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Rev. Bras. Anestesiol. vol.58 no.4 Campinas July/Aug. 2008
Eulogy to August Karl Gustav Bier on the 100th anniversary of intravenous regional block and the 110th anniversary of the spinal block*
A homenaje a August Karl Gustav Bier por ocasión de los 100 Años de la anestesia regional intravenosa y de los 110 años de la anestesia raquidea
Almiro dos Reis Jr, TSA
Anestesiologista do Serviço Médico de Anestesia (SMA) de São Paulo, Hospital Alemão Oswaldo Cruz
OBJECTIVES: August Karl Gustav Bier introduced two important techniques
in regional block: intravenous regional block and subarachnoid block, widely
used nowadays. Since the first one celebrates its 100th anniversary
and the second its 110th anniversary, it is only fair that we pay
homage to this extraordinary physician who created them.
CONTENTS: This report describes his family, school, academic course, and medical residency data, professional and university activities, personality, retirement, and death of A. K. G. Bier. It describes his countless contributions to Medicine and to Anesthesiology in particular. It discusses his research on intravenous regional block, many of them still valid nowadays or not completely explained. It mentions his initial studies and the controversies on his role in the creation of spinal block. It tells the experiences he had in both World Wars. It also mentions the great contributions of Bier to culture, sports, physical education and, especially, to ecology when he created the famous Sauen Forest. Finally, the well deserved honors he received in his home country and in other countries are mentioned.
CONCLUSIONS: A. K. G. Bier created and introduced two notable and still current methods of regional blocks in Anesthesiology and was a great defender of the preservation of the environment. Therefore, since this year we celebrate the 100th anniversary of intravenous regional block, his biography deserves to be told as a tribute to this important German physician.
Key Words: ANESTHESIA, Regional: subarachnoid, intravenous; ANESTHESIOLOGY: history.
Y OBJETIVOS: August Karl Gustav Bier fue el que inició las de los
importantes técnicas de anestesia regional: la anestesia regional intravenosa
y la anestesia subaracnoidea, ambas hasta hoy ampliamente usadas. Completando
este año de 2008 la primera de ellas 100 años y la segunda 110
años de existencia y sería muy justo que le prestásemos
un homenaje a aquel notable médico.
CONTENIDO: El texto relata los datos familiares y estudiantiles iniciales, del curso académico y de la residencia médica, las actividades profesionales y universitarias, la personalidad, la jubilación y el deceso de A. K. G. Bier. Describe sus innumerables aportes a la Medicina y en particular a la Anestesiología. Se refiere a las investigaciones que realizó sobre la anestesia regional intravenosa, muchas de ellas todavía válidas o no totalmente clarificadas. Cita las experiencias iniciales y las discordancias sobre su papel en la creación de la anestesia raquidea. Narra episodios que él vivió durante de los Grandes Guerras. Finalmente, se traen a colación los enormes aportes de Bier a la cultura, a los deportes, a la educación física y, principalmente, a la ecología, cuando inventó el famoso Bosque de Sauen. Finalmente citamos los merecidos homenajes que recibió en su patria y en varios otros países.
CONCLUSIONES: A. K. G. Bier creó e introdujo en la Anestesiología de los notables y actuales métodos de anestesia regional y fue el gran defensor de la preservación del medio ambiente. Por tanto, dado que es este año se cumple el primer centenario de la anestesia regional intravenosa, es válida la descripción de su biografía como un tributo al importante médico alemán.
Intravenous regional block is celebrating its 100th anniversary in 2008. Therefore, it is only deserving that we pay homage to August Karl Gustav Bier, his creator and also the creator of the spinal block, which is celebrating its 110th anniversary, by presenting a summary of his biography, emphasizing the main contributions of this remarkable physician.
August Karl Gustav Bier (Figure 1) was born in Helsen, in the Dukedom of Waldeck, Germany, on November 24, 1861. He was the son of Theodor Bier, a geometrician, and Christiane Becker 1-4. The couple had four children: a girl, who died when she was one year old, and three sons, Julius (a lawyer) and Ludwig (a phylogenist), who both died of tuberculosis at the age of 30 years, and August, who died at the age of 87 years 4.
On August 29, 1905, at the age of 43 years old he married Anna Esau, his first patient and the daughter of his very good friend, Dr. Viktor Esau, and moved to a house near the Bonn Zoo 4. The couple had five children, who were raised by Bier with Spartan discipline. The financial management of the family was the responsibility of his wife 4.
Bier started his studies in 1870 in Korbach (Gymnasium Freidericianum), where his parents lived. Early on, he was interested on the flora and fauna of the region and several sports. When he finished middle school in 1881, during which he was a brilliant student, he was in doubt whether he should dedicate his life to Zoology, Botanic, General Biology, or Medicine. He decided for Medicine, and studied at the Universities of Berlin (1881), Leipzig (1882-1883) and finally, attracted by the sea, he went to Kiel University (1883-1886) 4; he finished his medical studies in 1886 and became a surgical resident at the same university, under the guidance of the famous professor Friederich von Esmarch 4,5. At that time he felt the possibility to join the Navy; instead of remaining in Kiel for a few semesters, as planned, he stayed there for several years 4. While he was still a medical student, Bier substituted a general clinician in a small town in Germany 4.
PROFESSIONAL AND UNIVERSITY CARRERS
Initially, Bier practiced medicine at the small village of Gottorf, with 1,500 inhabitants, near Kiel. He was a volunteer physician in the Navy and traveled as ship's physician twice; during this time he had the opportunity to visit South America twice 4. Afterwards, he worked in Kiel and Greifswald 4.
The university life of Bier was largely influenced by the works of Ludwig, Leukaart, and Esmarch, and it was very productive. Bier was an assistant to Friedrich von Esmarch, having substituted him several times. Later, he became a professor in important medical centers of that time, such as Kiel (1895) and Greifswald (1899) 2-4; this town, near the place of production of the V2 missiles, is still beautiful and was not destroyed during the war 4. In 1903, Bier moved to Bonn, where he succeeded Max Schede, and later became a surgery professor at the University of Berlin (1907-1932) substituting the famous surgeon Ernest von Bergmann, who had died, and worked at the First Surgical Clinic of the University Hospital of this city that, at that time, was considered one of the largest centers of surgical research in the world 3,4,7.
Bier had a busy professional and academic life in Bonn and later in Berlin. 4 He arrived at the West Sanatorium at 5 a.m., operated from 6 to 7 a.m., and arrived exactly at 7:30 a.m. at the Surgical University Hospital of Berlin on Ziegelstrrasse, sitting by the driver in his convertible Mercedes, which gave him great pride; once a week he would walk. When he arrived at the clinic, a bell rang. At 8:30 a.m., Bier began his classes that were attended by students, assistants, and even by important physicians of the time, and finished at 10 a.m. From 10 a.m. to noon, Bier operated wearing his typical wooden clogs.
Although he had created and encouraged the use of special techniques, Bier was against extremely specialized activities, and always saw the human body as a whole; therefore, Bier considered John Hunter, the great English surgeon, one of the most notable medical individual 3-7. However, according to history, Bier operated (appendectomy) one of his daughters before allowing her to make a long trip to England because he did not believe in the ability of English surgeons 4.
Bier was considered one of the most fascinating physicians and the most renowned professors of the country during the transition between the 19th and 20th Centuries 2-4. Bier had the posture of a sovereign. As a human being, he was modest and friendly, and as a professor, he was humane. Bier was an enormously dynamic and productive individual, giving great contributions not only as a physician and surgeon, but also as a philosopher, philanthropist, and ecologist. It has been said that as a surgeon he was sublime, a man who followed his intuitions, with wide horizons, who made fast decisions, and was courageous regarding his beliefs. He had a very good relationship with students and nurses, and during residents' gatherings he worked as a sausage vendor.
During World War I, he was a consulting surgeon of the German army 2-4. In 1914, he was indicated to join the German Navy in Willdelmshaven but, since nothing happened there, he was transferred at his request to the 18th Fleet, acting in Belgium and France 4; at that time he noticed that 80% of severe cranial trauma were caused by grenade shrapnel. From this observation, he suggested an improvement on the steel helmet used by the armed forces of that country, which was made possible by Friedrich Schwerd; the new equipment, known as the Kaiser Wilhelm helmet, greatly improved the protection of the soldiers 2-4,6.
The decade of 1920 was the most shinny in Bier's professional life, when he became First Surgeon of the German Empire and was the President of the German Surgical Society twice 4. The number of patients was so large that, during the period Bier worked there, The University Clinic of Berlin became one of the biggest of the world 4. It has been reported that he treated, in Berlin alone, 50,000 people, including very important personalities, such as the Emperor Wilhelm, the President Friedrich Ebert, the extremely wealthy Hugo Stinnes, family members of the Russian czar, and Lenin, but he also treated many others free of charge 4. He was against family members visiting patients, because he thought this was a negative influence on their recovery 4.
CONTRIBUTIONS TO MEDICINE
Intensely dedicated to clinical practice, surgery, research, and teaching, Bier left countless and respected contributions to General Surgery and Anesthesiology.
General Surgery - A. K. Bier, H. Braun, and H. Kümmell wrote a Surgical Treatise, re-edited several times and for several decades it was the most popular and respected work in Germany 4. He published several works especially on surgeries for osteomyelitis, aneurysms, and prostatic hypertrophy, on intestinal stitching, arthritis, treatment with autologous blood, treatment of tuberculosis of the joints, elephantiasis, parotitis, and other disorders caused by hyperemia he observed after removal of limb garroting 4. In 1916, He wrote Publications and Regenerations of Legs and Joints 4.
Anesthesiology - Bier's contribution to the development of Anesthesiology is invaluable. During the beginning of the 20th Century he studied the most common complications of general anesthesia, such as nausea and severe vomiting that many times resulted in "ether pneumonia" 4. Besides, he created important methods of regional anesthesia: subarachnoid blockade (1898) and intravenous regional block (1908). One should remember that general anesthesia, introduced in 1842 by Crawford Williamson Long 8, preceded in almost half a century the introduction of local (topic) anesthesia in 1884 by Köller 9, whose first 100 years were celebrated in 1984 10-12.
Intravenous Regional Block
In 1908, August Karl Gustav Bier created intravenous regional block that is an unequivocal reason for celebration on its 100th anniversary in 2008 13. It is possible that Bier did not base his work on that of Corning on limb garroting to prolong the duration of the anesthetic blockade, although he was aware of Corning's work, and he did not have any knowledge about the research of Alms who, in 1886, was able to anesthetize frog paws with the intra-arterial injection of cocaine 1-3.
The creation of the intravenous regional block was followed by a similar technique, the intra-arterial regional block, initiated in Spain by Goyanes (1909) and in the United States by Ransohoff (1910) that preceded several techniques of regional block currently in use, what can partially explain the enormous interest that it has aroused in the beginning of the last century 1-3.
The experiments Bier practiced on himself and on his son, before creating the intravenous regional block, are impressive. Bier worked for three months with a tourniquet on one of his arms and, later, he tried the procedure on his 13-year old son; he studied on himself the effects of garroting an arm for several hours and, more unbelievably, on his own neck for an entire night to evaluate the possibility of preventing the local anesthetic from reaching the brain, which resulted in vertigo, headache, and edema and redness of the eyes for several hours 4.
As already described in other reports 1-3,13-15, the new anesthetic method, currently called regional intravenous block, in the beginning was done as follows 16-19: upper or lower limb exsanguination with an elastic bandage followed by placement of two tourniquets, one proximal, on the arm or thigh using Esmarch's bandage, and the other placed distally (10 to 30 cm from the first one) on the forearm or leg, which was not necessary when it was possible to administer the local anesthetic in a wrist or ankle vein; dissection of the vein on the antecubital fossa or the major saphenous vein at the level of the knee, as close as possible to the proximal tourniquet or, when accessible, any superficial vein in the forearm; introduction of a cannula in the distal direction and placement of the appropriate ligatures; injection of a certain volume of the anesthetic solution (0.5% procaine), according to the size of the limb, and removal of the distal tourniquet shortly after the installation of anesthesia. Bier described the sequence of events of the installation of insensitivity in two phases: an immediate phase, usually after 2 minutes, between the two tourniquets, calling it direct anesthesia, and a slower phase, in up to 20 minutes, beyond the distal tourniquet, which he called indirect anesthesia. To decrease the toxic effects of the local anesthetic, he recommended that, at the end of the surgery, the tourniquet should be loosened to allow the entrance of arterial blood in the area, exsanguination, and the consequent loss of the local anesthetic through the surgical wound, or by irrigation of the vascular bed with large amounts of NS.
The works Bier published in several journals revealed that he investigated most aspects of intravenous regional block, establishing several concepts 16-19; for example, he showed the importance of exsanguinating the limb in relation to the rate of installation and effectiveness of anesthesia, demonstrated that the region close to the tourniquet is never well-anesthetized, determined the order and time of disappearance and reappearance of thermal, pain, and tactile sensitivities, studied reactional hyperemia, described anesthetic failure and temporary muscle paralysis, proved that the duration of post-ischemic anesthesia does not change by modifying the concentration of procaine in the anesthetic solution, characterized the motor blockade, warned for the sensations patients felt when the local anesthetic was injected, undertook animal experiments and proved that the intravenous pressure can surpass that of garroting, and allowing the anesthetic to seep into the systemic circulation, discussed methods to counteract the pain caused by garroting by the subcutaneous infiltration of local anesthetic around the proximal border of the proximal tourniquet or, by suggestion of one of his students, by placing another tourniquet distally to the proximal tourniquet that should later be removed, investigated the mechanism and site of action of intravenous regional block, and proved, experimentally, that the intravenous administration of a solution of indigo carmine in the amputated limb spreads uniformly and dyes the cutaneous, muscular, bone, and nerve tissues and imagined that the same diffusion should happen with the local anesthetic, allowing the slow release of this agent into the general circulation. Therefore, most concepts established by Bier continue to be valid, some were changed, and others are still not completely understood 3,13,14,20.
Regarding the intravenous regional block, the enthusiasm of Bier seems to have been brief; after his initial studies, he did not publish any further material, probably due to the decreased interest on the subject secondary to the introduction of brachial plexus blockade, development of the spinal block, creation of the epidural blockade, lack of more appropriate equipment, and lack of knowledge about the scientific aspects of the method 1,3,21. Although several reports on the subject were published on the following years, none of them contributed for the development of the technique 1,3. Intravenous regional block was reborn in the decade of 1960 22 and the first 80 years of its introduction were celebrated with a publication in 1990 20.
Regional intravenous block was introduced in Brazil by Z. A. Amaral (1887-1962) in 1911, at the Santa Casa de Misericórdia de São Paulo, shortly after learning the technique in Germany 2,3,23.
Spinal block was introduced at the end of the XIX Century by August Bier, a few years after the introduction of topical (Köller) and local infiltrative (Schleich) anesthesia and peripheral nerve blocks (Halsted and Hall) 3,24.
On August 16, 1898, in order to perform a surgery to extract a tumor in one of the lower limbs of a young patient with tuberculosis, A. Bier, at that time a young surgeon, using a wide-caliber Quincke needle injected approximately 3 mL of 0.5% cocaine in the subarachnoid space, obtaining surprising results; this happened at the Royal Surgical Clinic of the University of Kiel (Germany) 3,4,25-29. The 100th anniversary of the spinal block was initially celebrated in 1985 25 and again in 1998 26,28 and, therefore, in 2008 we are celebrating its 110th anniversary.
Bier had been working with Heinrich Quincke at the University Hospital of Kiel since 1891, when the latter described the lumbar puncture technique to obtain spinal fluid for the diagnosis and treatment of neurologic disorders, similar to the work of W. E. Wynter at London's Middlex Hospital 30-32. This cooperation between Bier and Quincke had a great influence on the creation of the spinal block 4,31 that, paradoxically, only became a reality several years after the standardization of the lumbar tap; later, Bier recognized the importance of his work with Quincke 32.
Between August 16 and 24, 1898, Bier performed spinal block in some patients using 10-20 mg of cocaine for surgeries of the lower limbs 4,32. The first, and famous, report of Bier on the technique was published in 1899 33, a few months before those of Tuffier (Paris) and Matas (New Orleans) 4,25,32,34; Bier did not emphasize asepsis and anti-sepsis, but revealed he always diluted cocaine crystals in natural water, did not wear gloves, and covered the needle orifice with a finger to reduce as much as possible the loss of spinal fluid 32.
On August 24, 1898, Bier asked Hildebrandt, an assistant of von Esmarch, to perform a spinal block on him to investigate personally the effects of the technique, especially concerning headache, nausea and vomiting 28,30. Hildebrandt punctured Bier's subarachnoid space but could not attach the syringe completely to the needle, causing the loss of a large amount of fluid, cocaine, and, consequently, failure of the anesthesia 4,9,32. Bier made a new attempt on Hildebrandt, who had volunteered, and injected 5 mg of cocaine in his subarachnoid space 32. The anesthetic result was surprising; Hildebrandt felt the hotness but did not react when a lit cigarette was placed against his legs, when his pubic hairs were pulled or his testicles strongly pressed, or even when Bier hit the crest of one of his tibias with an iron hammer, and the anesthesia lasted for 45 minutes 4,32. Bier and Hildebrandt celebrated their discovery at 7:30 p.m. with a dinner, wine, and cigarettes 4,28,32. However, Bier developed a severe headache and dizziness, which only got better after he laid on; Hildebrandt developed vomiting. Both of them felt lousy for several days, which prevented them to work for over a week, and the wife of Dr. von Esmarch took care of Bier 4. Luckily, nothing more serious happened, although both procedures were done without asepsis or anti-sepsis 28,32.
The first spinal block in Latin America was performed in Rio de Janeiro by Paes Leme in 1898 at the Santa Casa de Misericórdia, shortly after his contact with Bier 24,28,9.
The implementation of the spinal block started in 1900 when Tuffier presented, at the V European Congress of Surgery, his work reporting the results achieved with 63 patients and adopting as reference an imaginary line that identifies the intervertebral space between L3 and L4, which is still known as Tuffier's line, and advised the participants that the local anesthetic should not be injected until they observed drops of spinal fluid 28-30,32.
From 1901 on, spinal block became an option to general anesthesia and, on that same year, several studies on the administration of cocaine in the subarachnoid space for several types of surgeries, including surgeries of the breasts and neck, were published 32,34. In view of the enthusiasm of French and Americans, Bier emphasized the risks of the new anesthetic technique and recommended that the spinal block should be interrupted until more animal studies were undertaken 32. Initially, there were several deaths and spinal anesthesia lost its importance for some time given that an adequate local anesthetic was not available at the time, high levels of blockade were obtained with the hypobaric solution used at the time, monitoring was through the symptoms of the patients, and intravenous access, vasopressor drugs, and oxygenation were not prevalent and, most importantly, there was a lack of experience with the method 4,29. Only after a few years Bier felt confident to recommend the use of the spinal block 32.
Between 1905 and 1907, after the introduction of procaine and the hyperbaric solution for spinal block by H. Braun and A. E. Barker, respectively, the technique began to develop but it would take several years until it became scientifically effective, safer, and widely used 29,34. Between 1945 and 1965, the fear of neurologic complications and medical liability, the incompatibility of spinal block with large size and long-duration surgeries, and the development of general anesthesia, reduced the use of this anesthetic technique; the recovery and development of the spinal block started after this period, especially with the introduction of modern local anesthetics and small-bore needles 34,35.
The priority of the introduction of subarachnoid block in surgeries has been the subject of many debates 17,25,29,31,32,34-36. Aristotle's thoughts fit perfectly well in this situation: "That who sees the growth of things from the beginning will see them in their most perfect form." It is not an easy task, original ideas are not always complete or provide a wide view of the problem, many times they are initially discredited, taken advantage of, and developed by third parties who are rewarded with the laurels of history, full of mistakes and injustice regarding clinical observations and the creation of medical procedures 25.
Initially, Hildebrandt himself tried to dispute the rights for the creation of the procedure 4, which caused and upheaval among physicians and lay people in Europe, including Germany, and in the United States 4. In 1906, Bier recommended to the illustrious plaintiff that he should not think of him in relation with the historical research of the spinal block 6. Wisely, Bier made Hildebrandt see the relative importance of the developers of great discoveries that came before them, since many of them did not have the necessary impact to be understood and, subsequently, were forgotten 6.
Tuffier also claimed the primacy for the discovery of the spinal block. Indeed, he always considered himself the inventor of the spinal block; he wrote 28 :"The spinal block, of which I consider myself the inventor, tested and soon abandoned by Bier, was the focus of my studies from 1899 to 1902." In reality, Tuffier had already injected cocaine in the subarachnoid space of a young man to alleviate the pain caused be a sarcoma of the leg because morphine was no longer effective; he stated that "the first results were remarkable." 32 Shortly after, he performed a similar procedure in a young woman with sarcoma of the thigh and, for his surprise, he was able to remove the tumor without causing any discomfort to the patient; he operated quickly, but noticed that there was no need to rush because analgesia lasted more than one hour 32. From 1901 on, Tuffier widened the applications of the spinal block to include surgeries of the perineum and even upper abdomen, recommended rigorous attention to asepsis and change in patient position shortly after the administration of the local anesthetic, and did not consider post-spinal block headache a serious complication and that the reason for it would be known in the future 32. However, this all happened after Bier's initial publication. By the details and concepts enounced by Tuffier, considered to be very important for the initial development of the spinal block, it has been thought of placing him side by side with Bier as a true participant of the introduction of the spinal block 28,31.
However, the greatest opponent of Bier has been the American neurologist James Leonard Corning, who has been credited, by some authors, usually without much conviction, as the creator of the spinal blockade. Corning was born in Stanford in 1855 and died in Morristown in 1923 25. Since, although reluctantly, Corning has been considered the pioneer by some authors, it is necessary to clear the matter to be sure of its veracity.
Until the end of the 19th Century, the idea that all drugs should be deposited as close as possible to the desired site of action was prevalent 32. Within this line of thinking, Corning was the first to inject cocaine inside or close to the spinal canal believing that it could reach the spinal cord and exert its neurologic actions 27,32.
Corning first experimented in a dog, injecting 2% cocaine (approximately 13 mg) 23,30,32,37 between the spinal processes of the last two dorsal vertebrae; the animal developed loss of sensitivity and lack of coordination in the hind limbs, but not in the anterior limbs, which lasted about two hours, and total regression occurred in four hours 25,30,32,37. Corning thought that, if the amount of the drug were greater, the anterior extremities could have been affected although, according to his thinking, it depended on the blood circulation in the area 27; he did not describe dripping of the spinal fluid, and it is possible that he did not realized what he had really done 25,37, since it is clear in his paper of 1885, the needle was introduced with the syringe connected to it 25,30,32,37. Considering the latency time and the small volume of anesthetic solution administered (less than one milliliter), it is believed that cocaine was partially or completely injected in the subarachnoid space 25,30.
In September 1885, Corning performed the same procedure in a man, in his office, without the objective of achieving surgical anesthesia 25,37. He considered that, from the inferior thoracic region down the transverse processes of the vertebrae are at the same depth of the lamina that forms the posterior limits of the vertebral canal 32. The needle was inserted between T11 and T12 directed initially towards the transverse process and, afterwards, introduced again in the midline and at the same depth and injected approximately 3 mL of 3% cocaine; since after 6 to 8 minutes he did not see any evident changes, he injected another dose apparently identical 24,27,30. Describing the results obtained, Corning stated that after 10 minutes his "legs fell asleep" and there was a reduction in cutaneous sensitivity which, after 10 to 20 minutes, reached the lower limbs, the lumbar region, and the genital area; he also suspected that the upper limbs were affected too 24,25,32,37. A urinary catheter was introduced without pain 25,37. Corning used in the man a dose approximately five times higher than that used in the dog and sent him home while he still experienced dizziness and some analgesia; traces of the blockade remained for several hours, besides dry mouth and pharynx, and headache 24,25,37. It is assumed that the results obtained were secondary to a possible epidural block 24,25,29,30.
In Corning's report it is not clear the size of the needle used or the site the drug was effectively injected, which, to this day, has not been clarified 25,32,37. A study relating the anatomical details of the spine and spinal canal with the description of Corning's punctures tried to demonstrate that, if the tip of the needle were superficial to the yellow ligament, the doses used (3 to 4 mL of 3% cocaine) would have no effect, and if it passed this ligament and reached the subarachnoid space, the results would be extraordinary 32.
In 1885, Corning wrote 37 that: "I thought it would be highly probable that, if the anesthetic were placed between the spinal processes of the vertebrae, it could be rapidly transported by the blood to the interior of the spinal cord, causing a blockade of the sensitive tracts and, maybe, of the motor tracts as well. To be more explicit, I hoped to produce an artificial state and physiological consequences analogous to those observed in transverse myelitis or total transection of the spinal cord. Consequently, I foresaw a greater or weaker action of the drug in the spinal cord 25,32.37." At the end of this report, Corning stated 25,32,37: "If it will be possible to use the method as a substitute to ether in genital-urinary surgeries or other branches of surgery only experience will tell. In this context, those observations seem to be worth recording." Some of those phrases have been incorrectly interpreted to give Corning credit for introducing the spinal block in surgery 32.
The medical knowledge of Corning was even unjustly criticized 25,30; however, he studied in good German universities and graduated in Würzburg (Germany), he was a member of the American Medical Association and of the New York Neurological Association, was part of the clinical staff of important hospitals in this city, and attended the demonstrations of Halstead and Hall on the use of cocaine to block peripheral nerves 25. Without a doubt, Corning was an active participant of the beginning of regional blocks and, just like Bier, also recognized his debt with Quincke 32. Besides the studies described so far, Corning undertook others after 1891 3,25,32,38,39; in 1894, he thought of using the lumbar tap technique to introduce a solution in direct contact with the cauda equina; he thought of injecting cocaine using a tourniquet to prolong the anesthesia, and Halstead considered himself to be the creator of this technique, but he inspired Braun to associate epinephrine to the local anesthetic to obtain what he called a chemical tourniquet 3; and he advised on the use of a guiding needle with a narrower needle inside to puncture the dura mater and arachnoid, a conduct we adopted in the decade of 1960 29,35. Corning introduced the expression spinal block and, for the terms conduction anesthesia or blockade, attributed to Braun and François-Frank, respectively 25, wrote that the idea of producing anesthesia by abolishing conduction in sensitive nerves, by the proper means, has been a common thought among progressionist physicians 25,30.
But why Corning did not develop his original proposition and why others did not do it immediately? This continues to be a mystery, and only several years later the idea would be rekindled by Bier who, as the discussion goes, would have, or not, knowledge of his studies 3,25. Therefore, it is strange that in 1894 when he introduced cocaine in the subarachnoid space, Corning did not realize that the case recorded in 1885 could have been an inadvertent spinal block and its importance; indeed, he reminds Humphrey Davy who, several decades before, noticed that the inhalation of nitrous oxide relieved a toothache but did not notice he could be discovering general anesthesia 32. According to Bier, that is what happened to Corning, who undoubtedly trailed the pathways of the spinal block 6. Corning never really thought of performing a real subarachnoid block, especially for surgeries, and, therefore, cannot be considered the creator of this technique 25,34, although his objective appears on the title of his 1885 work when he used the expression spinal anesthesia 37. The original work of Corning does not appear in any bibliography published until the beginning of the last century 25. But, after more than 100 years, his original idea that the spinal cord is one of the most important sites of action of local anesthetics seem remarkably close to the truth in regards to the epidural block 40. Anyhow, it should be recognized that he had a lot of courage and audacity to place, for the first time, such a toxic drug, like cocaine, in contact with the central nervous system. By making this decision, he became one of the precursors of those anesthetic techniques, and, therefore, we should also pay homage to him 25.
To conclude, several authors believe that A. K. G. Bier was, undoubtedly, the creator and the one who really introduced the use of the spinal block in surgeries 3,4,6,9,29,30,32. And it is also considered that the most exact report on the priority of August Bier regarding the discovery of the spinal block was published 50 years after his death 6,9.
CONTRIBUTIONS TO CULTURE, SPORTS, AND THE ENVIRONMENT
The works of Bier also included other areas of activity, fundamentally cultural, sports-related, and regarding the environment 2,4,6,41. Bier always demonstrated interest by Greek culture, philosophy, and especially the theories of Hippocrates. He defended the diffusion, practice and development of physical education and several sports, especially athleticism, swimming, navigation, and hunting, believing that physical exercises were a good prophylactic method against several disorders, and was a great defender of gymnastics for the population in general. He used to run and practice other physical activities once a week; based on those ideas he founded a sports academy in the city of Cologne where the German Sports Gymnasium has a commemorative plate 4.
August Bier was a pioneer on ecology 4. In 1912, he became a landowner in Sauen, near Berlin, that had a large farm house and most of it was covered by forest, and later he increased the size of his land. He loved horse back-ridding and every morning he walked barefoot to the city's lake to swim, regardless of the time of the year, and to hunt around Sauen. The dream of his youth was fulfilled and one of his great merits was his extreme dedication to environmental protection. With those objectives, he planted 750 hectares of different species of trees in Sauen, which he considered intricate living organisms, mixing conifers and large foliage plants, indigenous and exotic plants. He was against soil degradation by monocultures and his procedures increased the consistency, fertility, and water in the soil. All spaces were cultivated according to his own ideas and the forest became large, real, and inhabited by several deer and was home to several species of animals. To preserve the forest and keep the deer away, which he liked to hunt, he isolated the forest with protective fence. Bier supervised everything and all the funds from his international clientele were directed to the Sauen forest. He was a member of the German Dendrologic Society where he often explained his experiments and demonstrated his belief that the forest should be maintained intact for many years (two to three centuries). It is interesting to know that near the city of São Paulo and Rodovia dos Imigrantes there is a private project of 855 hectares, known as Sítio Curucutu Parque Ambiental, similar to Bier's, instituted be a lawyer, J. V. Roso, in the decade of 1960. Worried about what had been happening among us and with what he saw in Africa, he recuperated the Atlantic Forest partially by planting Pinus, mulberry trees, and Canadian Platanus, and, with 500,000 trees, he resuscitated or revitalized five water streams that run to the Billings Dam, which allowed the return of deer, tapir, monkeys of the genus Cebus, and other animals, and he did all this only with the support of a few friends and one Foundation without any government support 42.
Almost a century later, the Sauen forest, where currently 172 types of trees and hundreds of other types of plants grow, is the only of its kind in the world and a Mecca for silviculturists and ecologists who believe on the environmental benefits of this type of project 6. Its current biodiversity is enviable and it has a high-standard landscape and air quality. In many countries, mixed forests became the benchmark and the coverage of the soil with mature trees is mandatory 6.
In 1949, the Sauen forest became public property6 but Bier's son, Heinrich, continued his project. In 1963, the Silviculture Institute took control of the project and, in 1994, after the unification of Germany, its administration was handed over to the A. Bier Foundation presided by his grandson, also a physician, guaranteeing the continuation of his grandfather's ideas 6. Currently, the August Bier Ecological and Medical foundation (Sauen) manages the project initiated by the great physician and, therefore, his visionary ecological effort will continue and has been a fundamental example for the protection and prevention of the extinction of the world's forests 6.
HE LAST YEARS OF HIS LIFE
In 1932, Bier retired from medicine at the age of 71 years and his clinic was closed; the nurse who was more dedicated to him, Franziska Berthold, whose husband was killed in 1920 during the Kapp Putsch, committed suicide 4. During his last years of life, Bier dedicated himself to reading and writing, especially about the philosophy of Medicine at the time, correlating Hippocratic doctrine and other past doctrines, and also dedicated to Biology 3,7. Shortly after leaving medicine, Bier moved to Sauen to take closer care of the forest he had created, to study the European ecological problems, the conservation of forests and animal life, and to undertake tests of plant mutation, convinced of the close relationship between medicine and forests, and genetics and the environment 4. The last phrase written by Bier in 1949, shortly before his death, synthesizes what he thought about this project 6: "The Sauen Forest cannot be described, it should be seen."
Bier had certain empathy for some aspects of the "New Order" of the Hitler's Third Reich; order, discipline, training of youngsters, support for sports, and biomedicine; however, in 1934, his wife was detained by Himmler's Gestapo due to a casual encounter with an old school friend 4. During World War II, Bier, who at that time was almost blind and had lost his property in Sauen, was taken to a nursing home near Beeskow, close to a Soviet camp; there, he was under the protection of a Russian Surgeon who had worked with him 4. He escaped in an ambulance to Thüringen, which, at that time, was a center of secret arms development, and brought back to Sauen in 1945, and continued to be under the protection of Russian physicians 4.
Bier died in his property in Sauen, in East Germany, shortly before his 88th birthday due to a case of flu followed by pneumonia on March 12, 1949, and was buried in this city; his wife had died in 1947 2-4. Unfortunately, Bier did not have the opportunity to see the notable development and great diffusion that intravenous regional block and spinal blockade had in the last years, as well as the importance of his ideas on the care of forests and the environment achieved lately.
Bier was a famous physician, but there are some people who think that the impact of his forest project will someday surpass his fame as a physician due to the environmental success he foresaw and created 6. The Sauen Forest was a remarkable part of his life and a great legacy he left and its importance continues to grow.
NATIONAL AND INTERNATIONAL RECOGNITION
August Bier was honored, national and internationally, countless times, both in life and after his death 3,4,6,7,26,431. As "First Surgeon" of the German Empire he was famous, renown, and awarded several times by Emperor Wilhelm, having received from him the title "Geheimrat", and appointed Private Counselor. He was an Honorary Member of several Medical Societies, such as those in Germany (Berlin and Munich) and Austria (Vienna). In 1905, he became an honorary member of the Scottish Association of Surgeons and Honorary Doctor in Juridical Sciences of the University of Edinburgh, where he received the prestigious Cameron Prize for the treatment of tuberculosis with hyperemia. In 1913, he became chief of a rehabilitation service for wounded individuals, for which he was once again honored by Emperor Wilhelm. In 1931, the same Emperor awarded him the Hohenzollern Royal House Medal, and contemplated with a special edition of the Deutsche Zeitschrift für Chirurgie dedicated to him. In the same year, in his 70th birthday, Bier received several honors from national and international medical societies. In 1936, when he celebrated his 75th birthday, Bier received from Adolph Hitler the highest distinction of the German Empire. In 1937, along with the famous Ferdinand Sauerbruch, was awarded the National Award for Art and Science in Nuremberg, the German alternative for the Nobel Prize, having been awarded 100,000 RM. After World War II his house in Sauen was abandoned but a bronze plate was placed in its frontal wall with the inscription: "Here lived the famous surgeon, August Bier, from 1912 to 1949." In 1941, Karl Vogeler dedicated a book to Bier (August Bier, Life and Work), which became controversial in some aspects due to the historical changes that occurred in Germany after World War II. In 1987, a special stamp was printed in his honor.
The Life and Work of August Bier were mentioned briefly in several national and foreign publications 1-3,15,20,25,26,28,32,36, but they were more detailed in three special occasions: by Israel, at the time of his death in 1949 7; in the 50th anniversary of his death, by A. Van Zundert and M. Goering 4, whose publication contains several interesting pictures of him performing spinal block or delivering speeches, with his wife or Sauerbruch, of German military, and other important individuals; and, finally, at the time of the 50th International Symposium on the History of Anesthesia by J. Ruprecht and C. A. Baldamus 6, emphasizing his role as a great defender of the environment.
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Submitted em 10
de dezembro de 2007 *
Received from Hospital Alemão Oswaldo Cruz, São Paulo, SP
Accepted para publicação em 07 de abril de 2008
Submitted em 10
de dezembro de 2007
* Received from Hospital Alemão Oswaldo Cruz, São Paulo, SP