the heart and respiration and acts as a fine stimulant. It may be given in doses of 0 or abo grain, and at times, if necessity demands it, hypodermically, in such cases as extreme weak pulse, great dyspnea, and marked cyanosis and feeble respiration. As for nitro-glycerine I have no experience, but it is recommended very highly in of a grain. As for digitalis and strophanthus, I like the latter, because it dilates the arterioles, and in this way it invigorates the function of the skin, which is no small item.

AUBURN, KY.

THE USE OF COCAINE IN SURGERY.

BY EDWARD PENDLETON,

Student of the Louisville Medical College, Session 1894-5.

The subject which I have selected to write upon is very interesting to the surgeon, and should interest the general practitioner more than it does. Very little has been written on cocaine anesthesia. I suppose Dr. John A. Wyeth, of New York, has written more on this subject than any man in America. Dr. Koller, of Vienna, in September, 1884, first demonstrated that a solution of hydrochlorate of cocaine, two per cent, possessed the property of producing complete temporary anesthesia. Its analgesic effects when applied to a mucous membrane were demonstrated before the Ophthalmological Congress at Heidelberg. Only mucous membranes are rendered anesthetic. It has no effect when applied to the skin. The anesthetic effects were discovered long before Koller made his demonstration; nevertheless mankind will always owe to Koller a debt of gratitude. In the year 1855 Gadecke extracted an alkaloid from the leaves of erythroxylon coca. In 1857 Percy, of New York, exhibited an alkaloid which had been isolated. Even as far back as 1868 Schroff, Morbray, and Maiz had discovered the anesthetic properties of cocaine. The dose of cocaine is arbitrary; it differs not only in different individuals, but in the same individual at different times.

The symptoms shown when too much cocaine enters the circulation are the following: nausea, syncope, redness of the face, dilation of the pupil, increase in the heart-beat, but weak pulse, cold, clammy skin, convulsive movement, and at times exhilaration are not an uncommon symptoms, followed by drowsiness, headache, etc. In using cocaine

solutions begin only with a few minims, and increase slowly, watching the pupil, face, respiration, and pulse. Cocaine has been classed as a cardiac stimulant; in large quantities it is said to arrest the heart's action. In minute doses it increases the respiration, in large doses it arrests the action of the respiratory muscles. Remember never to use cocaine with children under ten years of age. I have in one or two instances seen fainting. Of course this might have been due to the fact that the patient saw the wound or blood, or it might have been due to the excitement of the operation. The solutions of cocaine ordinarily used are made from the hydrochlorate; the per cent will vary in different cases. The solution should be free from foreign matter of every description, and should have a neutral reaction. Clean water, free from visible impurities, is harmless. Solutions of cocaine kept too long are unfit for use hypodermatically; it seems that there is developed in them a penicillium, a minute organism which rapidly grows in an alkaloid solution. Always make fresh solutions when needed. It has been said that solutions prepared from spring or rain-water are less likely to produce inflammation and abscess than solutions prepared with distilled water. The solutions of cocaine that I have seen used were prepared with pure distilled water, and never in a single instance was inflammation or abscess the result.

When using the hypodermatic injection care should be taken not to puncture a vein. Serious have been the results of injecting solutions. into veins. Before inserting the point of the needle always force out the air which is in the syringe by allowing a few drops of the solution to escape from the point of the needle. Speaking of the minute organism, the penicillium, which develops in cocaine solutions, a very good way to destroy this germ is to boil the water used in the solution, add three or four grains of boracic acid to the solution, and in this way any organic matter is rendered innocuous. Solutions of cocaine of different strengths are used daily in laryngological, genito-urinary, obstetrical, gynecological, and rectal surgery. Cocaine may be used in amputating fingers, toes, incising felons, abscesses, removing ingrown and diseased nails, foreign bodies, tumors, all forms of neoplasms, moles, warts, cicatrices, impacted bodies, etc. I have seen cocaine successfully used in a division of the nerves. Cocaine is used in circumcision, exploration of the bladder, catheterization, internal and external urethrotomy. Usually a two-per-cent solution is used in the eye. In the buccal cavity a four-per-cent solution is applied with a mop, for the

removal of tonsils, uvula, cyst of the lips, epithelioma, ulcers, cleft palate. In the larynx and naso-pharynx it is used daily. In genito-urinary surgery it has found a field of much value. Before injecting the cocaine the parts should be shaven, scrubbed and cleansed in a mercurial lotion, I to 3,000. During the operation, when the syringe is not being used the point should be kept in a sterilized gauze sponge. When amputating fingers, toes, or in circumcision always use a rubber constrictor. After the parts have been cleansed in a bichloride solution, I to 3,000, the cocaine may be injected directly into the lines of the incision, or above the nerves. When cocaine is injected directly into the tissues it is said to retard healing. Force out every particle of air from the syringe; the point of the syringe is next thrust through the skin, about three minims of the fluid is injected, the needle pushed about a half an inch further and three more minims forced out, and so on until the parts are insensible to pain. The only pain experienced is the prick of the needle when it first enters, and a smart burning pain when the fluid comes in contact with the tissues. The absorption of cocaine may be hastened by massage over the parts. When the operation is finished, loosen the constrictor and allow the wound to bleed; tighten the constrictor; wash the wound in a bichloride solution, I to 3,000. Finally remove the constrictor and allow the wound to bleed for a minute or two, washing the part in a hot bichloride solution, I to 3,000, closing the wound if necessary and applying the ordinary dressing.

OWENSBORO, Ky.

THE BORDERLAND OF SANITY AND INSANITY, INCLUDING NORMAL AND ABNORMAL MAN.

BY T. B. GREENLEY, M. D.

[CONTINUED FROM PAGE 410.]

Lord Chatham did not do things as others; he was mysterious and violent, indolent and active, imperious and charming.

Pope "was rickety. He had his hallucinations. One day he seemed to see an arm come out from the wall, and inquired of his physician what this arm could be?"

Lord Byron "was scrofulous, rachitic, and club-footed. Sometimes he imagined he was visited by a ghost; this he attributed to the overexcitability of the brain. He was born in convulsions, and died at the age of thirty-seven. Lord Dudley believed that Byron was insane."

Napoleon "had a bent back, an involuntary movement of the right shoulder, and at the same time another movement of the mouth from left to right. When in anger, according to his own expression, he looked like a hurricane, and felt a vibration in the calf of his left leg. Having a delicate head he did not like new hats. He feared apoplexy. To a general in his room he said 'See up there.' The generad did not respond. 'What,' said Napoleon, 'Do you not discover it? it is before you, brilliant, becoming animated by degrees; it cried out that it never would abandon me. I see it on all great occasions; it says to me advance, and it is for me a constant sign of fortune.'"

Stammering troubled Esop, Virgil, Demosthenes, Alcibiades, Erasmus, Cato of Utica, and Charles the Fifth. Sterility is not uncommon in great men, as Dryden, Addison, Swift, Pope, Johnson, and Goldsmith.

Precocity may be regarded as an indication both of genius and insanity. Dante composed verses at nine years old, Tasso and Mirabeau at ten. Comte, Voltaire, and Pascal were great thinkers at thirteen; Niebuhr at seven; Jonathan Edwards, Bossuet, and Pope at twelve; Goethe before ten; Victor Hugo and Fenelon at fifteen; Handel and Beethoven composed at thirteen; Mozart gave concerts at six; Raphael was renowned at fourteen. Yet some great men were regarded as poor pupils, as, for example, Pestalozzi, Wellington, Balzac, Humboldt, Boccaccio, Linne, Newton, and Walter Scott.

Geniuses, like the insane, are inclined to misinterpret the acts of others, and consider themselves persecuted.

MacDonald points out some physical anomalies affecting alike men of genius and the insane.

"Not a few men of genius are rachitic, and some have cranial and cerebral lesions. Vico, Clement the Sixth, and Malbranche had their skulls fractured. Pericles, Bichat, Kant, and Dante had cranial asymmetry. The 'soudures' of the sutures in the crania of Byron, Pascal, and Humboldt are to be noted. Descartes was sub-microcephalic. Milton, Linneus, Cuvier, and Gibbon were hydrocephalic. Dante and Gambetta had small cranial capacity. Rousseau had hydropsical ventricles. Gauso and Bichat had a more developed left hemisphere than right."

Bischoff and Rudinger in a study of eighteen brains of German savants have found congenital anomalies of the cerebral convolutions. "Alienists hold in general that a large proportion of mental diseases are the result of degeneracy, that is to say, they are the offspring of

drunken, insane, syphilitic, and consumptive parents. The most frequent characteristics of mental diseases are apathy, weakness or loss of normal sense, impulsiveness, propensity to doubt, verbosity, or exaggerated acuteness, extreme vanity or eccentricity, excessive preoccupation with one's own personality, mystical interpretations of simple facts, hallucinations, abuse of symbols or special terms, sometimes suppressing every other form of expression, and a general physical disproportion through an excessive development of certain faculties or absence of others. These characteristics are very common among men of genius."

Mr. MacDonald "makes the equation of genius and insanity. If x were substituted for insanity and y for genius, so as to dispel preconceived notions, an impartial observer would be very liable to say that the characteristics of x and y bring them under the same general category."

Also some other physical characteristics of the insane are almost as frequent in geniuses; they are asymmetry of the face and head, inequality of the teeth, rachitism, face and head very small or very large, etc. Cerebral anemia is frequent, and hyperemia very frequent in the insane.

Size of brain or skull capacity does not indicate either genius or insanity. Some of the smallest heads have been found among men of great intellect, and, on the contrary, some of the largest among men of ordinary minds.

Bischoff found some of the largest among common laborers, weighing 1,650, 1,778, 1,770, and 1,925 grams. I believe the latter weight is the greatest on record. The average brain weight is 1,350 grams. De Quarterfages says the largest brain has been found in a lunatic, and the next largest in a genius. The celebrated scientist, Cuvier, had the largest brain among his class, weighing 1,829 grams.

In considering the history of men of genius it is seen that the normal line of intellect, or the border-line between insanity and genius is intricate and difficult to trace.

There can be little doubt from the biographies of some of our greatest authors, artists, scientists, philosophers, warriors, etc., that we are indebted in many instances to an insane temperament for the highest manifestations of brain power in their respective callings. In this respect the world has been benefited by abnormalities.

Where the dividing line between normal and abnormal mentality is so difficult to trace, we should not be astonished if, in many instances,