History and development of local anaesthesia

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History and development of local anaesthesia
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Publisher: 	Oxford	University	Press Print	Publication	Date: 	Nov	2012
Print	ISBN-13: 	9780199586691 Published	online: 	Nov	2012
DOI: 	10.1093/med/9780199586691.001.0001
Chapter: History	and	development	of	local	anaesthesia
Author(s): Tony	Wildsmith
DOI: 10.1093/med/9780199586691.003.0001
Oxford	Medicine
Principles	and	Practice	of	Regional	Anaesthesia	(4	ed.)
Edited	by	Graeme	McLeod,	Colin	McCartney,	and	Tony	Wildsmith
History	and	development	of	local	anaesthesia
The	first	steps
The	possible	production	of	local	anaesthesia	by	this	or	by	other	means,	is	certainly	an
object	well	worthy	of	study	and	attainment.	Surgeons	everywhere	seem	more	and	more
acknowledging	the	facility,	certainty,	and	safety	with	which	the	state	of	general
anaesthesia	can	be	produced	at	will	before	operating,	as	well	as	the	moral	and
professional	necessity	of	saving	their	patients	from	all	requisite	pain.	But	if	we	could	by
any	means	induce	a	local	anaesthesia,	without	that	temporary	absence	of
consciousness,	which	is	found	in	the	state	of	general	anaesthesia,	many	would	regard	it
as	a	still	greater	improvement	in	this	branch	of	practice.	If	a	man,	for	instance,	could
have	his	hand	so	obtunded	that	he	could	see,	but	not	feel,	the	performance	of
amputation	upon	his	own	fingers,	the	practice	of	anaesthesia	in	surgery	would,	in	all
likelihood,	advance	and	progress	even	still	more	rapidly	than	it	has	done.
This	striking	commentary	was	published	by	James	Young	Simpson	(Figure	1.1)	in	1848,
decades	before	local	anaesthesia	became	a	practical	possibility,	and	his	paper	describes	his
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(unsuccessful)	experiments	with	the	topical	application	of	various	liquids	and	vapours
(Simpson	1848).	Because	it	was	published	less	than	2	years	after	Oliver	Wendell	Holmes	had
suggested	the	word	‘anaesthesia’	to	William	Morton,	it	probably	represents	the	first	use	of	the
term	‘local	anaesthesia’.	However,	Simpson	was	aware	that	his	were	far	from	being	the	first
attempts	to	produce	peripheral	insensibility	because	the	paper	refers	to	some	ancient	methods
(which	he	considered	‘apocryphal’)	and	to	Moore’s	method	of	nerve	compression	(Figure	1.2)
which	had	been	used	with	some	success	towards	the	end	of	the	18th	century.
Figure	1.1
James	Young	Simpson.	Photograph	courtesy	of	the	Royal	Medical	Society.
History and development of local anaesthesia
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Figure	1.2
James	Moore’s	method	of	nerve	compression.
In	direct	response	to	Simpson’s	paper	James	Arnott	proposed	that	cold,	produced	by	the
application	of	ice	and	salt	mixtures,	would	be	effective,	but	his	technique	was	rather
cumbersome	(Bird	1949).	Another	eminent	Victorian	interested	in	producing	local	anaesthesia
was	Benjamin	Ward	Richardson	(Figure	1.3)	who	experimented	with	electricity	before	trying
the	effect	of	cold	(Richardson	1866).	As	with	nerve	compression,	reports	of	the	numbing	effect
of	cold	go	back	to	antiquity,	the	best	known	being	by	Napoleon’s	surgeon,	Baron	Larrey.
Richardson’s	work	culminated	in	the	introduction	of	the	ether	spray	(Figure	1.4),	which	worked
by	evaporation	and	was	the	only	practical	method	of	local	anaesthesia	until	the	local	action	of
cocaine	was	fully	appreciated.	Ethyl	chloride	supplanted	ether	as	the	cooling	agent	after	1880.
Figure	1.3
Benjamin	Ward	Richardson.	Photograph	from	Disciples	of	Aesculapius.
Figure	1.4
Richardson’s	ether	spray.
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The	development	of	the	hypodermic	syringe	and	needle	was	an	important	prerequisite	for	local
anaesthesia	by	injection,	but	these	items	evolved	over	many	years	so	their	introduction
cannot	be	ascribed	to	any	one	person.	However,	Alexander	Wood	(Figure	1.5),	an	Edinburgh
contemporary	of	Simpson,	was,	in	1853,	the	first	to	combine	them	for	hypodermic	medication
(Figure	1.6).	Wood	was	interested	in	the	treatment	of	neuralgia	and	he	reasoned	that
morphine	might	be	more	effective	if	it	were	injected	close	to	the	nerve	supplying	the	affected
area	(Wood	1855).	Although	morphine	may	have	some	peripheral	actions,	the	effect	of	Wood’s
morphine	was	probably	central,	but	he	was	nevertheless	the	first	to	think	of	the	possibility	of
producing	nerve	block	by	drug	injection	and	he	has	been	called	the	‘father-in-lore’	of	local
anaesthesia—all	he	lacked	was	an	agent	which	worked	locally.
Figure	1.5
Alexander	Wood.	Photograph	courtesy	of	the	Royal	Medical	Society.
Figure	1.6
Syringe	devised	by	Wood.	Photograph	courtesy	of	the	Royal	College	of	Surgeons	of
Edinburgh.
The	introduction	of	cocaine
The	events	leading	to	the	introduction	of	cocaine,	the	alkaloid	in	the	leaves	of	Erythroxylon
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coca,	into	clinical	practice	began	shortly	after	Wood’s	experiments	with	local	morphine
injection.	Sporadic	reports	of	the	systemic	effects	of	chewing	the	leaves	had	reached	Europe
from	the	time	of	the	Spanish	conquest,	but	it	was	not	until	1857	that	Montegazza	gave	the	first
detailed	description	of	these	actions.	Prior	to	that,	Gaedke	had	extracted	some	reddish
crystals,	but	it	was	Niemann	in	1860	who	produced	pure	white	crystals	which	he	named
cocaine.	Niemann	noted	that	these	crystals	produced	numbness	of	the	tongue,	an	observation
subsequently	confirmed	by	several	other	workers.	Alexander	Hughes	Bennett	was	the	first	to
demonstrate	(in	animals)	that	injection	of	cocaine	produces	sensory	block,	but,	as	with	the
work	of	others,	the	significance	of	his	observation	was	not	appreciated	(Wildsmith	1983).
During	this	time	cocaine	came	to	be	looked	upon	as	a	universal	panacea	and	was	even	used
to	treat	morphine	addiction.	This	latter	use	attracted	the	attention	of	Sigmund	Freud,	who
reviewed	the	literature	and	started	a	programme	of	research	on	the	drug’s	systemic	effects.	In
this	he	was	assisted	by	his	friend	Carl	Koller	(Figure	1.7),	another	young	graduate	of	the
Vienna	medical	school	also	working	part-time	in	Stricker’s	research	laboratories.	Koller	hoped
to	become	an	ophthalmologist	and,	having	heard	from	his	teacher—Ferdinand	Arlt—of	the
disadvantages	of	general	anaesthesia	for	eye	surgery,	he	had	applied	a	variety	of	agents	to
the	conjunctivawithout	success	(Wildsmith	1984).	However,	not	even	Koller	appreciated	the
significance	of	the	reports	of	local	insensibility	until	a	chance	comment	from	a	colleague	made
him	realize	that	he	had	in	his	possession	the	local	anaesthetic	agent	for	which	he	had	been
searching	(Becker	1963).	Experiments,	firstly	with	animals,	then	on	himself	and	colleagues,	led
on	to	clinical	trials	during	the	summer	of	1884.	A	preliminary	communication	was	read	(by	a
colleague—Joseph	Brettaur—because	Koller	could	not	afford	the	trip)	at	the	Heidelberg
meeting	of	the	German	Ophthalmological	Society	on	15	September	1884,	and	from	there	the
news	spread	with	amazing	speed.
Figure	1.7
Carl	Koller.	Photograph	courtesy	of	Mrs	Hortense	Koller	Becker.
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Immediate	developments
The	full	account	of	his	work	(Koller	1884)	appeared	shortly	after,	and	many	others	reported
their	experience	before	the	end	of	the	year.	Although	there	is	evidence	(Faulconer	&	Keys
1965)	that	William	Burke	may	have	absolute	priority	for	the	first	nerve	block	(performed	before
the	end	of	November	1884),	credit	is	usually	given	to	William	Halsted	and	Richard	Hall	of	New
York.	Before	the	end	of	1885	they	had	blocked	virtually	every	peripheral	somatic	nerve,
including	the	brachial	plexus,	and	had	demonstrated	the	effectiveness	of	such	methods
(Boulton	1984).
Central	neural	block	may	be	considered	to	have	been	performed	almost	as	early.	We	will
never	know	for	certain	whether	the	New	York	neurologist,	Leonard	Corning,	produced	epidural
or	subarachnoid	block	in	1885,	but	there	is	no	doubt	that	at	that	early	stage	he	deliberately
injected	cocaine	between	the	posterior	spinous	processes	of	both	a	dog	and	a	patient	and
produced	block	of	the	lower	half	of	the	body.	Although	he	suggested	that	it	might	be	used	in
surgery,	no	further	development	took	place	until	the	end	of	the	century.	In	1891,	Quincke	in
Kiel,	Germany,	showed	that	lumbar	puncture	was	a	practical	procedure,	and	it	was	in	the	same
centre	that	August	Bier	performed	the	first	spinal	blocks	for	surgery	in	1898.	However,	Bier
abandoned	the	technique	before	he	had	gained	much	experience	with	it,	and	it	was	Tuffier,
working	independently	in	Paris,	who	was	responsible	for	popularizing	the	method	in	Europe.	In
the	USA	Tait,	Caglieri,	and	Matas	were	the	early	pioneers.
Pharmacological	advances
The	major	factor	in	Bier’s	decision	to	abandon	spinal	anaesthesia	was	the	toxicity	of	cocaine.
It	was	also	difficult	to	sterilize,	brief	in	duration,	and	had	exacted	a	terrible	price	from	pioneers
like	Halsted	and	Hall	who	became	addicted	to	it	as	a	result	of	self-experimentation.	Because	of
these	factors	the	early	use	of	cocaine	was	largely	limited	to	topical	application.	Later,	Schleich
in	Germany	and	Reclus	in	France	developed	safe	dose	regimens	for,	and	popularized,
infiltration	anaesthesia.	Braun	increased	its	duration	and	reduced	its	toxicity,	first	by	the	use	of
a	tourniquet	and	later	by	adding	adrenaline	to	the	solution.
However,	widespread	use	of	local	methods	had	to	await	the	introduction	of	safer	drugs.
Niemann,	in	his	pioneer	work,	had	hydrolysed	benzoic	acid	from	cocaine	and	it	was	the
search	for	other	benzoic	acid	esters	that	produced	new	local	anaesthetics.	Amylocaine
(Stovaine)	was	introduced	in	1903	and	was	popular	for	spinal	anaesthesia	until	it	was	shown	to
be	irritant,	but	it	was	the	development	of	procaine	by	Einhorn	in	1904	that	was	the	really
significant	advance.	Its	low	toxicity,	lack	of	addictive	properties,	and	relative	stability	ensured
its	popularity	for	the	techniques	already	in	use,	and	made	feasible	the	development	of	new
ones	for	which	larger	doses	of	drug	were	required.
Procaine	is	still	far	from	ideal	because	it	hydrolyses	when	heated	in	solution,	has	a	short
duration	of	action,	and	may	induce	allergic	reactions.	Many	agents	were	tried,	but	the	only
others	to	become	well	established	were	amethocaine	and	cinchocaine.	Both	are	potent	and
toxic,	but	were	well	suited	to	spinal	anaesthesia	for	which	they	became	widely	used.
Chloroprocaine	is	the	only	ester-type	drug	to	be	developed	successfully	in	more	recent	times,
but	even	it	is	of	relatively	limited	availability.	The	1930s	saw	the	start	of	the	next	major
advance.	Trying	to	synthetize	the	alkaloid	gramine,	Erdtman,	a	Swedish	chemist	believing	in
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the	importance	of	the	senses	in	analysis,	tasted	one	of	the	substances	which	had	been
produced.	The	significance	of	the	ensuing	numbness	was	appreciated	and	the	search	for	a
clinically	useful	derivative	was	pursued	by	Nils	Lofgren,	who	synthesized	lidocaine	in	1943.
Perhaps	almost	as	important	was	Lofgren’s	systematic	study	of	a	whole	range	of	compounds
(Lofgren	1948),	so	laying	the	foundations	for	all	subsequent	studies	of	local	anaesthetic	drugs.
From	these	studies	have	come	derivatives	of	lidocaine	such	as	mepivacaine,	prilocaine,
bupivacaine,	and	ropivacaine.
While	the	introduction	of	these	agents	has	considerably	widened	the	scope	of	local
anaesthesia,	they	are	essentially	variations	on	a	theme.	Since	the	development	of	lidocaine
the	most	important	work	has	been	in	the	field	of	membrane	physiology.	Many	workers	have
contributed	to	this,	the	most	notable	being	Hodgkin	and	Huxley.	Use	of	apparatus	such	as	the
voltage	clamp	has	produced	major	advances	in	our	knowledge	of	the	mechanism	of	nerve
conduction	and	its	block	by	drugs	at	the	molecular	level.	This	has	yet	to	lead	to	the
development	of	new	drugs,	but	the	research	continues	to	examine	ever	more	detailed	aspects
of	the	transmission	of	nerve	impulses	(see	Chapter	6).
Concurrent	studies	of	the	pharmacokinetics	of	local	anaesthetic	drugs	have	made	a	more
practical	contribution	to	our	knowledge	because	they	have	indicated	the	most	appropriate
doses	and	agents	for	the	various	techniques.	They	have	thus	played	an	important	part	in
basing	clinical	local	anaesthesia	on	sound	scientific	principles.	In	more	recent	years,
pharmaceutical	research	has	led	to	the	development	of	novel	ways	of	delivering	local
anaesthetics.	The	first	local	anaesthetic	preparation	to	be	effective	on	application	to	intact	skin
(EMLA—the	eutectic	mixture	of	local	anaesthetics)	is	a	classic	example,	and	depot
preparations	(such	as	liposomal	local	anaesthetics)	continue	to	be	evaluated.
Developments	in	technique
As	has	been	mentioned,	most	local	techniques	had	been	described	by	1900,	even	if	they	were
not	widely	used.	In	1906,	Sellheim	introduced	paravertebral	and	intercostal	block,	and	2	years
later	Bier,	taking	advantage	of	the	low	toxicity	of	procaine,	developed	his	technique	of
intravenous	regional	anaesthesia.	Another	important	development	at	this	time	was	Barker’s
description	of	the	way	in	which	the	curves	of	the	lumbar	spine	and	gravity	interact	to	affect	the
spread	of	intrathecally	injected	solutions.	Epidural	block	is	very	much	a	product	of	the	20th
century.	The	sacral	approach,	described	independently	by	Sicard	and	Cathelin	in	1901,	was
used	by	Stoeckel	for	analgesia	during	vaginal	delivery	in	1909.	The	lumbar	approach	was	first
described	by	Pages	in	Spain	in	1921,	but	he	died	soon	afterwards	and	the	technique	was
‘rediscovered’	and	popularized	by	Dogliotti	in	Italy	a	decade	later.The	lumbar	approach	was
first	used	in	labour	in	1938	by	Graffagnino	and	Seyler,	and	Massey	Dawkins	performed	the	first
epidural	in	Britain	in	1942.
Most	other	subsequent	advances	in	technique	may	be	looked	upon	as	being	refinements	or
rediscoveries	of	techniques	which	had	been	described	previously.	This	is	not	to	deny	the
importance	of	these	later	authors	because	they	did	a	great	deal	to	improve	and	popularize	the
practice	of	local	anaesthesia.	One	important	technical	development	which	does	deserve
specific	mention	is	the	introduction	of	catheter	methods.	Continuous	spinal	anaesthesia	was
introduced	in	the	USA	in	1940	by	Lemmon	who	left	the	spinal	needle	in	situ	(projecting	through
a	gap	in	the	operating	table)	and	connected	it	to	a	length	of	rubber	tubing	for	the	repeat
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injections.	In	1945,	Tuohy	described	his	needle	for	the	insertion	of	a	catheter	into	the
subarachnoid	space,	and	in	1949	Curbelo	adapted	it	for	lumbar	epidural	block,	although	the
first	continuous	epidural	blocks	are	attributed	to	Hingson	and	Edwards	who	used	the	caudal
route	in	1942.
The	popularity	and	use	of	local	anaesthesia
Ever	since	Koller’s	original	work,	the	popularity	of	local	anaesthesia	has	waxed	and	waned,
like	that	of	many	other	medical	developments.	The	announcement	of	his	work	produced	a
massive	wave	of	enthusiasm,	which	was	tempered	as	the	problems	of	cocaine	became
appreciated.	The	first	resurgence	of	interest	came	with	the	introduction	of	safer	drugs	at	the
beginning	of	the	century,	and	the	second	as	a	result	of	the	efforts	of	Labat,	Lundy,	Maxson,
Odom,	and	Pitkin	in	the	USA	in	the	years	between	the	two	world	wars.
In	Britain	at	the	same	time,	general	anaesthesia	was	preferred,	perhaps	because	it	was	usually
administered	by	doctors	who,	though	rarely	specialists,	were	entirely	responsible	for	its
conduct	and	achieved	acceptable	standards.	By	contrast,	local	and	regional	techniques,	if
they	were	used	at	all,	were	performed	by	the	surgeon,	whose	interest	and	attention	were
divided	between	anaesthetic	and	operation	so	that	the	methods	were	not	seen	to	best
advantage.	Nevertheless,	when	the	examination	for	the	Diploma	in	Anaesthesia	was	instituted
in	1935,	the	curriculum	included	local	techniques.	This,	together	with	the	establishment	of
anaesthesia	as	an	independent	speciality	within	the	British	National	Health	Service	in	1948,	did
much	to	encourage	use	of	the	methods.
Unfortunately,	the	years	between	1950	and	1955	saw	a	sharp	decrease	in	the	use	of	local,
particularly	spinal,	anaesthesia	in	Britain.	The	many	contemporary	advances	in	general
anaesthesia	were	partly	responsible	because	they	encouraged	the	belief	that	a	local
technique	was	unnecessary,	but	more	important	was	the	fear	of	severe	neurological	damage.
The	1950	report	‘The	grave	spinal	cord	paralyses	caused	by	spinal	anesthesia’	by	a	British-
trained	New	York	neurologist,	Foster	Kennedy	(Kennedy	et	al.	1950),	was	followed	by	the
Woolley	and	Roe	case	(Cope	1954,	Hutter	1990),	and	the	use	of	local	anaesthesia	all	but	died
out.	That	it	did	not	do	so	entirely	was	due	to	anaesthetists	such	as	Macintosh,	Gillies,	Dawkins,
Doughty,	Lee,	and	Scott	who	were	prepared	to	advocate,	use,	and	teach	local	techniques,
and	to	encourage	formal	research	into	their	features.	Subsequently,	many	reports	appeared
describing	very	large	numbers	of	cases	without	neurological	sequelae,	and	local	anaesthesia
became	re-established	in	British	practice	during	the	1980s,	although	concerns	about	sequelae
have	persisted,	particularly	in	patients	receiving	antithrombotic	drugs.
There	were	more	positive	influences.	The	advantages	of	lidocaine	and	its	derivatives—potent,
predictable,	heat-resistant,	and	virtually	free	of	allergic	side	effects—should	not	be
underestimated.	The	introduction	of	bupivacaine	was	particularly	important	because	its	long
duration	of	action	allows	repeated	injection	with	relatively	little	risk	of	cumulative	toxicity.	This
was	a	major	factor	in	the	increased	use	of	continuous	epidural	techniques	in	labour	where
local	techniques	are	very	appropriate	because	they	are	effective	and	exert	minimal	effects	on
the	child.	Anaesthetists	observing	these	benefits	were	encouraged	to	try	them	in	other	areas,
especially	as	they	became	aware	that	general	anaesthesia	cannot	provide	the	ideal	answer	to
every	anaesthetic	problem.	The	formation	of	the	American	(1975)	and	European	(1982)
Societies	of	Regional	Anaesthesia	were	important	in	providing	platforms	where	clinicians	could
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hear	the	issues	debated	and	obtain	the	necessary	theoretical	education.
Regional	techniques	are	of	value	in	blocking	afferent	stimuli	after	any	type	of	surgery,
reducing	both	the	pain	and	stress	suffered	by	the	patient,	with	the	approach	even	extending
today	to	cardiac	surgery,	but	the	concept	is	far	from	new.	As	early	as	1902,	Harvey	Cushing
was	advocating	the	combination	of	local	with	general	anaesthesia	to	reduce	surgical	‘shock’,
a	concept	which	was	developed	by	Crile	into	‘anoci-association’.	The	term	‘balanced
anaesthesia’	often	implies	the	triad	of	sleep	(using	the	inhalational	or	intravenous	route),
profound	analgesia	with	opioid	drugs,	and	muscle	relaxation	by	neuromuscular	block,	but
when	Lundy	first	used	the	term	in	1926	the	second	and	third	components	were	produced	by	a
local	block.	This	combination	has	now	developed	into	the	‘fast-track’	approach	where	high-
quality	pain	relief	allows	rapid	mobilization	and	early	discharge	even	after	major	surgery.
There	have	been	other	advances	which,	although	more	difficult	to	quantify,	have	directly	or
indirectly	helped	the	cause	of	local	anaesthesia	in	the	last	50	years.	For	example,
developments	in	the	field	of	medical	plastics	have	resulted	in	safe	and	reliable	syringes,
catheters,	and	filters;	and	the	anaesthetist	can	select	from	a	wide	variety	of	sedative	and
anxiolytic	drugs	which,	carefully	used,	can	greatly	improve	the	patient’s	acceptance	of	a
nerve	block.	Of	great	importance	has	been	the	understanding	of	the	effects,	and	treatment,	of
sympathetic	block.	Ephedrine	became	available	in	1924	and	was	first	used	to	treat
hypotension	during	spinal	anaesthesia	in	1927,	but	readily	available	intravenous	fluids	and
equipment	for	their	administration	came	later.
Recent	developments
Over	the	last	20	years,	as	regional	techniques	have	been	used	more	widely,	there	have	been
a	number	of	attempts	to	‘prove’	that	they	have	a	positive	impact	on	the	outcomes	of	surgery.
These	issues	are	considered	in	Chapter	2,	but	fundamental	difficulties	have	been	recruiting
sufficiently	large	numbers	of	patients	to	produce	a	study	of	sufficient	‘power’	and,	possibly
more	important,	ensuring	that	those	managing	the	patients	have	equal	competence	in
managing	the	surgery	with	and	without	a	block.	Significant	reductions	in	postoperative	pain	are
easy	to	demonstrate,	and	no	study	has	even	suggested	that	the	outcome	may	be	worse	when
regional	methods	are	used,	but	it	is	difficult	to	draw	valid	comparisons	when	the	regional
technique	is	less	than	fully	effective	in	a	large	proportion	of	the	patients	who	are	supposed	to
receive	it	(Rigg	et	al.	2002).
As	noted	earlier,	there	have	been	concerns	aboutthe	risks	of	major	sequelae,	especially	after
central	nerve	block,	but	an	UK-wide	audit	of	such	problems	suggested	that	the	incidence	is
much	lower	than	some	had	feared	(Cook	et	al.	2009).	These	worries	did	encourage	wider	use
of	more	peripheral	blocks	such	as	paravertebral	for	thoracotomy,	interpleural,	subcostal,
rectus	sheath,	and	transversus	abdominis	plane	blocks	for	abdominal	surgery,	and
femoral/sciatic	block	and	intra-articular	techniques	for	lower	limb	arthroplasty.	The	French	led
in	the	development	of	peripheral	nerve	stimulation	techniques,	but	this	method	is	being
displaced	by	the	other	major,	recent	driver	to	the	increased	use	of	regional	techniques,	the
availability	of	portable	ultrasound	devices	for	the	identification	of	the	precise	position	of	target
nerves	prior	to	injection.	There	is	much	enthusiasm	for	their	use,	but	their	efficacy	is	not	yet
clearly	proven,	although	technical	advances	and	greater	experience	may	soon	confirm	that
they	increase	success	rates	and	decrease	the	risk	of	complications.
History and development of local anaesthesia
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Overview
Ever	since	the	first	recognition	of	the	significance	of	the	local	effects	of	cocaine	the	popularity
of	local	and	regional	methods	of	anaesthesia	has	varied	considerably.	New	drugs,	techniques,
and	equipment	have	all	stimulated	enthusiasm	and	usage,	but	the	risk	of	complications,
sometimes	related	to	other	aspects	of	patient	care	such	as	thromboprophylaxis,	balance	the
equation.	This	is	sometimes	over-simplified	and	presented	as	a	‘regional	versus	general’
anaesthesia	debate,	but	the	real	issues	are	to	identify	how	a	regional	technique	may
contribute	to	a	patient’s	care	and	then	perform	the	block	in	such	a	way	so	as	to	both	maximize
efficacy	and	minimize	complications.	This	is	the	underlying	theme	for	all	which	follows.
Further	reading
Ellis	ES	(1946).	Ancient	anodynes:	primitive	anaesthesia	and	allied	conditions.	London:
Heinemann.
Liljestrand	G	(1971).	The	historical	development	of	local	anesthesia.	In	Lechat	P	(Ed)
International	encyclopedia	of	pharmacology	and	therapeutics,	vol	1,	pp.	1–38.	New	York:
Pergamon.
On-line	resource
http://www.histansoc.org.uk	Proceedings	of	the	History	of	Anaesthesia	Society.
References
Becker	HK	(1963)	Carl	Koller	and	cocaine.	Psychoanalytic	Quarterly	32:	309–73.
Bird	HM	(1949)	James	Arnott,	M.D.	(Aberdeen)	1797–1883:	A	pioneer	in	refrigeration
anaesthesia.	Anaesthesia	4:	10–17.
Boulton	TB	(1984)	Classical	file.	Survey	of	Anesthesiology	28:	150–2.
Cook	TM,	Counsell	D,	Wildsmith	JAW	(2009)	Major	complications	of	central	neuraxial	block:
report	on	the	Third	National	Audit	Project	of	the	Royal	College	of	Anaesthetists.	British	Journal
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Cope	RW	(1954)	The	Woolley	and	Roe	case.	Anaesthesia	9:	249–70.
Faulconer	A,	Keys	TE	(1965)	Foundations	of	Anesthesiology,	vol	II,	pp.	769–845.	Springfield,
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Kennedy	FG,	Effron	AS,	Perry	G	(1950)	The	grave	spinal	cord	paralyses	caused	by	spinal
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Koller	C	(1884)	On	the	use	of	cocaine	for	producing	anaesthesia	of	the	eye.	Lancet	ii:	990–2.
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