Credited to Spain. The American neurologist James Corning probably gave an epidural injection in 1885 without understanding it, and Cathelin and Sicard described the caudal (sacral) route in France in 1901. Pagés's 1921 paper is recognized as the first description of thoracolumbar epidural anesthesia in human patients.
How it began
Fidel Pagés, born in Huesca in 1886, was a Spanish military surgeon who served in North Africa and later worked at the General Hospital of Madrid, where he founded the journal Revista Española de Cirugía. In 1921 he published Anestesia metamérica, describing the anatomy of the epidural space, his technique for reaching it, a series of operations and their complications. He wrote that the idea came to him while giving a spinal anesthetic: to stop the needle inside the spinal canal before it pierced the dura mater.
Before it existed
August Bier had demonstrated spinal anesthesia in 1898, and by the 1920s it was widespread and reliable, with a procaine spinal giving up to 60 minutes of operating time. A spinal injection could not, however, numb only a chosen segment of the body. In 1901 the French physicians Fernand Cathelin and Jean-Athanase Sicard had independently developed the caudal injection into the sacral epidural space, but variation in patients' sacral bones meant that it failed in a significant share of cases.
How it works
The anesthetic is placed outside the dura mater, where it blocks the nerve roots serving one region, which is why Pagés called it metameric, or segmental. He gave two ways to find the space: entering the spinal fluid and withdrawing the needle until the flow stopped, or judging the position by the sound and resistance as a short-beveled needle passed the yellow ligament. He used procaine with adrenaline. In his first case, numbness began within five minutes and an inguinal hernia was repaired after twenty.
How it spread
The technique spread once it became continuous. The Cuban anesthesiologist Miguel Curbelo pioneered the use of ureteral catheters for continuous lumbar epidural anesthesia, and his method gained popularity after a demonstration at the Mayo Clinic, leading to a publication in Anesthesia and Analgesia in 1949. John Bonica and Philip Bromage later studied the epidural scientifically and stressed the complications that could follow, including infection and nerve injury.
Who pushed back
Two years after the paper appeared, in 1923, Pagés was killed in a car crash at the age of 37. A review marking the centenary of his death notes that he was not credited with primacy when the method was later described again, possibly because of his early death and the limited circulation of the Spanish journals in which he published. A single injection also wore off, which limited the technique until continuous methods were devised.
Where it stands today
Epidural anesthesia is in routine use in clinical anesthesia. Historical accounts consistently recognize Pagés's 1921 paper as an early and clear presentation of lumbar epidural anesthesia as a surgical technique distinct from spinal anesthesia, intended for routine use and tested in a substantial series of operations. Later clinicians refined the way the space is located, the equipment, the dosing and the safety of the method.
