During the middle of the 19th century local anaesthesia was used rarely, being limited to the application of cold. At first, mixtures of ice and salt water were used and after 1858, evaporation of ether or ethyl chloride.
Chewed coca leaves, used by South American Indians were known for their anaesthetic properties. Alfred Niemann isolated cocaine in 1854 and noted its local anaesthetic effect on the edge of the tongue. Karl Koller, in 1884 was encouraged by the head of his department to find a method of producing local anaesthesia. Koller was a friend of Sigmund Freud who was working on cocaine but mainly to investigate its stimulant effects. Freud gave Koller a little cocaine to test who noted an anaesthetic effect on the edge of his tongue. Koller went into his laboratory and put a few drops of cocaine into the eye of a frog, a guinea pig and finally into his own eye and that of his assistant, noting the insensitivity produced to contact with a needle. He operated on cataracts on the 19th September 1884 and presented his findings to a congress in Heidelberg. This was truly a bolt from the blue and within a few months cocaine local anaesthesia was being used around the world. The technique was simple and consisted of just infiltrating with cocaine solution.
In 1906, August Bier invented regional intravenous anaesthesia which consisted of injecting the anaesthetic into veins of the arm or leg from which the blood flow had been interrupted using a tourniquet. In 1898 Bier invented subdural spinal anaesthesia of the lower part of the body. But it was really François Tuffier who perfected the technique. The French anaesthetists Fernand Cathelin and Jean Marie Athenase Sicard suggested anaesthetising nerve roots in the epidural space by injection through the sacro–coccygeal (caudal) canal. The idea of injecting into the epidural space but at a higher level in the lumbar region dates from the beginning of the 20th century.
In 1920, the Spanish anaesthetist Fidel Pagès described segmental regional anaesthesia but died in an accident and it was the Italian Achille Mario Doglliotti who, in 1931 became the champion of the technique.
In 1884, the American surgeon William Halstedt injected cocaine around the nerve endings of an area controlled by a specific nerve. George Washington Crile anaesthetised wider areas by injecting around major nerve trunks such as the brachial plexus, and the sciatic nerve after exposing them during surgery.
In 1911, Herchel and Kulenkampff would develop the technique with the use of sometimes complicated observations: confirmation of the correct positioning of the injecting needle was done by the patient noticing a small electric shock. To improve this development, neurostimulation using small electric currents allowed identification of the muscle response of the nerve being sought. This technique was perfected after 1912 by George Perthes but was never developed at the time. It would not be until 1970 that electronic developments allowed the use of more reliable and manageable stimulators. The technique was widely – used until being replaced at the beginning of the 21st century by echography.
The adoption of different local anaesthetic techniques was facilitated by the publication of large volumes about regional anaesthesia. The first was that of Heinrich Braun in 1905 but the most important was that of the Frenchman Victor Pauchet which was followed by his pupil in America Louis Labat before being adopted by John Adriani Cavinini, a major player in the development of local anaesthesia. However, its deleterious and toxic side effects, sometimes causing fatalities during operation became apparent. The search for substitutes started at the beginning of the 20th century.
The French doctor Ernest Fourneau produced Stovaine, the first truly synthetic local anaesthetic in 1903. Two years later, the German chemist Alfred Einhorn synthesised procaine, a far less toxic compound and opened the door for a new class of local anaesthetic agents, the amino esters. It would not be until 1948 that Xylocaine (lidocaine) appeared synthesised by the Swedish Nils Löfgren which remains the most widely – used local anaesthetic in the world. It also led to the development of a new class of agents, the amino – amides which were more powerful and manageable and, importantly had a near zero risk of allergic reaction.