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The History of Anesthesiology

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The History of Anesthesiology The History of Anesthesiology ReDnnt Series: Part Fourteen n The Introduction of Local Anesthesia «i* Carl Roller (1857-1944), discoverer of surgical local anesthesia with cocaine in 1884. Left, in Vienna, 1885; right, in New York, 1920. The Introduction of Local Anesthesia FOREWORD This set of reprints commemorates the advent of surgical local anesthesia in fin-de- siecle Vienna, one hundred years ago. It presents Roller and his epochal report on cocaine anesthesia of the eye in the context of precursors who foreshadowed but missed the discovery and innovative followers who soon extended it to nerve block, dental anes­ thesia, medication of the spinal cord, subarachnoid, sacral epidural, and intravenous routes to regional anesthesia, and, not least, the pioneering search for the active anes- thesiophoric group which culminated in the synthesis of a much less toxic drug (novocaine) by Einhorn. Lastly, we reprint, by permission of The Psychoanalytic Quar­ terly, the fascinating account of the discovery and its aftermath, retold with exemplary filial scholarship by Hortense Roller Becker. Rarely in the field of pain relief has so much been owed by so many to so few. The latter-day repercussions include the emergence of anesthesiology as an autonomous specialty of medical practice and, more recently, the burgeoning international assault on pain mechanisms and chronic pain. Fittingly, the Wood Library-Museum of Anes­ thesiology and the American Society of Anesthesiologists, who are responsible for its production, have made this commemorative set available for distribution to registrants of the IVth World Congress of the International Association for the Study of Pain, meeting in Seattle in 1984. For perspective on the significance of -the centennial, suppose for a moment that a congressional Big Brother took it into his head to ban all classes of drugs, save one to be selected by popular vote. Which would survive? Local anesthetics? Or go back to 1884 and allow the world just one medicinal plant. Erythroxylum coca? The discovery of surgical local anesthesia with cocaine intersected two major currents of biological thought of the second half of the nineteenth century, vitalism and reduc- tionism. Vitalists held that anaerobic release of energy within the cell is a vital action, a chemical process inseparable from the life and .organization of the cell. Cocaine, the active principle of Erythroxylum coca leaf, had an occult power to release energy not otherwise available to the organism. That was why the Indians of the Andean altiplano chewed the leaf. How else would they be able to endure the cold, the fatigue and the hunger of their thin existence? Freud had a notion that the Indians' traditional coca chew could be turned into an effective and manageable medicinal psyche booster if taken neat in the form of cocaine. Freud's efforts to verify his exciting conjecture did not work out, but they had the inestimable importance of bringing the drug to the mouth of his colleague and close friend, Carl Roller, who had a narrower, reductionist goal. Reduc­ tionist physiologists thought that the organism's release of energy was from a wholly physical or chemical machine, exemplified in the electrical action of nerves demon­ strated by DuBois-Reymond. If mechanical it must be controllable, and this, wittingly or not, underlay the conviction of Freud's junior colleague and friend, Carl Roller, that local anesthesia of the eye was within the realm of the possible. This idea had been implanted in Roller by Arlt, his professor of ophthalmology — ophthalmology, the first of the specialties — arousing in Roller the soaring ambition to become an assistant in the famous Viennese clinic, for which post he would qualify by making a notable discovery. Or so he hoped. He did make the discovery, for Roller's mind was well prepared and the time was ripe. But the appointment was denied him, as inexorably as in a Greek tragedy. B. Raymond Fink The Introduction of Local Anesthesia CONTENTS Foreword An organic base in coca W. (for A. Niemann) Researches on Peruvian Erythroxylon coca T. Moreno y Maiz The physiological action of cocaine B. von Anrep Cocaine anesthesia on the eye C. Roller Contribution to the knowledge of coca S. Freud Digital nerve block W. C. Burke Dental nerve block R.J. Hall (with W.Halsted) Spinal medication of the cord L. J. Corning Local anesthetic action of benzoyls W. Filehne Lumbar puncture for hydrocephalus H. Quincke Cocainization of the spinal cord A. Bier The sacrococcygeal extradural route A. Sicard Some new local anesthetics H. Braun New method for local anesthesia in the limbs A. Bier "Coca Roller" H. Roller Becker Concerning an Organic Base in Cbca by W. Coca, which consists of the leaves of Erythroxylon species, has been in general use in Peru and other South American countries ever since ancient times. The Indians chew it mixed with powdered chalk or ash, and this custom has made the coca bush an integral part of their culture. The most wonderful tales are told about the physiological consequences of its use. (*) See for example J.J. v. Tschudi's Peru, Vol II, p. 299) Enjoyed in moderation it acts as a stimulant able to substitute for food for long * Fran the Reports of the G. A. Uhiversitat and the Imperial Acadeny of Science in Gottingen, 21 March, 1860. The article was signed 'W1, for Friedrich Woehler (1800-1882), to whom Niemann was an assistant. It is clear from the text that Niemann was the first to observe and record the local anesthetic property of cocaine. He was also the first among the several outstanding investigators of cocaine - Schroff, Bennett, von Anrep, Hammond, Freud - who failed to appreciate the enormous importance of that property, until the fact dawned on Carl Koller. Koller was the one who, in 1884, realized and demon-strated the ability of cocaine to produce surgical local anesthesia. This landmark in humanity's long struggle against pain was one of the most important medical discoveries of the nineteenth century, or any century, and missed winning the Nobel Prize only because it was made a little too soon, and too convincingly (Liljestrand, G.: Acta physiol. scand. Suppl 299, 1967, p.5). t Translated from Ueber eine organische Base in der Coca. Justus Liebig's Annalen der Chemie, 114:213-217, 1860. periods and capable of making the severest exertion supportable. Its abuse, however, like that of morphine, often becomes a vice which, in those passionate coca chewers, the Goqueros, produces all the effects of narcotic poisons, an intoxication marked by visions, premature ageing, apathy and imbecility. These peculiar effects suggest the presence in this plant of a specific organic compound that constitutes the effective principle and which, in all probability, belongs to the class of organic bases. Indeed, several investigations into the active component have already been performed, though none has yet led to a positive result, perhaps because of an insufficient quantity of leaves or because of their deterioration with age, A chemist in La Paz, Bolivia, claims to have isolated a crystalline base; investigation of a sample of this supposed base which I obtained from Mr, v, Tfechudi quickly convinced me that it consisted of nothing but plaster of paris). It became possible to avoid these particular difficulties through the generosity of my friend W. Haidinger in Vienna, who enabled me to procure a large quantity of fresh coca leaves. He arranged for Dr. Scherzer to bring them from Lima in the course of the well known expedition of the Austrian frigate Novara, Being preoccupied by other matters, I was not able to undertake the intended study myself, I delegated it to one of the assistants in this laboratory, Mr, Niemann, who performed it with great skill and extreme perseverance. He succeeded in isolating from coca a characteristic specific crystallisable organic base, which, in accordance with accepted rules of nomenclature, may be termed cocaine. The work is still far from complete: although the existence and specificity of cocaine have been established, its compositional formula has not yet been definitely ascertained, and no investigation has yet been performed to determine whether it produces the physiological actions of coca, nor whether a suspected new tannic acid is present in other parts of the plant. After many fruitless attempts Mr. Niemann found that the most effective procedure for isolating cocaine was the following. The coca leaved were cut into small pieces and digested for several days in 85 per cent alcohol acidified with a little sulfuric acid. The resulting dark brown-green solution was expressed and filtered and then treated with weak calcium hydrate. This precipitated several substances, including part of the chlorophyll and a wax that could be rendered completely colorless. The alkaline liquid so obtained was filtered and neutralized with sulfuric acid, the alcohol was removed by distillation, and the remainder evaporated to dryness in a waterbath. The residue was mixed with water, resulting in the separation of a dark green, semiliquid mass containing the rest of the chlorophyll and in the formation of a yellowish brown solution which contained the cocaine as a sulfuric acid salt. Cocaine was deposited by sodium carbonate, as a still impure brown precipitate. The base was taken up in ether, which, when diluted, yielded a yellowish, smelly, amorphous residue in which, however, concentric rings of crystals soon began to form. On repeating the treatment with alcohol entirely pure and colorless crystals were obtained. Cocaine crystallizes in small colorless and odorless crystals. It is sparingly soluble in water, fairly soluble in alcohol, and very soluble in ether. Its reaction is strongly alkaline. It tastes bitter and produces a peculiar effect on the nerves of the tongue, inasmuch as the point of contact becomes deadened and very nearly insensitive.
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