656 
THE MEDICAL RECORD. 
[December 13, 1884. 
had pain during the whole operation, not great in the 
centre, but quite keen at the periphery of the wound. 
He was restless and uneasy. I etherized him, which 
took about one minute, and performed the same opera- 
tion on the other eye under perfect amesthesia. The 
four black silk-sutures which loosely closed each wound 
were removed to-day, a week later, before the class. 
There was no trace of suppuration ; primary union had 
taken place in both lids, though the wounds had been 
protected by nothing more than a clean handkerchief, and 
the boy had gone home to Harlem immediately after the 
operation. The result in both eyes is perfect. 
Case III.—Perforation of drumhead; cocauie anes- 
thetizes the inner wall of the drum-cavity, but not the 
drumhead.—Mr. , aged twenty-one, a student of 
medicine, presented himself on October 23d at my of- 
fice, with a middle-sized, clean-cut perforation in each 
drumhead. The drumheads, as well as the inner walls 
of the drum-cavity were quite sensitive to the touch of 
a probe. Fifteen minutes after the instillation of coca- 
ine, the drumheads had lost nothing of their sensibil- 
ity, but the inner walls of the drum-cavity were com- 
pletely anaesthetic. The patient felt a bitter taste in his 
throat. 
Case IV.—Cocaine in cataract operations pre-emi- 
nently useful.—Division of primary and secondary cata- 
ract is entirely without pain—a great advantage, for it re- 
moves also the reflex contraction of the globe, which 
favors too great a capsular opening in soft cataract, and 
prolapse of vitreous or of shreds of capsule in secondary 
cataract. The perfect rest of the eyeball is highly favor- 
able for an exact technique. 
In extraction of senile cataract under cocaine, there is 
only one step connected with pain, viz., the excision of 
the iris. This pain is commonly not great, and easily 
borne. The perfect insensibility of the conjunctiva and 
cornea insures the steadiness of the eyeball, and the cor- 
rect location of puncture, counter-puncture, and track of 
the section. The absence of pressure makes accidents, 
such as falling of iris before the knife, and prolapse of 
vitreous, less likely to occur. Without going into de- 
tails, I may say that it assists the operator in every step, 
but particularly in the so-called toilet of the wound, i.e.t 
its cleansing and final adjustment. 
The property of cocaine to contract the blood-vessels, 
which is of great advantage in operating, has been sus- 
pected of having bad after-effects. Dr. G. J. Ball, in the 
New York Medical Journal, November 22, 1884, page 
587, makes the following remark : “It became a ques- 
tion whether the new anaesthetic might not impair nutri- 
tion in certain operations in which the slightest impair- 
ment might affect the result injuriously. In two cases of 
cataract extraction in which cocaine was employed, the 
operations had been followed bv sloughing of the flap. 
It might be well to consider whether this was more than 
a mere coincidence.” I think it was not. Since the in- 
troduction of cocaine, fifteen successive extractions have 
been performed under the influence of cocaine at the 
New York Ophthalmic and Aural Institute. Only one 
operation was followed by some reaction—it was a com- 
plicated operation. The recovery was protracted, but 
good. The other cases were free from any disturbance 
both during the operation and the course of healing, and 
the results were good in all. 
I feel sure that in this, the most important operation 
in ophthalmic surgery, the rate of success will be increased 
by the introduction of the new amesthetic, through Dr. 
C. Koller. 
December 2, 1884. 
FURTHER OBSERVATIONS ON THE USE OF 
COCAINE. 
, By H. KNAPP, M.D., 
NEW YORK. 
Since my communication on cocaine and its application, 
Medical Rccord, October 25th of this year, I have used 
the new anaesthetic in a considerable number of cases, of 
which the following may be of interest even after the gal- 
axy of cocaine papers that have appeared in the Ameri- 
can and foreign press since October 18th. 
Case I.—Enucleation of an eyeball under anesthesia 
from injecting cocaitie into the post-ocular cellular tissue. 
—To-day, at my clinic at the University Medical College, 
I presented a patient, aged twenty-five years, in whose left 
eye I had diagnosticated a choroidal sarcoma. I stated 
before the class that it would be quite an interesting ex- 
periment to inject cocaine into the orbit, behind the globe, 
and afterward test the sensibility of the anterior parts of 
the eye, supplied by the ciliary nerves. The hour, however, 
drawing to a close, the practical indications of the case 
were the only ones we had time to attend to. I instilled two 
drops of a four per cent, solution of Merck’s hydrochlorate 
of cocaine into the conjunctival sac. Five minutes later 
another five drops were instilled, and about six minims of 
the same solution injected behind the globe. This was 
easily done and not felt at all by the patient. The eye- 
ball had been forcibly drawn toward the nose with a pair of 
fixing forceps, the point of the hypodermic syringe thrust 
into the orbital tissue as far as the posterior pole of the 
globe. Five minutes later the eye was enucleated in the 
usual way. The patient indicated slight pain at the di- 
vision of the tendons of the recti muscles. The division 
of the optic nerve and the dissection of the posterior 
segment of the globe caused almost no pain. When the 
eyeball was removed, I thrust the end of the forceps an 
inch deep into the wound of the orbital cellular tissue. 
The patient did not move, and said she felt nothing. 
The bleeding was very scant. The eyeball was opened 
at once, and a typical melanotic sarcoma of the choroid, 
the size of a cherry pit, covered by detached retina, was 
exhibited to the class. Ten minutes later, when the 
hemorrhage had completely ceased, I united the con- 
junctival wound with a continuous suture. By this time 
the sensibility had returned, and the patient screamed at 
every stitch, saying that this hurt her very much, whereas 
during the operation she had felt almost no pain. 
This observation has convinced me that even the re- 
moval of the eyeball does not lie outside the field of ap- 
plication of the new local anaesthetic. 
Case II.—Ptosis operation after subcutaneous i?ijection 
of cocaine ; anesthetic effect not very satisfactory.—A 
boy aged about ten years, with double congenital ptosis, 
was operated on at the clinic of the University, Novem- 
ber 25th. I injected a few drops of a four per cent, solu- 
tion of cocaine under the skin of the right upper eyelid, 
introducing the point of the syringe 3 mm. above the 
edge of the lid, near the outer commissure, and advancing 
it horizontally nearly to the inner commissure. In with- 
drawing the needle, I injected the liquid. The lid swelled 
slightly, was suffused with blood, and in ten minutes 
only partially insensible. I held it compressed between 
a clamp, removed an elliptical piece of skin and muscle, 
and stitched the lower lip of the wound to the upper, 
passing the sutures high up through the skin. The tissue 
which I removed was infiltrated with blood. The patient