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SOME COMPLICATIONS OF CAUDALANESTHESIA AND THEIR

MANAGEMENT

THOMAS G. GREADY Jr., M.D.CHICAGO

Recently there has been comparatively widespreadand in some instances indiscriminate use of continuouscaudal anesthesia in obstetrics. To prevent serious acci-dents, some of the hazards and the methods of pre-venting and combating them should be reemphasized.

As more data are accumulated, one learns of com-plications which might have been prevented had theproper safeguards been taken. Some of the complica-tions presented followed the single injection rather thanthe continuous administration of the anesthetic. How-ever, the same principles apply to the two groups.

In a series of 121 cases of caudal anesthesia at theChicago Lying-in Hospital there have been no deaths,either maternal or fetal. However, some interestingreactions have occurred, the most frequent being a dropin blood pressure. Our incidence of failures is 16 percent.

SUBDURAL INJECTION

Most serious and dangerous of the complications isthat of injecting the solution into the subarachnoidspace, and it has only been recently that precautionsother than simple aspiration have been taken to preventthis accident.

While no deaths have been reported due to thiscomplication since the introduction of continuous caudalanesthesia, there have been serious accidents, and in1920 Zweifel1 reported a series of 4,200 single caudalinjections with 10 deaths, 3 of which were attributedto the anesthesia, an incidence of 1 in 1,400. All 3deaths occurred within a few minutes of

respiratoryfailure, and in connection with 2 of them puncturesin the dura were demonstrated at autopsy. The thirdwas not investigated and was ascribed to acute procainepoisoning. About three years ago a similar accidentwas observed by Eastman.2 In approximately the onehundredth case of single dose caudal anesthesia in theobstetric service at Johns Hopkins Hospital a deathoccurred due to injection of 45 cc. of 1 per cent procainehydrochloride into the subarachnoid space althoughthe usual precaution of aspiration was carried out.Chemical analysis of the spinal fluid post mortemshowed lethal concentration of procaine.

My associates and I have observed perforation of thedura once in our series of 110 cases. In this instance the

needle was introduced into the caudal canal and onaspiration no spinal fluid was obtained. According tothe routine advocated by Hingson and Edwards 3 andGready and Hesseltine 4 a test dose of 8 cc. of a 1.5 percent solution of metycaine hydrochloride (120 mg.)was injected and ten minutes allowed to elapse. (Theimportance of this simple precaution cannot be toostrongly emphasized.) At the end of ten minutes thepatient had almost complete paralysis of the dependentextremity but was still able to move the toes on the

opposite foot. In another two minutes there was complete motor paralysis of both lower extremities, whileon the abdomen the anesthesia had risen to the levelof the third thoracic segment. Since no spinal fluid wasobtained by aspiration, it is apparent that had the precautionary measure of waiting ten minutes before injecting the 30 cc. dose not been taken the procedure wouldhave resulted in massive

spinalanesthesia

(approximately 450 mg. in 30 cc), which probably would havebeen fatal.

Block and Rochberg 5 report 1 case out of a seriesof 39 in which massive spinal anesthesia occurred. Intheir case 30 cc. of a 1 per cent solution of procainehydrochloride had been given. Fortunately the patientsurvived after a prolonged period of artificial respiration.

Small6 reported a similar case of possible massivesubdural injection in spite of careful precautionarymeasures. He employed the continuous drip technic.Respiratory failure also developed.

Another such case has been brought to my attentionby Brown.7 In this instance a single caudal injectionhad been made for a proposed cesarean section. Thepatient survived spinal anesthesia high enough to causeboth respiratory and vocal paralysis. These near catastrophic results illustrate the importance of combiningpreliminary aspiration with a suitable test for subarachnoid injection. Hingson and Edwards 3 reportedthat perforation of the dura had occurred only twicein more than 1,000 injections.

The best treatment for this unwelcome accident isprevention, and the test dose I believe is the best methodavailable to avoid a massive subdural injection. It isfurther recommended that a test dose of 5 to 8 cc. berepeated ten minutes prior to each subsequent injection.This is especially important when the needle technic

is used, since the needle may pierce the dura at anytime during the procedure. This apparently occurredin the case reported by Small.

A thorough knowledge of the normal anatomy of notonly the bony sacrum and sacral canal but also the duraisac and spinal cord is important and indeed fundamentalif one is to administer caudal anesthesia intelligentlyand safely. The spinal cord normally ends at the levelof the first lumbar vertebra, with the durai sac containing spinal fluid and the cauda equina tapering toa point in the sacral canal at the level of the secondsacral vertebra. The contour of the lower end of thedurai sac is not constant but varies with straining,

jugular compression and other forces, as has beenshown by x-rays after introduction of opaque substances. The sacral canal is continuous with the epi-dural space in the vertebral canal and extends all theway to the foramen magnum. Anatomic variations inthe sacrum are common and may at times interferewith the proper insertion of the needle.

The important fact that the durai sac may extendlower than the second sacral vertebra should be keptconstantly in mind. If the patient is thin and thesacrum short, the use of a 2J4 inch rather than a 3 inchneedle lessens the danger of perforating the dura. Thiscomplication also seems less likely when the cathetermethod is used. There is a continuation of the duraaround each of the nerves in the sacral canal for avariable distance, as can be seen in the illustration.

Eli Lilly & Co. furnished the metycaine used in this study.Dr. William J. Dieckmann and Dr. H. Close Hesseltine gave helpful

criticism of the manuscript.From the Department of Obstetrics and Gynecology of the University

of Chicago and the Chicago Lying-in Hospital.1. Zweifel, E.: Die Todesf\l=a"\lle bie Sakralan\l=a"\sthesie, Zentralbl. f.

Gyn\l=a"\k.44: 140, 1920.2. Eastman, Nicholson J.: Personal communication to the author.3. Hingson, R. A., and Edwards, W. B.: Continuous Caudal Anes-

thesia in Obstetrics, J. A. M. A. 121:225 (Jan. 23) 1943.4. Gready, T. G., and Hesseltine, H. C.: Continuous Caudal Anes-

thesia in Obstetrics, J. A. M. A. 121:229 (Jan. 23) 1943.

5. Block, Nathan, and Rochberg, Samuel: Continuous Caudal Anes-thesia in Obstetrics, Am. J. Obst. & Gynec. 45: 645 (April 1) 1943.

6. Small, M. J.: A Serious Complication of Caudal Anesthesia, J. A.M. A. 122:671 (July 3) 1943.

7. Brown, Hugh O.: Personal communication to the author.

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It is theoretically possible for the point of the needleto pierce this durai sheath, thus permitting the injectedsolution to dissect up into the subarachnoid space. Sucha puncture of this nerve sheath and subsequent injection may cause pain and so give some warning.

Should the recommended precautions be disregardedand massive spinal anesthesia occur, treatment shouldbe instituted immediately. The patient should be supported in a sitting position, and a lumbar punctureshould be done

usinga

largeneedle so that the

fluidwill flow rapidly. Walker 8 recommends that approximately 100 cc. of spinal fluid be withdrawn. The flowcan be hastened by compression of the jugular veins

Diagram showing the relationship of the durai sac and cord to the epdural spaceand to the sacral and the vertebral canal (after Toldt, Karl: Atlas of Human Anatomy,New York, Macmillan Company, 1926).

in the neck. Forced drainage may also be accomplished by giving 0.45 per cent saline solution intravenously while the lumbar puncture needle is in place.Hypertonie dextrose solution would decrease the amountof spinal fluid and thus retard drainage. It is extremelymportant that the fluid be drained off before the dru

has reached the vital centers in the brain. Even thoughthe respiratory center is anesthetized, the method shouldstill be tried in order to prevent involvement of thevasomotor center, which is at a higher level. Drop inblood pressure and shock are combated in the usualmanner with ephredine, stimulants and intravenouslyinjected fluids, such as plasma. Respiratory paralysismust be treated by artificial respiration. The presenceof a physician anesthetist skilled in the art of intubationand resuscitation might prove life saving, as it undoubtedly did in 2 of the cases reported.

INFECTION

Because its appearance is usually delayed, infectionis sometimes overlooked as a complication of caudalblock. It ranks second in importance to massive spinalanesthesia. It may occur either in the tissues outsidethe sacral canal or in the epidural space. The latteris more serious because of its proximity to the cordand nerves of the spinal and sacral canal. It maybe extremely dangerous and even cause death. Thatthe

epidural space is muchmore

susceptible to infectionthan the subarachnoid space is suggested by experiments on monkeys. Cultures of virulent organismswere injected directly into the spinal fluid without

causing any evidence of inflammation.9Edwards and Hingson 10 recently reported

a death from infection in a series of 650obstetric cases. An epidural abscess developed with which there were no localizingsigns or neurologic manifestations. Thepatient was treated with sulfonamides butdied on the thirty-first postpartum day. Postmortem examination revealed multiple smallpulmonary abscesses and a large abscess

involvingthe

peridural space andcommuni

cating through the foramina with a subpsoasabscess. The infection had not penetratedthe meninges.

Carlisle ' ' reported a death following continuous caudal anesthesia of a patient aged70. After laparotomy a large necrotic,sloughing ulcer developed over the sacrumwhich extended to the bone. Death on thetwentieth postoperative day was believed tohave been due to this infection. However,since autopsy was not permitted it is notknown whether or not the epidural space orthe meninges were involved.

Siever and Mousel 12 in their series of 300

cases had 1 case of epidural abscess. Theyreport "the patient was seriously ill for threeweeks but responded to large doses of sulfonamide compounds and completely recovered."

Manalan 13 reported staphylococcic meningitis occurring after 1 of 46 single caudalinjections made with the catheter technic.On the third postpartum day symptoms ofmalaise, headache and hyperirritability developed. No local infection in the sacral canalcould be determined by aspiration. The statement is made that "she recovered completely

following a critical illness." The complication wasbelieved to have been due to sacral block, but this wasnever proved.

In 1927, following an attempt at sacral block, Hall "reported a death from gas bacillus infection. South-worth, Edwards and Hingson15 reported low gradecellulitis about the sacral hiatus in 1 case in a seriesof 255.

8. Walker, A. Earl: Personal communication to the author.

9. Walker, A. Earl: Unpublished data.10. Edwards, W. B., and Hingson, R. A.: The Present Status of Con-

tinuous Caudal Analgesia in Obstetrics, Bull. New York Acad. Med. 19:507 (July) 1943.

11. Carlisle, William T.: Personal communication to the author.12. Siever, James M., and Mousel, L. H.: Continuous Caudal Anes-

thesia in 300 Unselected Obstetric Cases, J. A. M. A. 122:424 (June12) 1943.

13. Manalan, S. A.: Caudal Block Anesthesia in Obstetrics, J. IndianaM. A. 35: 564, 1942.

14. Hall, L. S.: Report of a Case of Septicemia Following a SacralAnesthetic, Am. J. Obst. & Gynec. 14:256 (Aug.) 1927.

15. Southworth, J. L.; Edwards, W. B., and Hingson, R. A.: Con-tinuous Caudal Analgesia in Surgery, Ann. Surg. 117:321 (March)1943.


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The principal etiologic factor in this type of case isobviously faulty technic. Extreme care should be takenin the sterilization of the apparatus and in the preparation of the solution. The site for injection normallyis not the cleanest part of the body, situated as it isclose to the anus. It should be as thoroughly cleanedand prepared as for a major surgical procedure. Rigidasepsis is of the utmost importance. If the needle

technic is used, the only bactriologie weak point inthe equipment once the tubing is connected is theplunger of the syringe. Since the anesthesia is sometimes carried out over a period of hours, it is not atall improbable that during one of the many injectionsthe plunger may be accidentally contaminated and then,on a subsequent injection, bacteria may be introducedinto the sacral canal.

Symptoms of, epidural abscess at first are those ofsystemic infections in general, such as malaise, feverand leukocytosis. According to textbooks,16 the symptom which first focuses attention on the spinal regionas the site of infection is usually pain in the back, whichmay be exaggerated by coughing, sneezing, jugular compression or movement of the spinal column. Therealso may be tenderness over the spine in the regionof the abscess. Radicular pains at the site of the abscessare common, and there may be hypesthesia or numbness in the dermatome supplied by the nerve rootsinvolved. If the abscess is situated in the Lumbarregion, spinal puncture should not be done becauseof the danger of penetrating the abscess with resultantcontamination of the subarachnoid space. Bagley andhis co-workers l6 recommend surgical drainage as soonas the diagnosis of abscess is established. This oftennecessitates laminectomy. Accessory measures, suchas the use of sulfonamides, blood transfusion and theinjection of a specific antitoxin, should be

employed.Siever and Mousel12 treated their patient with sulfonamides alone. She survived. The help of a competentneurologist may be of much value in locating the siteof infection.

Local infection about the site of injection does notpresent such a problem as infection in the epiduralspace. There the management is the same as for othersuperficial infections. In our series so far we havehad no infection of the epidural space-nor have we hadany local infection of the skin.

INTRAVENOUS INJECTIONIntravenous injection of the drug is another com

plication which cannot always be avoided. The minimum lethal

intravenous dose of procaine in animals hasbeen found to be one-tenth the amount necessary tokill the animal if given subcutaneously.17 Preliminaryaspiration must always be carried out to minimize thisdanger. If blood is obtained the position of the needlemust be changed until blood can no longer be aspirated,and then the injection should proceed slowly and expectantly. We have had 1 case in which this complicationoccurred. In this instance no blood appeared on preliminary aspiration, and with the patient in the knee-chest position the 8 cc. test dose was administered. Thepatient was then turned on the left side. In ten minutes

25 cc. of a 1.5 per cent metycaine hydrochloride solutionwas injected. The patient immediately became irrational, talked incoherently and underwent mild clonk-convulsions of both upper and lower extremities. Slightopisthotonos was present. This reaction lasted abouttwo minutes and disappeared spontaneously beforetreatment could be instituted. We are certain that thefluid went intravenously for three reasons: (1) Theneedle and approximately 1 foot of the pressure tubingwas found to be filled with blood; (2) absolutely noanesthesia developed although a total of 33 cc. of thedrug solution was injected; (3) the needle was reinserted and the caudal anesthesia carried out successful])and without reaction for the remainder of the labor.Possibly the 5 patients reported by Lahmann andMietusIR as becoming "irrational" and developing"clonic convulsions" received a certain amount of thedrug intravenously. In these cases the reactions alsopassed off in a few minutes without serious effect.Cases are on record, however, in which intravenousinjection of procaine has proved fatal. The toxicityfrom these drugs can be due to three factors :

(1

)rapid absorption. (2) intravenous injection and (3)idiosyncrasy. In richly vascular areas, such as theepidural space, rapid absorption is likely to take place.

Treatment for the condition is more or less specificand is the same as that for an overdose of the drug.The excellent work done on the toxicity of cocaine.by Tatum, Atkinson and Collins,19 using rabbits anddogs, proved that the various barbituric acid derivatives are of distinct value both in prophylaxis and intreatment. They showed that the prophylactic administration of a mixture of barbital sodium and paralde-hyde to the dog raised the minimum lethal close from26.7 mg. per kilogram to above 100 mg., representing

approximatelya fourfold increase in tolerance. In

severe reactions due to overdosage death may occurfrom either paralysis of the heart muscle or respirator}paralysis during a convulsion. It is imperative thatrespiration be maintained, by artificial means if necessary. One of the quick acting barbiturates, such asevipal sodium or pentothal sodium, should relieve theconvulsions immediately. When caudal anesthesia isused, it is wise to have one of these drugs readily available. In our case the reaction had disappeared by thetime the drug was prepared for administration; so itwas not given. Since the barbiturates counteract theuntoward effects of the local anesthetic, the administration of one of them is indicated as preoperative medication when this type of anesthesia is to be used.

Rapid absorption may be delayed by the addition ofepinephrine to the solution.

IDIOSYNCRASY

Sensitivity to locally employed anesthetic drugs mayoccur, one of the most dangerous types being thatmanifested in the anaphylactic reaction. Every patientshould be questioned prior to the initial injection asto a history of allergy and especially as to previousreactions to these drugs. Practically every patient hashad a tooth pulled at one time or another under localanesthesia. If a reaction occurs, its management shouldbe the same as for any other anaphylactic reaction,namely the immediate hypodermic administration of

16. Bagley, J.; Grant, F. C., and Horrax, G.: Infections of theNervous System and Its Coverings in Neurosurgery and Thoracic Sur-gery: Prepared and Edited by the Subcommittee on Neurosurgery andThoracic Surgery of the Committee on Surgery of the Division of MedicalSciences of the National Research Council, Philadelphia, W. B. SaundersCompany, 1943, chapter 5.

17. Gliman, S.: The Treatment of Dangerous Reactions to Novocain,New England J. Med. 219:841 (Nov. 24) 1938.

18.

Lahmann,A.

H.,and

Mietus, A. C.: Caudal Anesthesia: Its Usein Obstetrics, Surg., Gynec. & Obst. 74:63 (Jan.) 1942.19. Tatum, A. L.; Atkinson, A. J., and Collins, K. H.: Acute Cocaine

Poisoning; Its Prophylaxis and Treatment in Laboratory Animals,J. Pharmacol. & Exper. Therap. 26:325 (Dec.) 1925.


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epinephrine hydrochloride. Convulsions, should theyoccur, are controlled by using barbiturates intravenously, care being taken not to give an overdose.

INJURY OF NERVE ROOTS

Judging from the paucity of reports in the literature,injury of the nerve roots in the caudal canal does notoften occur. I report some observations from a case

which occurred in Hawkins's20

practice in Chicago :With the needle technic, continuous caudal anesthesia was

maintained for nine and one-half hours. A total of 215 cc.of a 1.5 per cent metycaine hydrochloride solution was given.On the second postpartum day the patient complained of painin the region of the sacrum, tingling and numbness of the leftgreat toe and anesthesia of the perineum. When the patientwas allowed to be up, she continued to have saddle anesthesiaand complained of numbness and burning in the region of thegreat toe. Her gait was definitely affected, with a tendencyto place the right foot forward, much like a tabetic patient.Two months later she was again seen by a neurologist, whoreported "There is slight difficulty in hopping on the rightfoot, and she can walk on her toes better than on her heels ;gait and station are not otherwise affected. There is rather

marked weakness of the anterior tibial and peroneal muscleson the right side and of extension of the toes. There is slightweakness of the muscles of the right calf and of plantar flexionof the feet and toes. Some impairment to pinprick was presentover the right foot, on both dorsal and plantar surfaces. Therewas also slight hypesthesia to pinprick in the saddle areabilaterally. This patient presents evidence of injury to thefourth and fifth sacral roots bilaterally and to the first sacraland fifth lumbar roots on the right side."

From the history, improvement was taking place and theprognosis for ultimate recovery was believed good.

BREAKING OF THE NEEDLE

The complication of a broken needle has not yetoccurred in our series, although of necessity we have

used some needlesmore

than five times. Hingson andEdwards 21 reported 12 cases of broken needle out ofa series of 850. In 4 instances a small incision wasnecessary for removal. Their last 250 consecutive procedures were done without a break. Block and Rot-stein

--

were unable to remove a broken needle fromthe canal, so they left it in place.A broken needle should be removed immediately lest

it migrate farther into the sacral canal and becomeinaccessible.

Cathelin 23 reported a case in which the needle fragment was recovered from the body of the fourth lumbar vertebra at autopsy six months later, and Meekerand Scholl,2'4 a case in which removal of the posterior

wall of thesacrum was

necessary torecover

the needle.The incidence of this complication has been considerably reduced since the development of the malleableneedle and catheter technic. The danger can be stillfurther minimized by keeping the patient on her sideduring labor and then giving an injection and removingthe needle just before she is placed on her back fordelivery. It is suggested that the needle not be withdrawn until the obstetrician is certain that the cervixis completely dilated and the patient ready for delivery.

CHANGES IN BLOOD PRESSURE

Mild and severe vasomotor reactions developed moreoften than has been reported by most investigators.Shaw 25 in 1925, however, using the single injectionmethod in urologie practice, described changes similarto those which my associates and I have observed.

The relaxation of a patient in labor, after the pains

have been relieved and the anxiety has subsided, usuallycauses a slight fall in blood pressure. Fifteen patientshad slight chills and complained of having the "shakes"but not being cold. Such complaints represent a mildvasomotor or toxic reaction. Preliminary administration of a barbiturate may prevent it. In our groupof cases there were 27 with a drop of more than 20 mm.in systolic pressure. Usually such a change is associatedwith a feeling of faintness, fatigue and sweating. Theface is pale and the pulse weak. Increased respiratoryexcursion may indicate mild air hunger. One patientcomplained of severe substernal pain. All the largerchanges in blood pressure occurred in patients in whomthe level of anesthesia was at or above the umbilicus.

The changes undoubtedly were due to splanchnic dilatation as the visceral sympathetic fibers were blocked.Of 39 patients with an anesthetic level at or abovethe umbilicus, 26 showed drops of more than 20 mm.Two patients definitely had shock reactions, the systolicpressure dropping to zero from 158/110 and 90/60respectively. In 2 instances slowing of the fetal heartrate was noticed during the period of lowest pressure.Every one of these patients responded to ephedrinesulfate administered hypodermically and oxygen inhalations. In 19 patients the anesthesia was pushed to ahigh level in preparation for cesarean section. The dropin blood pressure could have been minimized in this

group by preliminaryadministration of

ephedrine.Patients with severe heart disease probably would nottolerate the increased cardiac load associated with largedrops in blood pressure.

Control of dosage to prevent too high a level ofanesthesia should eliminate this reaction in most patientsduring labor. The semi-Fowler position or elevationof the head of the bed tends to keep the anasthesiaat a low level, whereas the Trendelenburg positionfavors an ascending level. Possibly the addition ofepinephrine to the solution would also prevent largedrops in pressure.

ANTESACRAL INJECTIONS

Owingto variation in the type of sacrum and in

angulation of the coccyx it is possible in difficult casesto penetrate the sacrococcygeal joint or the tissue lateralto it so that the point of the needle comes to rest onthe anterior surface of the sacrum close to the rectum.This has occurred twice in our series. In both casesthere was difficulty in identifying the sacral hiatus.One of the patients had evidence of ricketts. In casesin which the anatomy is obscure, preliminary rectalexamination with palpation of the sacrococcygeal jointis helpful in preventing this error. If the infant's headis low, it is conceivable that the rectum flattened againstthe sacrum may be penetrated. The accident occursmore frequently with beginners and in most instances

representscarelessness.

20. Hawkins, Robert J.: Unpublished data.21. Hingson, R. A., and Edwards, W. B.: Comprehensive Review of

Continuous Caudal Analgesia for Anesthetists, Anesthesiology 4: 181(March) 1943.

22. Block, Nathan, and Rotstein, Morris: Continuous Drip CaudalAnesthesia in Obstetrics, J. A. M. A. 122: 582 (June 26) 1943.

23. Cathelin, F.: Les injections epidurales par ponction du canalsacr\l=e'\et leurs applications dans les maladies des voies urinaires, Paris,J.-B. Balli\l=e`\re & fils, 1903, p. 231.

24. Meeker, W. R., and Scholl, A. J.: Sacral Nerve Block Anesthesia,Ann. Surg. 80:739 (Nov.) 1924.

25. Shaw, E. C.: Epidural Anesthesia for Perineal Prostatectomy: AnExperimental and Clinical Study with Report of One Hundred Consecu-tive Cases, J. Urol. 15:219 (March) 1926.


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COMPARISON OF METHODS WITH REFERENCE

TO COMPLICATIONS

Two principal methods are advocated for this type ofanesthesia, the malleable needle technic originated byHingson and Edwards and the catheter modificationdescribed by Adams, Lunde and Seldon 26 and Man-alan.13

Sincewe

have used only the malleable needle technic,we do not have two series to compare; however, logically, different methods are devised because they avoidcertain complications.

The advantage of the catheter technic aside from thefact that it allows greater freedom of movement on thepart of the patient is that there is less danger of perforation of the dura or a blood vessel once the needleis withdrawn over the catheter. Three disadvantagesare apparent : ( 1 ) There is more trauma associatedwith the introduction of the 13 gage needle; (2) thistrauma naturally increases th risk of infection; (3)the number of failures should be increased, owing tothe difficulties involved in the insertion of the large

needle insome

patients.With use of the needle technic the complicationswhich are increased in number are (1) the perforationof the durai sac after the needle is in place with subsequent intraspinal injection, (2) the broken needle and(3) the possible trauma inside the canal if the needleis manipulated by the patient moving about on her back.

The development of a smaller useful catheter whichcan be threaded through a 16 gage needle should combine the advantages of the two methods with resultingincreased safety.

DO NERVES BECOME REFRACTORY TO LOCAL

ANESTHETIC DRUGS?In general, we have noticed some difficulty in main

taining the effect of the anesthetic that is used overa long period of time. This same observation has beenmade by Wall '" and may be due to malposition ofthe needle. However, the thought has occurred to usthat possibly the nerve roots may become refractoryto the action of the drug after prolonged anesthesia.We have noticed this phenomenon in 3 cases in whichwe felt certain that the needle had not become dislodgedfrom its proper place in the caudal canal.

Rgnier and Lambin 28 noticed a disappearance of theanesthetic action of dilute solutions of cocaine hydrochloride after prolonged instillation of these on thecornea of the rabbit. The possibility of this occurringin peripheral nerves should be investigated.

5841 Maryland Avenue.26. Adams, R. C.; Lunde, J. S., and Seldon, T. H.: Continuous

Caudal Anesthesia or Analgesia, J. A. M . A. 122: 152 (May 15) 1943.27. Wall, David: Personal communication to the author.28. R\l=e'\gnier,J., and Lambin, S.: Sur la disparition de l'action anes-

th\l=e'\siquede solutions de chlorhydrate de cocaine en contact prolong\l=e'\avecla surface \l=a`\anesth\l=e'\sier.Essais sur la corn\l=e'\edu lapin, Anesth. et analg.4:497 (Nov.) 1938.

First Description of Pulmonary Circulation.Aroundthe middle of the thirteenth century an Arabic physician, Ibnan-Nafs, described the pulmonary circulation. This is theearliest description we know, and its rediscovery has put anend to the claims for priority of either Michael Servetus (1553)or Realdus Columbus (1559). However, it is not probable thatServetus knew of his Arabic predecessor, nor has any historical link been established between Ibn an-Nafis and Columbus.

Whether,on

the other hand, any connection existed betweenServetus and Columbus is a question still open for debate.Larkey, Sanford V., and Temkin, Owsei, in Essays in Biology,Berkeley, University of California Press, 1943.

DEFINITIVE TREATMENT OFSEVERE WOUNDS

LARGE SURFACE TO SMALL AREA

COLONEL JOHN L. GALLAGHERMEDICAL CORPS, ARMY OF THE UNITED STATES

It is generally understood that the first aim in thepractice of surgery and medicine is to get the patientthrough an ordeal alive, at all times keeping him atthe greatest possible distance from the possibility ofdeath. From the surgical standpoint this aim is achievedwhen the patient arrives at the hospital as a good risk.Yet often the traumatic patient arrives at the hospitalin extreme shock, even irreversible shock, when if ade-quate first aid had been given promptly after injuryhe would have arrived at the hospital in good physicalcondition. For example, a patient arrives practicallyexsanguinated by profuse hemorrhage from an other-wise minor wound, the hemorrhage from which couldhave been readily controlled by a compression dressing.Similar mischances are usual in all forms of injurieswhether they are surface wounds involving extensiveareas of the body, crushing injuries of moderate areasor severed blood vessels in small area wounds.

The medical profession has made great strides inthe care of these patients at the hospital, but it is mybelief that a great deal more can be done for patientswith traumatic injuries during the critical period fromthe time of injury to the time of admission. Sincethe care of the patient prior to admission to the hospitalis in the hands largely of nonprofessional and onlybriefly trained persons, treatment must be outlinedwhich will be simple in procedure but most effective infunctional result. This prehospital treatment shouldbe such that its principles will be carried on into andthrough hospitalization. It is to this goal that thepresent paper is directed.

To illustrate my meaning better, a number of casesare presented :

Approximately one year ago 22 men were working in a building about 20 by 30 by 10 feet. This building became filled withgasoline fumes, which ignited, resulting in a violent explosionfollowed by a total fire. Two men were blasted from thebuilding through the only door, one of them receiving a seconddegree burn forming a 4 inch band around the lower thirdof the left leg. Otherwise there was no injury to these 2 men.The negative pressure created by the blast slammed the doorshut. The inside of the building became entirely aflame, andthe 20 men remaining in the building received fatal or serious

flash type as well as slow type burns. It was not possiblefor any of the remaining men to get out of the building untilthe fire department arrived, broke in the door and had thefire under control. In the following confusion 2 of the severelyburned victims slipped out of the building, ran to a smallhospital 3 blocks distant, went into irreversible shock and diedwithout responding to shock treatment. Four were dead whenfound, and 2 died immediately after reaching the hospital.Except for the 2 men who ran from the building, the patientswere placed on litters and conducted to the hospital by ambulances. This particular hospital had only one operating roomand an emergency treatment room, necessitating the use ofimprovised operating rooms.

In accordance with hospital rules, all attendants immediatelytook cap, mask and gown precautions and by medical officers'orders gave every patient Yz grain (0.032 Gm.) of morphine

sulfate subcutaneously. The dead, dying and critically injuredpractically filled the hallway of the small hospital where theyhad been placed by the ambulance crews at the direction ofthe attending surgeon. The stench of the burned human flesh


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