Spinal anaesthesia during the 19th and 20th Centuries – cocaine and controversy
Thomas Boulton anaesthesia history prize-winning essay 2020
Spinal anaesthesia (subarachnoid radicular conduction block): principles & technique by Charles H. Evans. Wellcome Collection. Attribution 4.0 International (CC BY 4.0)
Spinal anaesthesia involves the administration of local anaesthetic into the spinal
(subarachnoid) space to produce a transient loss of sensation in the lower part of the body.
This makes it an excellent alternative to general anaesthesia for obstetric procedures and
other surgery to the lower abdomen, pelvis, and legs. From cocaine injections to court cases,
prilocaine to pencil-point needles, this essay investigates the significant developments in
spinal anaesthesia from its origins in the late 19th Century to the present day.
J. Leonard Corning’s experiments in 1885 were, for a time,
believed to be the first example of spinal anaesthesia. Corning
investigated the effects of cocaine on the nervous system of
dogs by performing injections between the spinous processes.
Believing that the cocaine was being transported along blood
vessels to the spinal cord itself, he then performed an injection
in a male patient, successfully achieving temporary lower limb
weakness. However, later research suggests that Corning’s
technique was, in fact, an epidural anaesthetic, given that the
dose of 3% cocaine he employed would have been likely to
have proved fatal if it had reached the intended target!
The first true spinal anaesthesia in humans is now known to
have been performed by August Bier in 1898. Using a lumbar
puncture technique described by Heinrich Irenaeus Quincke,
Bier injected 15 mg cocaine into the spinal space of a patient
undergoing surgery on a tuberculous ankle joint. The operation
was a success, and the patient reported no intra-operative pain.
A further five similar operations were also successful. Bier then
took the remarkable decision to try his technique on himself,
with the aid of his assistant August Hildebrandt. Unfortunately,
Hildebrandt failed to use the correct syringe size to inject the
cocaine, causing the experiment to fail. The roles were then
reversed, with Bier performing the injection, and this time
the technique was successful. Over the next 45 minutes Bier
performed a series of sensory tests on Hildebrandt, who did not
report pain even when Bier repeatedly hit his shins with an iron
hammer. Unsurprisingly, Hildebrandt later developed bruises
over these areas! Side effects suffered by both colleagues
included headaches, dizziness and vomiting, which lasted for
several days before resolving. Bier did not perform any further
spinal anaesthetics himself, but several other leading surgeons
of the time, such as Theodore Tuffier, were impressed with Bier’s work and helped promote his technique in Europe and the USA.
Indeed, the first recorded spinal anaesthesia in the USA was
soon performed by F. Dudley Tait and Guido E. Caglieri, closely
followed by Rudolph Matas a few weeks later.
Another major development in the history of spinal anaesthesia
occurred in 1900, when Oskar Kreis successfully employed this
technique for labouring women. However, uncertainty around
the effect of spinal anaesthesia on the fetus, coupled with the
side effects reported by Bier, meant that many obstetricians
remained reluctant to follow Kreis’ example.
Early experiments on spinal anaesthesia utilised cocaine.
However, significant effects on the heart, cardiovascular and
nervous systems meant that there was a need to develop safer
alternatives. Novocaine (procaine), invented in 1905 by Alfred
Einhorn, and amylocaine, synthesised by Ernest Fourneau,
were the first two agents developed. Later came dibucaine and
tetracaine, which had a lower incidence of allergic reactions.
The early part of the 20th Century also saw improvements in the
design of the spinal needle. Gaston Labat and Herbert Merton
Greene are both credited with creating safer needle tips that
allowed separation, rather than cutting, of tissues. This meant
less trauma to the dura mater and therefore reduced leakage of
cerebrospinal fluid, in turn reducing the incidence and severity
of post-dural puncture headache.
The mid-1940s saw several more significant advances.
Lidocaine, synthesised in 1943, was employed for shorter
operations, although more recent reports of post-operative
transient neurological side effects have affected its current use.
The technique of continuous spinal anaesthesia was also reintroduced during this decade by William Lemmon. Although first described by Henry Dean in 1907, Lemmon made it a reliable
technique for prolonged surgery. However, a higher risk of
post-dural puncture headache, and case reports of cauda equina
syndrome, limits its popularity today.
The 1940s also saw one of the major controversies surrounding
spinal anaesthesia in the UK. On 13th October 1947 two patients,
Albert Woolley and Cecil Roe, developed acute cauda equina
and paraplegia the day after receiving spinal anaesthesia at
Chesterfield Royal Hospital. In a case that gained significant
attention, Woolley and Roe took the hospital to court several
years later. Despite the court ultimately ruling in favour of the
anaesthetist (it was believed wrongly that ampoules containing
the local anaesthetic had become inadvertently contaminated
with the sterilising agent), the popularity of spinal anaesthesia
was significantly affected for many years in the UK. Attempts to
reassure the scientific community over the safety of the technique
were made; most notable was a long-term follow up study
published in 1954 by Dripps and Vandam, reporting an absence
of serious neurological complications such as cauda equina
syndrome or spinal cord infection in 10,000 patients.
The 1950s also saw key advances in needle design and
anaesthetic agents. The Whitacre ‘pencil-point’ needle had a
tapered point design to reduce the risk of damage to the dura
mater, thus reducing the rate and severity of post dural-puncture
headache. The amide local anaesthetic bupivacaine, synthesised
in 1957, demonstrated a fast onset of action coupled with a lower
rate of minor neurological side effects such as headache, leg
pain and backache compared with its predecessors. It remains
in use today, along with its stereoisomers ropivacaine and
levobupivacaine that were produced in the 1990s. 2-chloroprocaine and prilocaine are other agents developed
during this decade that also remain popular. However, following
the description of the Whitacre needle in the early 1950s,
no further notable design improvements took place until the
introduction of the Sprotte needle some 30 years later, developed
in 1987 and refined in 1993. A longer, wider tip facilitated needle
insertion while also reducing local tissue damage.
How have these major developments over the years contributed
to modern-day practice? One example relates to the use of
spinal anaesthesia for day surgery, utilising a combination
of the Whitacre needle, with a very low post-procedure
headache rate, and short-acting local anaesthetic agents such
as 2-chloroprocaine. This allows quick and safe post-operative
recovery and discharge. Another modern day example is the use
of ‘rapid sequence spinal anaesthesia’ for category 1 obstetric
emergencies. As the name suggests, this approach saves precious
time compared with the standard approach, and its favourable
risk profile compared with general anaesthesia promises
enhanced safety in the most urgent cases.
Clearly, spinal anaesthesia has come a long way since Bier’s
remarkable experiments with cocaine at the end of the 19th
Century. There have been setbacks along the journey - notably
with the Woolley and Roe controversy of the 1940s - but
improvements in needle design and local anaesthetics have
allowed spinal anaesthesia to become established as a key
technique within the fields of surgery and obstetrics today.
Serkan Cakir
Medical Student
Blandford Forum