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Centenary of epidural anaesthesia
Centenario de la anestesia epidural
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López Álvarez, P. Casas Reza, S. del Río Fernández" "autores" => array:3 [ 0 => array:3 [ "nombre" => "S." "apellidos" => "López Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "P." "apellidos" => "Casas Reza" "email" => array:1 [ 0 => "pablocasasreza@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "S." 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However, obtaining the true story is an uphill battle. Written history is not always right, because in medicine there are no absolute truths.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the case of the history of anaesthesia, the discipline has its roots in the dark ages of priests and sorcerers, passing through the age of classical philosophers to reach the modern day. All these pioneers should be considered our benefactors, because their discoveries have improved the lives of people around the world.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Throughout history, human beings have always devoted time and effort to alleviate suffering. Surgery was for a long time synonymous with pain, infection and bleeding, and little progress was made until the discovery of anaesthesia, antiseptic methods and haemostasis. The history of medicine is fascinating, and as we study it we realize that some scientists, despite making transcendental discoveries, have been unfairly treated by historians and biographers. Some have even been long forgotten. One such scientist is Fidel Pagés Miravé (1886–1923), the inventor of epidural anaesthesia, who has been side-lined by history for reasons we can only guess - maybe because of his death at an early age, because his studies were only published in Spain, or due to the French and German contempt of Spanish medicine at that time.</p><p id="par0020" class="elsevierStylePara elsevierViewall">There are few detailed studies on his work, and what information is available contains certain errors or omissions. This is particularly distressing in the light of his remarkable contribution to pain relief, a constant concern in all civilizations. The fact that his scientific and medical work has been ignored by a large number of historians is plain to see<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. It is striking to note that the <span class="elsevierStyleItalic">Tratado de la Historia de la Medicina Universal</span> makes no mention of Pagés Miravé, and that Faulconer and Keys<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in <span class="elsevierStyleItalic">Foundations of anesthesiology</span> claim that: “Not much can be found about the life of this important Spanish surgeon<span class="elsevierStyleItalic">"</span>. Nevertheless, many attempts have been made in recent years to acknowledge the value of his scientific work both in the field of surgery and anaesthesia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">"Anaesthesia", as we all know, derives from the Greek prefix <span class="elsevierStyleItalic">“An”</span> which means "without" and <span class="elsevierStyleItalic">Aesthesis</span> which means sensation. This term appears for the first time in Plato’s <span class="elsevierStyleItalic">Timaeus</span> to describe a general or partial loss of sensation. But anaesthesia acquired its true meaning in the letter sent by Oliver Wendel Holmes, dean of Harvard, to Thomas Morton on 21 November 1846, following his public demonstration of general anaesthesia (16 October 1846) at the Massachusetts General Hospital, in which he dubbed the technique <span class="elsevierStyleItalic">"anaesthesia"</span><a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>. This date is historically considered the "first general anaesthesia", and this that is why we celebrate World Anaesthesia Day on 21 November every year.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is hard to pinpoint the real birth of anaesthesia, because man has always tried to mitigate pain. It took years of trial and error, curiosities and anecdotes until the first anaesthetic agents were discovered. The path from alchemy to chemistry was full of twists and turns, and it was not until the 19th century that modern anaesthesia was born when Morton performed the first public demonstration of general anaesthesia. Morton’s achievement should not be discredited, but that demonstration would never have been possible without Wells and Jackson's discoveries and experiments. Morton got the idea of using gas from a medical school chemistry professor, Charles T. Jackson, who had undoubtedly known about Wells's experiments since 1845. Accused of plagiarism by Wells and Jackson, Morton, despite his resounding success, was disowned by his friends and died in oblivion, ignominy and poverty at the age of 49 in New York.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Perhaps Orwell was right when he said "history is written by the victors", or may even by phonies or profiteers. Historians need to scrutinise the past to set the record straight. Therefore, we would like to take the opportunity to do just that, and draw attention to the pioneering work of Fidel Pagés, the inventor of epidural anaesthesia, on the centenary of the publication of his <span class="elsevierStyleItalic">Metameric</span> anaesthesia <a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">The significance of the discovery of epidural anaesthesia</span><p id="par0040" class="elsevierStylePara elsevierViewall">Since it was first described, epidural anaesthesia has been considered highly effective and is widely used in anaesthesiology for anaesthesia, postoperative analgesia, and more recently, labour analgesia. Initially, the local anaesthetic was usually administered medially in the lumbar region. Since the 1950s, its use extended to the thorax, following publication of the results of the first 100 thoracic epidural anaesthesias performed for thoracic surgery in the <span class="elsevierStyleItalic">Missouri State Tuberculosis Sanatorium</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. Shortly thereafter, John Bonica<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> described his experience with a paramedial approach in more than 1000 patients with sharply angled spinous processes that made the medial technique more difficult.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Continuous epidural analgesia techniques were developed in the 1940s following the introduction of the Tuhoy needle and the possibility of inserting more suitable, functional epidural catheters that allowed continuous analgesia. Despite its ups and downs, this technique provided the best analgesia after open surgery, and was therefore increasingly used in the postoperative period. It was also shown to significantly reduce dynamic pain and reflex ileus in major abdominal surgery, and is the most widely indicated technique in thoracotomy (together with paravertebral block, its unilateral "counterpart")<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In obstetrics, it was not until the 1990s, following growing social demand and a series of studies evaluating its safety and efficacy, that epidural analgesia became the core analgesia technique. Its importance in this field is such that the dosage regimens and drugs used have been perfected to allow clinicians to individualize the analgesic needs of their patients at the different stages of delivery<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Today, postoperative epidural analgesia is still considered the gold standard for pain management in multiple open surgeries, and continues to play a central role in labour and delivery. However, following the introduction of increasingly less invasive surgical techniques (laparoscopic and robotic surgery) included in ERAS intensified recovery programmes, not to mention the major advances made in ultrasound-guided nerve blocks that reduce the risk of side effects, epidural anaesthesia is gradually losing its pre-eminence in the arsenal of analgesia tools.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Who was Fidel Pagés Miravé?</span><p id="par0060" class="elsevierStylePara elsevierViewall">Fidel Pagés Miravé was born on 26 January 1886 into a wealthy family in Huesca, Spain. He was educated in his city of birth during the period when Spain lost its last overseas colonies (disaster of ‘98), and completed his secondary education in June 1901. That same year, he enrolled in the Faculty of Medicine of the University of Zaragoza, and obtained his degree 7 years later, in 1908. He passed the Military Health Corps competitive exam, being ranked 3 that year, and was assigned to the Military Hospital of Carabanchel.</p><p id="par0065" class="elsevierStylePara elsevierViewall">He was posted to Melilla during the unrest in North Africa, but after the conflict returned to Tarragona in August 1911. He then worked in Toledo, Madrid, Ciudad Real, Mahón and Alicante before obtaining a permanent job at the Madrid Provincial Hospital in 1914. In 1915, he was appointed <span class="elsevierStyleItalic">cirujano de la beneficencia</span> [charity surgeon] at the General Hospital of Madrid. His popularity as a surgeon steadily increased, and he became the personal doctor and friend of Queen María Cristina.</p><p id="par0070" class="elsevierStylePara elsevierViewall">He was fluent in French and spoke good German, possibly due to his German father in law. In 1917 he was sent to Vienna as the Spanish Ambassador’s delegate to inspect the prison camps of the First World War, and worked as a surgeon at the Military Hospital in Vienna. Between 11 April and 8 September of that year he performed a great number of surgeries, and returned to Spain with extensive experience in treating war-wounded and multiple trauma patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In 1918, he became the editor in chief of the <span class="elsevierStyleItalic">Revista de Sanidad Militar</span>, and in 1919, together with Ramírez de la Mata, he started the <span class="elsevierStyleItalic">Revista Española de Cirugía</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). He published an article in the journal that same year, but mainly commented on anaesthesia-related articles. He was extremely interested in anaesthesia, and published comments on articles written by various authors, such as <span class="elsevierStyleItalic">La anestesia raquidiana alta y baja por la novocaína como procedimiento de anestesia general</span> [High and low spinal anaesthesia with novocaine for general anaesthesia], <span class="elsevierStyleItalic">Inconvenientes reales y contraindicaciones de la anestesia medular</span> [Real drawbacks and contraindications of spinal anaesthesia], <span class="elsevierStyleItalic">Toxicidad de los anestésicos locales más usados, como: novocaína, cocaína, apilina, estovaina, querocaína, amethocaína y athoxicaína</span> [Toxicity of the most widely used local anesthetics, such as: novocaine, cocaine, apiline, stovain, kerocaine, amethocaine and athoxicaine], <span class="elsevierStyleItalic">Anestesia en cirugía de guerra</span> [Anaesthesia in conflict-related surgery], <span class="elsevierStyleItalic">Valor actual de la anestesia raquídea por la novocaína,</span> [Current use of novocaine in spinal anaesthesia], <span class="elsevierStyleItalic">La raquianestesia con novocaína por vía lumbar</span> [Lumbar spine anaesthesia with novocaine], and <span class="elsevierStyleItalic">La raquianestesia general</span> [General spinal anaesthesia].</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">His first article – <span class="elsevierStyleItalic">La lucha en campaña contra de las enfermedades infecciosas</span> [<span class="elsevierStyleItalic">The fight against infectious diseases</span>] – was published in the <span class="elsevierStyleItalic">Revista de Sanidad Militar</span> in August 1912<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>, and was followed by many more, some detailing his experience in treating war wounded patients in the Rif War and the First World War. His growing prestige resulted in a university lectureship, teaching postoperative care, first aid, material preparation and sterilization practices, and local and general anaesthesia. However, his most important achievement came in March 1921 with the publication of <span class="elsevierStyleItalic">Metameric</span> anaesthesia<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in the <span class="elsevierStyleItalic">Revista Española de Cirugía</span>. In this, his most important article, he describes that we know today as epidural anaesthesia, the anatomical bases of the technique, its practical applications, and the characteristics of analgesia and motor paralysis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The same article was reprinted in the <span class="elsevierStyleItalic">Revista de Sanidad Militar</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> that same year, and again, with comments, in 1955 in the journal <span class="elsevierStyleItalic">Hypnos</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> of the Association of Anaesthesiologists of Barcelona.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Pagés, with his command of languages, was no doubt familiar with earlier studies describing the encouraging results obtained after administering local anaesthetic through the sacral hiatus. He chose the name <span class="elsevierStyleItalic">metamérica</span> [metameric] due to <span class="elsevierStyleItalic">"the possibility it gives of depriving a segment of the body of sensitivity without affecting the portions that are above and below the medullary segment from which the blocked roots arise"</span>.</p><p id="par0090" class="elsevierStylePara elsevierViewall">However, this lumbar epidural anaesthesia technique only received worldwide attention in 1931, when Dogliotti (1897–1966), professor of surgery at Modena University, published “<span class="elsevierStyleItalic">Segmental peridural spinal anaesthesia</span>”<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> in an American journal, without even mentioning Pagés's work published 10 years earlier. Dogliotti also spoke about his work at various conferences. In the 9th Conference of the International Society of Surgery held in 1932 Madrid, he presented a communication on the subject in which he also failed to mention Pagés. This was apparently due to ignorance, but Dogliotti could also have been attempting to go down in history as the pioneer of this technique, as Pagés was already dead. He would have been successful had it not been for Argentine surgeons Alberto Gutiérrez and Tomás Rodríguez Mata, who, in 1932, were the first to draw attention to Pagés and credit him with the development of epidural anaesthesia. Alberto Gutierrez<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> who was aware of the Dogliotti method but recognized Fidel Pagés as the pioneer of the technique, introduced the “hanging drop”, a different method for locating the epidural space that complements or replaces Dogliotti’s “liquid stylet” or loss of resistance technique.</p><p id="par0095" class="elsevierStylePara elsevierViewall">History, however, has a way of twisting the truth, as in the case of the Madrid Academy of Surgery, that suggested calling the procedure the Pagés-Dogliotti epidural anaesthesia technique, or in the case of various Spanish surgeons who write articles on Dogliotti's epidural anaesthesia without ever mentioning Pagés. It is striking that Jaime Pi-Figueras, writing in 1932, ignored Pagés in his article on epidural anaesthesia<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>. However, in 1935, at the meeting of the Italian Anaesthesia Society in the presence of Dogliotti himself, Pi-Figueras accredited Pagés with the invention of the technique, and published an article in which he talked about the Pagés-Dogliotti method<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Thus Pagés’s invention of epidural anaesthesia was finally recognized. The path to recognition was marked by various milestones: 1957, when the General Assembly of the Spanish Society of Anaesthesiology and Resuscitation (SEDAR) created the Fidel Pagés award, which was awarded for the first time in 1959 at the SEDAR national congress in Valencia; and 1961, when Pagés’s work was translated into English<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and 14 years later to French<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>. Following this, his study was cited by some authors, but true recognition only came in the 1990s, when his scientific work was recognized and published in various journals and cited in several articles. Evidence prevailed, and thanks to Alberto Gutiérrez, Pagés’s work has been rediscovered, allowing him to finally taken his well-deserved place in the history of anaesthesiology.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Two years after publication of his study, on September 21, returning home from a summer vacation in Cestona, near Burgos, Pagés’s car skidded off the road, rolled over several times and crashed into a tree. Pagés died in the accident, thus preventing him from completing his research and leaving it to others to write the epilogue to his experiments and rescue them from oblivion.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">The background to Pagés's discovery</span><p id="par0110" class="elsevierStylePara elsevierViewall">Between 1899 and 1901, the first studies on the use of spinal anaesthesia, written by August Bier<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> (1861–1949) and followed a few months later by Theódore Tuffier<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> (1861–1929), were published in leading scientific journals. Their work was presented in August 1900 at the 13th International Medical Congress held in Paris, and from there news rapidly spread around the world. However, initial enthusiasm for the technique ("cocainization of the spinal cord") subsided between 1901–1904 due to the side effects of cocaine, the only local anaesthetic available at that time. The introduction of stovain and novocaine, less toxic local anaesthetics, in 1904 and 1905 respectively, rekindled interest in the technique, although it did not become popular in Spain until 1914. Some early converts included professors Bartrina<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and Sagarra Lascuraín<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>, but the technique received its most influential endorsement from the school of Gómez Ulla<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> in the General Military Hospital of Carabanchel. Spinal anaesthesia was the subject of discussion, communications to congresses, and doctoral theses for several years.</p><p id="par0115" class="elsevierStylePara elsevierViewall">An alternative to the intradural approach to the spinal canal is the caudal approach, pioneered in 1901 by French urologist Jean Athanase Sicard<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>, although Fernando Cathelin also successfully performed the technique in animals that same year. Many other surgeons used this technique, with very mixed results. Gil Vernet<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>, professor of anatomy and surgeon in Barcelona, after performing a meticulous anatomical study, described the dimensions of the sacral canal as: <span class="elsevierStyleItalic">“The dural sac ends at the level of the lower border of the second sacral vertebra or the upper border of the third”</span> and <span class="elsevierStyleItalic">“The sacral canal is 25 mm wide and the sac measures 10 mm, thus leaving two spaces measuring 1.8 mm on either side, allowing a needle to be inserted into this space without piercing the dura mater”</span>. These studies allowed Gil Vernet to modify the techniques previously described and insert the needle deeper to inject the anaesthetic solution at a higher level and reach higher metameric levels. In 1917, he published a special article reporting his experiences in 27 patients, and in 1918 he read his doctoral thesis on the same subject, describing yet more cases. Despite his good results, his upper sacral epidural anaesthesia technique was soon forgotten.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Metameric anaesthesia</span><p id="par0120" class="elsevierStylePara elsevierViewall">Fidel Pagés was familiar with all the studies and results previously obtained, and used them to describe a new method of epidural anaesthesia involving accessing the spinal canal through the lumbar or thoracic region.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In 1921, he published his experience with 43 patients, stating that <span class="elsevierStyleItalic">“Blocking the nerve roots with anaesthetic agents in the epidural space, is capable of producing analgesia that can be useful in surgical interventions, and in the same way that Cathelin, Reclus, Laewen, Gaza and many others have achieved such good results with sacral anaesthesia that has been used for certain clinical interventions, the studies we have carried out to date allow us to state that the metameric anaesthesia obtained gave us considerable advantages during surgery”</span>. He called his technique metameric anaesthesia</p><p id="par0130" class="elsevierStylePara elsevierViewall">His study – <span class="elsevierStyleItalic">Anestesia métamerica</span><a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6,11</span></a> – was published in 3 Spanish medical journals, but inexplicably, despite his prestige as a surgeon, it failed to impress his colleagues, and was forgotten for more than 10 years. Some foreign authors cited his work, particularly Morisot, who praised his <span class="elsevierStyleItalic">Anestesia métamerica</span> as “<span class="elsevierStyleItalic">a study we still believe to be comparable in more than one respect to the best that have been written on the subject … in which everything is described, the anatomical bases, the characteristics of analgesia and motor paralysis, the technique, the signs and complications and contraindications”</span>. Morisot was also the only author to acknowledge Pagés as the pioneer of lumbar epidural anaesthesia.</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anestesia métamerica</span> is an exceptional article that describes the borders of the epidural space, the technique, the instruments required (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), the complications, and the indications and contraindications, and goes as far as to hint at the possibility of obtaining selective anaesthesia exclusively in one part of the body: <span class="elsevierStyleItalic">“Usually, when the operation is performed on only one side of the body, we choose the same side to perform the puncture, because we have observed that anaesthesia almost always occurs earlier and more extensively in the half of the body in which the injection is administered; however, it can also be administered on the opposite side”</span>. The establishment of epidural anaesthesia is described in great detail, indicating a careful, protocolized study of all patients.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">In his article, Pagés makes a detailed description based on real medical practice, after having verified the effectiveness of the method in various surgical interventions. Unfortunately, his discovery was not published in a journal of international impact. He perfectly describes the borders of the epidural space thus: <span class="elsevierStyleItalic">“the epidural space is bordered by two irregular cylindrical surfaces: the outer one corresponds to the inner surface of the spine; the inner one, to the outer surface of the dura mater. Between them there is a space that reaches upward as far as the contour of the foramen magnum, where the dura mater, firmly attached to the bone, seals off access to cranial cavity, and downward, as far as the coccyx”.</span> He also shows that the dimensions of the epidural space vary according to the position of the body, with the space being greatest in the forced bending position: <span class="elsevierStyleItalic">“This position increases the distance that normally separates the anterior face of the yellow lamina and ligaments and the posterior face of the dura mater"</span> (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">In his study, Pagés describes with great accuracy and detail 2 different approaches, lateral and central: <span class="elsevierStyleItalic">“In the lateral puncture, the cannula with its stylet gently penetrates the mass of the spinal muscle until, at a depth that varies depending on the patient's girth and the height of the puncture, a resistance is encountered that stops the advancement of the instrument; slight pressure of the hand will cause the needle to sink slightly, producing a clearly audible sound (a needle with a very short, not very sharp, bevel); if the stylet is removed, no liquid is released”</span>. <span class="elsevierStyleItalic">“The two clicks produced when the instrument passes through the yellow ligament and the dura mater are so loud that they can be heard by people in the immediate proximity of the patient. The interns who help us in the operating room often hear them, and the operator, who combines his hearing with his sense of touch, is always able to locate the aforementioned structures with the tip of the instrument”</span>. <span class="elsevierStyleItalic">“In central puncture, the sensation is completely different. As the density of the interspinous ligament and the yellow ligament are the same, we do not notice an increased resistance to the needle at the level of the ligament, but we perceive a sudden sensation when we have gone through it”</span>.</p><p id="par0150" class="elsevierStylePara elsevierViewall">On the subject of injecting the anaesthetic, Pagés says that the advance of the puncture needle must be stopped immediately once it has gone through the yellow ligament, and the anaesthetic solution should be injected at that point. He adds an interesting detail: <span class="elsevierStyleItalic">“As the yellow ligaments are oriented from posterior to anterior, and from medial to peripheral, it is important to ensure that the tip of the bevel is facing outwards, as this will ensure it is parallel to the plane of the aforementioned ligaments. This technical detail makes it easier to appreciate the ligamentous perforation needed to situate the injection inside the spinal canal; furthermore, even if the needle comes into contact with the dura mater, if the bevel is in the direction indicated it will slide over the convex surface without penetrating it, and will move slightly on contact. Performing the puncture according to this technique also prevents the problem of part of the bevel remaining outside the spinal cavity, and some of the anaesthetic being injected outside this space”</span>.</p><p id="par0155" class="elsevierStylePara elsevierViewall">He also describes the instrumentation needed (spinal anaesthesia cannula with short, blunt bevel) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), the correct anaesthetic solution (2% novocaine), and the spread of metameric anaesthesia: <span class="elsevierStyleItalic">“Shortly after injecting, 5 minutes later, an area of hypoesthesia begins to appear in a segment of the body corresponding to the roots bathed in the anaesthetic mixture. This area is bilateral, but at first somewhat more extensive in the side of the body corresponding to the side of the injection. Motility initially remains unchanged, as do vasomotor reactions. Sensitivity gradually subsides over time, and spreads to the non-injected side until it reaches the limits of the other. First, sensitivity to pain disappears, followed almost simultaneously by sensitivity to heat; after fifteen minutes, and sometimes earlier (ten minutes, and less in some patients), anaesthesia is complete in the metameres innervated by the blocked nerve roots. Sensitivity to touch nearly always persists, even with total analgesia, this being one of the most curious facts of both spinal anaesthesia and the anaesthesia we describe”</span>.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Also interesting is Pagés’s observation that <span class="elsevierStyleItalic">"The anaesthetic affects the sensory fibre before the motor fibre"</span>, and that the sympathetic system is affected: <span class="elsevierStyleItalic">"metameric anaesthesia achieves not only the total analgesia needed for a good, comfortable surgeon intervention, but abdominal silence is accompanied by sympathetic inhibition, so that sudden changes in pressure will only occur with violent visceral tractions"</span>.</p><p id="par0165" class="elsevierStylePara elsevierViewall">He also describes anaesthesia-related adverse effects, together with the advantages and disadvantages of his <span class="elsevierStyleItalic">"metameric anaesthesia"</span>. Pagés ends his study by establishing the indications and contraindications for his technique.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The thoroughness of Pagés’s description of the procedure - he does not overlook a single detail - is testament to his extensive foundational anatomical, physiological and pharmacological study. The reliability and reproducibility of what he describes makes Fidel Pagés’s study and its discovery something truly unique, and its author deserves our greatest respect, remembrance and gratitude. In this, the centenary of epidural anaesthesia, we honour Pagés and give him the recognition he was so long denied.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1655692" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1471634" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1655691" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1471633" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "The significance of the discovery of epidural anaesthesia" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Who was Fidel Pagés Miravé?" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "The background to Pagés's discovery" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Metameric anaesthesia" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-02-10" "fechaAceptado" => "2021-03-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1471634" "palabras" => array:4 [ 0 => "Fidel Pagés" 1 => "Metameric anesthesia" 2 => "Epidural anesthesia" 3 => "Centenary" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1471633" "palabras" => array:4 [ 0 => "Fidel Pagés" 1 => "Anestesia metamérica" 2 => "Anestesia epidural" 3 => "Centenario" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">March 2021 marked the first centenary of the publication of Fidel Pagés Miravé’s seminal article <span class="elsevierStyleItalic">Anestesia metamérica</span> in the <span class="elsevierStyleItalic">Revista Española de Cirugía</span>. Pagés’ knowledge of Bier and Tuffier’s intradural (1889–1900) and Gil Vernet’s sacral (1917–1918) techniques played a pivotal role in the development of the epidural anesthesia technique. Fidel Pagés’ extensive experience with treating the casualties of armed conflicts, his proficiency in French and German, and his vast knowledge of anatomy, physiology and pharmacology lie behind the accuracy with which he describes the different approaches, the different anesthetic solutions, or the different instruments used, and the indications, contraindications and complications associated with his technique.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In the centenary of his article, we would like to thank Fidel Pagés’ for describing an anesthetic and analgesic technique that has improved the lives of so many patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En marzo de 2021 celebramos el centenario de la publicación en la <span class="elsevierStyleItalic">Revista Española de Cirugía</span> del artículo de Fidel Pagés Miravé “Anestesia metamérica”. Para su autor el conocimiento de las técnicas de anestesia intradural de Bier y Tuffier (1889–1900) y la sacra de Gil Vernet (1917–1918) resultó fundamental a la hora de describir la técnica epidural. Su amplia experiencia con heridos de guerra, el amplio dominio del francés y alemán, junto con su profundo conocimiento anatómico, fisiológico y farmacológico, explica la precisión con que descrió la técnica en sus diversas vías de abordaje, la solución anestésica o el instrumental empleado, así como sus posibles complicaciones, indicaciones y contraindicaciones.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Cien años después a los anestesiólogos nos gustaría realizar un reconocimiento a Fidel Pagés, por describir una técnica anestésica y analgésica que mejora la vida de las personas.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López Álvarez S, Casas Reza P, del Río Fernández S. Centenario de la anestesia epidural. Rev Esp Anestesiol Reanim. 2022;69:4–11.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2514 "Ancho" => 3175 "Tamanyo" => 760534 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Photographs of Fidel Pagés, commemorative plaque on the house where he lived, cover the <span class="elsevierStyleItalic">Revista Cirugía Española</span> he founded (number 8 of 1919), and image of his article <span class="elsevierStyleItalic">Anestesia metamérica</span> (March 1921).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2182 "Ancho" => 3175 "Tamanyo" => 696787 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cover of <span class="elsevierStyleItalic">Revista Cirugía Española</span> and first page the article.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 250 "Ancho" => 905 "Tamanyo" => 43030 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Epidural anaesthesia needles in use at the time of Fidel Pagés (Museum of Anaesthesiology. Faculty of Medicine. Santiago de Compostela).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1648 "Ancho" => 2925 "Tamanyo" => 364964 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagrams of the technique, drawn by Fidel Pagés.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aproximación a la obra médica del comandante médico Fidel Pagés Miravé" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I. Velázquez Rivera" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev San Mil" "fecha" => "2011" "volumen" => "S1" "paginaInicial" => "131" "paginaFinal" => "134" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Foundations of anesthesiology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Faulconer" 1 => "T.E. Keys" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1965" "editorial" => "Charles C. Thomas Publishers" "editorialLocalizacion" => "Illinois" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Historia de la Anestesia en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Franco" 1 => "J. 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