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A group of 10,440 patients received lidocaine for spinal anesthesia. No patient developed a major central nervous problem, such as arachnoiditis or cauda equina syndrome. Eight patients had symptoms of abducens paralysis, which disappeared before they left the hospital; 367 patients (3.5 per cent) s

Forty-three cases of medulloblastoma were reviewed to determine the survival rate and response to irradiation. Cases were analyzed for age distribution, major presenting signs and symptoms, initial diagnostic evaluation, and initial therapy. Increased intracranial pressure was found to be the most common cause of the initial symptoms. Ventriculography was the preferred diagnostic technique. Initial surgery should be performed to establish the diagnosis and the presence of CSF flow, followed by irradiation with 3,600 rads to the CNS plus 1,400 rads to the brain. Radioactive gold gives a high incidence of cauda equina syndrome and has not been shown to increase survival.

Two examples of a cauda equina syndrome in chronic ankylosing spondylitis are described with post mortem examination in 1. The posterior aspect of the lower spinal canal was found to be eroded by numerous large arachnoid cysts but arachnoid adhesions were only present above the level of these diverticula. Suggestive myelographic evidence was found of the existence of similar diverticula in the other less severely affected patient and in one earlier report. Some degenerative changes were found in the roots of the cauda equina and distinct demyelination in the medial dorsal columns of the spinal cord. The evolution of the clinical syndrome had been extremely protracted but clinical examination of 54 patients with chronic ankylosing spondylitis failed to reveal convincing evidence of progressive neurological disability. From the present evidence and a review of the literature it is suggested that both the arachnoid cysts and the cauda equina syndrome are late sequelae of arachnoiditis existing at an earlier stage of the disease. One patient presenting with paraparesis and ankylosing spondylitis was found to have multiple sclerosis and previous case reports indicate that spinal cord disease without evidence of compression is not due to the spondylitis but to some associated condition. It is recommended that further attention should be paid to Von Bechterew 's original concept of meningeal and epidural involvement in ankylosing spondylitis.

Spinal analgesia may be considered as safe as any method of pain relief, provided meticulous care is observed, common sense is exercised, and the technique is reserved for patients who want it, surgeons who desire it, and anesthetists who can perform it intelligently.

SummaryA case of herniation of the L4 - L2 intervertebral disc is described, resulting in a cauda equina syndrome with bilateral anesthesia or hypesthesia in the L5 to S5 root zones, important loss of power in the corresponding segmental musculature, and bladder distension. Painful symptoms remained unconspicuous. Contrast X-Ray picture showed spinal block at the medial level of the L4 vertebral body. Transdural approach was chosen and an upward luxated piece of spinal disc was resected. Early recovery from all symptoms except bilateral hypesthesia in the S2 - 3 root zones was obtained.

✓ A case of ankylosing spondylitis in a patient with a cauda equina syndrome is reported. A lumbar myelogram revealed erosions of the bones of the neural canal with enclosed multiple intraspinal cysts.

Nine patients, 8 with medulloblastoma and 1 with ependymoblastoma, were treated with intrathecal colloidal Au198. Six of these patients were treated for cure using a combination of surgery, total neuraxis irradiation from external sources, and the intrathecal radionuclide. Five of these patients are alive and free of disease for periods ranging from 12 to 42 months (32 months median).The cauda equina syndrome, a complication encountered in some patients treated earlier with intrathecal radiogold, appears to have been avoided with the use of a new technique. This calls for the use of smaller doses of radionuclide, and prompt cephalad flow of the radioactive material by tilting the head down immediately after instillation of the isotope.A projected long-term survival (3 years or more) of 75 per cent in a collected group of patients is encouraging.

In a review of 45 patients with ankylosing spondylitis 10 had neurological symptoms and signs and three of them had two separate neuropathological disorders. The neurological profiles fell into five main categories—multiple sclerosis, the cauda equina syndrome, focal epilepsy, vertebrobasilar insufficiency, and peripheral nerve lesions. An association between ankylosing spondylitis and multiple sclerosis is suggested, possibly due to an immunological defect or to one being a complication of the other.

As WE ENTER A NEW DECADE it is interesting to think retrospectively and consider the changes we have witnessed. Anaesthesia is becoming a clinical science. We attempt to train our younger men to be selective in the methods best adapted to meet a wide variety of clinical situations. The modern practitioner is less prone to be influenced by habit, personal preferences and expediency. Progress of this type demands a continuing reappraisal of both methods and agents. Spinal anaesthesia is one of the older techniques in our armamentarium. Since first introduced some sixty years ago, the record has been turbulent at times. A massive bibliography is now available and it can be condensed into an interesting history. Many have contributed to improvements in safety and in decreasing the factors responsible for morbidity. Others have introduced alternative conduction methods in an attempt to avoid some of the complications of spinal anaesthesia. It is important to establish an objective appraisal as a result of current knowledge. Composite experience should enable us to decide whether or not spinal anaesthesia deserves a continuing and recognized place in the armamentarium of younger men being prepared for careers as anaesthetists. Historically, spinal anaesthesia was introduced by Bier in 1898. It was ten years later that Mr. Barker, ~ a British surgeon, presented a paper to the Section of Pharmacology and Therapeutics of the British Medical Association. This was the formn for all topics on anaesthesia at that time. He described the findings following performance of lumbar puncture on nine patients two days after the administration of intraspinal Stovaine. He reported the spinal fluid to be turbid due to pleoeytosis. These findings substantiated the clinical manifestations of meningeal irritation which were encountered. This was one of the first reports of what was probably a chemical irritation produced by a local anaesthetic agent injected intraspinally. The method continued to be used for another ten years before another and more dramatic hazard began to appear. Respiratory arrest resulting from total spinal anaesthesia began to be reported as the responsible factor in many anaesthetic deaths in the early 1920s. This is now a completely preventable complication, and if it does occur we can prevent serious sequelae by artificially supporting respiratory function. However, in those days the situation was different and in 1929 an article appeared by Sise, 2 who wrote as follows: "During the past year when spinal anaesthesia has enjoyed a great wave of popularity, there have

THE EARLY MANIFESTATIONS of rectal carcinoma are frequently insidious in onset, with symptoms not directly referable to the rectum. Digital, proctoscopic and roentgen studies may fail to disclose the presence of a rectal tumor, unless these procedures are repeated (1). Anemia, weakness, weight loss, and ill-defined, non -localized bowel distress are the most common symptoms of these silent lesions. Even these complaints are not invariably present, as in the case to be described. Rectal carcinoma does not often metastasize to bone. Mayo and Schlicke found skeletal metastasis in only 1.2 per cent of a group of cases of carcinoma of the colon (2). There are no precise figures on the incidence of sacral involvement, but patients with advanced rectal carcinoma occasionally show evidence of direct extension to the sacrum and sacral nerve roots (3). The case to be presented is interesting in that the initial presenting problem was a cauda equina syndrome. The primary rectal carcinoma remained silent and unsuspec...

The narrow lumbar spinal canal syndrome is characterized by (a) constriction of the interpediculate and anteroposterior diameters of the bony canal, (b) thickening and vertical orientation of the laminae as well as thickening of the facets and pedicles, (c) difficult, often markedly uncomfortable lumbar puncture, (d) prominence of the defects caused by relatively small extradural lesions, with varying degrees of obstruction, and (e) sharp delineation of the nerve roots of the cauda equina. The “cauda equina syndrome” and intermittent neurogenic claudication may be observed. Thirty-three cases are reviewed, with emphasis on diagnostic criteria, myelographic appearance, and clinical aspects.

A rare case of sacral extradural cyst is reported. Symptoms included postural faimings and cauda equina compression. They were attributed to sudden escape of CSF into the cyst through a communication

This paper draws attention to the poor prognosis for complete recovery of function in some patients with cauda equina syndrome due to compression by prolapse or extrusion of lumbar disk. The study of a comprehensive group of these patients in a neurological centre brings out two important points (1) the relative ease of arriving at an early diagnosis ; and (2) that early operation is an essential prerequisite for improvement in prognosis.

A critical evaluation of spinal anesthesia was made by studying the records of 8,460 patients who received 10,098 injections of spinal anesthetics; this group was compared with a group of 1,000 persons who received general anesthetics for the same types of operations and with 100 persons who received spinal anesthetics after induction with general anesthetics. No instance of adhesive arachnitis, transverse myelitis, or cauda equina syndrome was found, but neurological complications occasionally resulted from lumbar puncture per se. Two cases are described in which various persistent symptoms and disabilities followed unsuccessful attempts at administration of spinal anesthetics; in 17 other cases of difficult lumbar puncture paresthesias and other complaints occurred after the successful injection of the anesthetic. In spinal anesthesia proper selection of patients is essential, and lumbar puncture, whether for purposes of diagnosis or anesthesia, must be performed with meticulous attention to certain well-known details of technique.

The authors give the following picture of the disease: the disease begins with pain in the lower back, thigh and sciatic area with motor disorders and sphincter disorder: during full development, there is pain of tabetic and sciatic neuralgia character, accompanied by paralysis, muscle atrophy, radicular sensitivity disorders, changes in electrical excitability and disappearance or weakening of tendon reflexes.

In describing his technic of the subarachnoid injection of alcohol for intractable pain, Dogliotti 1 warns against possible sequelae, particularly of injury to the cauda equina. Transient bladder and bowel embarrassment following lumbar sac injection is mentioned by those who are familiar with this procedure. A recent report by Sloane 2 described the permanent relief of pain, but sphincteric disturbances which had developed had been persisting for eight months when the report was made. In the two cases described in this paper, very transient relief was afforded from the pain for which Dogliotti's treatment was used. On the other hand, the bladder disturbances have persisted for over a year in one case and for the entire period of observation (eight months) in the second case. Furthermore, it is of significance that although the lesion produced by the alcohol was unilateral, there nevertheless resulted a profound urinary incontinence. REPORT OF CASES

The occurrence of the cauda equina syndrome with long-standing ankylosing spondylitis is a little-known association that may be overlooked or misdiagnosed. Three patients are reported and ...

To the Editor:— In connection with the paper of Drs. Nicholson and Eversole on "Neurologic Complications of Spinal Anesthesia" (The Journal, Nov. 23, 1946), the following case seen in an Army hospital in 1943 may be of interest: A Negro aged 30 had undergone an appendectomy about three months prior to the time I saw him. The operation was performed under spinal anesthesia, and metycaine (dose unknown) was used. Because the anesthetic would not take, a second dose of the same drug was introduced into the spinal canal and the operation successfully completed. The postoperative course was complicated by a slowly improving cauda equina syndrome. There was a complete paralysis of the lower extremities for about three days; urinary difficulties were reduced to mere hesitancy by the time the patient came under my observation. Hyperreflexia and sensory changes also were present. The interesting feature of this case was the presence