satisfactory. A large proportion, however, of patients presented for this operation are children, and when very young or nervous, or spoiled and unreasonable, it is necessary, as of old, to administer bromide of ethyl or some other general anesthetic. I have, however, operated on several as young as six years without difficulty, and one of these cases I give more in detail.

Case.-L. G., six years old, was brought to my office December 16, from southern Virginia, having an int. squint of 4°. His eyes had been crossed since infancy. He was hypermetropic to 3 D. Two years previously he had been brought to a specialist in this city for operation, and an attempt was made to administer chloroform. There was some difficulty in its administration, however, and his father took him home without the operation being performed, and with the impression that chloroform could not be administered to him. He was a sensible little fellow, and, relying on my promise not to hurt him, had the drops put in his eyes three times, at intervals of a few minutes; mounted himself on a reclining chair, and, without assistance, I cut both internal recti tendons and straightened the eyes.

There are a few eye troubles, in operation for the relief of which cocaine does not act satisfactorily. In glaucoma, where the plus tension is marked and much congestion is present, the cocaine solution will not be absorbed sufficiently for the operation to be done without pain. In a case of chronic and hereditary glaucoma, however, reported more fully elsewhere,* in which there was little congestion and not much tension, I did a double iridectomy without difficulty.

"A Case of Hereditary Glaucoma," reported in Ophthalmological Section of American Medical Association at New Orleans, April 28, 1885.