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sion. Nothing definite or satisfactory to its possibilities." (Int. Jour. Surgery, the mass of the profession was recorded, N. Y., Feb., 1899.) and still the thinking, conscientious ele- “Always remember, gentlemen, when ment have sought some agent or method you induce surgical anesthesia you are which might be applied to the injured or taking your patient into the very valley diseased part in such a manner as to se- of the shadows of death. You must not, cure absolute freedom from pain without you dare not, do this unless you have all jeopardizing in the least degree the life of the knowledge obtainable from the best the helpless and trusting patient. And authority upon the action and dangers of altho the drug almost capable of producing the administration of these drugs." (H. this desideratum was known for centuries, C. Wood, Lectures, U. of P., 1895.) it was not until 1884 that cocain came into From among the various methods and prominence as a local anesthetic, or per- drugs now known, one may easily select haps more properly, local analgesic. an anesthetic whose employment will be
Local analgesia has been secured in practically devoid of any danger except numerous ways, and by the aid of a variety under exceptionable circumstances or in of drugs; but still the records tell a sor- performances of the gravest and most inrowful tale of death even under local tricate surgical procedures. But; of course, analgesia. The careful student of to-day such selection presupposes an intimate no longer believes these deaths entirely knowledge of all anesthetics, both general excusable, since we now have drugs and and local, with their various limitations, methods for producing satisfactory local uses, merits and demerits, dangers and analgesia against which no death has yet contraindications. been charged.
Most of the prominent drugs now before We will not here consider the various the profession as local analgesics are proarguments advanced in the controversy prietary, and many of them are patented; over the method of choice as to the em- but in consideration of this subject we can ployment of general or local anesthesia. not allow mooted questions of ethics to There will always be a field for both exclude widely known and extensively methods, despite the dreams of enthusi- used articles of proven merit and expediasts; for there is no real antagonism be- ency. tween the two procedures. The seeming Local analgesics are divided into two antagonism lies in our ignorance of the classes : Those which are capable of obpowers and actions of the various drugs tunding local sensibility under any manipuemployed in either method.
lation or procedure, and those capable of We know that an occasional patient bringing about freedom from pain by local dies from failure of respiration or deficient application, instillation or injection in cerheart action while under an anesthetic, tain regions or under stated conditions but until we can discover just why disso- only. While many of our local analgesics lution occurred we would better spend our possess both powers to certain or slight detime in the endeavor to prevent such unfor- gree, a considerable number of them belong tunate occurrences in future. The surest distinctively to the one class, and are useway to accomplish this will be found in a
less or even harmful when employed in a more perfect knowledge of local analgesics. different manner or in another field. Surely it would seem that, given the exact Undoubtedly, cocain is not only the truth regarding the dangers and disadvan- pioneer in the field of local analgesia, but tages of both methods, any surgeon capa- it is still the most widely used of all the ble of operating properly would be fitted drugs employed for this purpose, despite to make proper selection of method in its well-known and treacherous character. every case presenting itself,
Cocain. This drug first came into prom"İt is remarkable how unimportant a inence as a local anesthetic in 1884, altho place local anesthesia still occupies in sur- “ from the days of the Incas the faves of gery. It is an indisputable fact that com- the cocoa plant have been enormously used plete anesthesia is still, and will always by the natives of western South America, remain, a matter of dread to patients; and and it is stated that about forty million that surgeons do not make any very pounds of them are annually harvested.” strenuous endeavors to avoid it when they (Wood, Therapeutics; 9th Ed.) Cocain could possibly do without it. The oph- is the principal alkaloid derived from the thalmologists are nearly the only ones who erythroxylon coca leaves; it was first disuse local anesthesia to the full extent of covered by Gardeke in 1855, and named by him erythroxyline, but it remained for poisoning. (Frost.) “On the other hand, Dr. Albert Niemann to investigate it cocain has been very largely used as a thoroly and systematically, and to coin local application without the production the term, cocain. It occurs in colorless, of symptoms; nevertheless the employ. transparent prisms, soluble in seven hun- ment of any large quantity locally is not dred and four parts of cold water, and safe ; probably it is not safe to apply more forms with acids bitter, soluble, crystalliz- than 1 of a grain at any time to any able salts (Wood; Ibid.) It was first used mucous membrane." (Wood.) as a local anesthetic by Schroff in 1862 ; The solutions of cocain are not stable, but was not thoroly exploited until the in- and should always be freshly prepared. vestigations of Koller in 1884. (Park. Hist. They should be made up aseptically, since Med., p. 314.) It sprang immediately into they cannot be sterilized after being prepopular and professional favor, and has pared without great risk of deterioration. ever since been in extensive use by all Various drugs have been used in the effort kinds of practitioners, all over the world. to make the cocain solutions more stable. Altho treacherous, and very toxic, it has, “ Ten grains of boric acid to the ounce of rightly or wrongly, held the faith of the cocain solution preserves it for a month or profession in the face of evil reports and more without noticeable contamination the production of numerous substitutes, from the growth of mould fungi. Salicyboth Galenical and synthetic. It remains lates are used for the same purpose. to-day the base of the nearest approach to (Med. Record, June 10, 1899. Johnson.) ideal local anesthesia, the infiltration The great toxicity and treacherous method. It is a reliable and constantly action of seemingly safe doses of cocain acting local analgesic when so applied that have led experimenters to endeavor to cirit can reach the nerve in sufficient concen- cumvent the possibilities of accident by tration, and can be retuined in contact various procedures. The most prominent with it for the required duration of the has been the use of constriction between operation. It will not permeate sound the site of injection and the heart, apskin, and cannot therefore be used for in- plicable of course only to the limbs. A duction of cutaneous anesthesia. It acts number of modifications of this plan bave most quickly on such macous membranes been suggested. When first used, the as the eye and nose; the throat, vagina constriction merely served to keep the and urethra are often slow in responding cocain in contact with the parts for a sufto its influence. It is applied to mucous ficient period of time; later it was sugsurfaces in 2 to 10 per cent. solution ; into gested that the constriction might be recavities, as the conjunctival sac and ure- moved intermittently, as in spake bite, thra, by instillation, in quantities of a thus admitting the cocain gradually into very few drops; and into other tissues by the system in such minute quantities at a hypodermatic injection. Instilled into the time as to avoid fatal poisoning. Later eye, it partially or entirely paralyzes ac- it was proposed to deprive the part of commodation, and constantly dilates the blood before the injection, aster the method pupil. Applied to the tongue it tempo- of Esmarch, and then by intermittent rarily destroys the sense of taste.
loosening of the ligature to allow the blood The following serious and fatal cases are current to dilute the cocain and wash it mentioned as following its use in small from the injected tissues into the system. quantities: (Wood ; Therapeutics; 9th Ed.) Under the use of this method it was noted 4 per cent. solution used locally for tooth- that sometimes anesthesia was produced ache, in unknown quantity; death. Twelve before cocain was injected, and from this drops of a 4 per cent. solution, hypoder- grew the suggestion that anesthesia be matically, to a girl of eleven years; death produced by compression and abstraction in 40 seconds. (Cocain. Mattison. Med. of blood alone, without the use of any Reg., Vol. 1, 1887.) One dram of 20 per drug. (See article by Dr. Loup, Bulletin cent. solution injected into urethra, fol. Medical, 1896). lowed immediately by convulsions and by Method of Corning. Dr. Corning first death in 20 minutes. (Simes. Med. News, suggested that the nerve trunk be cocain1888.) Four minims of a 35 per cent. so- ized by direct-injection, with constriction lution given to a strong man produced applied between site of proposed injection convulsions, followed by mania. (Stevens.) and heart, and thus secure analgesia of One drop of a 1 per cent. solution in the all the parts reacht by the peripheral diseye of a.child of fourteen produced markt tribution of said nerve, with the ad
vantages of intermittent loosening of con- proposed injection rendered anesthetic by striction after the operation. The method an ether or rbigolene spray. The skin is has been extensively used with satisfaction.' then firmly pincht up and a fine sterilized Matas, in Tulane University, New · Or- needle thrust obliquely into, but not thru leans, has removed epitheliomatous fingers the skin. The solution is used cold, and and frost-bitten Chopart stumps without is now injected until a white, elevated appreciable pain by this method. He used wheal appears. The needle is then withsolutions varying from .02 to 1 per cent. drawn and again inserted at the inner (Phila. Med. Jour., p. 919, 1899.) Much edge of the whead, and enuf fluid injected the same theory is mentioned in the Jour. to form another, and so on until a suffiAm. Med. Asso., page 1169, as follows: cient area has been rendered anesthetic. “The theoretic assumption that cocain Schleich proved his confidence in the introduced directly into the spinal cord method by performing a number of minor would temporarily suppress the function and major operations, even so grave operaof the ganglionic cells of the nerve roots tions as celiotomies, absolutely without and sheathless nerves has been fully con- pain. He did not hesitate to voice the firmed by results in various experiences. hope that in the near future general anesOne-half to three C. C. of a .5 to a 1 per thesia would be a surgical curiosity, cent. solution were introduced into the Later experiments have been made with spinal cord by lumbar puncture. In five some of the newer local analgesics with to eight minutes the analgesia of lower fully as satisfactory results, and without members was complete, extending to the the danger of an over dose of cocain. nipple, or including the entire body ex- Other modifications of the method have cept the head, and continuing for forty-five been suggested by numerous experimenminutes, when it gradually past away. ters, but it is doubtful whether any real Eight patients were thus anesthetized and advantage has been attained outside the osteo-tubercular and myelitic foci were replacement of cocain. evacuated and bones resected without the Speaking of his experience, Riesmeyer slightest pain, altho tactile and thermic says: " Anesthesia was complete, and in sensation were retained. There were no
was there necrosis.
Primary immediate disturbances in any case, but wound healing resulted in every case. in three there was vomiting and cephalgia The psychic effect was not at all objectionlater." (From Deutsch Ztft. f. Chir. able.” (St. Louis Med. Review, Apr. 22, 1. 3. 4.)
1899.) Herman in the following words Method of Schleich. This is, perhaps, the expresses his results: "The best results most widely known of all the more modern are to be obtained by Schleich's infiltration methods of inducing regional analgesia. method. Cocain and eucain in stronger It is safe, easy, and satisfactory. To be solutions and necessarily smaller amounts sure, it is not yet perfect, and the advo- have failed to produce complete anesthesia. cates of general anesthesia under all cir- The greatest objection to this method is cumstances where the slightest pain might the danger of infection, which in an aseptic be felt have offered objections to it. Only operation is slight.” Concluding he says: two objections are worth considering; the "Schleich's fluid, if made with freshly disfirst, that in major operations it is too tilled and boiled water, and if hands and much trouble to stop operating to reinfil. instruments used in its preparation be trate tissues becoming sensitive; and the sterile, may be regarded as aseptic. It is second, that where a large amount of fluid not antiseptic, and if accidentally contamis injected the field of operation is dis- inated is unfit for use unless it shall have torted. The method, however, is popular been again sterilized. If sterilized, too with patients, and is extensively used. high temperatures, and antiseptic fluids The technique has been described as fol. must be guarded against, as they tend to lows: The solution most commonly used render it unfit for use." (Weiner klinische contains one and one-half grains of cocain, Wochen. II. Jahrg. No. 49.): three grains of sodium chlorid, and one- Sterile normal salt solution has been third morning ounces and used in lieu of water in the Schleich meththree ofer. Two od with seemngåntage, other soupe
vone con Poulsson Svigated compounds in taining ouble quaniocain and which the radical methyl, ethyl and prothe othe one-tenth the mount. The pyl are substituted for the benzoic acid, skin is rendered aseptic and the site of and to which he gave the names homomethincocain, homoethinococain and homo- Cocain has some properties which have propincocain. He found that these sub- never yet been duplicated in any other stances acted upon the animal organism drug, and it will continue to be used like cocain. Benzoylhomoecgonin does on account of these properties until some not have the physiological action of cocain. agent is discovered to take its place. The investigations of M. Ehrlich showed Without cocain and its chemical formula benzoylęcgonin and methylecgonin to be we would never have been able to produce twenty times less poisonous than cocain, such arugs as orthoform and nirvanin ; while the derivatives of cocain obtained and had cocain not been so deadly, such by substituting in the benzoylecgonin drugs would never have been sought. other alcohol radicals than methyl for the Cocain has recently advanced over $2.00 hydrogen of the carboxyl group, cocaethy- an ounce, and doubtless this will cause a lin, cocopropylin, isopropylin and cocoiso- larger amount of the synthetic substitutes butylin are as toxic as cocain and act like to be used. it. (Gaz. Med. de Paris, Oct., 1890.)
(To be Continued.) With the various acids, cocain forms
Midway, Pa. A. L. RUSSELL, M.D. soluble, crystallizable salts, which are more
Sulfonal Habit. bitter than the alkaloid itself. (U. S. P.) The more common salts of cocain used
Editor MEDICAL WORLD :-Cases of sulas local anesthetics are the hydrochlorate, fonal habit, such as Dr. Wardner describes citrate, carbolate, each used in same man- in October WORLD, page 431, are not by ner as the cocain itself or its most exten- any means uncommon. I have met with sively used salt, the hydrochlorate. Other four cases in the last year. Treatment preparations of cocain are the cerate, should be the substitution of trional for made up in proportions of one to thirty, procuring sleep; or, better yet, chloretone useful in burns, superficial abrasions, etc.; in three grain doses. Nitroglycerin two the oleate, a 10 per cent. solution in oleić or three times a day will control circulaacid used as an unguent; and the phenate, tory symptoms which in the case described used in 5 to 10 per cent. alcoholic solu- evidently produced. the unpleasant effects. tions as a topical application .in catarrhs To control nervousness tr. passiflora acts and rheumatism. Some of the later co- well. These cases generally recover quickly cain preparations are the cocain-alumi- under appropriate treatment. num-citrate, soluble in hot water, insolu- Laporte, Ind. J. Lucius GRAY, M. D. ble in alcohol; it is an astringent local [How about the formation of a trional anesthetic. The cocain-aluminum-sulfate habit? What is “chloretone” ?—ED.] is used as its sister salt. Cocain borate is the best of all the cocain salts for subcuta- Extraction of Teeth Without Pain. neous injection and eye use, because of the Editor MEDICAL WORLD:-In reply to stability of its aqueous solutions and the Dr. S. J. Smith, University Place, Neb., I indifference of the boric acid. (Coblentz, wish to state that I use the following forNew Remedies.) Cocain cantharidate is mula for extracting teeth, which gives a white inodorous powder somewhat solu- entire satisfaction : ble in hot water, insoluble in alcohol, used
R subcutaneously in tuberculosis of larynx Cocain and catarrh of the upper air passages. Sulfate of morphin Cocain lactate is a soft mass, soluble in Sulfate of atropin
gr. do water, used in cystitis, 1 gram in 9 grams
Sterilized water. :
gtt. XXX water is injected into the bladder after distilled water containing 8 to iops: :ent. of euthy
Mix and inject hypodermically gtt, v to xv.
I use evacuation. Cocain nitrate is used in mol to keep it sterile. combination with silver nitrate in genito- The above is the formula of Dr. N. S. urinary diseases. The carbolate is a soft Hoff, of Ann Arbor, Mich. It is put up mass, insoluble in water, soluble in alco- in tablet form by Parke, Davis & Co., hol, used as local application and also Detroit, Mich. If you desire a 2 per cent. subcutaneously ; it is weaker than the hy
(ind beyond Yearly Index drochlorid. The saccharate is preferable for throat work on account of its sweet The Yed
ed in the taste; a 5 per cent. sol. is the equivalent center 80 ye
ut cutting of a 4 per cent, sol. of hydrochlorid. The
the leaves.exet lonna loosen the wires,
lift out the Tedure, then bend the wife back again. stearate is used in place of the oleate in
Then the Index and Title Page may be bound into the inunction and suppositories.
yearly volume at any place desired.
solution dissolve one of the tablets in 25
Medical State Laws. minims of water. A1 per cent. solution Editor MEDICAL WORLD :- Since my can be made by dissolving one tablet in former letter in regard to State medical twice this quantity of water, or 50 minims. laws was publisht in THE WORLD I have A 4 per cent. solution can be made either had a volume of correspondence from by reducing the water one-half or adding nearly every State in the Union ; and another tablet to the 25 minims, etc. I the universal cry is for a change in the prefer to make a fresh solution as needed. present medical laws so that no barriers It is self-evident that an aseptic syringe can be raised that will shut out from should be used, and the solution injected practice in any State a duly qualified only a little faster than the tissues will medical man who is a bona fide graduate absorb it.
of any reputable medical college. From I have seen at a dental infirmary a the unanimity of sentiment that is thus number of "obtundents” applied to the far manifested, and in view of the fact gums (the gums being dried with absorb- that each wall so put up by state legisent cotton prior to application), but with- latures is, if not de jure, at any rate de out entire satisfaction. Such an applica- facto, a violation of that noble federal tion can at best produce only superficial system that is to-day the corner stone of anesthesia, as there is no drug which will the greatness and the liberty of this anesthetize all the structures from the nation, I think the time has come when mucous membrane to the pericementum, the federal system should be applied by when so applied. I would suggest that in Congress to a common medical Act for the all cases where a physician is of the opin- United States. There are many reasons ion that a certain tooth or teeth should be why this Act should be past and become extracted, that he refer such patients to a
law. Since many of us were students the dentist if there is one in the vicinity. A field of medicin and surgery has been so dentist may be able to treat and save the enlarged that no student can now hope to offending tooth. The aching of a tooth, compass that field and master it, even its without any other indications, is not a rudiments, in the time many of our colsign that it should be extracted. It leges allot as a course for graduation ; would be well if physicians would advise hence the crying necessity for a common their patients to have their teeth exam
law for the Republic; hence the pressing ined occasionally, as the dentist could necessity for a law that shall make a time detect caries, abrasions or erosions of the basis of study that will give the student teeth and advise them of the proper treat
time enuf to master the various fields of ment.
medical learning that are now a sine qua JOSEPH POSPISIEL, M.D., D.D.S. non in preparing for practice. Then 213 H. Street, N. E., Washington, D. C.
again, no matter what a man's qualifi
cations may have been at graduation, DEAR DOCTOR TAYLOR :-In the beauti- when he goes into the practice of medicin ful poem by Will Carleton entitled “The and has past from the student to the Country Doctor,'' in November WORLD, practising physician, he soon gets rusty ; page 486, you omitted the third verse, he soon forgets the foramen of the sphenoid which is as follows:
bone from a technical standpoint; he soon Maybe half the congregation now of great or little worth, forgets the exact technical relations of the Found this watcher waiting for them when they came upon the earth;
femoral artery, the profundus femoris, This undecorated soldier of a hard unequal strife,
and the great sciatic nerve. Yet he is Fought in many stubborn battles with the foes that sought
practical, and with each year's store of The Arlington Chemical Company, of practical knowledge laid by, his technical Yonkers, N. Y., a few years ago printed knowledge that he must have to stand an this poem with illustrations, which I
examination recedes. There can be no framed and value more highly than any
more cogent reasons for a common medipicture I have.
cal act, if our federal system is to be preRolesville, N. C. L. B. Young.
served and medical oligarchies are not to
assume supreme State command. A mediDEAR DOCTOR:-I have been reading your “Monthly
cal act that prevents inter-state medical Talks" for some time, and while I consider THE MEDICAL. commerce is an unrighteous law, not in WORLD one of the best journals I take, I think your“ Monthly Talks" will do the average doctor more good than all the
the interests of the people, and it often balance of the journal. You make the doctor think, which prevents the migration of medical men of is more than any other journal I take does. Morehead, Kans.
W. C. MCCONNELL, M.D. high standing from one state to another.