Two surgeons had finished work for the day. But instead of going home, they began to prepare for one more operation- a little out of hours experiment intended to advance the art of anaesthesia. August Bier was a rising star at the royal surgical clinic in Kiel, North Germany. His young assistant, Augustus Hildebrandt, had agreed to help him.
What happened next was not so much heroic as comic. Just one little mistake and courageous selflessness turned to black comedy. It made Bier’s name. But the events of that evening would be forever etched in Hildebrandt’s memory, not to mention several other parts of his body.
In the 1890’s, general anaesthesia was decidedly dodgy. Chloroform sent patients gently to sleep, but there was no room for error. A few drops too many and the patient would be dead before the surgeon picked up his scalpel. Ether wasn’t as dangerous, but it was slow to act – surgeons sometimes started to operate before their patients had gone under. The survivors suffered unpleasant side-effects from violent headaches and vomiting to pneumonia.
Bier reasoned it should be possible to banish sensation from most of the body without knocking the patient out completely by injecting a small dose of cocaine into the cerebro-fluid that baths the spinal cord. He tried this technique on half a dozen patients. They lost sensation from the lower part of their bodies long enough for him to carve out chunks of diseased bone and pelvis. On the other hand so many complaints had arisen from this that they equaled the complaints received after general anaesthesia. He wrote “To arrive at a valid opinion, I decided to conduct an experiment on my own body”
The procedure was simple enough. Hildebrandt had to make a lumbar puncture by plunging a large needle through the membranes that protected Bier’s spinal cord into the fluid-filled space underneath. Then he had to fit a syringe on the needle and inject a solution of cocaine. But preparations for the experiment had been less than meticulous.Hildebrandt made the lumbar puncture. Then, with his finger over the hub of the needle to prevent fluid from leaking out, he took up the syringe of cocaine – only to find it was the wrong fit. As he fumbled with the needles, Bier’s cerebro-spinal fluid began to squirt out.Horrified, Hildebrandt stopped and plugged the wound. This was when the pair should have called it a day. Instead, Hildebrandt offered to take his bosses place.
At 7.38pm, after checking the needles more carefully, Bier began. The cocaine worked fast. “After 7 minutes: needle pricks in the thigh were felt as pressure; tickling of the soles of the feet was hardly felt” Bier jabbed Hildebrandt in the thigh with a needle, nothing. He tried harder, stabbing the thigh with a surgical equivalent of a stiletto, still no response. Then 13 minutes into the experiment, Bier went further stubbing out a cigar on his assistants leg.
Bier now wanted to know how far the insensitivity extended, and invented a simple test. “Pulling out pubic hairs was felt in the form of elevation of skinfold; pulling out chest hairs above the nipples caused vivid pain” So now they knew. It was now more than 20 minutes since Hildebrandt has stopped feeling pain. How much more could he take? Bier increased his efforts. He smashed a heavy iron hammer into Hildebrandt’s shin bone and then, when that failed to have an effect, gave his testicles a sharp tug. In a final burst of enthusiasm, Bier stabbed the right thigh to the bone, squashed hard on a testicle and, for good measure, rained blows on Hildebrandt’s shin with his knuckles.
After 45 minutes, the effect of the cocaine began to wear off, the two surgeons, one missing a significant amount of spinal fluid, the other battered, burnt and suffering from serious stab wounds, went out for dinner. “We drank wine and smoked several cigars” wrote Bier.
The next morning, Bier awoke feeling bright and breezy. By the afternoon though he had turned pale, his pulse was weak and he felt dizzy whenever he stood up. “All these symptoms disappeared as soon as I lay horizontally, but returned when I arose. In the late afternoon, therefore I had to go to bed” He stayed there for the next 9 days. When he finally got up again he felt quite well “I was perfectly able to tolerate the strain of a weeks hunting in the mountains” he wrote.
Hildebrandt didn’t escape so lightly. The first night he was violently ill. He developed a splitting headache and was sick. But someone had to tend to the clinics patients and with Bier in bed, the job fell to him. Each morning for the next week, Hildebrandt dragged himself to work. Each afternoon, he staggered home and collapsed into bed. “Dr Hildebrandt’s legs were painful, and bruises appeared in several places” wrote Bier, rather understating the case.
When Bier wrote his groundbreaking paper describing the experiment, he gave a blow by blow account of what Hildebrandt had endured. As far as Bier was concerned the experiment had been a huge success. He had shown that a tiny dose of cocaine could deaden sensation for long enough to perform major operations. Spinal anaesthesia was far safer than general anaesthesia and within two years surgeons around the world were using his technique.
Bier put the headaches down to the loss of cerebrospinal fluid, and he was right – this was finally proved in the 1950’s.
Hildebrandt though, had gone right off Bier and became one of his most vehement critics. When a row blew up over who had really been first to invent spinal anaesthesia, the once loyal assistant championed Bier’s rival, an American neurologist called James Corning. Hildebrandt never said why. Perhaps he was shocked by the zeal with which Bier had battered him. Maybe he was miffed because in the end Bier was recognised as a pioneering surgeon, while he was forever known as the man whose boss had tugged his testicles.
Whatever the reasons. Spinal anaesthesia, although now out of fashion in the developed world, is still administered thousands of times a day all over the world.
My advise though, if anyone says “this won’t hurt a bit” get it in writing.
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