sion. Nothing definite or satisfactory to the mass of the profession was recorded, and still the thinking, conscientious element have sought some agent or method which might be applied to the injured or diseased part in such a manner as to secure absolute freedom from pain without jeopardizing in the least degree the life of the helpless and trusting patient. And altho the drug almost capable of producing this desideratum was known for centuries, it was not until 1884 that cocain came into prominence as a local anesthetic, or perhaps more properly, local analgesic.

in

Local analgesia has been secured numerous ways, and by the aid of a variety of drugs; but still the records tell a sorrowful tale of death even under local analgesia. The careful student of to-day no longer believes these deaths entirely excusable, since we now have drugs and methods for producing satisfactory local analgesia against which no death has yet been charged.

We will not here consider the various arguments advanced in the controversy over the method of choice as to the employment of general or local anesthesia. There will always be a field for both methods, despite the dreams of enthusiasts; for there is no real antagonism between the two procedures. The seeming antagonism lies in our ignorance of the powers and actions of the. various drugs employed in either method.

We know that an occasional patient dies from failure of respiration or deficient heart action while under an anesthetic, but until we can discover just why dissolution occurred we would better spend our time in the endeavor to prevent such unfortunate occurrences in future. The surest way to accomplish this will be found in a more perfect knowledge of local analgesics. Surely it would seem that, given the exact truth regarding the dangers and disadvantages of both methods, any surgeon capable of operating properly would be fitted to make proper selection of method in every case presenting itself.

"It is remarkable how unimportant a place local anesthesia still occupies in surgery. It is an indisputable fact that complete anesthesia is still, and will always remain, a matter of dread to patients; and that surgeons do not make any very strenuous endeavors to avoid it when they could possibly do without it. The ophthalmologists are nearly the only ones who use local anesthesia to the full extent of

"Always remember, gentlemen, when you induce surgical anesthesia you are taking your patient into the very valley of the shadows of death. You must not, you dare not, do this unless you have all the knowledge obtainable from the best authority upon the action and dangers of the administration of these drugs." (H. C. Wood, Lectures, U. of P., 1895.)

From among the various methods and drugs now known, one may easily select an anesthetic whose employment will be practically devoid of any danger except under exceptionable circumstances or in performances of the gravest and most intricate surgical procedures. But; of course, such selection presupposes an intimate knowledge of all anesthetics, both general and local, with their various limitations, uses, merits and demerits, dangers and contraindications.

Most of the prominent drugs now before the profession as local analgesics are proprietary, and many of them are patented; but in consideration of this subject we can not allow mooted questions of ethics to exclude widely known and extensively used articles of proven merit and expedi

ency.

Local analgesics are divided into two classes: Those which are capable of obtunding local sensibility under any manipulation or procedure. and those capable of bringing about freedom from pain by local application, instillation or injection in certain regions or under stated conditions only. While many of our local analgesics possess both powers to certain or slight degree, a considerable number of them belong distinctively to the one class, and are useless or even harmful when employed in a different manner or in another field.

Undoubtedly, cocain is not only the pioneer in the field of local analgesia, but it is still the most widely used of all the drugs employed for this purpose, despite its well-known and treacherous character.

Cocain. This drug first came into prominence as a local anesthetic in 1884, altho "from the days of the Incas the haves of the cocoa plant have been enormously used by the natives of western South America, and it is stated that about forty million pounds of them are annually harvested." (Wood, Therapeutics; 9th Ed.) Cocain is the principal alkaloid derived from the erythroxylon coca leaves; it was first discovered by Gardeke in 1855, and named

by him erythroxyline, but it remained for Dr. Albert Niemann to investigate it thoroly and systematically, and to coin the term, cocain. It occurs in colorless, transparent prisms, soluble in seven hundred and four parts of cold water, and forms with acids bitter, soluble, crystallizable salts (Wood; Ibid.) It was first used as a local anesthetic by Schroff in 1862; but was not thoroly exploited until the investigations of Koller in 1884. (Park. Hist. Med., p. 314.) It sprang immediately into popular and professional favor, and has ever since been in extensive use by all kinds of practitioners, all over the world. Altho treacherous, and very toxic, it has, rightly or wrongly, held the faith of the profession in the face of evil reports and the production of numerous substitutes, both Galenical and synthetic. It remains to-day the base of the nearest approach to ideal local anesthesia, the infiltration method. It is a reliable and constantly acting local analgesic when so applied that it can reach the nerve in sufficient concentration, and can be retained in contact with it for the required duration of the operation. It will not permeate sound skin, and cannot therefore be used for induction of cutaneous anesthesia. It acts most quickly on such mucous membranes as the eye and nose; the throat, vagina and urethra are often slow in responding to its influence. It is applied to mucous surfaces in 2 to 10 per cent. solution; into cavities, as the conjunctival sac and urethra, by instillation, in quantities of a very few drops; and into other tissues by hypodermatic injection. Instilled into the eye, it partially or entirely paralyzes accommodation, and constantly dilates the pupil. Applied to the tongue it temporarily destroys the sense of taste.

The following serious and fatal cases are mentioned as following its use in small quantities: (Wood; Therapeutics; 9th Ed.) 4 per cent. solution used locally for toothache, in unknown quantity; death. Twelve drops of a 4 per cent. solution, hypodermatically, to a girl of eleven years; death in 40 seconds. (Cocain. Mattison. Med. Reg., Vol. 1, 1887.) One dram of 20 per cent. solution injected into urethra, followed immediately by convulsions and by death in 20 minutes. (Simes. Med. News, 1888.) Four minims of a 3 per cent. solution given to a strong man produced convulsions, followed by mania. (Stevens.) One drop of a 1 per cent. solution in the eye of a child of fourteen produced markt

poisoning. (Frost.) "On the other hand, cocain has been very largely used as a local application without the production of symptoms; nevertheless the employment of any large quantity locally is not safe; probably it is not safe to apply more than of a grain at any time to any mucous membrane." (Wood.)

The solutions of cocain are not stable, and should always be freshly prepared. They should be made up aseptically, since they cannot be sterilized after being prepared without great risk of deterioration. Various drugs have been used in the effort to make the cocain solutions more stable. "Ten grains of boric acid to the ounce of cocain solution preserves it for a month or more without noticeable contamination from the growth of mould fungi. Salicylates are used for the same purpose. (Med. Record, June 10, 1899. Johnson.)

The great toxicity and treacherous action of seemingly safe doses of cocain have led experimenters to endeavor to circumvent the possibilities of accident by various procedures. The most prominent has been the use of constriction between the site of injection and the heart, applicable of course only to the limbs. A number of modifications of this plan have been suggested. When first used, the constriction merely served to keep the cocain in contact with the parts for a sufficient period of time; later it was suggested that the constriction might be removed intermittently, as in snake bite, thus admitting the cocain gradually into the system in such minute quantities at a time as to avoid fatal poisoning. Later it was proposed to deprive the part of blood before the injection, after the method of Esmarch, and then by intermittent loosening of the ligature to allow the blood current to dilute the cocain and wash it from the injected tissues into the system. Under the use of this method it was noted that sometimes anesthesia was produced before cocain was injected, and from this grew the suggestion that anesthesia be produced by compression and abstraction of blood alone, without the use of any drug. (See article by Dr. Loup, Bulletin Medical, 1896).

Method of Corning. Dr. Corning first suggested that the nerve trunk be cocainized by direct injection, with constriction applied between site of proposed injection and heart, and thus secure analgesia of all the parts reacht by the peripheral distribution of said nerve, with the ad

vantages of intermittent loosening of constriction after the operation. The method has been extensively used with satisfaction. Matas, in Tulane University, New Orleans, has removed epitheliomatous fingers and frost-bitten Chopart stumps without appreciable pain by this method. He used solutions varying from .02 to 1 per cent. (Phila. Med. Jour., p. 919, 1899.) Much the same theory is mentioned in the Jour. Am. Med. Asso., page 1169, as follows: "The theoretic assumption that cocain introduced directly into the spinal cord would temporarily suppress the function of the ganglionic cells of the nerve roots and sheathless nerves has been fully confirmed by results in various experiences. One-half to three C. C. of a .5 to a 1 per cent. solution were introduced into the spinal cord by lumbar puncture. In five to eight minutes the analgesia of lower members was complete, extending to the nipple, or including the entire body except the head, and continuing for forty-five minutes, when it gradually past away. Eight patients were thus anesthetized and osteo-tubercular and myelitic foci were evacuated and bones resected without the slightest pain, altho tactile and thermic sensation were retained. There were no immediate disturbances in any case, but in three there was vomiting and cephalgia later." (From Deutsch Ztft. f. Chir. 1. 3. 4.)

Method of Schleich. This is, perhaps, the most widely known of all the more modern methods of inducing regional analgesia. It is safe, easy, and satisfactory. To be sure, it is not yet perfect, and the advocates of general anesthesia under all circumstances where the slightest pain might be felt have offered objections to it. Only two objections are worth considering; the first, that in major operations it is too much trouble to stop operating to reinfiltrate tissues becoming sensitive; and the second, that where a large amount of fluid is injected the field of operation is distorted. The method, however, is popular with patients, and is extensively used. The technique has been described as follows: The solution most commonly used contains one and one-half grains of cocain, three grains of sodium chlorid, and onethird nces and r. Two

three

other so

orp

taining double quan d

one con

ocain and the othe one-tenth the mount. The skin is rendered aseptic and the site of

proposed injection rendered anesthetic by an ether or rhigolene spray. The skin is then firmly pincht up and a fine sterilized needle thrust obliquely into, but not thru the skin. The solution is used cold, and is now injected until a white, elevated wheal appears. The needle is then withdrawn and again inserted at the inner edge of the wheal, and enuf fluid injected to form another, and so on until a sufficient area has been rendered anesthetic. Schleich proved his confidence in the method by performing a number of minor and major operations, even so grave operations as celiotomies, absolutely without pain. He did not hesitate to voice the hope that in the near future general anesthesia would be a surgical curiosity.

Later experiments have been made with some of the newer local analgesics with fully as satisfactory results, and without the danger of an over dose of cocain. Other modifications of the method have been suggested by numerous experimenters, but it is doubtful whether any real advantage has been attained outside the replacement of cocain.

Speaking of his experience, Riesmeyer says: "Anesthesia was complete, and in no case was there necrosis. Primary wound healing resulted in every case. The psychic effect was not at all objectionable." (St. Louis Med. Review, Apr. 22, 1899.) Herman in the following words expresses his results: "The best results are to be obtained by Schleich's infiltration method. Cocain and eucain in stronger solutions and necessarily smaller amounts have failed to produce complete anesthesia. The greatest objection to this method is the danger of infection, which in an aseptic operation is slight." Concluding he says: "Schleich's fluid, if made with freshly distilled and boiled water, and if hands and instruments used in its preparation be sterile, may be regarded as aseptic. It is not antiseptic, and if accidentally contaminated is unfit for use unless it shall have been again sterilized. If sterilized, too high temperatures, and antiseptic fluids must be guarded against, as they tend to render it unfit for use." (Weiner klinische Wochen. II. Jahrg. No. 49.):

Sterile normal salt solution has been used in lieu of water in the Schleich method with seemingvantage.

Poulsson investigated compounds in which the radical methyl, ethyl and propyl are substituted for the benzoic acid, and to which he gave the names homome

thincocain, homoethinococain and homopropincocain. He found that these substances acted upon the animal organism like cocain. Benzoylhomoecgonin does not have the physiological action of cocain. The investigations of M. Ehrlich showed benzoylecgonin and methyleegonin to be twenty times less poisonous than cocain, while the derivatives of cocain obtained by substituting in the benzoylecgonin other alcohol radicals than methyl for the hydrogen of the carboxyl group, cocaethylin, cocopropylin, isopropylin and cocoisobutylin are as toxic as cocain and act like (Gaz. Med. de Paris, Oct., 1890.) With the various acids, cocain forms soluble, crystallizable salts, which are more bitter than the alkaloid itself. (U. S. P.)

The more common salts of cocain used as local anesthetics are the hydrochlorate, citrate, carbolate, each used in same manner as the cocain itself or its most extensively used salt, the hydrochlorate. Other preparations of cocain are the cerate, made up in proportions of one to thirty, useful in burns, superficial abrasions, etc.; the oleate, a 10 per cent. solution in oleic acid used as an unguent; and the phenate, used in 5 to 10 per cent. alcoholic solutions as a topical application in catarrhs and rheumatism. Some of the later cocain preparations are the cocain-aluminum-citrate, soluble in hot water, insoluble in alcohol; it is an astringent local anesthetic. The cocain-aluminum-sulfate is used as its sister salt. Cocain borate is the best of all the cocain salts for subcutaneous injection and eye use, because of the stability of its aqueous solutions and the indifference of the boric acid. (Coblentz, New Remedies.) Cocain cantharidate is a white inodorous powder somewhat soluble in hot water, insoluble in alcohol, used subcutaneously in tuberculosis of larynx and catarrh of the upper air passages. Cocain lactate is a soft mass, soluble in water, used in cystitis, 1 gram in 9 grams water is injected into the bladder after evacuation. Cocain nitrate is used in combination with silver nitrate in genitourinary diseases. The carbolate is a soft mass, insoluble in water, soluble in alcohol, used as local application and also subcutaneously; it is weaker than the hydrochlorid. The saccharate is preferable for throat work on account of its sweet taste; a 5 per cent. sol. is the equivalent of a 4 per cent, sol. of hydrochlorid. The stearate is used in place of the oleate in inunction and suppositories.

Cocain has some properties which have never yet been duplicated in any other drug, and it will continue to be used on account of these properties until some agent is discovered to take its place. Without cocain and its chemical formula we would never have been able to produce such drugs as orthoform and nirvanin; and had cocain not been so deadly, such drugs would never have been sought. Cocain has recently advanced over $2.00 an ounce, and doubtless this will cause a larger amount of the synthetic substitutes to be used. (To be Continued.)

Midway, Pa.

A. L. RUSSELL, M.D.

Sulfonal Habit.

Editor MEDICAL WORLD :-Cases of sulfonal habit, such as Dr. Wardner describes in October WORLD, page 431, are not by any means uncommon. I have met with four cases in the last year. Treatment should be the substitution of trional for procuring sleep; or, better yet, chloretone in three grain doses. Nitroglycerin two or three times a day will control circulatory symptoms which in the case described evidently produced. the unpleasant effects. To control nervousness tr. passiflora acts well. These cases generally recover quickly under appropriate treatment.

Laporte, Ind. J. LUCIUS GRAY, M. D. [How about the formation of a trional habit? What is "chloretone "?-ED.]

solution dissolve one of the tablets in 25 minims of water. A 1 per cent. solution can be made by dissolving one tablet in twice this quantity of water, or 50 minims. A 4 per cent. solution can be made either by reducing the water one-half or adding another tablet to the 25 minims, etc. I prefer to make a fresh solution as needed. It is self-evident that an aseptic syringe should be used, and the solution injected only a little faster than the tissues will absorb it.

I have seen at a dental infirmary a number of "obtundents" applied to the gums (the gums being dried with absorbent cotton prior to application), but without entire satisfaction. Such an application can at best produce only superficial anesthesia, as there is no drug which will anesthetize all the structures from the' mucous membrane to the pericementum, when so applied. I would suggest that in all cases where a physician is of the opinion that a certain tooth or teeth should be extracted, that he refer such patients to a dentist if there is one in the vicinity. dentist may be able to treat and save the offending tooth. The aching of a tooth, without any other indications, is not a sign that it should be extracted. It would be well if physicians would advise their patients to have their teeth examined occasionally, as the dentist could detect caries, abrasions or erosions of the teeth and advise them of the proper treatment.

JOSEPH POSPISIEL, M. D., D. D.S. 213 H. Street, N. E., Washington, D. C.

A

DEAR DOCTOR TAYLOR:-In the beautiful poem by Will Carleton entitled "The Country Doctor," in November WORLD, page 486, you omitted the third verse, which is as follows:

Maybe half the congregation now of great or little worth, Found this watcher waiting for them when they came upon the earth;

This undecorated soldier of a hard unequal strife, Fought in many stubborn battles with the foes that sought their life.

The Arlington Chemical Company, of Yonkers, N. Y., a few years ago printed this poem with illustrations, which I framed and value more highly than any picture I have.

Rolesville, N. C.

L. B. YOUNG.

"Monthly

DEAR DOCTOR-I have been reading your Talks" for some time, and while I consider THE MEDICAL WORLD one of the best journals I take, I think your "Monthly Talks" will do the average doctor more good than all the balance of the journal. You make the doctor think, which is more than any other journal I take does. Morehead, Kans.

W. C. MCCONNELL, M.D.

Medical State Laws.

Editor MEDICAL WORLD:-Since my former letter in regard to State medical laws was publisht in THE WORLD I have had a volume of correspondence from nearly every State in the Union; and the universal cry is for a change in the present medical laws so that no barriers can be raised that will shut out from practice in any State a duly qualified medical man who is a bona fide graduate of any reputable medical college. From the unanimity of sentiment that is thus far manifested, and in view of the fact that each wall so put up by state legislatures is, if not de jure, at any rate de facto, a violation of that noble federal system that is to-day the corner stone of the greatness and the liberty of this nation, I think the time has come when the federal system should be applied by Congress to a common medical Act for the United States. There are many reasons why this Act should be past and become law. Since many of us were students the field of medicin and surgery has been so enlarged that no student can now hope to compass that field and master it, even its rudiments, in the time many of our colleges allot as a course for graduation; hence the crying necessity for a common law for the Republic; hence the pressing necessity for a law that shall make a time basis of study that will give the student time enuf to master the various fields of medical learning that are now a sine qua non in preparing for practice. again, no matter what a man's qualifications may have been at graduation, when he goes into the practice of medicin and has past from the student to the practising physician, he soon gets rusty; he soon forgets the foramen of the sphenoid bone from a technical standpoint; he soon forgets the exact technical relations of the femoral artery, the profundus femoris, and the great sciatic nerve. Yet he is practical, and with each year's store of practical knowledge laid by, his technical knowledge that he must have to stand an

Then

examination recedes. There can be no more cogent reasons for a common medical act, if our federal system is to be preserved and medical oligarchies are not to assume supreme State command. A medical act that prevents inter-state medical commerce is an unrighteous law, not in the interests of the people, and it often prevents the migration of medical men of high standing from one state to another.