Overcoming Obstacles: The Legacy of Fidel Pagés, Founder of the Epidural, 100 Years After His Passing.

Fidel Pagés, a Spanish surgeon, tragically died in 1923 at the age of 37, just 2 years after his publication "Anestesia Metamérica," the first description of human thoracolumbar epidural anesthesia. In the intervening 100 years, epidural anesthesia has faced countless obstacles, starting with the dissemination of his initial report, which was not widely read nor appreciated at the time. However, the merits of the technique have fueled innovations to meet these challenges over the years. Even today, while epidural anesthesia is widely embraced, particularly in obstetric and chronic pain medicine, the pressures of the operating room for efficiency and a low tolerance for failure, pose modern-day challenges. Here, we revisit Pagés' original report and highlight the key innovations that have allowed for the evolution of this essential anesthesia technique.

Génesis y evolución de la anestesia epidural lumbar en su primer centenario / Genesis and evolution of lumbar epidural anesthesia in its first century

Introducción: La anestesia epidural lumbar es la técnica predilecta para gran número de anestesiólogos. Permite variadas intervenciones quirúrgicas, es útil para el tratamiento del dolor agudo y crónico, a la vez provee al paciente de distintos beneficios. También resalta su versatilidad ya que puede combinarse con otros métodos anestésicos, así como extenderla para el alivio del dolor posoperatorio. Objetivo: Describir los adelantos científicos que propiciaron la aparición de la anestesia epidural lumbar y cuál ha sido la evolución de esta técnica anestésica a lo largo de un siglo. Desarrollo: El acceso por vía lumbar al espacio epidural con fines anestésicos fue publicado por el cirujano español Fidel Pagés en marzo de 1921, luego de una década en el olvido fue introducida por el cirujano italiano Archile Dogliotti en 1931. A partir de entonces, se le han incorporado diversos y valiosos adelantos. Conclusiones: La anestesia epidural lumbar fue descrita hace un siglo por el doctor Pagés. Han sido variados y numerosos los aportes que han recibido, algunos de los cuales han sido objeto de controversias; no obstante, se ha tornado una técnica universal que sigue captando la preferencia de muchos anestesiólogos(AU)

Introduction: Lumbar epidural anesthesia is the technique preferred by a great number of anesthesiologists. It allows performing several surgical interventions and is useful for the treatment of acute and chronic pain; at the same time, it provides the patient with different benefits. It ls also worth highlighting its versatility, since it can be combined with other anesthetic methods, as well as to be extended for postoperative pain relief. Objective: To describe the scientific advances that led to the appearance of lumbar epidural anesthesia and what has been the evolution of this anesthetic technique over a century. Development: the Spanish surgeon Fidel Pagés published lumbar access to the epidural space for anesthetic purposes in March 1921. After a decade in oblivion, the Italian surgeon Archile Dogliotti introduced it, in 1931. From then on, it has been incorporated several valuable advances. Conclusions: Dr. Pagés described lumbar epidural anesthesia a century ago. The contributions achieved have been varied and numerous, some of which have been the subject of controversy; however, it has become a universal technique that continues to capture the preference of many anesthesiologists(AU)

Fidel Pagés Miravé en el centenario de su publicación de 1921. Historia de la anestesia epidural / Fidel Pagés Miravé one hundred years after its publication in 1921. The history of epidural anaesthesia

Sicard y Cathelin en 1901, introducen de manera simultánea la administración sacra de fármacos. En 1919, Läwen fue un gran defensor de la anestesia regional. Gil-Vernet en 1917 describe los fundamentos anatómicos de la técnica de abordaje sacro al espacio epidural. Fidel Pagés Miravé es el verdadero introductor de la anestesia epidural. Su artículo publicado en 1921, Anestesia Metamérica, en la Revista Española de Cirugía, constituye un hito en la historia de la anestesia. Diez años más tarde Dogliotti publica sus resultados, sin citar la aportación de Pagés. La gran mayoría de los historiadores citan a Dogliotti en la bibliografía, ignorando a Pagés. Gutiérrez un cirujano argentino alertó del error histórico y revindicó la aportación original de Pagés. En la actualidad todos los libros de historia de la anestesia reseñan la publicación de Pagés. El anestesiólogo cubano Manuel Martínez Curbelo, introduce en la clínica la anestesia epidural continua. En esta publicación revisamos la historia del abordaje sacro, torácico y lumbar del espacio epidural. Describimos las distintas agujas y catéteres utilizados. En la práctica diaria anestésica la analgesia/anestesia epidural se utiliza en cirugía, analgesia del trabajo del parto, tratamiento del dolor agudo y crónico. (AU)

Sicard and Cathelin in 1901 introduced independently the sacral injection of drugs. In 1910 Läwen was an enthusiastic defender of regional anaesthesia. Gil-Vernet in 1917 introduced new anatomical concepts in epidural sacral approach. Fidel Pagés Mirave was true pioneer of epidural anaesthesia. His publication in 1921, Metameric Anaesthesia, in the Spanish Journal of Surgery is a landmark in the history of world anaesthesia. Ten years later Dogliotti published his experiences with epidural anaesthesia, without anyreference to Pagés’ research. Most medical historians date the regular use of epidural anaesthesia from Dogliotti’s paper, published ten years later, and ignoring Pagés research. Gutierrez a surgeon born in Argentina, recognized the error and promoted the original scientific publication of Pages. Today all the important books of anaesthesia reference the first discoverer of epidural anaesthesia. The Cuban anaesthesiologist Manuel Martinez Curbelo, introduced into clinical practice continuous epidural anaesthesia. In this article we review the history of sacral and thoracic and lumbar approach to the epidural space, its different needles and catheters used in these techniques. Epidural analgesia/ anaesthesia are commonly used in daily practice in surgery, labour pain, and in the treatment of acute and chronic pain. (AU)

The Historical Development of Obstetric Anesthesia and Its Contributions to Perinatology.

Scottish obstetrician James Young Simpson first introduced the use of ether and chloroform anesthesia for labor in 1847, just 1 year after William Morton's first successful public demonstration of ether anesthesia at the Massachusetts General Hospital. The contemporaneous development of surgical anesthesia and obstetrics enabled obstetric anesthesia to address the pain of childbirth. Shortly after its introduction, obstetricians raised concerns regarding placental transport, or the idea that drugs not only crossed the placenta, but exerted detrimental effects on the neonate. The development of regional anesthesia and clinical work in obstetric anesthesia and perinatology addressed issues of the safety of the neonate, enabling obstetric anesthesia to safely and dramatically reduce the pain of childbirth.

Ryszard Rodzinski-A Forgotten Polish Inventor and Pioneer of Combined Spinal-Epidural Anesthesia.

Dr. Ryszard Rodzinski was a Polish surgeon who, in spite of his short life, had a productive career. His most important discovery was a safer method of performing regional anesthesia for abdominal surgery. The first description of combined spinal epidural anesthesia is generally attributed to Soresi in 1937. In the early 20th century, Rodzinski invented a novel technique, "combined lumbosacral anesthesia," which combined lumbar spinal anesthesia and sacral epidural anesthesia. During the 19th Meeting of Polish Surgeons in July 1922 in Warsaw, Rodzinski presented an article entitled "On Combined Lumbosacral Anaesthesia," in which he described this technique used in surgical clinic in Lwów since October 1921. Given this presentation, Rodzinski could be considered to have made the first known presentation of the combined spinal and epidural anesthesia.

A personal history of the MASTER Trial and its link to the clinical trials network of the Australian and New Zealand College of Anaesthetists.

The aim of this paper is to link the history of the Multicentre Australian Study of Epidural Anaesthesia in high risk surgery, the MASTER Trial, the first National Health and Medical Research Council (NHMRC) funded multicentre randomised clinical trial in Australia led by anaesthetist researchers, and the decision of The Australian and New Zealand College of Anaesthetists (ANZCA) to establish a clinical trials network, in 2003, to the success of contemporary researchers in Australia and New Zealand in anaesthesia and perioperative medicine.

[History and Technique of Epidural Anaesthesia]. / Epiduralanästhesie - Geschichte und Technik der Epiduralanästhesie.

In 1901, the first Epidural anesthesia via a caudal approach was independently described by two FrenchmanJean-Anthanase Sicard and Fernand Cathelin.. The Spanish military surgeon, Fidel Pagés Miravé, completed the lumbar approach successfully in 1921. The two possibilities for identification of the epidural space the "loss of resistance" technique and the technique of the "hanging drop" were developed by Achille Mario Dogliotti, an Italian, and Alberto Gutierrez, an Argentinean physician, at the same time. In 1956 John J. Bonica published the paramedian approach to the epidural space. As early as 1931 Eugene Aburel, a Romanian obstetrician, injected local anaesthetics via a silk catheter to perform lumbar obstetric Epidural analgesia. In 1949 the first successful continuous lumbar Epidural anaesthesia was reported by Manuel Martinez Curbelo, a Cuban. Epidural anaesthesia can be performed in sitting or lateral position in all segments of the spinal column via the median or paramedian approach. Different off-axis angles pose the challenge in learning the technique.

Epidural catheter design: history, innovations, and clinical implications.

Epidural catheters have evolved during the past several decades, as clinicians and manufacturers have sought to influence the quality of analgesia and anesthesia and reduce the incidence of catheter-related complications. This evolution has allowed a transformation from single-shot to continuous-infusion techniques and resulted in easier passage into the epidural space, more extensive medication distribution, and ultimately, improved patient satisfaction. Particular catheter features, including the materials used, tip design, and orifice number and arrangement, have been associated with specific outcomes and provide direction for future development.

From the Journal archives: Epidural anesthesia in young children: what have we learned in the past 60 years?

UNLABELLED: Francis G. Ruston MD CITATION: Ruston FG. Epidural anaesthesia in infants and children. Can Anaesth Soc J 1954: 1: 37-44. PURPOSE: The author describes the use of single-shot epidural anesthesia in a series of 44 infants and children. The patients were anesthetized in hospitals in Hamilton, Ontario from 1949 until the time of publication in 1954. The study aimed to describe the indications and efficacy of this technique as well as any apparent complications. A detailed description of the management of these patients was given, including many tips and suggestions that are still applicable in 2013. PRINCIPAL FINDINGS: Seventy-seven infants and children received epidural anesthesia for a variety of procedures, particularly for pyloric stenosis. Forty-four of the procedures were carried out by the author. All patients survived, apart from one child who died of recurrent intestinal obstruction unrelated to the anesthetic. It was found, after some experience, that the sitting position was preferable for epidural needle insertion. Use of the hanging drop technique for identification of the epidural space proved to be simple and reliable. Surgical conditions were found to be excellent and relaxation was profound; however, some sedation was often required to obtain optimal conditions for surgery. The surgeons became sold on the technique and began to request an epidural on a regular basis. CONCLUSIONS: Epidural anesthesia in infants and young children is effective for a variety of procedures below the diaphragm, even in moribund patients.

Aproximación a la obra científica del Comandante médico Fidel Pagés Miravé / Approach to the scientific work of medical Commander Fidel Pagés Miravé

A. Faulconer en su libro «Foundations of Anesthesiology» refiriéndose a Pagés afirma: «No se encuentran apenas datos sobre la vida de este importante cirujano español». Esta concluyente afirmación unida a imperdonables omisiones de la figura de Pagés por historiógrafos de la anestesia o de la cirugía, y a graves errores en datos sobre su vida u obra, nos movió a realizar una aproximación, lo más exacta posible, a la obra científica del Comandante Médico Fidel Pagés Miravé. Escasas han sido las figuras españolas que hayan aportado alguna interesante novedad al mundo de la anestesia. Pero ninguna tan injustamente tratada y olvidada como la de Pagés, verdadero pionero de la anestesia epidural, que él denominaría Anestesia Metamérica en su artículo publicado en el mes de marzo de 1921 en la Revista Española de Cirugía, por él fundada. Años después, en 1931, Dogliotti, Profesor de Cirugía de Modena publicó sus experiencias sobre la anestesia epidural, a la que llamó Anestesia Peridural Segmentaria, ignorando el trabajo de Pagés publicado diez años antes. El trabajo de Dogliotti fue rápidamente reconocido, asumiendo todos los méritos de la paternidad de la técnica epidural, quedando Pagés relegado a un olvido injusto que con este trabajo tratamos de reparar. En la necesidad de ubicar a Pagés en el entorno en el que desarrolló su obra científica, tratamos de realizar una visión de las principales aportaciones quirúrgicas y anestésicas de aquellos cirujanos que fueron coetáneos con nuestro personaje. Con especial abundamiento, profundizamos en los precedentes históricos de las técnicas de anestesia intradural o caudal, así como las descripciones posteriores a Pagés sobre el abordaje lumbar de la vía epidural. A su vez realizamos un análisis comparativo del trabajo de Pagés sobre la anestesia metamérica, en relación con la actual vigencia que puedan tener sus observaciones, descripciones, indicaciones y contraindicaciones. La idea central del trabajo versará sobre el reconocimiento de Pagés como verdadero promotor del abordaje epidural con fines quirúrgicos. Así como valorar una obra que, aunque corta, bien pudiera incluirse entre los mejores cirujanos españoles de principio de siglo. Nos centramos, para la recopilación de datos, en sus expedientes académicos (Zaragoza y Madrid), en su hoja de servicios como Médico Militar y en las publicaciones sobre Historia de la Anestesia, Historia de la Cirugía y de la Sanidad Militar. Para mejor conocer al Personaje hemos localizado a su familia y revisamos los diarios oficiales del Ministerio de la Guerra las colecciones completas de la principal prensa de la época, especialmente las de Madrid y Melilla (AU)

A. Faulconer in his book «Foundations of Anesthesiology», referring to Pagés says: «There are little data on the life of this important Spanish surgeon». This conclusive statement attached to unforgivable omissions to the figure of Pagés by historians of anesthesia or surgery, and to serious errors in facts about his life or work, led us to make an approximation as accurate as possible, to the scientific work of the Medical commander Fidel Pagés Miravé. Few figures have been the Spanish who have made some interesting news to the world of anesthesia. But none so wronged and forgotten like Pagés, a true pioneer of epidural anesthesia, that he would call Metameric Anesthesia in his article published in the month of March, 1921, in the Spanish Journal of Surgery, founded by him. Years later, in 1931, Dogliotti, Professor of Surgery in Modena published his experiences on the epidural, which he called Segmental Epidural Anesthesia, ignoring the work published ten years earlier by Pagés. Dogliotti’s work was quickly recognized, assuming all the merits of the paternity of the epidural technique, being Pagés relegated to an unfair oblivion that this work is trying to repair. Feeling the need to locate Pagés on the environment in which he developed his scientific work, we try to realize a vision of the main surgical and anesthetic contributions of surgeons who were contemporaries with Pagés. With special sake, we delve into the historical precedents of spinal or caudal anesthesia techniques, as well as Pagés later descriptions on the lumbar approach of the epidural route. At the same time, we conducted a comparative analysis of the work of Pagés on metameric anesthesia in relation to the current force that may have their comments, descriptions, indications and contraindications. The central idea of the work will focus on the recognition of Pagés as a true promoter of the epidural approach with surgical aims. And to evaluate a work which, though short, may well be included among the best spanish surgeons in the beginning of the century. We focus for the collection of data on their records (Zaragoza and Madrid), on his records as a military doctor and on publications about the History of Anesthesia, history of Surgery and of the Military Health. To better know his character we have located his family and review the official journals of the Ministry of War, the complete collections of the main newspapers of the time, especially in Madrid and Melilla (AU)

Analgesia del parto: ¿qué más podemos hacer? / Is epidural the optimal technique for labor analgesia?

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The historical narrative: tales of professionalism?

The historical narrative is a story told to illustrate a point, however subconsciously. The "giants" of obstetric anesthesia -- Simpson, Snow, Apgar -- and countless other less well-known physicians all contributed to the history of obstetric anesthesia. We remember them by retelling this history to illustrate elements of professionalism and how we as a profession wish to act. The Physician Charter is an excellent first approximation of a workable definition of this quality, which can and does change over time. By using the three principles and 10 professional responsibilities as a template, the past comes alive as a teaching method to each and every obstetric anesthesiologist.

[History of rachianesthesia and epidural anesthesia in Spain]. / Historia de la raquianestesia y de la anestesia epidural en España.

OBJECTIVES: To show the beginning of spinal and epidural anesthesia in our country and the contributions of Spanish urologists. METHODS: We reviewed books and writings of History of Medicine, Urology and Anesthesia and Doctoral thesis about spinal and epidural anesthesia. RESULTS: In the 20th century, surgeons also gave the anesthetic drugs to the patients. Spinal and epidural anesthesia were used for the first time in 1900. A lot of Spanish urologists like F Rusca Doménech, J.M. Batrina, M. Barragán Bonet, R. Lozano Monzón, L. Guedea Calvo, Gil Vernet, Fidel Pagés Miravé, V Sagarra Lascurain, Gómez Ulla, etc, did research, writings in scientific journals and Doctoral thesis about anesthesia.

La Anestesia epidural continua por via lumbar: antecedentes y descubrimiento / The epidural continues for lumbar via: background and discovery

Se presenta la historia de la anestesia peridural y la contribución del anestesiólogo cubano Dr Pío Manuel Martínez Curbelo. Informar a las jóvenes generaciones de anestesiólogos sobre la historia de la anestesia epidural continua, así como los detalles de su autor. Se realizó una revisión exhaustiva de la literatura sobre el tema, así como entrevistas a personalidades de la anestesiología Mundial, para reconstruir esta historia apasionante. Se exponen los resultados de la búsqueda realizada. El conocimiento exhaustivo de la historia, constituye un hecho importante que ningún ciudadano debe olvidar(AU

Historia de la raquianestesia y de la anestesia epidural en España / History of rachianesthesia and epidural anesthesia in Spain

Objetivo: Conocer como se desarrollaron en nuestro país las técnicas de la raquianestesia y la anestesia epidural, y cuales fueron las aportaciones de los urólogos españoles. Métodos: Hemos revisado los libros de Historia de la Medicina, de la Urología y de Anestesia, las publicaciones periódicas y las Tesis Doctorales que sobre este tema se realizaron en la época. Resultados: En buena parte del siglo XX aquellos que se dedicaban a la cirugía administraban también la anestesia. Es a partir del año 1900 cuando comienzan a desarrollarse la raquianestesia y la anestesia epidural siendo numerosas y fundamentales las aportaciones de los urólogos españoles como F. Rusca Doménech, J.M. Batrina, M. Barragán Bonet, R. Lozano Monzón, L. Guedea Calvo, Gil Vernet, Fidel Pagés Miravé, V. Sagarra Lascuraín, Gómez Ulla, etc. realizando publicaciones en revistas de prestigio, comunicaciones en congresos y tesis doctorales sobre la anestesia raquídea y epidural (AU)

Objectives: To show the beginning of spinal and epidural anesthesia in our country and the contributions of Spanish urologists. Methods: We reviewed books and writings of History of Medicine, Urology and Anesthesia and Doctoral thesis about spinal and epidural anesthesia. Results: In the 20th century, surgeons also gave the anesthetic drugs to the patients. Spinal and epidural anesthesia were used for the first time in 1900. A lot of Spanish urologists like F. Rusca Doménech, J.M. Batrina, M. Barragán Bonet, R. Lozano Monzón, L. Guedea Calvo, Gil Vernet, Fidel Pagés Miravé, V. Sagarra Lascuraín, Gómez Ulla, etc, did research, writings in scientific journals and Doctoral thesis about anesthesia (AU)