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wine occasionally. I gave the pill only at night. We continued this treatment for several days. Occasionally, traces of adipose matter could be distinguished in his stools, yet his general appear. ance was improved, the appetite and digestion were better, and the temperature was more natural. He expressed himself as much better and insisted on getting up and going down to his meals. As this was the season in which fruit ripens, some boys had been engaged to pick the pears from his trees. Observing that the boys were not able to raise a ladder, he went to their aid, against the wishes of Mrs. S., and assisted them. He was so exhausted on his return to the house that I was sent for immediately. I found, on my arrival, the prostration so great that I was obliged to give stimulants. I put him in bed and wrapped him in warm blankets. This treatment revived him. A few days after this occurrence, he went in a propeller to Albany, crossing the river seyeral times. I did not visit him for several days, as he deemed it unnecessary and said he would notify me if he needed my services again. About a week or ten days after, I was sent for hurriedly, at 3 A, M. I found him in a semi-comatose condition. I asked him how he felt. He replied, without noticing me, “Boss." I inquired if he had pain; be replied, “None.” He had no movement of bowels and voided no urine since he had retired to bed. Mrs. S. said she had “noticed the day previous that he did not appear as well as usual, and at 2 A. M. had spoken to himn. He had answered in monosyllables." I inquired if he had taken food before he retired. Mrs. S. said he had. As they had company at tea, Mrs. S. was obliged to leave the table for a few min. utes, and the captain said "he would eat the fried pork-steak if it killed him.” I examined his abdomen externally, and there appeared to be no unnatural distention or tenderness and no fullness of the bladder, The skin was warm and natural. Thinking there might be suppression of urine, I introduced the catheter and found about a tablespoonful. Ten hours having now passed since eating the pork-steak, I was at a loss to know whether indigestion had influenced the coma or if it had been induced by uræmic poisoning. Wishing to analyze the urine, I left the patient, promising to call again before going elsewhere, leaving a few general directions, but giving Mrs. S. no hope of his recovery from this attack.
Early in the morning, accompanied by my son, I visited him again. He introduced the catheter and drew about a gill of urine.
The coma remained the same during the entire day. I informed Mrs. S. that we thought her husband could not recover, and, if she desired a consultation, that I would obtain it. Mrs. S. said she wished counsel. I accordingly telephoned for Dr. Albert Vanderveer, of Albany, who arrived at 4 P. M. He examined the patient thoroughly, by percussion and auscultation, thinking that there might be latent pneumonia. He noted the sputa, which was gray in color. The eye and abdomen were also carefully examined. The Doctor inquired how long since I had given any opium. I replied, About three weeks. In the interval between the morning visit and the arrival of Dr. Vanderveer, my son had analyzed the urine and found one fourth sugar and about one sixth albumen, with earthy phosphates. The urine was afterward examined microscopically by my son, and was found to contain epithelium, hyaline casts, and broken-down blood-corpuscles, which we thought were sufficient evidence of Bright's disease.
Mrs. S. asked Dr. Vanderveer what he thought of the case. He replied that it was very serious. He did not name the disease but wished to hear from the patient in the morning. My son and I called again at 10 P. m., and found the patient gradually sinking, the breathing slow and labored, profound coma, and insensibility to sound and touch. Mrs. S. inquired how long he would last. I replied I did not think he would last until morning. He died at 1.45 A. M. I tried to obtain an autopsy but failed, as Mrs. S. objected and his son in New York city could not be communicated with in time. He died twenty-four hours after his wife noticed a change, when I was last sent for.
Now, gentlemen, this case, which I have related at some length, is before you, and, to my mind, it is a very peculiar one and of great interest. I have never seen a case of the kind in more than thirty-four years' practice. Dr. Vanderveer said to me that he had never in his practice seen such a case. I thought, from what I had read on the subject, that the case was one of adipose diarrhea. I therefore submit it for your consideration; but, before closing, allow me to quote from two authorities which have come under my notice since the above case
occurred, which may have some bearing on this subject. In 1832, Dr. Bright, in a paper read before the Medical and Chirurgical Society of London, said he had observed in a patient peculiar discharges of fatty matter which, when cold, encrusted the fæces. This statement applies to the conditions in the case under consideration, but the fatty substance in his case floated about in the form of globules. In the “Journal of the American Medical Association,” for July 19, 1884, is an account of a case which more nearly resembles the case I have presented to you. It was reported by Dr. Ziehl, in a paper taken from the “Edinburgh Medical Journal,” in which he says that fat was mixed with the fæcal discharges in a case of obstruction to the head of the pancreatic duct, in various forms, either as a yellowish compact mass, or as an oily fluid, or more rarely in form of acicular crystals, united in bundles which can only be discovered with the microscope. The crystals, he says, had been described by Friedreich in two cases only. They were not tyrosin, as had been maintained by some. Tyrosin-crystals are light-brown in color and are not soluble in ether, whereas the other crystals were clear and transparent, and soluble in ether; and he recorded a case where the presence of these crystals helped him to make a diagnosis. The dejections, which were dry and formed and silver-gray in color, contained a large quantity of microscopic, needle-like crystals, which were either isolated or united in bundles, and which, after being dissolved in ether and evaporated, left an abundant deposit of fat. The case now under consideration resembles this in some particulars. The fæces were formed and silvery gray, and the crystals were discernible with the eye. The liquid resembled oil, and, when cold, formed a yellowish coating over the fæces, of about one eighth to one fourth of an inch in thickness and of a very offensive odor.
I have thus given in detail the history of this case. I regret that an autopsy could not have been obtained, as that, I have no doubt, would have revealed carcinoma or some serious organic disease of the pancreas.
THE HYDROCHLORATE OF COCAINE AS A LOCAL
ANÆSTHETIC IN OPHTHALMIC SURGERY.
By CHARLES STEDMAN Bull, M. D., of New York County.
Read November 19, 1884.
THERE has very recently been brought to our knowledge a new local anæsthetic agent, the hydrochlorate of cocaine, which within certain limits has proved of very great value in ophthal
Our first knowledge of the effects of the drug on this side of the Atlantic came in a letter from Dr. H. D. Noyes, of New York, to Dr. E. R. Squibb, of Brooklyn, dated Kreuznach, September 19th. An open letter from Dr. Noyes to the “Medical Record,” dated Heidelberg, September 19th, was published in the issue of the “Record ” of October 11, 1884. In this letter, he describes the effects of the drug upon the cornea and conjunctiva of patients, as demonstrated at the Heidelberg Ophthalmological Congress in September last. It is not the intention of the writer of this paper to discuss either the origin, nature, or physiological properties of the drug, except from a clinical stand-point. Let it suffice to say that cocaine is the alkaloid made from the leaves of Erythroxylon coca, a shrub which grows wild and is extensively cultivated in certain portions of South America. The leaves resemble those of the Chinese tea-plant, and they have been used for many years as a nerve-stimulant by the natives of Peru and Bolivia, especially by those dwelling upon the slopes of the Andes. The alkaloid was first isolated in 1855, but its physiological properties were not thoroughly studied until Lossen investigated the subject in 1860 or 1861. The value of its anæsthetic properties was not recognized in ophthalmic therapeutics until the present summer, when Dr. Karl Koller, Assistant Physician in the General Hospital at Vienna, having seen its beneficial anæsthetic effects upon the sensitive mucous membrane of the larynx, applied it to the eye and produced a superficial and transient but complete anæsthesia of the cornea and conjunctiva. He brought it to the notice of Dr. Brettauer, a well-known ophthalmic surgeon
of Trieste, who communicated it to the Ophthalmological Congress at Heidelberg. Through the kindness of Dr. E. R. Squibb, of Brooklyn, the writer was furnished, on October 7th, with a small supply of a two-per-cent and a four-per-cent solution of the salt, made from Merck's crystals, and the physiological experiments which form the basis of this paper were made with these preparations. These experiments may be classed under three heads: 1. Experiments as to the anæsthetic effects of the drug on the sensory nerves of the cornea and conjunctiva. 2. Experiments on the pupil. 3. Experiments on the accommodation,
The drug was for the first time employed in this country, as a local anæsthetic on the eye, by the writer, on October 8th, in his office, for the removal of a cinder from the cornea.
1. The Effects upon the Cornea and Conjunctiva.— The effects of the drug in producing anæsthesia of the cornea and conjunctiva are complete and positive, although the diminution of sensibility varies in different persons. The writer has used the drug in more than one hundred and fifty cases and has succeeded in producing complete anæsthesia in all but three, while, in these three cases, the sensibility was decidedly diminished. When a two-per-cent solution is used, the diminution of sensibility begins within the first three minutes after the first instillation, and the anesthesia is always complete within fifteen minutes and usually within ten minutes. It begins to diminish in about twenty minutes and disappears in from thirty to thirty-five minutes. If a second instillation be made, the anæsthesia comes on more rapidly and lasts longer, sometimes