Freud and Anaesthesia

DR S.K. VIJAYAN

ANAESTHETIST

WESTON GENERAL HOSPITAL

WESTON SUPER MARE

Natural History

Cocaine was first synthesized in pure form by Albert Niemann. In 1860, he extracted pure cocaine powder from the leaves of Erythroxylum coca (more commonly known as the coca plant). Soon after it was isolated, cocaine was used to try to cure almost all the illnesses and maladies that were known to man.

The coca leaf doesn't travel well. By the time leaves sent by early colonists in South America reached Europe, they had lost much of their potency. So for centuries the plant remained litte more than a curiosity of interest only to obscure European botanists. The active alkaloid of the coca plant, cocaine, was first isolated from coca leaves by the German chemist Friedrich Gaedcke (1828-1890) in 1855. Gaedcke published his discovery in Archives de Pharmacie; he called it "Erythroxyline".

Association with Cocaine

In 1850, about three centuries after the conquest of Peru by Pizzaro, the Austrian von Scherzer brought a sufficient quantum of coca leaves to Europe to permit the isolation of cocaine. As suggested by his friend Sigmund Freud, descriptions of the properties of the coca prompted the Austrian Koller to perform in 1884 the first clinical operation under local anesthesia, by administration of cocaine on the eye. The use of cocaine for local and regional anesthesia rapidly spread throughout Europe and America. The toxic effects of cocaine were soon identified resulting in many deaths among both patients and addicted medical staff.

 In 1884, Sigmund Freud asked Viennese ophthalmologist Dr Karl Koller to work with coca leaves. Dr Koller was looking for a procedure or agent to use during eye operations. Eye operations often needed a conscious, awake subject. Before the advent of local anaesthetia, such operations were fiendishly difficult for the surgeon and profoundly distressing for the patient.

The numbing effect of chewing coca leaves had long been known; but this action had long been disregarded as an unwanted side-effect. Dr Koller realised that cocaine was an ideal local anaesthetic for eye surgery, its only real drawback being that it is also an eminentlty abusable euphoriant.

 An improved step-by-step purification process was described by Albert Niemann (1834-1861) of Gottingen University in 1859. Niemann called the compound "cocaine"; and the name stuck. He was awarded a PhD; his dissertation was published in March 1860 as a slim volume called On a New Organic Base in the Coca Leaves. Niemann writes of its "colourless transparent prisms...Its solutions have an alkaline reaction, a bitter taste, promote the flow of saliva and leave a peculiar numbness, followed by a a sense of cold when applied to the tongue." Niemann had discovered that cocaine acted as a local anaesthetic. He died a year or so later in mysterious circumstances. The exact molecular formula of cocaine (i.e. C17H21NO4 ) was elucidated in 1863 by Niemann's colleague Wilhelm Lossen (1838-1906). In 1894, German chemist Richard Willstaetter (1872-1942) was awarded his doctorate from the University of Munich for discovering the its structural formula.

It wasn't long after the isolation of pure cocaine until people became aware of the addictive potential of the drug. Today, use in medicine had been tempered by experience. Medical use has been largely restricted to producing local anesthesia. Even in this area, the dangers of cocaine led to the early development of safer drugs.

One of its first non medical uses was military. In 1883 Theodor Aschenbrandt administered cocaine to members of the Bavarian army. It was found that the drug enhanced their endurance on manoeuvre. His positive findings were published in a German medical journal, which brought the effects of this wonder drug to a wider medical audience, including Sigmund Freud.

Personal Experience

On April 24, 1884, Sigmund Freud ordered his first gram of cocaine from the local apothecary.

It was not to be his last. He'd read about coke, it was supposed to be great for fatigue. So great, the German army used it to stave off exhaustion, and he thought it might help out a few of his patients suffering nervous disorders. Like most people who purchase their first gram of coke, he was rather shocked - it cost him a small fortune. One tenth of his monthly salary to be precise. And again, like new kids in the cocaine game, the first thing he did was take a dose himself.

Then another. And another

Freud was living in the dormitory at the Vienna General when he met Carl Koller who was also in residence. They became close friends and experimented with cocaine together. In 1884, while Freud was away, Koller continued the experiments with the assistance of his friend Dr Engel. Engel licked some cocaine on his penknife and remarked that his tongue was numb. Later Koller wrote “... in that moment it flashed upon me that I was carrying in my pocket the local anaesthetic for which I had searched for some years earlier. I went straight to the laboratory, asked the assistant for a guinea pig for the experiment, made a solution of cocaine from the powder which I carried in my pocketbook, and instilled this into the eye of the animal.”

He sent some to his friends; he sent some to his fiancee, Martha Bernays, who lived some miles away, saying:

I will kiss you quite red and feed you till you are plump. And if you are forward you shall see who is the stronger, a little girl who doesn't eat enough or a big strong man with cocaine in his body. In my last serious depression I took cocaine again and a small dose lifted me to the heights in a wonderful fashion. I am just now collecting the literature for a song of praise to this magical substance.

Freud was going through a bad patch. He desperately wanted to marry the fetching Martha, but her parents were rich and sceptical of this young upstart who presumed to ask for their daughter's hand. He'd started studying a variety of sea creatures in the hope of making great leaps forward in the new science of neurology and had the honour of being the first person to find the genitals of an eel (how he found the genitals while looking for the brain is a bit of a mystery). But it wasn't enough. Poking around in the nether regions of fish wasn't going to impress anybody, not least Martha's snooty parents.

So when the cocaine came along, he had high hopes. How could a highly addictive simulant not impress one's presumptive in-laws? Not only did this new drug cure hunger, thirst and melancholy, it made him feel fantastic. Like totally groovy, man. He couldn't wait to announce this new wonder drug to the scientific community, publishing "On Coca" in June 1884.

Considering Freud was the father of psychoanalysis and spurred an entire new realm of intellectual discourse, the article was a complete mess. Rife with misspellings and inaccuracies, he managed to even get the comparatively simple chemical formula of cocaine incorrect.

 At this time Koller was a junior resident who was anxious to gain an assistantship in the ophthalmology unit. The professor of ophthalmology in the unit was obsessed with the risks of general anaesthesia for eye surgery and it may have been this that led Koller to search for a local anaesthetic for the eye. Either way, he had already conducted a number of experiments with topical bromide, morphine and chloral before he tried topical cocaine.

Koller continued his cocaine experiments on himself and his colleagues and prepared a paper for the Heidelberg Ophthalmological Society which was to be held in a few weeks time. He was unable to afford to attend the meeting and persuaded a friend, Joseph Brettauer to present the paper and demonstrate the technique at the conference. The paper was presented on September 19, 1884.

An American, Henry Noyes from New York City was at the meeting and mailed an account of the meeting to the New York Medical Record. This was published in October 1884 and within six weeks Squibb had received three hundred orders for cocaine. Two months earlier Edward Squibb had made his decision to stop making cocaine products. The rapid increase in demand, and price, meant that he quickly had to rethink this decision. Merck’s laboratory had the same problem; over the next three years, Merck’s cocaine production increased from less than a pound to 158,352 pounds in 1886!

Noye’s article was printed before Koller’s but the discovery was Koller’s. Unfortunately it did not gain him the appointment he wanted. In January 1885 he removed a tourniquet on a casualty patient. Zinner, Bilroth’s intern, was upset by his management and called him an “impudent Jew”. Koller slapped Zinner and Zinner challenged Koller to a fencing duel. Koller won the duel but wounded his opponent and was charged with criminal offences. Charges were dropped but his career prospects were not great and he eventually emigrated to New York where he maintained a successful practice and died in 1944. His recognition came late in his life and he was awarded the American Ophthalmological Society’s first gold medal in 1921. He was proposed on several occasions for the Nobel Prize but unfortunately they were not awarded for old discoveries unless recognition of its importance had been recent. Koller’s discovery had received widespread acceptance almost immediately, years before the Nobel Prize was created, and was certainly the beginning of a new era in anaesthesia

During this time, Freud had made the acquaintance of an ophthalmology intern named Carl Koller. Koller was keen to find a local anaesthetic for eye surgery, which, as one can imagine, was a terrible business, particularly given that the patient was generally required to stay awake throughout the procedure, rendering other available anaesthetics useless. Try convincing someone to hold still while you push a scalpel into their eyeball and you'll get the picture. It involved much fussing about with burly lads holding down the patient and the use of gags and other apparatus to restrain the struggling victim; and a bullet or wooden spoon to bite, perhaps. Stitches were often torn out, and the results were, in a word, an eyesore.

Freud and Koller started dosing up on cocaine together, doing a variety of medical experiments on themselves. Noticing that cocaine numbed his lips when he drank it, Koller had the bright idea to try putting a coke solution into his patients' eyes before surgery. It worked a treat

Sadly, for Freud, he was on leave at the time. He was off being a "big strong man" for Martha, whom he hadn't seen in a year When he returned, he was mortified to know that his new discovery had been hijacked and that Koller was currently enjoying the accolades of his colleagues as the discoverer of the first local anaesthetic for eye surgery.

While Freud was lamenting the loss of his breakthrough, the rest of the medical fraternity on both sides of the Atlantic were chattering like monkeys about the possible applications of this new drug. They started testing it in droves - mostly on themselves.

They painted it on their skin, in their ears and up their noses. They injected it, ingested it and snorted it by the bucketload. They stuffed it into a variety of orifices. One particularly fervent researcher injected it into his penis, following up with the insertion of a range of objects to test its efficacy in anaesthetising mucus membranes.

Research at the time suggested that cocaine could be used for urethral operations, removing ingrown toenails, catarrh, asthma, nymphomania, impotency, masturbation, lip waxing, seasickness, weight problems, head colds, gastritis, and toothache. And best of all, it had no side effects. They could all agree on one thing -- coke felt good.

Back in Vienna, Freud was having a similar problem with a good friend of his. Dr. Ernst Fleishl von Markow had developed a morphine addiction treating his painful thumb, and the young Freud figured there was one cure - cocaine and plenty of it.

He started dosing Fleishl regularly, and miraculously, his morphine dependence seemed to be on the wane. Things were looking good. But the tide turned, and before long Fleishl had developed an enormous addiction - equivalent to one full gram of pure cocaine a day. He became paranoid, experienced convulsions and tactile hallucinations better know to cocaine aficionados as "coke bugs". This is a sensation caused by chronic cocaine toxicity where the sufferer feels that there are insects or snakes crawling under their skin. Fleishl spent hours at a time trying to pick them out. Eventually, he settled on a morphine-cocaine combo more affectionately known today as a speedball - the very same cocaine cocktail that sent John Belushi to oblivion. Fleishl suffered the same fate, dying in agony six years later in 1891.

Now one would think that watching the slow, tortuous death of a friend and colleague would be enough to suggest that perhaps it was time to get out of the coke game. It wasn't.

The Coke-a-Rama Mutual Nasal Admiration Society

Some four years before Fleishl's death, Freud had had the pleasure of the acquaintance of a young ear, nose and throat specialist called Wilhelm Fleiss. They became firm friends and remained so for years.

His admiration for the young doctor bordered on the extremely creepy. In 1896 he wrote in a letter to Fleiss:

Your kind should not die out, my dear friend; the rest of us need people like you too much. How much I owe you: solace, understanding, stimulation in my loneliness, meaning to my life that I gained through you, and finally even health that no one else could have given back to me. It is primarily through your example that intellectually I gained the strength to trust my judgment, even when I am left alone - though not by you - and like you, to face with lofty

humility all the difficulties that the future may bring. For all that, accept my humble thanks! I know that you do not need me as much as I need you, but I also know that I have a secure place in your affection.

To all outsiders, Freud exhibited all the symptoms of a man in love. He shared intimacies about his disappointing sex life with Martha, and told him all the dark secrets of his emotional health. There was only one problem -- Fleiss was a nutter.

He was a master of quackery, a snake-oil merchant of the very first order. He and Freud spent long nights together concocting hare-brained theories.

And Fleiss had a corker. He believed that the nose was the centre of all human illness - both physical and psychological. Rather in the way that phrenologists believed that the bumps on your head dictate the kind of person you are Freud wholeheartedly agreed. And why not? High on cocaine, he was soaring at dizzy heights somewhere outside the galaxy. The two congratulated each other on their genius, named their new science "nasal reflex neurosis" and got down to working out the details.

They experimented extensively with cocaine paint, diagnosed each other and occasioned the odd operation, where they used cocaine beforehand as an anaesthetic, and afterwards to dull the pain of surgery.

After the first operation, Sigmund started to feel better. A lot better actually. In April 1897 he wrote:

I put a noticeable end to the last horrible attack with cocaine; since then things have been fine and a great amount of pus is coming out... Since the last cocainisation three circumstances have continued to coincide: 1. I feel well; 2. I am discharging ample amounts of pus; 3. I am feeling very well..."the fact that the drug may have been the primary factor in this feel good saga didn't occur to either of them.

Freud's inevitable disillusionment started around the same time, with the treatment of a young woman by the name of Emma Eckstein. Emma suffered from hysteria, and Freud figured that there was no-one better to cure her disease than his good friend and "magical healer" Fleiss. So he summoned him to Vienna to take a look at the hapless young woman.

Fleiss immediately diagnosed the source of the problem - a bump on the inside of her nose. So he operated and split the city. A month later, Emma came to see Freud again - she was in considerable pain and had clearly developed a serious infection. Other surgeons were consulted, and discovered, stuffed into her nasal cavity, a length of gauze, which Fleiss had negligently, if unwittingly, left behind. In Freud's words:

There was still moderate bleeding from the nose and mouth; the fetid odour was very bad. [The doctor] suddenly pulled at something like a thread, kept on pulling. Before either of us had time to think, at least half a meter of gauze had been removed from the cavity. The next moment came a flood of blood. The patient turned white, her eyes bulged, and she had no pulse...At the moment the foreign body came out and everything became clear to me...I felt sick. After she had been packed, I fled to the next room, drank a bottle of water, and felt miserable...

It was the beginning of the end of the friendship.

The lost friendship

It's difficult to ascertain exactly when Freud gave up his coke habit. We know he was using in the late 1890s and by 1904 had stopped completely. So what happened in between?

By 1900 the friendship was becoming strained -- Freud was on the brink of success with psychoanalysis, while Fleiss was becoming increasingly grandiose in his theories, which largely centred around the idea of a male and female sexual cycle, and finally that many illnesses could be attributed to left and right handedness. But this is only part of the story.

Freud behaved like a petulant lover, overly sensitive, and prone to fits of depression if Fleiss didn't respond to his communications immediately. In one letter he wrote:

There has never been a six-month period in which I so constantly and ardently longed to be living in the same place as you.

A few months later Freud's jealousy had all but destroyed the friendship. They met for the last time. Freud was cold and cross. He slandered ideas and theories that he had once rapturously congratulated Fleiss for. Typically, Fleiss put it down to envy. We think it was more likely to be the absence of the happy juice.

The theories about the potency of caffeine were short-lived as Freud and Koller were both to make major pronouncements about cocaine in that same year. At this time, Sigmund Freud was twenty-eight years old and only recently out of medical school. He had about a year of clinical experience at the Vienna General Hospital and no experience with drug addiction except for a close friend, a pathologist by the name of Fleischl-Marxow who had become addicted to morphine after a thumb amputation.

The articles he reviewed in his publication were principally sponsored by Parke Davis and published in their own gazette “Therapeutics”. Parke Davis manufactured coca products and some of the articles were little more than advertisements. Freud concluded by recommending cocaine for several conditions including morphine addiction and asthma. He also suggested its use as a local anaesthetic although he had not conducted any research along this line.

Unfortunately the suggestion that cocaine should be used for morphine addiction was warmly embraced and within months morphine addicts all over Europe were also addicted to cocaine. Criticism swiftly followed; however, to be fair, Freud had recommended oral cocaine for morphine addiction but unfortunately all the addicts decided to inject it.

References

• C Ball, RN Westhorpe J Dent Res. 1998 Apr; 77(4):535-8.
• C Ball, Westhorpe R. Anaesth Intensive Care. 2003 Jun; 31(3):249.
• McAuley JE, Carl Koller: the man and the drug. Br Dent J. 1985 May 11;158(9):339-42
• Altman AJ, Albert DM, Fournier GA, Cocaine's use in ophthalmology: our 100-year heritage. Surv Ophthalmol. 1985 Jan-Feb; 29(4):300-6.
  
• Ball C, Westhorpe R,Local anaesthesia after cocaine. Anaesth Intensive Care. 2004 Apr;32(2):157
• Leonard M.Carl Koller: mankind's greatest benefactor? The story of local anesthesia, J Dent Res. 1998 Apr; 77(4):535-8.
• Oeppen RS. Discovery of the first local anaesthetic--Carl Koller (1857-1944), Br J Oral Maxillofac Surg. 2003 Aug;41(4):243,
• Ruetsch YA, Boni T, Borgeat A., From cocaine to ropivacaine: the history of local anesthetic drugs. Curr Top Med Chem. 2001 Aug; 1(3):175-82. Review

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