654 THE MEDICAL RECORD. [December 13, 1884. COCAINE IN INTRA-NASM, SURGERY. By WILLIAM CHAPMAN JARVIS, M.D., LECTURER ON LARYNGOLOGY IN THE NEW YORK UNIVERSITY MEDICAL COLLEGE. On the receipt of the intelligence of Roller’s experi- ments 1 with cocaine, through Dr. Noyes’ communication to The Medical Record, the first thought was naturally one suggestive of startling possibilities corresponding in direction with the reader’s line of inquiry. In response to this impulse I have conducted a series of experiments with the new amesthetic in operations upon the nares, and in view of the remarkable and positive character of the results obtained feel encouraged to relate my experi- ence, with certain additional corroborative testimony. My first experiments, conducted several weeks since with a two per cent, solution of the salt, were not ex- tended on account of the unfavorable impression received. Though sceptical regarding the action of this solution for my purposes, I was nevertheless inclined to expect better results from a stronger preparation. A four per cent, solution of the crystalline hydrochlorate of cocaine was afterward obtained from a differeut source. My method of applying the salt consisted in placing pledgets of absorbent cotton in contact with the structures requir- ing removal, and projecting upon them, by means of a glass tube, from five to drops of the cocaine fluid. The cotton once moistened can be used several times at a single sitting; indeed cotton saturated with the fluid and afterward dried will remain cocainized for many hours. I employ an exceedingly fine home-made spray to produce more extensive effects. The cases reported have been selected on account of the exaggerated sensibility of the structures involved, and as such offer excellent evidence of the powerful analgesic action of cocaine. Mr. , banker, consulted me on account of an an- noying nasal catarrh. Examination revealed, among other things, a deviated septum pressing against a con- gestive hypertrophy of the left antero-inferior turbinated tissues. The deviated cartilage extended as a narrow horizontal ledge to the osseous edge of the septum, and obstructed nasal respiration through the left nostril. While employing a probe to point out the site of the af- fection, it happened to lightly touch the septum. The patient started as if severely injured, and invariably ex- hibited signs of intense discomfort. When the manipu- lation was repeated, intense sensitiveness was exhibited, and my prospects of assistance from the patient in a delib- erate operation could hardly have been less favorable. A pledget of absorbent cotton was inserted in the nostril, against the abnormal structures, and a few drops of the co- caine fluid placed upon it by means of a camel’s-hair brush. At the expiration of twenty minutes the cotton was re- moved. The first effect observed was the retreat of the lower turbinated tissue from contact with the septum, thus affording more room for operative manipulation. This peculiar action of the cocaine has already been de- scribed by Dr. Bosworth. I tentatively nipped off a piece of the septum with my fenestrated cartilage forceps ; the procedure, according to the patient’s statement, was perfectly painless. Emboldened by this I commenced work in earnest, the slight amount of bleeding enabling me to continue operating uninterruptedly for five min- utes. During this interval the patient declared there was an entire absence of sensation. The parts were then cleansed of tissue debris. In five minutes sensation had returned. I reapplied the cocainized cotton, and after leaving it in five minutes, proceeded with the op- eration. In this interval I removed the whole length of the remaining deviated cartilage. The patient could with difficulty find words to express his profound sense of satisfaction.. Amanda D , aged sixteen, referred to me by Dr. S. Hemingway. Congenital occlusion of the nares from malformation of nasal and turbinated bones. Bridge of the nose almost entirely wanting. Interocular space very broad, falling of the lower jaws, with associated signs of habitual mouth-breathing. Both nostrils impacted with flesh-like masses, having almost the firmness and elasticity of rubber. The structures were jammed so tightly against the wall of the septum as to give at first sight the impres- sion of its fusion with the cartilage. The turbinated tis- sues present none of the usual signs of hypertrophied membrane, having the appearance of slightly congested turbinated tissues, and having only a trifling tendency to retract when touched with cocaine. The tissues still possessed a sensibility evidently equalling that of the normal erectile structures. The posterior nares were obstructed. A case of congenital stenosis successfully treated by me several years since presented many feat- ures in common with this one.1 I had operated upon Amanda D on a previous occasion, employing my transfixion needle and ecraseur. The child did not possess a particle of fortitude, causing me a great deal of trouble by her persistent crying, and in spite of every precaution for her comfort she proved her- self to be one of the most intractable patients I ever had to contend with. This state of hyperesthesia was probably due to the prolonged contact of these delicate tissues with the septum narium. The case seemed an excellent one for the employment of cocaine. I therefore placed a pledget of absorbent cotton in the left nares, and moistened it with a few drops of the solution, carried into the nostril upon a camel’s-hair brush. After the expira- tion of fifteen minutes I removed the cotton, and delib- erately transfixed the pale tissues, the passage of the needle, as stated by the patient, causing absolutely no pain. The loop was likewise painlessly introduced, and the operation satisfactorily completed. After an interval of five days I continued operating, re- plenishing my cocaine bottle from a neighboring druggist. The solution, though applied as in the first instance, did not have the desired effect. I then procured a fresh solu- tion from still another druggist. This fluid likewise failed. Later in the day I procured some of the original prepa- ration, and found it as effective as in the first instance. Small portions of the turbinated bodies were successfully removed by means of the fenestrated cartilage forceps, an expeditious but more painful and bloody method than excision with the wire, and therefore never employed by me for this purpose. The controlling influence of the cocaine over the blood supply removed this objectionable feature, and furnished a clear field for operation. As the incisions gradually included the deeper-lying tissues they became sensitive, requiring fresh applications of the cocainized cotton. Mr. P , merchant, thirty-two years of age, was seen by me in consultation with Dr. Bellows, of Brooklyn. The patient had been unable to breathe through the nose for fourteen months. The nostrils closed gradually, the right being the first to become involved. Dr. Bellows informed me that he had already been in the hands of a physician, who employed the galvano-cau- tery for several weeks. A surgical procedure of a more formidable character was next employed, the patient emerging from etherization only to be confined to the house for three weeks on account of the severity of the operation, and an otitis media acuta set up by the trau- matism. After recovering from these unfortunate sequelae his condition was worse than before the operation. An examination showed the right nostril to be ditirely oc- cluded by a combined deviation of the septum and tur- binated hypertrophy. A very narrow chink in the left nostril permitted the occasional entrance of a feeble cur- rent of air, enabling the patient to partially remove pent-up nasal secretions. It possessed, however, very little respiratory value. I have been gradually clearing the nostrils for several 1 Wiener MedizinischeJWochenschrift, No. 44, 1884, 1 Archives of Laryngology, vol. iii., 1882 December 13, 1884.] THE MEDICAL RECORD 655 weeks, removing small portions of the tissues in such way as not to interfere with the patient’s business. Al- though the careful excision of small portions of bone and cartilage greatly diminished his suffering, there were, nevertheless, moments when he complained severely of the pain inflicted by the rongeur and cutting forceps. I employed cocaine by placing small bits of absorbent cotton in contact with the already wounded and tender surfaces, and dropping the solution upon it by means of a pipette. In thirty minutes the pledgets were removed and a tentative test made. Although the forceps inflicted pain, superficial sensation was reduced to a degree per- mitting the stripping off of membranes partly divided in a previous operation. Another application of cocaine was made, the cotton being again removed after an inter- val of fifteen minutes. 1 then commenced to divide the tissues, and was told to continue the operation, as no pain was inflicted. I continued operating for three min- utes, when the patient interrupted me while cutting away the deeper structures over the vomer. In this interval bone and cartilage were alike divided without causing the slightest pain. This method of alternately benumb- ing and cutting was continued for more than two hours and a half, the patient being in the best of spirits during the entire interval. He left the office breathing through a free opening into the posterior nares, and thoroughly convinced of the pain-relieving properties of cocaine. The following history, reported through the courtesy of Dr. William Vanderpoel, offers additional evidence in a case in which my ecraseur was recommended : Mrs. Annie M , aged twenty-nine years and six months, pregnant, presented herself at my office, November 3d, suffering from a growth in the left nostril which pro- truded three-fourths of an inch, was about three-fourths of an inch in diameter, of a dark red color, firm upon pressure, and insensible to ordinary manipulation. Two months previous she had come to me, presenting a small growth in the left nostril, which had all the characteristics of an ordinary gelatinous polypus. Under ordinary cir- cumstances I should have removed it at once ; but con- sidering the fact that she was then four months pregnant, and had previously miscarried three times, in each in- stance with profuse flooding, I feared the shock of an operation and ordered a spray of carbolic solution under which treatment the growth seemed to disappear, but a month later returned. Still fearing an operation, on November 9th I injected the tumor with a few drops of.glacial acetic acid, and also gave the patient a powder, composed of tannin, to be snuffed up the nostril as best she could. On November 15th, there was little improvement, so I decided upon an operation. To lessen the pain and shock of the operation, I employed the muriate of cocaine, two per cent, solu- tion, applied with a camel’s-hair brush, to inside of the nostril, as well as the tumor would permit the insertion of the brush. I made three applications at intervals of ten minutes, using in all 3 ss. of the solution, or about one grain of co- caine muriate. The first application was rather painful from the contact of the brush, but the subsequent caused no uneasiness. The Jarvis’ snare was then applied without any discomfort, and passed well up to the root of the tumor, which seemed to have origin from the middle tur- binated bone. No pain was experienced during the opera- tion, and after an hour and a half the tumor came away, the patient not losing more than a few drops of blood during the entire operation, and no hemorrhage fol- lowed it. In addition to the foregoing cases I have employed cocaine to remove polypi and hypertrophied turbinated tissues, and have found it useful to facilitate the prac- tice of posterior rhinoscopy and to alleviate pain in the larynx and pharynx. I do not consider its em- ployment urgent in the removal of polypi and tur- binated hypertrophies, since these growths, especially the former, can be in most instances removed with little or no pain by means of my nasal ecraseur. The time required to make the operation painless with the snare is necessary also to prevent the occurrence of annoy- ing hemorrhage. Although cocaine at times restrains bleeding, its action in this respect is not necessarily per- manent. I have observed tissues pale and bloodless when divided under the influence of cocaine, bleed pro- fusely as soon as the effect wore off. The employment of cocaine in the nostril has been referred to in this country by Bosworth, Bettman, Ingals, Knapp, Gruen- ing, and Claiborne. It is curious to note that while Professor Wohler and Dr. Niemann mention its effects upon the tongue, they claimed it possessed no action upon the eye.1 Von Anrep (Archives fur Physiologie, p. 56, 1880) experi- mented upon himself by pencilling the tongue with a weak solution of cocaine, and observed a loss of sensa- tion. The blood-vessels were first constricted, then di- lated, and eventually resumed their normal condition. It was probably this discovery that induced Fauvel and other European laryngologists to employ cocaine in examina- tions of the throat. Although I have only employed a four per cent, preparation of the salt, the experiments of Jelenek2 indicate an advantage to be obtained by the employment of stronger solutions (twenty and thirty per cent, alcoholic) of the salt. The difference will prob- ably show itself in a deeper and more rapid effect. My remarks upon cocaine analgesia would be incomplete without reference to another agent of this kind. I al- lude to rhigolene. Although no record of its use in intra-nasal surgery has come under my notice, rhigolene has yielded excellent results in my hands. For the pres- ent I must content myself with a brief account of the method, since a detailed description would be foreign to the subject of my paper. This petroleum naphtha, proposed by Dr. H. J. Bige- low, of Boston, as a local anaesthetic, boils at 70° F., and, in the form of a spray, is capable of reducing the temperature 150 below zero. Rhigolene, when applied with a suitable atomizing apparatus, will effectually freeze the tissues in less than a minute. 1. make use of a special contrivance for this purpose. Its action is more prompt and deeper, but of shorter duration than that of cocaine. Cartilage and mucous membrane can be deeply and freely divided without pain or hemorrhage. The rapid disappearance of the . artificial congelation makes it necessary for the operator to act with promptness and energy. In cases requiring extensive operative interference, frequently repeated ap- plications of the rhigolene spray are necessary. This, however, does not apply to the practice of ecrasement. Tissues properly snared with the wire loop of my nasal ecraseur can be continuously frozen and divided. I have utilized partial cocaine anaesthesia to facilitate transfixion and snaring of the turbinated tissues, rapidly completing the operation with the rhigolene spray. It is hardly necessary to add that daylight must be em- ployed for illumination, on account of the inflammability of the naphtha fumes. Rhigolene acts more rapidly than ether, and for this and other reasons is to be preferred.3 Conclusions.—1. Cocaine is useful in intra-nasal sur- gery, as a local anaesthetic, for the removal of deep as well as superficial tissue abnormalities. 2. Repeated applications are required for the re- moval of the deeper structures, the time requisite for anaesthesia always being shorter after the first effect has been obtained. 3. By promoting quiet and preventing secretion, hem- orrhage, and sneezing, it facilitates the employment of cutting instruments within the nasal cavity. 4. The action of cocaine for profound anaesthesia de- pends upon the quality and quantity of the salt. 1 American Journal of Pharmacy, i860, vol. xxxii., p. 450. 2 Wiener Medizinische Wochenschrift, No. 45, 1884. 3 Dictionnaire de Medecine, etc., Littre and Robin. 65 6 THE MEDICAL RECORD. [December 13, 1884. 5. In rhigolene we possess a most valuable local an- aesthetic for intra-nasal operations, the effects produced being more rapid and complete but of shorter duration than those of cocaine. 6. Rhigolene is advantageously employed in conjunc- tion with cocaine. 25 East Thirty-first Street.