Matsuki A
Department of Anesthesiology, University of Hirosaki School of Medicine.
Masui. 2000 Jun;49(6):686-92.
A famous medical accident that is widely known as Woolley and Roe case occurred on Oct 13th, 1947 at the Chesterfield Royal Hospital, England. The patients Albert Woolley and Cecil Roe underwent minor operations under spinal anesthesia using cinchocaine to develop spinal cord myelopathy with paralisis of bilateral legs. Both patients sued Dr James M. Graham, the anesthetist, and the Ministry of Health. Seven years later, Dr Graham and the Ministry of Health were given a verdict of not guilty, because three judges unanimously accepted the phenol theory proposed by a witness Prof Macintosh of Oxford University. He allged that phenol entered into the ampoule of cinchocaine through invisible cracks. Thus the plaintiffs were not compensated. Recentry Dr Hutter of Nottingham University found no validity of phenol theory and also no possibility of invisible cracks. Syringes and needles for spinal anesthesia were used to be sterilised by water-boiling steriliser, and mineral acid was used for descaling the deposition of line at that time. Dr Hutter concluded that the severe spinal myelopathy occurred both in Woolley and Roe would have been caused by mineral acid which was conveyed into their subarachnoidal space by acid-contaminated syringes and needles.