International Congress Series 1242 (2002) 571 – 575 Sigmund Freud and Carl Koller: the controversy surrounding the discovery of local anesthesia David Galbis-Reig* Department of Internal Medicine, Aurora Healthcare/Aurora Sinai Medical Center Milwaukee, Milwaukee, WI, USA Abstract Would history still credit Carl Koller with discovering the local anesthetic properties of cocaine if Sigmund Freud had staked a claim to the discovery? This paper discusses and evaluates the contribution of both men with respect to this momentous discovery. An extensive literature search (in Spanish and English) of several Internet search engines, the University of Maryland Online Library, and Medline database for books and articles relating to the role of Sigmund Freud and Carl Koller in the discovery of local anesthesia was conducted. While Sigmund Freud’s role in the discovery of the local anesthetic properties of cocaine cannot be overlooked, it was Carl Koller who took the important steps required of scientific investigation, namely, those of experimentation, clinical application, and scientific dissemination. For this reason, Koller is rightly regarded as the discoverer of local anesthesia. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Sigmund Freud; Carl Koller; Local anesthesia; History of medicine; Anesthesia; Cocaine 1. Introduction The medical establishment in Vienna, Austria was full of ambition during the late 19th and early 20th centuries. With faculty that included the surgeon Christian Theodor Billroth (today considered to be the father of modern abdominal surgery), the embryologist Oscar Hertwig, the pathologist Carl von Rokitansky, and Willem Einthoven, (who would later develop the electrocardiogram), the medical establishment in Vienna was considered to be one of the most important in the world [1]. Not surprisingly, then, late 19th century, Vienna set the stage for a controversy involving two pupils of the medical school, Sigmund Freud and Carl Koller, regarding the discovery of local anesthesia. * Tel.: +1-414-688-2204; fax: +1-501-423-1588. E-mail address: [email protected] (D. Galbis-Reig). 0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 6 0 6 - 4 572 D. Galbis-Reig / International Congress Series 1242 (2002) 571–575 In his autobiographical study during the latter part of his life, Sigmund Freud renounced his claim to the discovery of the local anesthetic properties of cocaine saying, ‘‘Koller is rightly regarded as the discoverer of local anaesthesia by cocaine, which has become so important in minor surgery’’ [2]. Even so, previous statements in this same work [2] as well as some evidence from his earlier writings [3,4] suggest that had he not become famous in his own right for the theory of psychoanalysis, Freud would not have been so generous. Would history still credit Carl Koller with the discovery of the local anesthetic properties of cocaine if Sigmund Freud had staked his claim to the discovery? This paper discusses and evaluates the contribution of both men with respect to this momentous discovery. 2. Method An extensive literature search (in Spanish and English) of several internet search engines, the University of Maryland Online Library, and PubMed database for books and articles relating to the role of Sigmund Freud and Carl Koller in the discovery of local anesthesia was conducted using the following key words: scientific process, Carl Koller, Sigmund Freud, history, anesthesia, and cocaine. 3. Results The scientific process, initiated when observation and experience lead to the formation of a question, is utilized to test a hypothesis regarding a possible answer to the proposed question. The scientific process involves a formalized series of steps that include: observation, hypothesis formation, experimentation (hypothesis testing), clinical application, and scientific dissemination [5]. The process of observation occurs naturally as a consequence of experience. When an observation produces a question, a hypothesis (or possible explanation) of the observation can be developed and tested via experimentation. Following initial experimentation, in medicine, the scientific process must also include a formalized sequence of clinical application. Finally, the investigator must disseminate his/her findings throughout the scientific and medical community. 3.1. The scientific process applied to the discovery of local anesthesia 3.1.1. Observation After reviewing the early writings of Sigmund Freud, including an English translation of his publication, Uber Coca [6], published in July 1884, it is evident that Freud was aware of previous literature referring to the local anesthetic properties of cocaine. In fact, Freud closes his publication Uber Coca by describing the ‘‘local application of coca,’’ stating in his last sentence, ‘‘Indeed, the anesthetizing properties of cocaine should make it suitable for good many further applications’’ [6]. Evidence also suggests that it was Sigmund Freud who initially introduced his friend and colleague, Carl Koller, to the D. Galbis-Reig / International Congress Series 1242 (2002) 571–575 573 potential anesthetic qualities of cocaine [1– 3,7,8]. Given his keen interest in discovering a local anesthetic for use in ophthalmic surgery, it is likely that Carl Koller quickly became aware of previous literature on cocaine (with Freud’s assistance) including the writings of Albert Nieman in Gottingen who first described anesthesia of the tongue when tasting the alkaloid in 1862 [9]; the writings of Moreno y Maiz who wrote about cocaine, ‘‘Could it be used as a local anesthetic?. . . it must be decided by the future’’ [10]; and the work of Von Anrep in 1880 who developed a solution of cocaine, painted his tongue with it, and described a sensation of profound numbness.[9] The observations of all of these men (and Freud’s assertion in Uber Coca that it could potentially be used as a local anesthetic) inspired Carl Koller to hypothesize that cocaine may be of value as a local anesthetic. 3.1.2. Hypothesis First, Sigmund Freud (as evidenced by Uber Coca) and then Carl Koller developed the hypothesis that cocaine possessed anesthetic qualities. Freud made his hypothesis public in Uber Coca and later asked a mutual friend, Konigstein, to carry out the necessary experiments prior to leaving Vienna during the summer of 1884 to join his fiancée [1 –3]. Unfortunately, Freud’s friend was not successful. Meanwhile, Carl Koller (another of Freud’s friend) was busy working in the laboratory of Dr. Engel searching for a local anesthetic for use in ophthalmic surgery. It was not until Dr. Engel placed a bit of the substance on his own tongue and experienced the numbness that had been documented in the literature that the ‘‘eureka’’ moment occurred in Koller’s mind as he recalled what his friend Freud had told him about the possible anesthetic qualities of the alkaloid [1]. At that instant, Carl Koller, realizing the true potential of the alkaloid, began working diligently to develop an aqueous solution of cocaine to test his hypothesis that cocaine possessed local anesthetic properties. Given his previous unsuccessful attempts to discover a substance with local anesthetic properties [8] (including experimentation with chloral hydrate, bromide, morphine, and others), Koller was very enthusiastic about the potential use of cocaine as a local anesthetic and worked feverishly throughout the summer of 1884 to test the hypothesis. 3.1.3. Experimentation (hypothesis testing) As with his previous experiments, Carl Koller set to work immediately to prepare an aqueous solution of cocaine with which to anesthetize the eye of a frog. Koller instilled a drop of the solution into one of the frog’s eyes and used a needle to determine the sensitivity of the anesthetized eye, using the frog’s unanesthetized eye as the control. Finding excellent results with the frog, Koller and his assistant, Dr. Gaertner, then proceeded to test the same solution on several other animals and, finally, on each other until they were satisfied with the results of the experiment. By today’s standards, not the most rigorous of experiments, but it accomplished its goal; Koller demonstrated that cocaine possessed local anesthetic properties. As Sigmund Freud later recalled in his autobiographical study [2]: I may here go back a little and explain how it was the fault of my fiancée that I was not already famous at that early age. A side interest, though it was a deep one, had 574 D. Galbis-Reig / International Congress Series 1242 (2002) 571–575 led me in 1884 to obtain from Merck some of what was then the little-known alkaloid cocaine and to study its physiological action. While I was in the middle of this work, an opportunity arose for making a journey to visit my fiancée, from whom I had been parted for two years. I hastily wound up my investigation of cocaine and contented myself in my book on the subject with prophesying that further uses for it would soon be found. I suggested, however, to my friend Konigstein, the ophthalmologist, that he should investigate the question of how far the anaesthetizing properties of cocaine were applicable in diseases of the eye. When I returned from my holiday I found that not he, but another of my friends, Carl Koller (now in New York), whom I had also spoken to about cocaine, had made the decisive experiments upon animals’ eyes and had demonstrated them at the Ophthalmological Congress in Heidelburg. 3.1.4. Clinical application and scientific dissemination Scientific dissemination is an integral part of the scientific process. Without dissemination, knowledge essentially exists in a vacuum and is useless. Within medicine, in order for scientific discoveries to gain widespread acceptance and recognition, the findings must first be applied to a clinical situation followed by dissemination throughout the medical community. These final steps in the scientific process guarantee that the scientific community will have the opportunity to critically evaluate and verify the results of the study prior to the same becoming widely applied to patient care. These final steps in the scientific process are also meant to provide safeguards that ensure appropriate conduct of investigators, clinicians, and scientists. If Carl Koller had not pursued clinical application and dissemination of his work with cocaine, local anesthetic use in surgery may not have gained the widespread acceptance that it received following the presentation of Koller’s experiments at the German Ophthalmological Society meeting in Heidelberg during the fall of 1884 [1,3,11]. Even though Koller himself was unable to attend these proceedings and present his own work (due to financial difficulties), he realized the importance of his findings and entrusted a friend, Brettauer of Trieste, with the mission of presenting his results at the meeting in Heidelburg. Not only did Trieste present the findings, he also proceeded to verify Koller’s results in front of the all the attendees by using a dog to demonstrate the anesthetic effects of cocaine upon the eye. Later that same year (on 25 October, 1884), Carl Koller himself was finally able to present his paper regarding the anesthetic qualities of cocaine before the Medical Society of Vienna [3]. He finally published his paper in November of that same year in Wiener Medizinische Wochenschrift [3]. Koller’s work, while immediately interesting within certain medical circles, would not have gained widespread acceptance without support from more experienced clinicians. In the United States, for example, skepticism still abounded until a well known and respected ophthalmologist, Dr. Herman Knapp, read Koller’s article, repeated the experiments on himself, certain family members, and his patients, and finally published his own report on cocaine in the Archives of Ophthalmology [12]. With this approbation, cocaine’s use as a local anesthetic became rapidly accepted and well established in the United States and around the world. D. Galbis-Reig / International Congress Series 1242 (2002) 571–575 575 4. Conclusion The scientific process involves a formalized sequence of events leading eventually to the widespread application of empirical knowledge (what is commonly known as evidence-based medicine today). These sequential steps include observation, hypothesis, experimentation, clinical application, and scientific dissemination. While Sigmund Freud’s role in the discovery of the local anesthetic properties of cocaine cannot be overlooked, it was Carl Koller who took several of the important steps required of scientific investigation, namely, those of experimentation, clinical application, and scientific dissemination. Koller was the final link in a very important chain of events leading to the discovery of local anesthesia, and for that reason, is rightly regarded as the discoverer of local anesthesia. Acknowledgements An abstract of this paper was presented as a poster entitled, ‘‘Sigmund Freud and Carl Koller: The Controversy Surrounding the Discovery of Local Anesthesia,’’ at the 5th International Symposium on the History of Anesthesia in Santiago de Compostela, Spain between 19 September, 2001 and 23 September, 2001. References [1] M. Leonard, Carl Koller: mankind’s greatest benefactor? The story of local anesthesia, J. Dent. Res. 77 (4) (1998, April) 535 – 538. [2] S. Freud, An Autobiographical Study, W.W. Norton & Company, New York, NY, 1952, p. 13, The standard edition. Introduction by Peter Gay. [3] M.F. Goldberg, Cocaine: the first local anesthetic and the ‘third scourge of humanity’: a centennial melodrama, Arch. Ophthalmol. 102 (10) (1984, October) 1443 – 1447. [4] M.A. Pabon Morales, La Influencia de la Cocaina en el Surgimiento de la Teoria Psicoanalitica. Seminario de Introduccion al Psicoanalisis. Universidad Nacional de San Luis, 1997. Retrieved on 03/06/01 from http://www.advance.com.ar/usuarios/mpabon/cocaina.htm. [5] B.S. Blumberg, Comments on scientific process in clinical research, Perspect. Biol. Med. 24 (1) (1980) 15 – 30. [6] Anonymous, Classics revisited. Uber Coca. By Sigmund Freud, J. Subst. Abuse Treat. 1 (3) (1984) 206 – 217. [7] S.F. Malamed, Local anesthetics: dentistry’s most important drugs, J. Am. Dent. Assoc. 125 (12) (1994, December) 1571 – 1576. [8] A.J. Altman, D.M. Albert, G.A. Fournier, Cocaine’s use in ophthalmology: our 100-year heritage, Surv. Ophthalmol. 29 (4) (1985, Jan – Feb) 300 – 306. [9] S.B. Karch, A Brief History of Cocaine, CRC Press, LLC, Boca Raton, FL, 1998, pp. 37 – 52. [10] R. Siegel, A. Hirschman, Moreno and the first study on cocaine: a historical note and translation, J. Psychoact. Drugs 15 (3) (1983) 219 – 220. [11] J.A. Wildsmith, G.R. Strichartz, Local anaesthetic drugs—a historical perspective, Br. J. Anaesth. 56 (9) (1984, September) 937 – 939. [12] H. Knapp, On cocaine and its use in ophthalmic and general surgery, Arch. Ophthalmol. 13 (1884) 402 – 448.
