Stefano Ricci
The first clinical application of local anesthesia was officially announced the 15 of September of 1884, 130 years ago. It concerned corneal anesthesia for glaucoma operation. The importance of this event is demonstrated by the fact that between September 1884 and late 1885, 60 publications concerning local anesthesia using cocaine appeared in the United States and Canada.2 Local Anesthesia is, today, one of the most important tools in phlebological practice, not only for the everyday veins operations, actually done mostly as day surgery or office surgery, but also for biopsy, ulcer debridement, scar revision. Curiously, as a constant pattern, most the chief characters of this story developed their experience through self-administration of the agents, accepting the risks for satisfying their desire of progress. And the consequences have been quite dramatic in some cases. On October 16, 1846, W.T. Morton performed the first total anesthesia, using the Letheon (diethylic ether), on a patient having a lateral neck vascular lesion, operated on by J.C. Warren.3 In spite of the huge importance of this discovery, which would radically influence the progress of surgery, and its immediate diffusion in the world scientific community (in December 1846 it was already applied in England) the process of inducing unconsciousness was not as simple as it appeared, the first official anesthetic death being reported in England in 1847.4 A system of locally providing agents for pain analgesia in a limited area was still requested. Till then acupuncture, hypnotism, refrigeration and nerve compression are known to have been used to alleviate surgical pain, but with limited success. In 1853 A. Wood5 invented the hollow metal needle in order to inject morphine directly in the painful area. Although it was later realized that the main action of morphine is systemic rather than local, this event opened the possibility of the local administration of those alkaloids that will be discovered three decades later.3 Cocaine, an extract of coca leaves, is the first known local anesthetic. For Incas people it was a gift of the gods, used as a reward to noblemen. For the mountain people of those great heights chewing of coca leaves provided energy and fatigue insensibility (and mucosal numbness).6 Folk physicians in ancient Peru chewed coca leaves and employed the saliva for minimizing pain of the injuries they were treating. This was a unique situation in anesthesia: operator and his patient shared the effects of the same drug.6 In 1860 A. Niemann,7 an Austrian chemist, receiving coca leaves from a friend returning from a tour around the world, isolated the alkaloid that he named cocaine.8 The crystals of this substance had a numbing effect on the tongue. This is the way that still now is in use for testing the purity of the street cocaine.6 The stimulating effect of the drug was the reason for it’s immediate success. The Corsican chemist Angelo Mariano invented the Vin Mariano by steeping coca leaves in wine, obtaining a huge popularity. Coca Cola was created in 1886 by the same principle and kept cocaine in its formula till its replacement with caffeine in 1906.6 Although the anesthetic properties of cocaine were already signaled by T. Moreno,6 a military physician, and in 1879 by von Arep,6 who noticed on its own the skin insensibility after the injection of a dilute solution of the drug, the first clinical application of the effect of cocaine is due to Carl Koller, a surgical intern at Vienna University, in 1884.7 Koller was interested in ophthalmology and was trying to solve several problems of his field of interest that general anesthesia, although already widespread, could not eliminate. The patients, when anesthetized, could not cooperate, like advisable, with the surgeon. The anesthesiologist’s apparatus interfered with the surgical access area. Fine sutures being non available at that time, many surgical incisions on the eye where not closed; in this situation the high incidence of vomiting after anesthesia created the risk of extrusion of the globe internal content with possible irrevocable blindness. The attempts made previously with morphine, chloral hydrate and other drugs appeared useless.3 Koller was a colleague of Sigmund Freud (they worked at the same hospital floor) who was extremely interested about the general effects of cocaine. This seemed an harmless drug, although very interesting as stimulant, therapeutic agent (consumption, asthma, psychosis), drug addition treatments (alcohol, morphine), aphrodisiac, and local use.9 The anecdote tells that Freud gave a small amount of cocaine in an envelope to Koller, which he placed in his pocket. A leakage of some drug contaminated Koller’s fingers. When he casually touched his tongue, he felt the numbing effect.6, 11 For the young doctor the association of this effect with his researches on the eye anesthesia was immediate. After making a solution in water of cocaine crystals, together with his assistant Dr. Gartner, Koller experimented the anesthetic effect on the eyes of a frog, a rabbit, a dog, and finally on it's own. Within a minute the eyes became insensible to touch and any kind of trauma.8, 12 The discovery was immediately revealed at the Congress of German Ophthalmologists in Heidelberg,13 but not by poor Koller, who could not afford to attend the congress, but by a friend from Trieste, J. Breattauer, with his agreement.14 It was the 15th of September 1884.
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