The surgeons Halsted and Hall, cocaine and the discovery of dental anesthesia by nerve blocking

Abstract

William Stewart Halsted is considered to be one of the most influential and innovative surgeons the USA has ever produced. His contributions to surgery are abundant, ranging from sophisticated surgical techniques in the field of breast surgery, surgery of the digestive apparatus and traumatological interventions, to the introduction of gloves in the operating theatre. Here we present Dr Halsted, together with his aide Dr Hall, as the discoverers of the technique for blocking the inferior alveolar nerve and the antero-superior dental nerve using cocaine as an anaesthetic. The anaesthetic technique, described perfectly by both surgeons in 1885, has been revolutionary in the practice of odontology since its introduction, offering dentists the possibility of performing invasive interventions to the maxillary without pain.

Full text

The surgeons Halsted and Hall,
cocaine and the discovery
of dental anaesthesia
by nerve blocking
A. López-Valverde,1 J. De Vicente2 and A. Cutando3
VERIFIABLE CPD PAPER
and then went on to occupy the position of
Chief of Surgery until 1922, when he died.1
Richard John Hall (Fig.2), who was born
in Ireland, emigrated as a child to New
York. He followed medical studies at the
College of Physicians and Surgeons at the
University of New York, earning himself
a Doctorate in Medicine in 1878. Like his
colleague Halsted, he also travelled to
Europe, visiting the best universities and
clinics of those times.
In New York he worked as a surgeon at
the Roosevelt Hospital and was the rst,
in 1886, to perform an appendectomy. In a
cruel twist of fate, the man who had been
pioneer in this type of intervention died of
acute appendicitis on 24 January 1897.2
THE DISCOVERY OF COCAINE
AS AN ANAESTHETIC
We owe the rst reference to the anaes-
thetic effects of coca to Spanish Jesuit
Bernabé Cobo (1582-1657), who in his
1653 manuscript work on the New World,
mentions that toothaches can be alleviated
by chewing coca leaves.3,4
In 1884, Carl Koller reported the use
of cocaine as a topical anaesthetic for
the mucosa of the eye at a Congress of
Ophthalmology in Heidelberg, held on 15
September of that year.5
News of Koller’s discovery spread
across the world faster than did the dis-
covery of general anaesthesia, because
DISCOVERY
Biographical data, travels,
and training in Europe
William Stewart Halsted (Fig.1) was born
in New York in 1852. In 1875 he entered
the College of Physicians and Surgeons at
the University of Columbia (NY), earning
a doctorate in Medicine in 1877.
He periodically travelled to Europe
and, in Vienna, he worked as an assistant
to Billroth, famed for his surgery of the
digestive system. In Germany, he bene-
ted from the teaching of prestigious sur-
geons such as Volkmann, Kaposi, Chiari
and Zuckerland. In Switzerland he met
Hermann Kocher, renowned for his surgi-
cal skills and knowledge of diseases of the
thyroid gland, with whom, over the years,
he developed a profound friendship.
In 1883, at the age of 36, he was awarded
a professorship and became the Head of
the Department of Surgery of the Johns
Hopkins Hospital in Baltimore (Maryland),
William Stewart Halsted is considered to be one of the most inuential and innovative surgeons the USA has ever pro-
duced. His contributions to surgery are abundant, ranging from sophisticated surgical techniques in the eld of breast
surgery, surgery of the digestive apparatus and traumatological interventions, to the introduction of gloves in the operat-
ing theatre. Here we present Dr Halsted, together with his aide Dr Hall, as the discoverers of the technique for blocking the
inferior alveolar nerve and the antero-superior dental nerve using cocaine as an anaesthetic. The anaesthetic technique,
described perfectly by both surgeons in 1885, has been revolutionary in the practice of odontology since its introduction,
offering dentists the possibility of performing invasive interventions to the maxillary without pain.
1*,2As sociate Professors, School of Dentistry, Faculty of
Medicine, Department of Surgery, Universit y of Sala-
manca, Spain; 3Tenured lecturer, School of Dentistry,
Faculty of Odontology, University of Granada, Spain
*Correspondence to: Dr Antonio López-Valverde
Email: alopezvalverde@gmail.com
Refereed Paper
Accepted 7 October 2011
DOI: 10.1038/sj.bdj. 2011.961
©British Dental Journal 2011; 211: 458-487
• Describes the discovery and use of
cocaine as an anaesthetic and the
dangers of self-experimentation.
• Dr Halsted and his aide Dr Hall discovered
the technique for blocking the inferior
alveolar ner ve and the antero-superior
dental nerve using cocaine as an
anaesthetic.
• Since its introduction, the anaesthetic
technique described has been revolutionar y
in the practice of odontology.
IN BRIEF
GENERAL
Fig. 1 William Stewart Halsted
Fig. 2 Richard John Hall
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GENERAL
communications had improved as transat-
lantic cables had been laid, thereby affording
almost instantaneous telegraphic contact.
A doctor present at that Congress of
Ophthalmology in Heidelberg, Dr Henry D.
Noyes, from New York, sent a letter that
was published on 11 October 1884 in the
New York Medical Records, even before
Koller made the presentation of his discov-
ery in Vienna on 16 October the same year.6
Halsted and his colleague Hall learned
about the discovery through the ‘Noyes
Report’ addressing the Congress of
Ophthalmology in Heidelberg, although
some investigators consider that Halsted
and Koller had already been meeting at
the University of Vienna between 1878
and 1880 at the Department of Pathology
of the Allgemeines Krankenhaus, where
Koller worked next to Sigmund Freud.7
After that time, Halsted and Hall began
their rst clinical trials, initially inltrat-
ing the nerve trunks with 4% solutions of
cocaine injected into the branchial plexus
and the posterior tibial nerve, using the
hypodermic syringe described by Charles
Gabriel Pravaz to do so. In this way they
managed to perform painless operations
on the upper and lower limbs. They also
began to use cocaine subcutaneously as a
local anaesthetic, following the technique
developed by the Frenchman Reclus and
the German Schleich.
In 1892, Dr Schleich was the first
to publish a clinical report addressing
more than 1,000 operations in which the
cocaine inltration technique was used,
and he later presented his ndings and the
Annual Congress of the German Society
for Surgery in Berlin.8
THE DISCOVERY OF NERVE
BLOCK ANAESTHESIA
In 1884, William Stewart Halsted was
already a successful surgeon in New York.
He had worked for two years in Berlin with
Ernst von Bergmann and Karl Thiersch in
Leipzig, and with Richard von Volkmann
in Halle, where he became interested in
asepsis and antisepsis and the study of the
basic sciences and anatomy.9
When he returned to the USA, he started
to work at the Roosevelt Hospital and in
another four hospitals in New York, there
meeting Richard Hall, with whom he
began to develop nerve block anaesthe-
sia, teaching their colleagues and students
in practical exercises. Halsted, Hall and
their colleagues performed more than
1,000 painless minor surgical interven-
tions at the Outpatient Department of the
Roosevelt Hospital.
Halsted was a meticulous and very
patient anatomist. He acquired a 4%
solution of Cocaine from Parke Davies &
Company (the extracting and distribut-
ing company of cocaine in the USA) and
started to test it on his students at the
College of Physicians and Surgeons in New
York. The results were spectacular. When
the cocaine was injected along the course
of a nerve it anaesthetised the innervated
region. However, it did have some unde-
sirable side effects, such that it became
necessary to dilute the solution in order
to use lower doses, which also proved to
be effective. One of the most striking appli-
cations was tooth extraction, which until
then had always been extremely painful.
On the same day that the rst article
in English of Koller’s work appeared in
The Lancet, at the beginning of December
1884, Hall reported its results in the New
York Medical Journal.
The Editor’s comment accompanying
the initial publication of Hall’s ndings
recommended that the drug should not be
considered innocuous, pointing out that Dr
Hall himself had observed marked consti-
tutional symptoms with the injection of 32
‘minima’ (1 ‘minima’ = 0.059 ml) of a 4%
solution of cocaine hydrochloride.
The self-experimentation was to have
tragic consequences for the protagonists,
who ended up completely addicted to
the substance.10
COCAINE ADDICTION
The frequent use of the alkaloid itself,
for experimental ends, led to the doctors
becoming addicted to the substance and
they began to exhibit erratic social and
professional behaviour; this is turn leading
to several admissions to hospital and cures
to combat their addiction.11
For Halsted this meant the end of his
career as a surgeon in New York. William
H. Welch, a great friend and colleague
of Halsted, was the person who – with
great efforts and acting as a true friend
– managed to rehabilitate the renowned
surgeon and restore his reputation, offer-
ing him a place at his laboratory at the
Johns Hopkins Hospital in Baltimore as
occupational therapy. Shortly afterwards,
Welch hired a boat to sail to the Leeward
Islands in February and March 1886 and,
in turn, keep Halsted safely out of contact
with cocaine.12
The trip did not prove to be the solu-
tion and not very long afterwards Welch
and McBride, two of Halsted’s friends, and
even his brother Richard convinced him to
check into the Butler Hospital (Providence,
Rhode Island), which was a facility for
alcoholics since in those times addiction
to drugs was relatively rare. There, he
remained under strict surveillance for six
months. In those days he was consuming
at least three ‘grains’ of cocaine a day (1
grain = 64.79891mg), which is a danger-
ous amount.9
The key to the treatment received by
Halsted was the replacement of cocaine
by morphine.
In 1887, he entered rehabilitation again,
this time for nine months, after which he
returned to the laboratory and progres-
sively resumed his clinical activities.
Thanks to Welch’s support, almost two
years later in 1889 he was named, pro-
visionally and for only one year, assis-
tant professor and surgeon at the Johns
Hopkins Hospital.1
His dedication to his work and his prow-
ess as a surgeon led him to be awarded a
professorship in 1892, despite his precari-
ous state of health. There is considerable
controversy as to whether Halsted nally
managed to cure himself of the cocaine
habit since despite his great achievements
as a surgeon and professor there were sud-
den ‘trips away’ and he sometimes aban-
doned his post claiming different illnesses.
In 1969, on the occasion of the eighth dec-
ade of the Johns Hopkins Hospital, a sealed
black box was opened with a silver key;
this box contained a secret report writ-
ten by William Osler, who revealed that
Halsted had tried to cure his addiction to
cocaine by using morphine, and that it was
his addiction to this substance that led to
his death.9
In turn, Hall moved to Santa Barbara
in California working as a surgeon in a
rural hospital, although he was never to
free himself of his own addiction.2
DISCUSSION
Several researchers pre-empted Halsted
and Hall in the description of nerve block
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© 2011 Macmillan Publishers Limited. All rights reserved.

GENERAL
anaesthesia with cocaine (Table1).
Moreno and Maiz (1868) and Bennet
(1873) had investigated the effects of
cocaine in experimental animals, describ-
ing block of the sciatic nerve in frogs
and suggesting the use of cocaine as a
local anaesthetic.13,14
In 1875, Jacob Mendes da Costa also
reported the successful use of cocaine
administered hypodermically and described
its usefulness in tooth extractions.15
W. B. Burke, from South Norwalk,
Connecticut, reported in the New York
Medical Journal the block of the ulnar
nerve by cocaine injection in an interven-
tion with the goal of removing a lead pellet
from the little nger of a patient.16,17
In November 1884, the Russian Vassily
von Antrep described the block of an
intercostal nerve in a case of a broken rib,
mentioning the possible use of cocaine in
surgery and he was the rst physician, in
1890, to use cocaine subcutaneously.18,19
Halsted claimed the authorship of anaes-
thesia by nerve nerve blocking in two letters,
one of them sent to Rudolph Matas, one of
the greatest proponents of local and regional
anaesthesia in the USA, and the other to
Sir William Osler, referring to the book
by James Leonard Corning, dealing with
local anaesthesia and published in 1886, in
which he complained that Corning’s book
was based almost exclusively on Halsted’s
own work.20
In November and December 1884, Halsted
and Hall also sent reports to the New York
Medical Journal in which they told of their
experiences in the production of nerve
block with cocaine in the cubital nerve, the
anterosuperior alveolar nerve, the inferior
alveolar nerve and the lingual nerve, as well
as the use of cocaine in the form of topical
administration or in inltrations.21,22.
Both were pioneers in the development
of the block of different nerves, in describ-
ing the superiority of intradermal injection
over the hypodermic route, and the pos-
sibility of obtaining adequate anaesthesia,
using the lowest amounts of dilute solu-
tions of cocaine. They pre-empted Schleich
and Reclus by several years, although
unfortunately they never published two
papers written in 1886 and 1902 concern-
ing the use of cocaine as an anaesthetic in
different types of surgical intervention.9
Although Halsted and Hall were not the
rst physicians to perform nerve blocks,
they should both be considered pioneers
in describing many nerve block techniques
of great use in dentistry and oral surgery.
In April 1922, just six months before
Dr Halsted’s death, the American National
Dental Association recognised the sig-
nicance of Halsted’s discovery in local
and regional anaesthesia, presenting him
with a gold medal and giving him full
credit for the discovery of neuroregional
anaesthesia.20
The authors are grateful to the reviewers of the
manuscript for the insights shared and the valuable
contributions and suggestions.
1. MacCallum WG. Biographical memoir of William
Stewart Halsted 1852–1922. pp 151–170. National
Academy of Sciences of the United States of
America Biographical Memoirs. Volume XVII –
Seventh Memoir. Presented to the Academy at the
Autumn Meeting, 1935.
2. Redmon M. Santa Barbara Historical Society.
Santa Barbara’s history. The New York Times, 25
January 1897.
3. Cobo B. Historia del nuevo mundo. Manuscrito en
Lima, Perú, 1653, libro 5°, capítulo XXIX. Modern
edition: Bernabe Cobo. Historia del nuevo mundo.
Publicado por la Sociedad de Bibliólos Andaluces. Con
notas de Marcos Jiménez de la Espada. E. Rasco ed. Vol
I, Book 5th, Chapter XXIX. pp 473–447. Sevilla 1890.
4. López-Valverde A. Recopilación de artículos y
comentarios sobre anestésicos en la revista ‘La
Odontología. 1892–1936’. PhD dissertation. Spain:
University of Salamanca, 2009.
5. Koller C. On the use of cocaine for producing
anaesthesia on the eye. Lancet 1884; 2: 990–992.
6. Noyes HD. The ophthalmological congress in
Heidelberg. NY Med Rec 1884; 26: 417–418.
7. McKeown JL. Koller and Halsted: two of the great
ones. American Society of Anesthesiologists, 2010.
8. Schleich CL. Die Inltrationsanästhesie (locale
Anästhesie) und ihr Verhältniss zur allgemeinen
Narcose (inhalationsanästhesie). Verhandlungen der
Dtsch Gesellschaft Chirurgie 1892; 1: 121–127.
9. Olch PD, William S. Halsted and local anesthesia:
contributions and complications. Anesthesiology
1975; 42: 479–486.
10. Halsted WS. Practical comments on the use and
abuse of cocaine; suggested by its invariably suc-
cessful employment in more than a thousand minor
surgical operations. NY Med J 1885; 42: 294–295.
11. Goodger NM, Wang J, Pogrel MA. Palatal and nasal
necrosis resulting from cocaine misuse. Br Dent J
2005; 198: 333–334.
12. Killian H. La lucha contra el dolor. Planeta ed. pp
147. Barcelona, 1981.
13. Moreno y Maíz T. Recherches chimiques et phy-
siologiques for l’erythroxylum coca du Perou et la
cocaine. Louis Leclerc ed. pp 65–78. Paris, 1868.
14. Bennett A. An experimental inquiry into the physiolog-
ical actions of theine, caffeine, guaranine, cocaine and
theobromine. Edinburgh Med J 1873; 19: 323–341.
15. Byck R. Cocaine papers. p 136. New York: New
American Library, 1974.
16. Burke WC. Hydroclorate of cocaine in minor
surgery. NY Med J 1884; 40: 616.
17. Little Jr DM. Classical anesthesia les. p 73.
Chicago: Waverly Press, 1985.
18. Anrep VK. Kokain kak sredstvo mestno anesteziruy-
ushtee [Cocaine as a means of local anesthesia].
Vrach 1884; 5: 773–774.
19. Yentis SM, Vlassakov KV. Vassily von Anrep,
forgotten pioneer of regional anesthesia.
Anesthesiology 1999; 90: 890–895.
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Stewart Halsted. Surgery 1952; 32: 530–537.
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40: 643–644. In Cole F. Milestones in anesthesia.
Lincoln: University of Nebraska Press, 1965.
Table 1 Contributions of the different authors to the discovery of the nerve
blocking method
Authors Year Contribution to the discovery
T. Moreno y Maíz
A. Bennett
1868
1873 Sciatic nerve block in frogs
J. M. Da Costa 1875 Use of cocaine in dental interventions
W. B. Burke 1884 Ulnar nerve block by cocaine injection
W. S. Halsted
R. J. Hall 1884
Cubital, anterosuperior, inferior alveolar and lingual nerve’s
block with cocaine and the use of the substance in topical
application or inltration
V. von Anrep 1890 Intercostal nerve block
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© 2011 Macmillan Publishers Limited. All rights reserved.
© 2011 Macmillan Publishers Limited. All rights reserved.
© 2011 Macmillan Publishers Limited. All rights reserved.