anesthesia lasts twenty-six minutes. The solution is of three strengths To each of these solutions 3 minims of a 5 per cent. solution of carbolic acid are added. The second solution is the one commonly used. The first is employed where acute inflammation is present, and the third where repeated injections are necessary. (See Fig. 34.) FIG. 34. This method of producing anesthesia has now been tried long enough to define its limits of usefulness. For minor localized operations it is very satisfactory; but for long and deep incisions it is of little value, as its effects are too superficial, and because it in no way diminishes the fear and mental suffering of the patient, in whom the dread of the operation is worse than the actual pain. Under certain circumstances, however, it may be used in major surgery, such as tracheotomy, the removal of small superficial tumors, and in those patients who are so profoundly ill that it is dangerous to use a general anæsthetic, as, for example, in intestinal perforation in typhoid fever, an operation which has been done many times with this method. As the operation proceeds the needle is inserted at each succesdeeper tissues are anesthetized by infiltra- line of anesthesia is complete. tion if possible, and are cut, not torn, as Infiltration anaesthesia. The sive point as numbered until the the tearing produces great pain. Great care is necessary that the fluid injected is sterile. In some instances in which we are fearful of the effects of prolonged ether or chloroform anæsthesia we can use alternately ethyl chloride locally, infiltration anæsthesia, and, finally, the general anesthetic when deeper tissues are reached and the major portion of the operation is to be performed. Morphine may be given before the operation in such instances to benumb the nervous system. When skin-grafting is to be done, we may resort to the use of cocaine anesthesia of the skin produced by the aid of cataphoresis. (See Cataphoresis.) Within the last few years cocaine and eucaine have both been used to produce anæsthesia of large areas of the lower portions of the body and limbs by injecting them into the subarachnoidean cavity below the termination of the spinal cord by means of a long hypodermic needle, which is usually introduced between the fourth and fifth lumbar vertebræ. By this means the cocaine is brought in contact with the cord and its nerve-roots, and anæsthesia in all the tributary parts is produced. The operation is performed more easily with the patient in the sitting posture, very slightly bent forward, than when he is recumbent, but it is safer as far as disagreeable effects are concerned that he should be recumbent. The skin over the last lumbar vertebra is carefully sterilized and then infiltrated with Schleich's fluid. A long needle is then inserted. at the side of the third or fourth lumbar vertebra in a line drawn between the iliac crests across the back. (Fig. 35.) It can be felt to pass between the bodies of the vertebræ. (Fig. 36.) If there is no escape of subarachnoid fluid, the needle is not in the right place. As A FIG. 35. 10 B soon as this fluid appears the syringe, already filled with a 2 per cent. cocaine solution, is attached to the needle, and from 10 to 15 minims (0.60-1.0) are injected. Anæsthesia is developed in from two to fifteen minutes, and lasts from one to five hours. It is needless to point out that not only the skin, but also the needle, the syringe and the solution should be most carefully sterilized before the operation. This method has been resorted to in cases demanding operation below the area injected, and in case of labor, which is thereby rendered painless. Considerable fever, nervous and circulatory disturbance may arise in susceptible persons; but Marx asserts that if grain (0.0003) of hyoscine is given hypodermically these symptoms are prevented. In the opinion of the writer, this practice will soon cease to be employed except in a few instances in which some extraordinary contraindication to ether and chloroform exists, as it is unsatisfactory and dangerous. A number of deaths have followed its use. In Hahn's statistics there were 8 deaths in 1708 operations. It would seem, therefore, more dangerous than chloroform, and it is certainly not so satisfactory. The proof of its inefficiency lies in the fact that it is not generally used. A, space between the third and fourth lumbar vertebræ for subarachnoidean injection (Quincke's area). B, area of puncture suggested by Tuffier. Internally, cocaine or the fluid extract of coca may be used as a temporary supportant and stimulant in low fevers, and in cases where great physical and mental strain must be borne. Its use for any length of time is dangerous and harmful. Thorington has found cocaine of great value in yellow fever as a stimulant for a short time and as an anti-emetic. In the vomiting of pregnancy and other forms of excessive emesis it is of great service by depressing the gastric sensory nerves and thereby decreasing the irritability of the stomach. Cocaine is stated to be an antidote to morphine poisoning. Showing the introduction of the needle between the last two lumbar vertebræ to produce spinal anesthesia. The syringe is attached to the needle to provide a handle. After the physician believes that the needle point is in the subarachnoid space, the syringe is detached from the needle in order to see if any cerebrospinal fluid escapes. If it does, this proves that the puncture has been successfully performed. The syringe filled with the fluid to be injected is then attached to the syringe and the injection given. (See Fig. 35.) Cocaine is undoubtedly of service in the opium habit, but if continuously used soon evolves the patient from a morphinomaniac to a "coca fiend." The dose of the fluid extract (Fluidextractum Coca, U. S., and Extractum Coco Liquidum, B. P.) is from to 1 drachm (2.0-4.0); that of cocaine, from to grain (0.015-0.03). The other B. P. preparations are Lamella Cocaina, each disk containing grain (0.0012) of cocaine hydrochloride, and Unguentum Cocaina and Injectio Cocaina Hypodermica, given in the dose of 1 to 5 minims (0.06–0.3). The cocaine habit is a condition unfortunately frequently met with since the introduction of this drug into therapeutics. It is often combined with the morphine habit, and sometimes cocaine is employed as a substitute for morphine. The symptoms of the cocaine habit consist of marked loss of flesh, disorders of the circulatory system, mental failure, and delusions sometimes resembling those of chronic alcoholism. Often disagreeable hallucinations are present. The habit is difficult to cure, for relapses are frequent. The sudden withdrawal of cocaine from a patient may result in profound collapse. According to Magnan, a pathognomonic symptom of chronic or subacute cocaine-intoxication is a sensation of a crawling worm or bug under the skin. Untoward Effects.-Loss of speech, blindness, nausea and vomiting, syncope, and unconsciousness have followed the internal use or local application of cocaine. Epileptiform convulsions have also been noted, while the circulation and respiration have been disordered in every possible manner. In many of these cases the urine passed after the poisoning has been copious, limpid, and contained albumin. Curiously enough, a large number of cases of severe poisoning have followed the injection of cocaine into the urethra previous to operation for the relief of chronic gonorrhoea or stricture. The hypodermic injection of cocaine as a stimulant sometimes causes vomiting. The treatment of the poisoning consists in the use of ammonia, coffee, strychnine, or ether and alcohol if the symptoms are those of depression. If they are convulsive in type, then the treatment to be instituted is identical with that of strychnine poisoning (which see). Reichert asserts that morphine is the best antidote to cocaine poisoning. Of 250 cases of accidental poisoning arising from the medicinal use of the drug, but 13 proved fatal. CODEINE. Codeina, U. S. and B. P., is an alkaloid derived from opium, and is often contaminated by morphine. The sulphate of codeine (Codeine Sulphas, U.S.) is generally used, as it is more soluble than codeine itself. Codeine phosphate (Codeine Phosphas, U. S. and B. P.) is also official. Physiological Action.-Codeine resembles morphine very decidedly in its physiological action, the chief difference being that it possesses less narcotizing power, but in large amount more readily produces tetanus and final paralysis of the peripheral motor nerves in the lower animals (Dott and Stockman). It does not arrest secretion in the respiratory and intestinal tract, as does morphine, and therefore is less apt to cause constipation Therapeutics.-Codeine has been highly recommended for years as a nerve quietant, and in the United States in nervous cough and in cases where the cough is excessive in bronchitis and phthisis. In diabetes mellitus some clinicians have found it of value, while others. have been disappointed in its use. It should, however, always be tried in this disease, in the hope that it may exercise a favorable effect. When given for cough it should be used in the dose of from to 2 grains (0.03-0.12) three or four times a day, in the syrup of wildcherry bark. When given for diabetes the dose should be much larger, beginning at 1 or 2 grains (0.06–0.12), and rapidly increasing it till the glycosuria is diminished. Sometimes as much as 20 or 30 grains (1.3-2.0) or more may be given daily. The B. P. recognizes a syrup (Syrupus Codeina) given in the dose of 1 to 2 drachms. (4.0-8.0). COD-LIVER OIL. Oleum Morrhua, U. S. and B. P., sometimes called Oleum Jecoris Aselli, is a fixed oil obtained from the fresh livers of Gadus Morrhua, or cod-fish. There are several species of cod from which the oil is obtained other than the one named, but that given is the chief source of supply. The oil is pale or dark according to its freedom from foreign materials. Although the paler oils are generally prescribed, there can be little doubt that the darker ones are more medicinally active. The most prominent inorganic constituents of the oil are iodine, bromine, and sulphuric and phosphoric acids. It also contains more or less of the biliary salts. Lofoten cod-liver oil, obtained from cod caught near the Lofoten Islands, is generally considered the best for medicinal use. Physiological Action.-Cod-liver oil depends on a number of substances for its peculiar effect. The iodine certainly exerts definite alterative powers, and the oil seems peculiarly adapted to digestion and absorption, for cod-liver oil passes through animal membranes very readily, probably owing to the biliary salts contained in it. The oil aids in the maintenance of bodily temperature by its oxidation, and causes a deposit of fat in the tissues. It also seems to influence the blood directly, for clinical observation shows that anæmic persons become healthy-looking under its use, and Cutler and Bradford have found that this apparent improvement is a physiological fact by the use of Malassez's blood-cell-counting apparatus, the red corpuscles being always increased. It has been proved by experiment that cod-liver oil is more readily oxidized than any other oil. The belief among physicians that the effects of cod-liver oil are dependent upon some peculiar combination of substances has shown itself in the attempts of physiological chemists to isolate the combination. One of the best results reached is the so-called "morrhuol" of Chapoteau, who seems to have isolated a crystalline substance containing phosphorus, iodine, and bromine: 3 to 5 grains of this prepa |