COCAINE PAVED THE WAY FOR ANESTHESIA

Dr. Karl Koller looked in the mirror and proceeded to poke himself in
the eye with the head of a pin. He felt nothing.

The cocaine solution he had dripped into his eye that day in 1884 had
clearly done its job.

More than that, the experiment would prove to be the springboard for a
giant leap in medicine.

Koller was an ophthalmologist and colleague of Sigmund Freud at the
Vienna General Hospital. Freud had become interested in studying
cocaine as a possible treatment for morphine addiction and enlisted
Koller as a collaborator.

Since Koller specialized in eye surgery, his interest was drawn to an
effect that had first been noted by South American natives who chewed
the leaves of the coca plant for its stimulant effect. Cocaine numbed
the tongue. Could it do the same to the eye, Koller wondered?

An experiment with a frog proved to be successful and prompted Koller
to undertake the classic experiment on his own eye.

In September 1884, he made his discovery public at the meeting of the
German Ophthalmological Society at Heidelberg, precipitating the
widespread use of cocaine as an anesthetic in eye surgery.

A report of that meeting caught the eye of Dr. William Halsted, an
American surgeon practising in New York.

Halsted had already garnered a degree of fame for performing a gall
bladder operation on his mother in the middle of the night on the
kitchen table, and for giving his sister a transfusion of his own
blood when she was on the verge of death from blood loss after giving
birth. Having a doctor in the family sure is useful.

If cocaine could numb the eye, it might be effective elsewhere as
well, Halsted thought.

Like Koller, he became his own guinea pig and found that an injection
of cocaine produced safe and effective local anesthesia. But he also
experienced some of the other classic effects of cocaine and became
addicted to the drug. It took a stay at a sanatorium to beat the
habit.

Halsted went on to a brilliant surgical career at Johns Hopkins
University School of Medicine where, besides the use of local
anesthetics, he introduced various antiseptic techniques, including
latex gloves for surgeons. He devised ingenious procedures for breast
cancer and aneurysm repair, and is credited with starting the first
formal surgical residency training program in the U.S.

Like Halsted, the American neurologist James Leonard Corning heard
about Koller's report. His thinking, though, took a different
direction. Corning knew that injecting strychnine into the spinal cord
of a frog caused the animal to go into violent spasms. Now he wondered
if cocaine, with its demonstrated numbing effect on nerves, could have
a therapeutic potential if injected into the spinal cord.

Corning wasn't foolhardy enough to try this on himself, but he did
inject a dog. Within minutes the animal's hind legs became
uncoordinated, and as far as Corning could tell, insensitive to pain.
He didn't hesitate in putting this observation to use and injected a
patient who suffered from "spinal weakness" with his cocaine solution.
He was gratified to see the appearance of anesthesia in the lower
extremities. In 1885 his report of the case appeared in the New York
Medical Journal, concluding with the statement: "Whether the method
will ever find application as a substitute for etherization in
surgery, further experience alone can show."

That experience came in 1898 in the hands of August Bier, a young
surgeon at the Royal Surgical Clinic in Kiel, Germany.

By this time, general anesthesia with ether or chloroform was widely
practised, but came with a slew of problems. Dosages were hard to
control and side effects such as headaches and vomiting were common.
Corning's preliminary experiments with cocaine seemed worthy of
pursuit. Since there were no ethics committees in those days, Bier
proceeded. In a series of six cases, he injected cocaine into the
cerebrospinal fluid before surgery for infections of the bones - his
specialty. The results were excellent, the patients complained of no
pain. But they did complain of major headaches after. Bier wasn't sure
how seriously he should take these complaints, and as he later wrote:
"To arrive at a valid opinion, I decided to conduct an experiment on
my own body." That did not turn out to be a happy experience.

A colleague, Dr. August Hildebrandt, agreed to help. The plan was for
Hildebrand to perform a lumbar puncture with a large needle, and then
attach a cocaine-filled syringe. Unfortunately, preparations had been
less than meticulous and when Hildebrandt tried to attach the syringe
he found it didn't fit. As he fumbled around, Bier's cerebrospinal
fluid began to squirt out and a horrified Hildebrandt plugged the hole
with a piece of collodion. Gallantly taking blame for the botched
procedure, Hildebrandt now volunteered his own spine for the
experiment. No one would accuse these two of being spineless.

After carefully checking the needles, they pushed on. Within minutes
Hildebrandt's legs were anesthetized. Stabbing with a needle elicited
no response, neither did the stubbing out of a cigar on his leg. To
investigate the extent of the anesthesia, Bier pulled out chest hairs
and pubic hairs. Tugging on the chest hairs, but not the pubic hairs,
caused pain. Finally, Bier gave Hildebrandt's testicles a sharp tug
and then stabbed his thigh right to the bone. No pain!

The two celebrated with wine and cigars, but, as it turned out, a bit
too soon. Both developed splitting headaches the next day, a common
symptom of loss of cerebrospinal fluid. However, they had demonstrated
that surgery could be performed under spinal anesthesia and that side
effects could be minimized if loss of cerebrospinal fluid was
prevented. Spinal anesthesia proved to be safer than general, and
within two years was commonly used around the world. Cocaine has since
been replaced by a variety of other drugs, but it still holds a place
of honour as the substance that triggered the march towards successful
local and spinal anesthesia. And it all started with a poke in the
eye.