have occurred, and it must be considered much more dangerous than general anesthesia. It has been used mostly for operations for hernia, hemorrhoids, plastic operations on the perineum, and for some uterine and prostatic operations. If the heart is weak and general anesthesia is inadvisable, it probably has its uses.

A frequent after effect is headache, which may be prolonged for several days, and may be very severe. Vomiting has occurred, and occasionally serious disturbance of the respiration has been caused. With great care not to remove too much fluid from the spinal canal, and not to force too much fluid into the spinal canal if the pressure is high, and to keep the patient at rest for some days after the injection, headache may be avoided, but it is not an infrequent occurrence, even in spite of care.

This method of anesthesia seems to prevent shock, and certainly precludes an anesthesia pneumonia. The bloodpressure generally falls during the anesthesia.

Cocaine Hydrochloride.-Administration. The active principle of coca (erythroxylon) leaves is cocaine, and the preparation that is generally used is the hydrochloride. There is no special medicinal excuse for using coca or preparations of coca internally.

In South America, the home of erythroxylon, the leaves are chewed by the natives, both as a stimulant and to prevent muscle fatigue, and for such purposes it is certainly efficient. How serious the coca habit is with these natives has not been determined.

The hydrochloride of cocaine occurs as colorless prisms or as a white crystalline powder, is very soluble in water, and the dose is stated as 0.015 Gm. (14 grain). There is no good excuse for using cocaine internally or hypodermatically for any purpose except to produce local anesthesia. When internally administered it readily produces severe poisoning, and if small doses are repeated, it quickly causes the cocaine habit. Therefore, to repeat, there is no good excuse for using cocaine internally. It also should not be used in sprays or ointments for the nose, or in sprays or gargles for the throat. It should only be used in the nose, throat, or eye by the physician. Prescriptions for cocaine should not be given to a patient, except in rare instances.

Cocaine hydrochloride in solutions is decomposed by more

than a few minutes' boiling, but tablets of cocaine dissolved in sterile salt water furnish a sufficiently aseptic solution.

Action.-Externally there is very little action of cocaine on the unbroken skin. On mucous membranes it is readily absorbed, causes vaso-constriction, blanching of the part, and therefore inhibits mucous secretion and prevents rapid absorption, provided the solution is strong. If the solution is very weak, more of the cocaine may be rapidly absorbed. A 1 per cent. solution is the strength most used for infiltration and a 2 to 4 per cent. solution for mucous membrane anesthesia. The anesthesia is complete in from seven to ten minutes, and lasts from ten to fifteen minutes, depending upon the amount absorbed. It will not penetrate deeply into the tissues below the mucous membrane unless it is injected into them.

When cocaine is used for infiltration anesthesia, part of the immediate anesthetic action is due to the distention from the water or salt solution in which the cocaine is dissolved. The addition of epinephrine to the cocaine solution lengthens the time the parts will be anesthetized, as it prevents rapid absorption. Also the addition of the epinephrine allows less bleeding when the tissues are incised. As soon as anesthesia is complete, the parts injected should be quickly operated upon so as to release the cocaine in the tissues, allow it to flow externally, and prevent much absorption. If much absorption occurs, poisoning may result.

The first effect of absorption is frequently some cerebral stimulation; the patient may be rendered talkative, to be later followed by some depression. At first the respiratory centers are stimulated, the blood-pressure is raised, and the heart is somewhat stimulated. Later, depression of the respiratory center occurs. Consequently, although cocaine may primarily cause stimulation in depression from different drugs or in circulatory failure, its secondary action is depressant and therefore it should never be used for this purpose. When injected into nerve trunks it first paralyzes the sensory fibers and finally the motor fibers; but it should also be recognized that even plain water, from pressure, may have this same effect. The pupils are dilated when it is absorbed, or when it is taken internally.

When applied locally to the eye the pupils dilate, and it is sometimes used for this purpose by ophthalmologists. It may be rapidly absorbed from the stomach, and in weak solutions from the nostrils and throat; on the tongue it inhibits the sense of taste. From the urethra it may be rapidly absorbed and cause poisoning, and hence should rarely be used to facilitate the passage of catheters or for other instrumentation, as it has frequently caused poisoning when so used.

Cocaine is partly destroyed in the body and partly slowly excreted in the urine.

Over-action. It may cause very high blood-pressure, rapid heart action, great cerebral excitation, and sometimes convulsions. On the other hand, it may cause the opposite, considerable faintness, prostration, collapse, and respiratory failure. While deaths may not often occur from acute poisoning, serious symptoms do frequently occur, although such cases are not often reported.

Treatment of Poisoning.—If the drug is in the stomach, tannic acid and emetics should be given, or the stomach should be washed out. Antidotes to the depression are atropine, strychnine, camphor, and caffeine; and the usual treatments of collapse, as dry heat, elevation of the feet and legs, and artificial respiration, if necessary.

Cocaine Habit. This habit was greatly on the increase before the State and National laws prevented the sale of cocaine without the prescription of a physician. Also many nostrums were on the market which contained cocaine, and many snuffs and catarrh powders contained this vicious drug.. In spite of the length of time since these laws have been in operation, the cocaine habit is still frequently in evidence, and is more serious than is the morphine habit. The periods of depression, when the desire for the cocaine is in evidence, are terrible, but are immediately allayed by the usual dose. Sometimes there is an unusual stimulation from it, and the individual is loquacious and excited; the difference is readily noted between his moods of excitement and depression, and the pupils are very evidently dilated soon after the drug has been taken. Patients with this habit have a great deal of indigestion.

Some patients have a combination of the morphine and cocaine habits. With such patients the pupils do not react as usual to these drugs.

The treatment is to withdraw the drug as rapidly as possible, but as there is likely to be very serious symptoms of depression, the patient should always be in an institution, under the best medical care. There is no way to cure such a patient except by the institutional method. Catharsis and the substitution of other drugs for the time being are part of the treatment.

Uses. As above stated, there is no good logical use for cocaine internally. As a local anesthetic either it or some closely allied drug is very valuable. Injections of 1 or 2 per cent. solutions into the tissues will stop local pain, but for anesthesia a stronger solution may be needed. Sometimes cocaine is injected into a nerve trunk to block pain, thus allowing an operation to be done painlessly on the region of the nerve distribution. Sometimes in ether and chloroform narcosis it has seemed wise to block the nerve trunk of the region to be operated to prevent shock, Crile's anoci-association method.

To anesthetize the mucous membrane for operation, pledgets of cotton soaked in the solution of cocaine are pressed firmly against the tissues, and the tonsils may be painted with the solution. Care should be taken in the nose and throat that these solutions are not swallowed. Infiltration anesthesia has already been described.

Beta-eucaine Hydrochloridum.-Beta-eucaine hydrochloride is similar to cocaine in its action, but weaker, and it does not cause the cerebral or vasomotor stimulation that cocaine does. It is more used in ophthalmology because it is less irritant to the conjunctiva than is cocaine, and its solutions may be boiled without causing disintegration. It may be used in solutions of various strength from 2 per cent. for the eye to as much as 10 per cent. for the nose and throat. As a local anesthetic it may be even used in much weaker solutions than 1 per cent.

Holocaine Hydrochloride, N.N.R.—This drug acts like cocaine, and more quickly, and is popular with the ophthalmologists. It seems to cause less irritation of the conjunctiva, and is used in 1 per cent. solutions.

Procaine, N.N.R.-Novocaine is much used now as a local anesthetic in operations on the mouth and teeth. It is less toxic in its action than cocaine and acts more quickly, but unless combined with epinephrine, its anesthetic action does not last as long as cocaine. This drug is very frequently used for infiltration anesthesia, and in spinal anesthesia.

Several efficient preparations of this drug are on the market, and, also, it may be obtained combined with epinephrine. Instructions come with each package as to how to make solutions of varying strength for different purposes.

Stovaine and Alypin, N.N.R. are closely allied anesthetics of about the same activity as cocaine, but they do not cause contraction of the blood-vessels or dilatation of the pupils. These drugs are said to be less toxic than cocaine, but the same care should be used with any of these local anesthetics as is taken in the use of cocaine.

Apothesine is offered as effective for producing local anesthesia both by infiltration and intraspinally. It seems not to be as active on the mucous membrane as is cocaine.

Benzyl Alcohol. -Though Sollmann' has found this substance to be a local anesthetic on mucous membranes, it seems to have no advantage over cocaine and cocaine-like preparations.

Ethyl Chloride.—Ethyl chloride comes in hermetically sealed glass containers with an attached atomizing apparatus. When this tube is held a short distance from the skin and the spray is directed against it the part is quickly frozen and benumbed, allowing incisions into boils and abscesses to be made painlessly. Ethyl chloride has been used as a general anesthetic, but it should not be used for such a purpose.

Anesthol is stated to be a mixture of ethyl chloride, chloroform and ether.

CLASS VI

DRUGS USED TO LOWER THE TEMPERATURE OF THE BODY ANTIPYRETICS

Fever may be defined as an abnormal elevation of temperature of the body, due to a disturbed state of the system of which 1 Journal of Pharm. and Exp. Ther., July, 1919.