MURIATE OF COCAINE 
IN 
OPHTHALMIC SURGERY 
J$Y 
0. .1. LUNDY, A. M„ M. D., 
Professor of Diseases of the Eye, Ear and Throat in the Michigan 
College of Medicine. 
Reprinted from the November (1884) number of The Physician and Surgeon, 
Ann Arbor, Michigan. MURIATE OF COCAINE IN OPHTHALMIC SURGERY. 
BY C. J. LUNDY. A. M„ M. D., Detroit, Michigan. 
I'rofe>.«or of Diseases of the Eye, Ear and Throat in the Michigan College of Medicine. 
Muriate of cocaine, the new local anresthetic, is attracting 
much attention from medical men all over the country, although 
it was first heard of in this country much less than two months 
ago. Probably the introduction of no other agent into medical 
and surgical practice has excited so much interest as has muri- 
ate of cocaine. It is to be hoped that this agent will not prove 
to be one of the ephemera which have so frequently made their 
appearance in the medical horizon of late. From present indi- 
cations this will prove to be a valuable agent for producing local 
anesthesia previous to performing certain surgical operations. 
So far as I am aware it has been used much more extensively 
in ophthalmic surgery than elsewhere. Already, scores of oper- 
ations have been performed while the parts were under its 
influence, and the results have, in the main, been satisfactory. 
Its use in many instances renders unnecessary the use of a 
general anaesthetic, such as chloroform or ether, but it cannot 
always be employed to the exclusion of these latter. It has 
been successfully employed in operations on the eye, the nose, 
the uterus, etc. I have made many experiments with it, and 
have used it in a number of cases previous to operating, and 
the results obtained have been generally uniform. I employ 
a four per cent, solution, and one weaker than this is not likely 
to give satisfaction. After two drops of this solution were 
dropped into the eye, and repeated every three minutes till 
eight drops were used, it was observed that tolerably complete 
anaesthesia of the parts soon followed. Applied to the mucous 
membrane of the mouth or nose the results were similar. It 
seems to paralyze sensation in all parts of the trifacial nerve 
with which it comes in contact. As it h 'S been used in uterine 
operations, and has there produced anaesthesia, it is quite prob- 
able that all parts of the human economy are susceptible to its 
influence. Although it produces anaesthesia of the conjunc- 
tiva and cornea, it is thought by some that it will not antes- 
thetize the iris. No doubt it will be difficult to affect this 
tissue by muriate of cocaine, owing to the fact that it is bathed 
with the aqueous humor of the anterior chamber. This humor 
will dilute the cocaine to such an extent that it will not be 
likely to produce complete anesthesia of that tissue. But that 
it does exert a paralyzing influence upon the iris there can 
be no doubt, for its effects can be observed both in operations 
and otherwise. As we shall see, it partially paralyzes the 2 
MURIATE OF COCAINE IN OPHTHALMIC SURGERY. 
sphincter of the pupil, and dilates it widely. This it would 
not be likely to do, without also affecting its sensibility; espe- 
cially so, when it paralyzes other branches of the same nerves 
which supply the iris. 
After the use of the cocaine solution, the cornea begins to 
lose its sensibility within three or four minutes, and in many 
cases the corneal antesthesia is complete in five minutes. How- 
ever, in some cases the antesthesia is not complete until the 
expiration of eight or ten minutes. The following case will 
illustrate its anaesthetic effect on the cornea: 
A gentlemen who was under treatment for an irritable and 
painful ulcer of the eye, and who had been treated with atro- 
pine, etc., in the morning, came several miles from an adjacent 
village in the afternoon, seeking relief from intense pain. Two 
drops of the muriate of cocaine were instilled into the eye, and 
this was repeated in four minutes. In less than eight minutes 
he was not only relieved of the pain, but the corneal ulcer 
could be touched with the point of a sharp instrument, with- 
out producing the slightest sensation. 
The conjunctiva loses its sensibility after the use of cocaine 
in six to ten minutes, and can be firmly grasped with a fixation 
forceps without producing pain or discomfort. When the eye 
is turned from side to side by the forceps the patient experi- 
ences simply a sense of motion. 
The anaesthesia of the cornea and conjunctiva lasts from 
twenty to thirty minutes after which time sensation gradually 
returns. In the case of painful ulcer already referred to, the 
relief from pain was complete for several hours. 
Its action on the pupil and on the muscle of accommodation 
(ciliary muscle) were observed as follows: In five or six min- 
utes the pupil began to dilate. The dilatation increased slowly 
for fifteen or twenty minutes, at which time the pupil was 
twice the normal size. In no case did I observe that the pupil 
was dilated ad maximum. The dilatation of the pupil lasts from 
twelve to twenty hours according to the quantity and strength 
of the solution employed. At no time was the pupil wholly 
irresponsive to light. In twelve to fifteen minutes I observed 
the first signs of failure in the power of accommodation. In 
twenty minutes the effect on the ciliary muscle was tolerably 
well marked, and print which before the use of the medicine 
could be seen at five or six inches, could not now be seen 
nearer than twrelve to fourteen inches. Repeated attempts to 
fully dilate the pupil and render it wholly irresponsive to light 
were not successful in my hands. Neither did I succeed in 
producing anything like complete paralysis of accommodation. 
It will be seen that muriate of cocaine.not only produces 
tolerably complete paralysis of sensation, but that it also im- 
pairs the motility of parts to which it is applied. Although its 
influence in producing motor paralysis is slight, yet it does not MURIATE OK COCAINE IN OPHTHALMIC SURGERY. 
3 
appear to be of such short duration as is the paralysis of sensa- 
sation. While sensation is completely restored within thirty to 
sixty minutes in the normal eye, the power of accommodation 
does not return for several hours, and the pupillary sphincter 
does not regain its power for twenty hours. 
It was observed that the parts became slightly hyperaemic 
soon after the use of the cocaine solution, and that they bled 
more freely when incised, than is usual in similar operations. 
From this I was led to infer that the cocaine exerted some 
influence over the vaso-motor nerves. This of course did not 
amount to anything like complete vaso-motor paralysis. It 
was also observed that the hyperaemia produced was of short 
duration—probably not lasting more than twenty to thirty 
minutes, after which time the parts presented a somewhat paler 
appearance than normal. For example, a medical student pre- 
sented himself for experiment before the Wayne county med- 
ical society. The conjunctiva, both ocular and palpebral, was 
somewhat injected before the drug was used For a short time 
(about halfan hour) after its use the congestion was well marked, 
but later the conjunctiva was much paler than in the other eye. 
I have employed cocaine muriate in a considerable number 
of operations upon the eye, such as extraction of cataract, enu- 
cleation, strabotomy, the removal of tarsal tumors, operations 
on lachrymal apparatus, etc. In most instances the patient 
experienced little or no pain, and where patients had any self- 
control the results were highly gratifying. 
The use of this local anaesthetic will not prove entirely sat- 
isfactory in operating on children and persons who are ex- 
tremely nervous and timid. Such persons think an operation 
must of necessity be attended with pain, and imagine the oper- 
ation is painful whether it is or not. In one case, that of an 
extremely nervous boy, whose timidity was so great that the 
drops could be put in bis eye with great difficulty, it was neces- 
sary to administer a little chloroform while operating for con- 
vergent strabismus. The right eye was bandaged while the 
left was being operated upon, but the bandage came off, and as 
soon as he could see distinctly what was being done he became 
uncontrollable, and it was necessary to give a little chloroform. 
In one ease of enucleation, I was able to do the greater part 
of the operation before the patient felt any pain. Had the 
patient not been a nervous, timid person, I think the operation 
could have been completed without difficulty. As it was a little 
chloroform was given previous to section of the optic and cil- 
iary nerves. This patient was a bad subject for general anaes- 
thesia, and by the use of the local anaesthetic, the necessity for, 
and the risk of, complete general anaesthesia were avoided. In 
cases of this character, muriate of cocaine will probably prove 
itself of great value, for while it produces a sufficient degree of 
anaesthesia of the part operated upon, the danger of chloroform 4 
MURIATE OF COCAINE IN OPHTHALMIC SURGERY. 
is avoided. Even if chloroform is administered at the same 
time, it need not be carried to the point of complete narcosis. 
In an operation for cataract the patient stated that he felt 
no pain whatever. The only thing of which he was cognizant 
was a pressure; but whether this was from the speculum 
between the lids, or from the pressure of the shell scoop upon 
the cornea in delivering the lens, I do not know. 
Bowman’s operation upon the lachrymal apparatus was 
done several times with scarcely a particle of pain. In one 
case the division of stricture in the nasal duct produced as 
much pain as that operation usually does. When I succeeded 
in getting any of the solution through the duct into the nose, 
the passage of the knife produced but little suffering. In one 
very nervous subject, who fainted during an operation done 
previously for removal of a tarsal tumor, no pain was felt when 
a similar operation was done after the use of the cocaine. In 
this case the incision was made upon the conjunctival surface 
of the lid. Patients who have been operated upon for strabis- 
mus say that while they feel no pain they experience a “sen- 
sation of motion,” or a drawing or pulling of the eye when the 
stabismus hook raises the tendon previous to the tenotomy. 
In a canthoplastic operation, the pain was less severe than 
usual, but the operation was by no means painless. Had the 
skin at the outer angles of the eye been well bathed with the 
cocaine I doubt if the operation would have produced any con- 
siderable pain. While cocaine lessens the sensibility of the 
skin, it does not destroy it; therefore, for operations involving 
the integument it will not be valuable, unless the hypodermic 
injection of the drug can be done with safety. Under such cir- 
cumstances it would seem that some of the minor operations 
might be done without producing pain. 
In regard to enucleation of the eye, which is regarded as a 
painful operation, and one which is seldom or never done with- 
out an anaesthetic, I would suggest that a subconjunctival injec- 
tion of the cocaine solution be made previous to beginning the 
operation. If the medicine have been previously dropped 
upon the conjunctiva, the passage of the hypodermic needle 
would scarcely be felt and sensation could thus be destroyed 
in all nerves likely to be severed in the operation. 
How wide will be the range of usefulness of this new drug, 
time alone can determine. It may have objectionable features 
which we have not yet discovered, and like other lights it may 
prove to have a shadow. It will be sometime before we can 
estimate its real value and give it its proper place in our list of 
useful agents. If, however, it proves to be in reality all that it 
seems to be, it will be an invaluable addition to the armamen- 
tarium of the ophthalmic surgeon. And its usefulness will 
not be confined to ophthalmic practice, for its amesthetic power 
will prove advantageous in a thousand ways. 1