THE HISTORY OF LOCAL ANAESTHESIA

I am once again back with an equally interesting story about the history of Medical Science and my source remains my most favorite senior colleague from Trichy in Kerala, Prof. Hirji Adenwalla. The octogenarian professor is an avid story teller and has, in his illustrious career, interacted with so many 'greats' in the field of medicine, and has such a profound memory, that every time he walks down the memory lane, it is a pure pleasure to walk alongside him.

Though not as tragic, the history of the evolution of local anaeathesia is just as bizarre as that of the history of general anaesthesia and involves the names of many great scientists and research workers and starts with no less a person than the celebrated Sigmund Freud-  immortalized for his work on the human psyche. His role in the discovery of local anaesthesia is forgotten.

In 1532 Pizarro during the conquest of Peru discovered that natives of Peru chewed the leaves of a shrub called Coca and the juice of these leaves enabled them to perform prodigious physical feets. This discovery made no impression on the world in general. In the mid ninth century a traveller and linguist by the name of J J Von Tschudi again got interested in the ability of these leaves to increase physical performance. This prompted Mariani, a Parisian manufacturer to make an infusion of Coca leaves in wine and sell it as a general tonic and a cure for every disease under the sun. This of course smacked of quackery of a high order and made no impression on the medical world. In 1858 a Dr. Scherzer a Ships doctor of the Austrian frigate Novara brought dried coca leaves in quantity and gave them to a German Chemist Wohler Gottengen for analysis. Wohler’s pupil Niemann succeeded in extracting the effective component of the leaves which he called Cocaine.

The word went round in Europe that a Carl Koller, a minor assistant ophthalmic surgeon in the Vienna General Hospital was to read a paper at a major conference in Heidelberg on the anaesthetic properties of Cocaine, and that a cataract could be removed painlessly if a few drops of Cocaine were trickled into the eye. Koller did not have the finance to travel to Heidelberg therefore, he requested his friend Dr. Brettauer to read the paper. The truth of what he claimed was demonstrated to a group of senior surgeons at the conference, and this made a sensation.

However, the twist to the tale lies in the historical fact that it was not Carl Koller, who was the man with whom the story of Cocaine and local anaesthesia begins but with another young Viennese doctor Sigmund Freud who much later was immortalized for his work on the analysis of the human mind and the treatment of insanity. Freud was then 27 years old, the son of an impoverished Jewish textile merchant, marginalized, despised and humiliated as a Jew. Sigmund thought that he could overcome all the disadvantages of birth by becoming a great lawyer or statesman: All doors were closed to this poor Jew and so he turned to the study of medicine. After qualifying, he took a job in Professor Brckes physiological institute and had no idea of going into the practice of medicine.

Then a strange thing happened Sigmund  Freud fell in love with a beautiful 20 years old Jewish girl called Martha Bernays. There was no way her family would agree to the match unless Freud was earning well and so he decided to go into medical practice. Freud did not do well in general practice. At about the time he chanced to read an article by a German Army Doctor called Theodore Aschenbrandt entitled “The Physiological effect and importance of Cocaine”, he claimed that the drug had considerably heightened his soldiers’ marching performances. Freud had never heard of Cocaine before but he was looking for some sensational discovery so that he could become famous and marry Martha. He thought that Cocaine might help in combating nervous diseases. Freud was already getting interested in mental conditions. He approached Merek in Darmastadt and bought some Cocaine and started a series of experiments with the drug. He used it on himself and his depression disappeared. He started using it on Morphine addicts and found that the symptoms of morphine addiction disappeared but did not then realise that the symptoms of Cocaine addiction would be far worse. During his experiments on himself he found that Cocaine aneathetised his tongue and gums and could relieve severe tooth ache. It was Freud who introduce Carl Koller to the anaesthetic properties of Cocaine and he was the first in his monumental paper on Cocaine to mention its aneasthetic properties. But Freud had no surgical interests at all and so it was left to Carl Koller to steal the limelight from his friend Sigmund Freud.

In Hamburg while he was with Martha, he heard nothing of Koller’s success with Cocaine at the conference at Heidelberg. Freud married Martha in 1886 and heard of Koller’s success when he returned to Vienna. Curiously Freud was not at all shaken by the news for he was only interested in what Cocaine would do to neurological diseases. It must however, be mentioned that Koller had the honesty to mention when he next spoke at a major conference that “a careful and interesting  paper by my colleague Dr. Sigmund Freud introduced Cocaine to the physicians of Vienna”. Freud realized that he had missed the bus and took to Cocaine to relieve his depression. It is a miracle that he did not become a Cocaine addict. His role in furthering the research on Cocaine was soon forgotten or relegated to history. Other men spread the use of Cocaine as an anaesthetic to other parts of the body and these men, were William Halstead, Paul Reclus, Carl Ludwig Schleich, August Bier, Leonard Corning and Heinrich Braun. Halstead’s story with Cocaine is full of pathos and great suffering. He was at the time an up and coming surgeon working at the Roosevelt Hospital in New York and passionately taught the principles of antiseptic surgery. This young bold dynamic surgeon was also a fun loving extrovert. By chance he stumbled upon the work of Carl Koller on local aneasthesia and Cocaine and that completely changed his life. Halstead with his searching mind refused to be limited by the local use of Cocaine in the eye and in the mouth. He proved that Cocaine could be injected to provide not only local anaesthesia but one could inject major nerves like the sciatic nerve and cause wide spread regional anaesthesia. During these experiments he started injecting Cocaine on himself and his students and these experiments led to the tragedy of his Cocaine addiction. Halstead in his prime had become a nervous wreck and had to be taken to Providence virtually by force and admitted in an asylum. They tried to wean him off Cocaine by using morphine but it was like from the frying pan into the fire. William Welch, the great pathologist took him under his wing and after several admissions to the asylum moved him to the Johns Hopkins University Hospital in Baltimore. Welch and William Osler slowly pulled Halstead out of his Cocaine addiction. But he was never the same man. The brilliant bold and rather reckless surgeon became slow, meticulous and extremely careful.  A radical mastectomy which he could do in one hour took four to five hours to do. Out of his Cocaine addiction came the three cardinal principles of good surgery- reverence for tissue, complete hemostasis and elimination of dead space. The fun loving Halstead had become a recluse. Cocaine had damaged him for life. Welch said of him “this restless man of action was transformed into a master pedant who brought to American surgery-still coloured by the devil- may-care attitudes of the pioneering days a fool proof system of safe surgery”. Backed by Welch and Osler, Halstead was appointed to the prestigious chair of Professor of surgery at the Johns Hopkins. He never spoke of Cocaine or local anaesthesia or ever used it after that on his patients.

Following on Halstead’s work the year 1886 to 1888 saw a worldwide use of Cocaine for local and regional anaesthesia, the enthusiasm for Cocaine knew no bounds. Then in the summer of 1888 came the crash.  Journals all over the world started reporting “Cocaine deaths” Professor Kolommin, a doyen among Russian surgeons lost a patient after an operation performed under Cocaine. The patient died of Cocaine toxicity. Prof Kolomnin shot himself. Next came reports from Paul Reclus in Paris of deaths due to Cocaine poisoning. Dr. Brouardel reported 30 deaths in Paris due to Cocaine injections. But soon came a ray of hope for Cocaine, Dr. Oberst working in Prof Volkman’s clinic developed a method of preventing Cocaine absorption into the system by tying a tourniquet above the site of injection but this could only work on peripheral parts of the body like the fingers or the hand but the great Volkman was not particularly enthusiastic about it.

In the mean time Paul Reclus did not give up, he analysed Bouardel’s list of 30 fatalities. Only nine had died of Cocaine poisoning. Of the nine fatalities six were due to Cocaine overdosage. He set out to find   out the toxic dose of Cocaine. So far 30% Cocaine solutions were injected. He found that a mere 3% solution was sufficient to produce analgesia, and that the surgeon should inject Cocaine as he went along the operation over a duration of time. With this technique Reclus reported a series of 200 cases without a single mortality. Reclus was a cautious investigator. He was now experimenting on his own infected finger which surgeons wanted to amputate to save his life. He managed to open and drain the infection with a ½ % solution. Reclus brought Cocaine and local anaesthesia back on the scene by proving that Cocaine was safe if used in the correct concentration and in the way that he advocated.

           

Carl Ludwig Schleich was not aware of Reclus’s work but came to the same conclusion. In addition he injected saline into the tissues. The pressure on the nerves dampened the sensations and then he used just 0.1to 1 percent of Cocaine. Schleich and Reclus may be jointly credited for not letting Cocaine and local anaesthesia die a natural death.

           

At Esmarch’s department at Kiel Prof Heinrich Quincke discovered that the spinal canal could be punctured with a needle. He called the procedure “Lumbar Puncture”. He first performed it on a two years old child suffering from symptoms of raised intracranial pressure and he relieved the child’s symptoms by draining the cerebro-spinal fluid. From this August Bier working in the same department concluded that it would be possible to inject Cocaine into the spinal canal to anesthetize the lower part of the body. On the morning of August 16^th 1898, August Bier aided by his assistant August Hildebrandt injected 3 cc of 3.5% Cocaine into the spinal canal. The patient was operated on for tuberculosis of the ankle joint. An extensive debridement of the joint was performed without any pain. Bier recorded that the anaesthetic effect lasted for an hour and a half. This was the birth of spinal anaesthesia now used in every operating theatre of the world. Heinrich Quincke and August Bier must share the honor for this great advance in anaesthesia.

           

At about this time arose a great controversy about spinal aneasthesia. James Leonard Corning, an American claimed that he had discovered spinal anaesthesia 14 years before August Bier. He claimed that he had written three papers on the subject in 1885, 1888, and 1894. In America, patriotic fervor got the better of facts. An inquiry was held and it was found that Corning had injected Cocaine near the spinal canal but not in the spinal canal. The mild anaesthetic effect in some cases was due to permeation of the Cocaine. In his 1894 paper he had injected in the canal various drugs to cure neurological diseases with no success. He never injected Cocaine to produce anaesthesia. He drew no conclusions about Cocaine and anaesthesia. So credit for spinal anaesthesia ultimately went to August Bier. Corning’s story was the repetition of the story of Sigmund Freud all over again. Had not Freud clung to the idea that Carl Koller’s discovery concerned only a minor subsidiary aspect of the use of Cocaine? Had he not, with obsessive stubbornness, clung to the notion of Cocaine as a superlative treatment for neurological diseases? Freud’s thinking on this was one of medicine’s more dreadful errors.

           

Bier worked on to eliminate the side effects of spinal anesthesia. Bier was one of the first surgeons to use Novacaine synthesised by the German Chemist Einhorn, which had virtually no toxic effects.

           

The curtain now must be raised on the last act in this convoluted story. His name is Heinrich Braun working as head physician at the Sisters of Charity Hospital in Leipzig. In his early experiences with Cocaine he had seen that the effects of Cocaine were most lasting when the circulation of the blood was interrupted by a tourniquet thus hindering the removal of Cocaine. Braun had witnessed Oberst’s experiment in anaesthetisng fingers and toes. He worked out a Cocaine -adrenaline formula, the adrenaline caused vaso-constriction and thus delayed the absorption of Cocaine into the general circulation. This made the anaesthetic effect of Cocaine to last much longer. His paper was published in 1903 and Novocaine adrenaline became the combination that was used for all local anaesthesia. Local anaesthesia was no longer a dream but became a reality. It lent a tremendous impetus to thyroid surgery. Many operations were now feasible which before had been ruled out because of the perils of general anaesthesia. New vistas were opened up for surgical exploration. A new dawn had broken on the surgical horizon, soon to be further enhanced by the discovery of antibiotics and the advance in optics.