Myer S. Leonard, MD, DDS
Have you ever wondered, as you inject local anesthetic, who invented this miracle drug? It renders the area injected insensible to the transmission of pain sensation without affecting the sensorium or diminishing motor function... and the whole area is back to normal in sometimes as little as a couple of hours!
A personal discovery
To be candid, I never gave a thought about who invented it until 1990. That year, I was invited to deliver one of the lectures to celebrate the centennial of Beth Israel Hospital in New York. I thought that rather than present the topic of "rigid fixation in oral and maxillofacial surgery" as a straight account, I would try to place it in a historical perspective of the past 100 years. I was particularly attracted to the idea of showing the natural development of the procedure. To capture something of the flavor of New York in the late 1880s, I scoured photo files and microfiche.
I came across a photo that showed the southern end of Broadway. In it, I could just make out the name of a dentist and his claim of painless dentistry. That surprised me because I always had thought that local anesthesia was invented around 1905. Perhaps our colleague was using a form of general anesthesia.
I decided to write to the Astra Company in Stockholm (the makers of Xylocaine) and ask for clarification. The company`s officials told me that the centennial celebration marking the introduction of local anesthesia had been held in Edinburgh, Scotland, in 1984 under the direction of Edinburgh University Professor J.A.W. Wildsmith. They asked him to contact me. The professor sent me a large volume of documentation that so intrigued me that I decided to look more closely into the whole topic.
The cocaine story
In 1884, the medical school of Vienna, Austria, was one of the most outstanding establishments in the world. Two young men who had just completed their medical studies in 1882 to 1883 (different texts offer different dates) were to leave their mark on the 20th century. One was Sigmund Freud and the other was Carl Koller. They were classmates and good friends.
In July 1884, Freud published his monograph on cocaine. Reading this today makes one tingle. At once, you realize that you are in the company of an amazing mind. Freud`s interest in cocaine was born from a desire to wean a friend from an addiction to morphine. The friend had injured his thumb, which had become infected and was amputated. The morphine he used to relieve pain became an addiction. Freud believed that cocaine would eliminate this addiction.
In 1880, a man named B. Von Anrep made a solution of cocaine and painted one side of his tongue with it. His tongue became numb, and he was unable to differentiate between the taste of salt and sugar. He noted that the painted side was insensible to pin pricks. A professor, C. D. Schroff, had made this same observation in 1862. Despite these experiments, no one thought of using it as a solution to easing pain during dental treatment.
Enter Carl Koller
Prior to publishing his monograph in 1884, Freud and Carl Koller had collaborated on some experiments to determine the effects of cocaine on muscle strength and fatigue.
Carl Koller was 27 in 1884 and had made some remarkable observations on the origin of the mesoderm. His work soon was incorporated into Oscar Hertwig`s text, Embryology of Man and Mammals.
Koller, who hoped for a career in ophthalmology, spent the summer working in a lab. One day, a colleague placed some cocaine in his mouth from the point of his penknife. "How that numbs the tongue," he remarked. Koller replied, "Yes, that has been noticed by everyone who has eaten it." And then, in a flash, he realized that he was carrying in his pocket (he carried a small amount of cocaine powder) the local anesthetic for which everyone had been searching. He went straight to the laboratory and asked the assistant to help him make up a solution from the powder.
Koller remarked, "I hope - indeed, I expect - that this powder will anesthetize the eye." A few grains of the substance were dissolved in a small quantity of distilled water. A drop of solution was trickled into the eye of a frog. A few seconds later, they tested the cornea by touching it with the eye of a needle. The frog did not move. It permitted its cornea to be touched without a trace of reflex action.
They repeated the test on a rabbit and a dog. Subsequently, they tested it on themselves and rejoiced as they proclaimed that "I can`t feel a thing."
Prior to this discovery, eye surgery was almost impossible to undertake. The postoperative effects of any general narcosis or general anesthesia, with its coughing and vomiting, raised the pressure in the orbit and tore out any sutures that were inserted.
Koller was too impoverished to deliver his paper on the discovery in September 1884 at the German Ophthalmological Society meeting in Heidelberg. A friend delivered his paper for him. Attending the Heidelberg meeting was Dr. Henry Noyes of New York. He sent word to the New York Medical Record, which published his letter on October 11, 1884.
Dental use of local anesthetic
On November 26, 1884, physician R. J. Hall wrote to the New York Medical Journal about his experiments with his friend, Dr. William S. Halsted. He wrote that he had his left first-upper incisor filled and that the dentin was extremely sensitive. He persuaded his dentist to try the effects of cocaine. A needle was passed through the mucous membrane of his mouth to a point as close as possible to the infraorbital foramen and a small quantity of cocaine was injected. Within two minutes, there was complete anesthesia of the left half of the upper lip and cheek. The dentist completed the restoration without Dr. Hall having any discomfort. The anesthesia lasted for 26 minutes and reduced sensitivity for another 10 to 15 minutes.
He added a postscript to his letter that, on December 1, Dr. Halsted gave a medical student an injection of cocaine to hit the inferior dental nerve where it entered the dental canal. There was complete anesthesia of the gingiva and all of the teeth on that side, and complete numbness of the tongue.
Later, the experiment was repeated with Dr. Halsted giving Dr. Hall an injection that anesthetized the whole of the inferior dental nerve and its branches, the tongue, and the floor of the mouth. Dr. Hall suffered no discomfort when a pin was passed completely through his lip.
In 1888, Dr. Koller set sail for New York. There, he became an eminent ophthalmologist, serving on the staff of Mount Sinai Hospital. He practiced there until his death in 1944. Dr. Koller, who shunned personal publicity, was awarded the first gold medal of the American Ophthalmological So-ciety in 1922. Other awards followed, including a scroll of recognition by the International Anesthesia Society (1927) and the first gold medal of the New York Academy of Medicine (1930). A gold medal presented in 1934 by the American Academy of Ophthalmology and Otolaryngology marked the 50th anniversary of his discovery.
He was nominated on several occasions for the Nobel Prize, but it was not awarded because his discovery was made 17 years before the Nobel Prize was created. Cocaine was abandoned because of inconsistency in efficacy, and it was difficult to obtain.
In 1905, Procaine (Novocaine) was introduced. To this was added Epinephrine, which reduced the dissipation of the drug. The "caines" developed subsequent to cocaine have no relationship to cocaine other than an etymological and pharmacological one in that they cause anesthesia.
Whether Dr. Koller was mankind`s greatest benefactor or whether he shares this accolade with a few others is a matter for discussion. What cannot be denied is that his discovery did more than any other to transform the dental trade into the dental profession.
Editor`s Note: This article was adapted from the Journal of Dental Research.