Hutter C D
University Hospital, Queen's Medical Centre, Nottingham.
Anaesthesia. 1990 Oct;45(10):859-64. doi: 10.1111/j.1365-2044.1990.tb14573.x.
In 1953, two patients, Cecil Roe and Albert Woolley, sued their anaesthetist for alleged negligence because they had developed painful spastic paraparesis after spinal anaesthesia. The court found that phenol, which was used to sterilise the outside of the ampoules of local anaesthetic, had percolated the glass through invisible cracks, contaminating the solution, but that the anaesthetist could not have been aware of this risk. The case was important, despite the fact that judgement was in favour of the anaesthetist, because of the fears that it generated over the incidence of paralysis after spinal anaesthesia. The 'invisible crack' theory has been the subject of much scepticism. New information has been obtained, and the case re-examined objectively. The most probable source of contamination, which led to paralysis in the two patients, and in a third who received spinal anaesthesia on the same day, has been identified. A similar explanation may lie behind a number of other episodes of paralysis associated with spinal anaesthesia.
1953年，两名患者塞西尔·罗伊（Cecil Roe）和阿尔伯特·伍利（Albert Woolley）起诉他们的麻醉师玩忽职守，因为他们在脊髓麻醉后出现了疼痛性痉挛性截瘫。法院认定，用于对局部麻醉剂安瓿外部进行消毒的苯酚通过肉眼看不见的裂缝渗透到玻璃中，污染了溶液，但麻醉师不可能意识到这种风险。尽管判决有利于麻醉师，但该案件仍很重要，因为它引发了人们对脊髓麻醉后瘫痪发生率的担忧。“看不见的裂缝”理论一直备受质疑。现已获得新信息，并对该案件进行了客观重新审视。导致这两名患者以及同一天接受脊髓麻醉的第三名患者瘫痪的最可能污染源已被确定。与脊髓麻醉相关的其他一些瘫痪事件背后可能也有类似的解释。
