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well be pardoned. In plastic operations about the eyelids, the drug has not been tried; and, owing to its very slight effect in diminishing the sensibility of the skin, it would probably prove of little avail. A four-per-cent solution has proved very useful in the writer's hands, in certain operations upon the membrana. tympani and middle ear. Paracentesis of the drum-membrane has been performed three times under its influence, with entire absence of pain. In one case of exuberant granulations springing from the external surface of the drum-membrane and the auditory canal in the immediate vicinity, after one instillation of a four-per-cent solution, these granulations were removed with a sharp scoop without causing any pain.
The action of the drug upon the swollen mucous membrane covering the nasal septum and turbinated bones, in cases of acute coryza, is very marked. The writer has used it in his own person, when suffering an attack of acute naso-pharyngeal catarrh with almost complete occlusion of both nostrils. A probe covered with cotton was dipped into a four-per-cent solution, and the entire surface of the septum and turbinated bones, as far as could be reached anteriorly, was covered with the solution. The same solution was also applied on a brush through the mouth to the posterior nares, with such effect that, in less than ten minutes, both nostrils were entirely free and remained so for about five hours. The swelling then returned, but to a less degree.
DR. ROBERT NEWMAN, of New York County, asked three questions: First. What sort of sensation was produced by the anæsthetic? Second. Could it be used by the atomizer? Third. What was the expense of the drug?
DR. BULL replied that the sensation produced by the drug was' at first that of cold, and afterward sensation ceased. The drug
could be used in the atomizer, but that this method was costly. He employed a four-per-cent solution, costing at the rate of forty cents a grain. Eight drops were sufficient for an operation upon the eye.
DR. H. E. MITCHELL, of Rensselaer County.-I can confirm all that Dr. Bull has said as to the value of hydrochlorate of cocaine as an anæsthetic. I desire, also, to call attention to the value of the drug in allaying pain, not only in the eye, but in the ear and nose. I have always felt that it is desirable to do operations with as little discomfort to patients as possible, and have been in the habit, for the past three years, of using the bromide of ethyl in performing minor operations upon the eye as well as for diagnostic purposes. I have been much pleased with the effects of this drug, but it is probable that the new anesthetic will prove superior to, and finally supersede it. The effects of the bromide of ethyl are remarkably prompt, complete anæsthesia taking place within from one to two minutes, and disappearing in nearly as short a time. In my own practice, the anesthetic has been used with perfect safety; but, since hydrochlorate of cocaine has been introduced, I wish to advocate the importance of its use for diagnostic purposes and for the relief of slight ailments in children, in whom it is almost impossible to carry out any plan of treatment so long as extreme sensitiveness of the eye exists.
DR. E. R. SQUIBB, of Kings County.-I received a letter from Dr. Noyes bearing about the same date as one published later in the "Medical Record" from the same author; and I immediately sent the letter, with some cocaine hydrochlorate, to Dr. C. S. Bull, who, I believe, was the first physician in this country to test its anææsthetic properties. It is a remarkable fact that coca, from which cocaine is made, is a stimulant, while cocaine is a powerful sedative to the tissues with which it comes in contact.
Dr. Squibb then spoke at some length of the manufacture of cocaine, and said that the price which had been demanded for it by the importer before its anæsthetic properties were known had been about sixteen or seventeen cents a grain; and, as the extracting process was very costly, it was probable the price would not fall below that figure. The four-per-cent solution, which was about the only form in which the drug could be obtained in this country at the present time, was generally sold at from sixty cents
to one dollar a drachm; but even at that price it was a cheap anæsthetic, inasmuch as only about five drops were used during an operation. From ten to twelve cents' worth of ether was usually consumed in anesthetizing a man. Dr. Squibb thought the anæsthetic was a valuable one, and that it would not prove to be one of the fashionable novelties destined to go out of use.
PROTECTING THE PERINEUM.
By JACOB HARTMANN, M. D., of New York County.
Read by Title, November 19, 1884.
Ir is generally admitted by writers on obstetrics, in connection with the subject of protecting or supporting the perinæum during the second stage of labor, that something should be done to prevent its laceration; and many suggestions, experiments, and trials have been made to that end. We may assume it to be true that the perinæum does not require support in all cases; and I am not far out of the way when I say that, in the vast majority, it is not necessary, and that nature will and does accomplish all that can be desired. Meddlesome interference in all such cases is injurious, and it tends rather to delay than hasten labor. In multiparæ, for example, the perinæum yields readily and seldom offers any serious obstruction, and, with very few exceptions, the expulsion of the head is accomplished without artificial interference. It is only in a certain class of cases, therefore, that artificial protection of the perinæum is requisite, and that class, generally speaking, is among primiparous women. Even among these, however, it is not always called for. As to a laceration occurring during the passage of the shoulders through the vulva, this should never take place if a reasonable amount of care and attention be exercised. If a laceration occur, it is in the effort of expelling the head and during its passage over that commissure. I may say, without apology and with perfect confidence, that, in the great majority of existing lacerations, the damage has not been done by the natural passage of the head over the perinæum, whether supported or
not, but by the uncalled-for, reckless, and injudicious use of forceps. The cases are rare in which instruments are necessary; in multiparæ, scarcely ever, and in primiparæ, very, very seldom. That the perinæum should remain intact there is no doubt; and that it should be carefully guarded in all cases, to prevent laceration, no one will deny.
Having carefully examined the principal authorities upon the subject and the various methods and practices recommended, I desire briefly to describe my own method, which differs essentially from the different modes of procedure mentioned by obstetric writers.
Position of the Woman.-The woman is placed in the dorsal position, with her right side near the right edge of the bed. The limbs are flexed and abducted, and the feet are firmly planted on the bed. It is not necessary to expose the parturient at any time, and the manipulations should be made under the bedclothes.
Position of the Accoucheur.-The physician takes a standing position, his right side toward the right side of the woman, so that he and the patient face each other. The right hand can be used freely at any moment. He should stand firmly and should assume a position that will lend force to the arm and hand when the time comes to act. The left hand may be held
by the patient.
Introduction of the Hand.-The right hand is introduced under the bedclothes, between the abducted limbs of the woman, with the finger-tips directed downward, and the arm semi-flexed. The fingers are disposed around the perinæum, between the anus and the anterior border of that commissure, in the following manner:
The tips of the middle and the ring-finger take their position a little behind the anterior border of the perinæum, and on either side of the anus, while the tip of the index-finger performs duty at the left, and the little finger, at the right posterior portion of the labia majora. The fingers, thus disposed, yield and bend as the circumstances of the case demand, so that the hand becomes hollow, accommodating itself to the head, be