Popular Science Monthly/Volume 59/July 1901/Cocaine Analgesia of the Spinal Cord
|COCAINE ANALGESIA OF THE SPINAL CORD.|
By SMITH ELY JELLIFFE, M.D., Ph.D.
THERE are surgeons living to-day who remember the fascination and horrors of necessary operations, when speed was as great a requisite as skill to shorten the mortal agony, and when a famous surgeon would remove a limb in eleven minutes. There are many who remember how slowly the boon of chloroform worked its way against prejudice. To give it to ease the pain of childbirth was not only unsafe, according to the family doctor, but sacrilegious, according to the preacher, for did not the Holy Writ say, 'In sorrow shalt thou bring forth children,' and who of Adam's daughters should presume to escape the curse? Had it not been for the wit of Dr. Simpson, who insisted that the Lord performed the first surgical operation under anæsthesia when He caused Adam to fall into a deep sleep and took a rib from his side, and the courage of Queen Victoria, who set the example to the women of her empire by trusting her physician to give her chloroform at the birth of one of her children, it is quite possible that the ease from pain of all kinds might have been longer delayed.
Soon after chloroform came ether, the safer anæsthetic, and the one more frequently used, to produce unconsciousness in pain; and then cocaine, that peculiar drug that, injected into the tissues, benumbs the nerves and abolishes sensation of pain, and that gives the last word of the century on anæsthesia.
When the anæsthetic properties of this alkaloid of coca were discovered, and it had been demonstrated that abscesses could be opened and slight, but otherwise very painful, operations could be performed without pain, under its influence, it was considered the one thing necessary to complete the series of anæsthetics. The nerves, however, quickly recovered from the effects of the drug, and hence operations had to be accomplished in a comparatively short time. Until recently, only minor operations of the external parts of the body could be performed, and cocaine has been classed merely as a local anæsthetic; but its future has suddenly opened along new and startling lines in the discovery that when it is injected into the spinal cord it causes a total loss of sensation to pain below the point of puncture, so that most elaborate and difficult operations may be carried on while the patient chats pleasantly with the surgeon and attendants.
This discovery, like so many in medical science, did not flash into existence like a new star in the firmament, but was the result of researches of different men of various nationalities, which finally culminated in a practical result.
It was to an American, a well-known physician in New York, that we owe the first suggestion of the idea. Dr. J. Leonard Corning, in 1885, discovered that frogs, those benefactors to the human race on whom so many of the experiments for the good of man have been tried, could get the characteristic reaction of strychnine from very small solutions of the drug if it were injected into the spinal cord. He then bethought him to try the effect of cocaine; he accordingly experimented on dogs, injecting the anæsthetic between the superior processes of the vertebræ, where the numerous minute vessels would carry it to the cord. After a few minutes the dog lost all sensation in its hind legs; it could be pinched and pricked and touched with an electric bnsh without knowing it, but the same treatment applied to its fore legs brought forth yelps and howls.
As there were no evil effects seen in the various dogs on which Dr. Corning experimented, he tried the effect upon one of his patients who had for some time suffered from spinal weakness; injecting sixty drops of a 3 per cent, solution of cocaine into the tissues about the spine, between the eleventh and twelfth dorsal vertebræ. For the space of half an hour the man had absolutely no sensations of pain in his lower limbs; electricity and pin pricks were alike unnoticed, and Dr. Corning might have amputated a leg had his patient needed to lose one of those members, and at one stroke have taken all the fame of the discovery of a new form of anæsthesia; but in an hour or more the patient arose and walked home, with no unpleasant after-effects, except for a slight headache and dizziness. Dr. Corning reported on the frog, and dog, and man, to his medical colleagues, and threw out a general hint as to the possibility of extending the usefulness of cocaine in operations; but there the matter dropped. His experiments were, however, the germ of a new idea.
Some years later, the German investigator, Quincke, devised a method of puncturing the membrane surrounding the cord, so that he might draw out a few drops of the spinal fluid, to see whether, in such a disease as spinal meningitis, for instance, there were any bacteria present, or whether he could discover any characteristics that would help to diagnose certain obscure cases of disease by observing the pressure of the fluid of the spinal cord.
To penetrate to the very marrow of one's backbone would have seemed, fifteen years ago, to toy with the seat of life. Dr. Corning did not go nearer than the nerve tissues near the cord; but, once Quincke had shown that the needle of a hypodermic syringe could be thrust easily and painlessly and accurately into the space surrounding the spinal cord, and that a few drops of the cerebro-spinal fluid might be drawn out, it occurred to Dr. Bier, of Kiel, who was the true genius of the discovery, that a few drops of a cocaine solution might be put in, to produce local anaesthæsia on a large scale. He worked out the technique of the injection, operated on conscious patients, and reported his success. Although the operations and experiments performed by Bier were published and commented on with interest, they aroused no special excitement beyond a small circle of investigators, and might have remained merely scientific experiments, had it not been for the International Medical Congress, which met at the Paris Exposition. The benefit of the interchange of thought of the ablest scientific men of all countries that is offered by these congresses, which have come into fashion in the last twenty-five years, is incalculable. Every medical journal in every language tells the physician and surgeon of something new, but every day's experience teaches him that it is better to pay attention to the workings of old laws, instead of trying to apply every new remedy; therefore, it was not surprising that even so great a discovery should meet tardy recognition, and should need the dramatic setting of a world exposition to place it prominently before the medical profession. This it obtained at the Paris clinics held by M. Tuffier, where, with all nations for eye-witnesses, he performed one operation after another on patients who were perfectly conscious and yet who were absolutely insensible to pain below the nipple line. His feats were the talk of the Congress; many of the most famous surgeons of the world were present and saw how comparatively simple it was, after first rendering the point of puncture insensible with a little cocaine, to cause the patient to lean forward, as if scorching on a bicycle, thus straining the vertebræ slightly apart, when it was easy to insert the hypodermic needle until the appearance of a few drops of the spinal fluid showed that the cord had been tapped, and then to attach the syringe and inject the cocaine solution.
The surgeons soon dispersed to their own parts of the planet, glorifying the deeds of Tuffier, almost forgetting Bier, who was Tuffier's authority, and never mentioning Corning, from whom came the original idea. But the question of homage was insignificant in comparison with the test of the idea, and, within a few months, the members of the Congress had, in their own clinics and practice, cocainized the spinal cord for laparotomies, amputations and childbearing, with a varying amount of success.
But, in spite of the fact that in some operations the patients left the operating table with almost no unpleasant sensations, yet in the majority there was dizziness, nausea and frightful headache, which in some cases lasted as long as eight days, in spite of everything to bring relief.
None of the surgeons who have attempted spinal cocainization seem to be able to agree upon the smallest quantity that will ensure anesthæsia, and they are between the horns of the dilemma, that too strong a solution produces violent poisonous effects on the body, and one too weak gives out before the operation is ended, causing the predicament in which one surgeon found himself, when the anæsthetic effects wore off when he was half through, and, having opened the abdomen, he did not dare to permit the patient to sit up and lean over for a second injection.
In all cases, surgeons feel safer to have chloroform or ether at hand in chance of failure, and, when all is said, they do not see any very great advantage in performing the operation under cocaine over the old method. Moreover, many of them say that there is something rather uncanny in the feeling that the patient is conscious of and perhaps watching every stroke of the knife, for, strange to say sensations of heat and cold, touch and pressure, are still present, and only pain is absent. The older surgeons, before the days of any anaæthetic, mentioned this eerie feeling, and welcomed the patient's unconsciousness of what was being done to him as much as the patient did himself.
There is not enough yet known of the structure of that most wonderful detail of the human organism, the ganglionic nerve cell, to say what may be the effects of certain drugs upon it. Cocaine certainly has a sufficiently anæsthetic effect to make it valuable in those cases where an operation cannot be performed under ether or chloroform on account of a weak heart, or tendencies to asthma, kidney disease, or other complication. Where death would occur either with or without such an operation, it affords a comparatively safe loophole of escape; and at present it will perhaps be confined to such cases.
But, though cocaine anæsthesia cannot at present take the place of the other anæsthetics, it has given a hint of what may be developed; experiments will be continued, to render the lumbar puncture perfectly harmless, to determine the exact amount and strength of cocaine or any other drug that will produce a definite length of anæsthesia, to administer it in such a way as to lessen the unpleasant after-effects, and, if possible, to discover how the upper part of the body may also be rendered anæsthetic. The ideal, absolutely safe and universally applicable general anæsthetic is not yet discovered; but unquestionably a new way has been pointed out, and within a few years the results of scientific experiment will justify the hope that has sprung up at this method of cocainizing the spinal cord, the hope that anæsthesia is still in its infancy, and that when more is known about the effect of drugs on the nerve cells, it will be possible to banish pain, sensation and consciousness at will, and without danger to life.