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 Hadzic’s Textbook of
Regional Anesthesia and
Acute Pain Management
Self-Assessment and Review

Hadzic_FM_p00i-pxx.indd 1 22/04/19 6:40 PM

 NOTICE
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 Hadzic’s Textbook of
Regional Anesthesia and
Acute Pain Management
Self-Assessment and Review

Editor

Admir Hadzic, MD, PhD

Professor of Anesthesiology
Consultant, Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy
Ziekenhuis Oost-Limburg
Genk, Belgium
Director, NYSORA, The New York School of Regional Anesthesia
New York, New York

Assistant Editor

Angela Lucia Balocco, MD

Anesthesiologist
Research Fellow
NYSORA, The New York School of Regional Anesthesia
New York, New York

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto

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Copyright © 2019 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States
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 This book is dedicated to all students of anesthesiology and regional anesthesia and acute pain medicine.

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 Contents

Contributors............................................................................................ xi 16 Local Anesthetics, Regional Anesthesia,

Preface...................................................................................................xvii and Cancer Recurrence .................................................65
17 Perioperative Regional Anesthesia and
Acknowledgments.............................................................................. xix
Analgesia: Effects on Cancer Recurrence and
Survival After Oncological Surgery ............................71
PART 1 History 1
1 The History of Local Anesthesia.................................... 3
PART 3 Clinical Practice of Regional
Anesthesia 75
PART 2 Foundations of Local and
Regional Anesthesia 5 PART 3A Local and Infiltrational
Anesthesia 75
SECTION 1 A NATOMY AND HISTOLOGY OF
PERIPHERAL NERVOUS SYSTEM 18 Intra-articular and Periarticular Infiltration
of Local Anesthetics ......................................................77
AND NEURAXIS 5 19 Regional and Topical Anesthesia for
2 Functional Regional Anesthesia Anatomy.................. 7 Awake Endotracheal Intubation .................................81
3 Histology of the Peripheral Nerves and
Light Microscopy............................................................11 PART 3B Intravenous Regional Block for
4 Connective Tissues of Peripheral Nerves...................15 Upper and Lower Extremity 85
5 Ultrastructural Anatomy of the Spinal
Meninges and Related Structures...............................17 20 Intravenous Regional Block for Upper
and Lower Extremity Surgery .....................................87
SECTION 2 PHARMACOLOGY 21
PART 3C Neuraxial Anesthesia 91
6 Clinical Pharmacology of Local Anesthetics.............23
7 Controlled-Release Local Anesthetics .......................27 SECTION 1 SPINAL ANESTHESIA 91
8 Analgesic Adjuvants in the Peripheral
Nervous System..............................................................31 21 Neuraxial Anatomy (Anatomy Relevant
9 Local Anesthetic Mixtures for Peripheral to Neuraxial Anesthesia) ..............................................93
Nerve Blocks....................................................................35 22 Spinal Anesthesia ..........................................................99
10 Continuous Peripheral Nerve Blocks: Local 22A Mechanisms and Management of
Anesthetic Solutions and Infusion Strategies...........37 Failed Spinal Anesthesia ............................................103

SECTION 3 E QUIPMENT FOR PERIPHERAL SECTION 2 EPIDURAL ANESTHESIA 107

NERVE BLOCKS 41 23 Epidural Anesthesia and Analgesia .........................109
11 Equipment for Regional Anesthesia ..........................43
12 Equipment for Continuous Peripheral SECTION 3 CAUDAL ANESTHESIA 121
Nerve Blocks ...................................................................49
13 Electrical Nerve Stimulators and Localization 24 Caudal Anesthesia .......................................................123
of Peripheral Nerves .....................................................53
SECTION 4 C OMBINED SPINAL AND EPIDURAL
SECTION 4 PATIENT MANAGEMENT ANESTHESIA 127
CONSIDERATIONS 57 25 Combined Spinal-Epidural Anesthesia....................129
14 Developing Regional Anesthesia Pathways .............59
15 Infection Control in Regional Anesthesia .................63

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 viii Contents

SECTION 5 POSTDURAL PUNCTURE HEADACHE 135 PART 3E Local and Regional Anesthesia for
Oral and Maxillofacial Surgery 231
26 Postdural Puncture Headache ..................................137
35 Oral and Maxillofacial Regional Anesthesia ...........233
PART 3D Ultrasound-Guided Nerve
Blocks 141 PART 3F Local and Regional Anesthesia
for the Eye 237
SECTION 1 F UNDAMENTALS OF ULTRASOUND-
36 Local and Regional Anesthesia for
GUIDED REGIONAL ANESTHESIA 141 Ophthalmic Surgery ....................................................239
27 Physics of Ultrasound .................................................143
28 Optimizing an Ultrasound Image .............................147 PART 4 Ultrasound Imaging of Neuraxial
29 Introduction to Ultrasound-Guided and Perivertebral Space 243
Regional Anesthesia ...................................................151
37 Sonography of the Lumbar Paravertebral Space
and Considerations for Ultrasound-Guided
SECTION 2 ULTRASOUND-GUIDED HEAD Lumbar Plexus Block ...................................................245
AND NECK NERVE BLOCKS 155 38 Lumbar Paravertebral Sonography and
Considerations for Ultrasound-Guided
30 Nerve Blocks of the Face ............................................157
Lumbar Plexus Block ...................................................249
39 Spinal Sonography and Applications of
SECTION 3 U LTRASOUND-GUIDED NERVE BLOCKS Ultrasound for Central Neuraxial Blocks .................255
FOR THE UPPER EXTREMITY 161
PART 5 Obstetric Anesthesia 261
31A Ultrasound-Guided Cervical Plexus Block ..............163
31B Ultrasound-Guided Interscalene 40 Obstetric Regional Anesthesia ..................................263
Brachial Plexus Block...................................................167
31C Ultrasound-Guided Supraclavicular PART 6 Pediatric Anesthesia 271
Brachial Plexus Block ..................................................169
31D Ultrasound-Guided Infraclavicular 41 Regional Anesthesia in Pediatric Patients:
Brachial Plexus Block ..................................................173 General Considerations ..............................................273
31E Ultrasound-Guided Axillary Brachial 42 Pediatric Epidural and Spinal Anesthesia
Plexus Block ..................................................................177 and Analgesia ...............................................................277
31F Ultrasound-Guided Blocks at the Elbow .................181 43 Peripheral Nerve Blocks for Children .......................283
31G Ultrasound-Guided Wrist Block ................................185 44 Acute and Chronic Pain Management
in Children ....................................................................285
SECTION 4 ULTRASOUND-GUIDED NERVE
BLOCKS FOR THE LOWER EXTREMITY 187 PART 7 Anesthesia in Patients with
Specific Considerations 287
32A Ultrasound-Guided Femoral Nerve Block ...............189
32B Ultrasound-Guided Fascia Iliaca Block ....................195 45 Perioperative Regional Anesthesia
32C Ultrasound-Guided Lateral Femoral in the Elderly ................................................................289
Cutaneous Nerve Block ..............................................201 46 Regional Anesthesia and Cardiovascular
32D Ultrasound-Guided Obturator Nerve Block ...........203 Disease ..........................................................................295
32E Ultrasound-Guided Saphenous 47 Regional Anesthesia and Systemic Disease ...........299
(Subsartorius/Adductor Canal) Nerve Block ..........205 48 Regional Anesthesia in the Patient
32F Ultrasound-Guided Sciatic Nerve Block ..................207 with Preexisting Neurologic Disease .......................303
32G Ultrasound-Guided Popliteal Sciatic Block .............213 49 Acute Compartment Syndrome of the Limb:
32H Ultrasound-Guided Ankle Block ...............................215 Implications for Regional Anesthesia ......................307
50 Peripheral Nerve Blocks for
SECTION 5 ULTRASOUND-GUIDED NERVE Outpatient Surgery .....................................................309
51 Neuraxial Anesthesia and Peripheral
BLOCKS FOR ABDOMINAL AND Nerve Blocks in Patients on Anticoagulants ..........313
THORACIC WALL 217 52 Regional Analgesia in the Critically Ill .....................317
53 Acute Pain Management in the
33 Ultrasound-Guided Transversus Abdominis Opioid-Dependent Patient ........................................319
Plane and Quadratus Lumborum Blocks ................219 54 Regional Anesthesia in Patients
34 Pectoralis and Serratus Plane Blocks .......................225 with Trauma ..................................................................325

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 Contents ix

55 Regional Anesthesia for Cardiac and 66 Regional Anesthesia and Perioperative

Thoracic Anesthesia ....................................................329 Outcome ........................................................................381
56 Regional Anesthesia in Austere 67 The Effects of Regional Anesthesia on
Environment Medicine ...............................................333 Functional Outcome After Surgery ..........................383
57 Anesthesia for Humanitarian
Relief Operations .........................................................337 PART 12 Acute Pain Management 385
PART 8 Regional Anesthesia in the 68 Intravenous Patient-Controlled Analgesia .............387
69 Continuous Peripheral Nerve Blocks .......................389
Emergency Department 341
70 Organization of an Acute Pain Management
58 Regional Anesthesia and Acute Pain Service Incorporating Regional
Management in the Emergency Department ........343 Anesthesia Techniques ...............................................391
71 Multimodal Analgesia: Pharmacologic
PART 9 Complications of Local and Interventions and Prevention of Persistent
Postoperative Pain ......................................................393
Regional Anesthesia 347 72 The Role of Nonopioid Analgesic Infusions
59 Complications and Prevention of Neurologic in the Management of Postoperative Pain .............397
Injury with Peripheral Nerve Blocks ........................349
60 Assessment of Neurologic Complications PART 13 Education in Regional
of Regional Anesthesia ...............................................355 Anesthesia 401
61 Perioperative Nerve Injury Unrelated to
Nerve Blockade ............................................................359 73 Teaching Regional Anesthesia ..................................403
62 Monitoring, Documentation, and Consent
for Regional Anesthesia Procedures ........................363 PART 14 Statistics and Principles of Research
63 Diagnosis and Management of Spinal Design in Regional Anesthesia
and Peripheral Nerve Hematoma .............................367 and Acute Pain Medicine 407
PART 10 LAST: Local Anesthetic Systemic 74 Principles of Statistical Methods for
Toxicity 371 Research in Regional Anesthesia .............................409

64 Local Anesthetic Systemic Toxicity ...........................373 Index.........................................................................................413

PART 11 Perioperative Outcome and

Economics of Regional
Anesthesia 377
65 Regional Anesthesia, Cost, Operating
Room, and Personnel Management ........................379

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 Contributors

Sherif Abbas, MD Jan Boublik, MD, PhD

Anesthesiologist Clinical Assistant Professor
UZ Leuven, Catholic University of Leuven Stanford University
Leuven, Vlaams-Brabant, Belgium Stanford Medical School
Department of Anesthesiology, Perioperative and Pain Medicine
Michael Akerman, MD Stanford, California
Assistant Professor of Anesthesiology
Regional Anesthesia and Acute Pain Medicine Astrid De Bruyn, MD
Weill Cornell Hospital Resident Anesthesiology
New York, New York Jessa Hospital
Hasselt, Belgium
Arthur Atchabahian, MD, FASA
Professor of Clinical Anesthesiology Donal J. Buggy, MD, FRCPI, FCAI, FRCA
Director, Regional Anesthesia Fellowship Full Professor, Anaesthesiology & Perioperative Medicine &
NYU School of Medicine Consultant in Anaesthesiology
New York, New York Mater University Hospital, School of Medicine, University College
Dublin, Ireland
Angela Lucia Balocco, MD
Anesthesiologist Christiana Burt, MA (Cantab), FRCA
Research Fellow Consultant Anaesthetist
NYSORA, The New York School of Regional Anesthesia Royal College of Anaesthetists College Tutor
New York, New York Royal Papworth Foundation Hospital Trust
Cambridge, Cambridgeshire
Vikram Bansal, MD
Assistant Professor of Anesthesiology Asokumar Buvanendran, MD
Vanderbilt University Medical Center William Gottschalk Professor of Anesthesiology
Nashville, Tennessee Rush University Medical Center
Chicago, Illinois
Michael J. Barrington, PhD
Professor, Centre for Integrated Critical Care | Department of Kenneth D. Candido, MD
Medicine & Radiology | Melbourne Medical School Chairman
Faculty of Medicine, Dentistry and Health Sciences Advocate Illinois Masonic Medical Center
The University of Melbourne, Victoria 3010 Australia Professor of Anesthesiology and Surgery
Senior Staff Anaesthetist University of Illinois
St.Vincent’s Hospital Melbourne Chicago, Illinois
Melbourne, Australia
Kathleen Chan, MD
Thomas Fichtner Bendtsen, MD, PhD Fellow in the Division of Acute and Perioperative Pain Medicine
Professor of Anesthesiology University of Florida College of Medicine
Aarhus University Hospital Gainesville, Florida
Aarhus, Denmark
Franklin Chiao, MD, LAc
Siska Bjørn, BSc Director of Acute Pain Management
PhD Fellow Attending Physician
Aarhus University Hospital Westchester Medical Center
Aarhus, Denmark Ardsley, New York

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 xii Contributors

Ki Jinn Chin, MBBS(Hons), MMed, FRCPC Matthias Desmet, MD, PhD

Associate Professor, Department of Anesthesia Consultant Anesthesist
Toronto Western Hospital, University of Toronto AZ Groeninge
Toronto, Ontario, Canada Kortrijk, Belgium

Jason Choi, MD Hesham Elsharkawy, MD, MBA, MSc, FASA

Attending Anesthesiologist Associate Professor of Anesthesiology Case Western
White Plains Hospital Reserve University
White Plains, New York Staff, Departments of General Anesthesiology
and Outcomes Research
Stephen Choi, BSc, MD, FRCPC, MSc Anesthesiology Institute
Staff Anesthesiologist, Sunnybrook Health Sciences Centre Cleveland Clinic
Associate Professor, Department of Anesthesia, Cleveland, Ohio
University of Toronto
Toronto, Ontario, Canada Paul Fettes, MBChB, BSc
Consultant Anaesthetist and Honorary Senior Lecturer
Alwin Chuan, MBBS, PhD, FANZCA Department of Anaesthesia
Conjoint Associate Professor, University of New South Wales Ninewells Hospital & Medical School
Director, Regional Anaesthesia Fellowship Dundee, United Kingdom
Liverpool Hospital
Sydney, Australia Jeff Gadsden, MD, FRCPC, FANZCA
Associate Professor of Anesthesiology
Cara Connolly, MB, BCh, BAO, LRCP & SI (Hons), Chief, Division of Orthopedic, Plastic and Regional
MSc, FCAI Anesthesiology
Consultant Anaesthetist Regional Anesthesiology and Acute Pain Medicine
Mater Misericordiae University Hospital Fellowship Director
Dublin, Ireland Duke University Medical Center
Durham, North Carolina
Steve Coppens, MD
Head of Clinic Anesthesiology Tong J. Gan, MD, MBA, MHS, FRCA
Fellowshipdirector Regional Anesthesia Professor and Chairman
University Hospitals Leuven Department of Anesthesiology
Leuven, Belgium Stony Brook University
Stony Brook, New York
Jennifer L. Cowell, MD
Assistant Professor of Anesthesiology and Perioperative Medicine Will Gauntlett, MBBCh, FRCA
Rutgers Robert Wood Johnson Medical School Consultant Anaesthetists
New Brunswick, New Jersey Alder Hey Children’s Hospital
Liverpool, Cheshire
Pieter Vander Cruyssen, MD, FIPP
Anesthesiologist, Department of Anesthesiology Philippe Gautier, MD
and Pain Management Head of Department
AZ Maria Middelares Department of Anesthesiology
Gent, Belgium Clinique Ste Anne-St Remi, CHIREC
Brussels, Belgium
Seppe Dehaene, MD
Anesthesiologist Liane Germond, MD
OLV van Lourdesziekenhuis Director Obstetric Anesthesia
Waregem, Belgium Ochsner Health System
New Orleans, Louisiana
Lejla Dervišević, MD
Senior Teaching Assistant of Human Anatomy Leen Govaers, MD
Department of Human Anatomy Medical Doctor in Anesthesiology
Medical Faculty University of Sarajevo Fellow in Regional Anesthesia
Sarajevo, Bosnia and Herzegovina Universitair Ziekenhuis Leuven
Leuven, Belgium

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 Contributors xiii

Admir Hadzic, MD, PhD Hassanin Jalil, MD

Professor of Anesthesiology Anesthesiologist
Consultant, Anesthesiology, Intensive Care, Emergency Medicine Intensive Care Specialist
and Pain Therapy Regional Anesthesia, NYSORA
Ziekenhuis Oost-Limburg Hasselt, Jessa Hospital
Genk, Belgium Hasselt, Belgium
Director, NYSORA, The New York School of Regional Anesthesia
New York, New York Hari Kalagara, MD, FCARCSI, EDRA
Assistant Professor of Anesthesiology
Thomas M. Halaszynski, DMD, MD, MBA The University of Alabama at Birmingham (UAB)
Professor of Anesthesiology Birmingham, Alabama
Senior Director of Regional Anesthesia/Acute Pain Medicine
Yale University School of Medicine Sowmya Kantamneni, MD
New Haven, Connecticut Fellow in the Division of Acute and Perioperative Pain Medicine
University of Florida College of Medicine
Brian E. Harrington, MD Gainesville, Florida
Staff Anesthesiologist
Billings Clinic Hospital Gary Kao, MD
Billings, Montana Interventional Pain Physician
Tricity Pain Associates
Ilvana Hasanbegovic, MD Corpus Christi, Texas
Associate Professor of Anatomy
Department of Anatomy Manoj K. Karmakar, MD, FRCA, DA (UK), FHKCA,
Faculty of Medicine FHKAM
University of Sarajevo Director of Paediatric Anaesthesia
Sarajevo, Bosnia and Herzegovina Department of Anaesthesia and Intensive Care, Faculty of
Medicine, The Chinese University of Hong Kong
Daryl Steven Henshaw, MD Hong Kong, SAR, China
Associate Professor of Anesthesiology
Medical Director Section of Regional Anesthesia Brendan Keen, MD
and Acute Pain Management Anesthesiologist
Wake Forest School of Medicine US Anesthesia Partners Colorado
Winston Salem, North Carolina Denver, Colorado

Jacob Hutchins, MD, MHA James K. Kim, MD

Director of the Division of Regional Anesthesia, Assistant Professor
Acute Pain, and Ambulatory Anesthesia University of Pennsylvania Health System
University of Minnesota Hospital Philadelphia, Pennsylvania
Minneapolis, Minnesota
Jung H. Kim, MD
Barys Ihnatsenka, MD Assistant Professor
Associate Professor of Anesthesiology Icahn School of Medicine at Mt. Sinai St. Luke’s
College of Medicine, University of Florida and Mt. Sinai West Hospitals
Gainesville, Florida New York, New York

Vivian H. Y. Ip, MBChB, FRCA Nebojsa Nick Knezevic, MD, PhD

Associate Clinical Professor Vice Chair for Research and Education
University of Alberta Hospital Advocate Illinois Masonic Medical Center
Edmonton, Canada Associate Professor of Anesthesiology and Surgery
University of Illinois
J. Douglas Jaffe, DO, FASA Chicago, Illinois
Fellowship Director: Regional Anesthesiology and
Acute Pain Medicine Sree Kolli, MD, EDRA
Associate Professor of Anesthesiology Staff Anesthesiologist
Wake Forest School of Medicine Associate Director Acute Pain/Regional Anesthesia
Wake Forest Baptist Hospital Cleveland Clinic
Winston Salem, North Carolina Cleveland, Ohio

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 xiv Contributors

Samantha Kransingh, MD Sofie Louage, MD

Anesthesiologist Fellow in Regional Anesthesia Anesthesiologist-Intensivist
Department of Anesthesiology, Intensive Care, Emergency AZ Glorieux
Medicine and Pain Therapy Ronse, Belgium
Ziekenhuis Oost-Limburg
Genk, Belgium Belen De Jose Maria, MD, PhD, ECFMG
Consultant in Pediatric Anesthesia
Alison Krishna, MD Hospital Sant Joan de Deu, University of Barcelona
Assistant Professor of Anesthesiology Barcelona, Spain
Mount Sinai St. Luke’s and Mount Sinai West
Department of Anesthesiology Colleen Mccally, DO
New York, New York Assistant professor of Anesthesiology
Assistant Director of East Hills ASC
Lisa Kumar, MD St Francis Hospital
Anesthesiologist Roslyn, New York
Baptist Hospital of Miami
Miami, Florida Colin J. L. McCartney, MBChB, PhD, FRCA, FRCPC
Professor and Chair of Anesthesiology and Pain Medicine
Maxine M. Kuroda, PhD, MPH University of Ottawa
Epidemiologist/Biostatistician Ottawa, Ontario, Canada
NYSORA
New York, New York Shaun De Meirsman, MD
President Belgian Anesthesia Trainees
M. Kwesi Kwofie, MD, FRCPC University Hospitals Leuven
Director of Regional Anesthesia and Acute Pain Leuven, Belgium
Assistant Professor
Department of Anesthesia, Pain Management Justin Morello, MD
and Perioperative Medicine Department of Anesthesiology
Dalhousie University Ochsner Clinic Foundation
Halifax, Nova Scotia, Canada New Orleans, Louisiana

Malikah Latmore, MD Hiroaki Murata, MD, PhD

Assistant Professor of Anesthesiology Associate Professor
Mount Sinai St. Luke’s and West Hospitals Department of Anesthesiology
New York, New York Nagasaki University Graduate School of Biomedical Sciences
Nagasaki, Japan
Chad Lee, MD
Interventional Pain Physician Tatsuo Nakamoto, MD, PhD
Georgia Pain and Wellness Center Professor of Anesthesiology
Atlanta, Georgia Director Regioal Anesthesia/Pain Medicine
Kansai Medical University Hospital
Ine Leunen, MD Hirakata, Osaka, Japan
Anesthesiologist
Intensive Care Medicine Kristof Nijs, MD
AZ Turnhout Anesthesiology Resident
Turnhout, Belgium Jessa Hospital
Hasselt, Belgium
Matt Levine, MBChB, FANZCA
Specialist Anaesthetist John-Paul J. Pozek, MD
Capital and Coast District Health Board Assistant Professor of Anesthesiology
Wellington, New Zealand Residency Research Coordinator
The University of Kansas Health System
Ana M. Lopez, MD, PhD, DESA Kansas City, Kansas
Visiting Professor, KU Leuven
Consultant Anesthesiology Stavros Prineas BSc(Med), MBBS, FRCA, FANZCA
Ziekenhuis Oost-Limburg Specialist Anaesthetist
Genk, Belgium Nepean Hospital
Sydney, Australia

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 Contributors xv

John Rae, FRCA, FFICM Yanxia Sun, MD, PhD

Specialty Registrar in Anaesthesia Chairman
Ninewells Hospital Department of Anesthesiology
Dundee, United Kingdom Bejing Lu Dao Pei Hospital
Staff Anesthesiologist
Pascal A. Ramsodit, MSc, MD Department of Anesthesiology
Anesthesiologist and Chronic Pain Specialist. Beijing TongRen Hospital
Dijklander Ziekenhuis Capital Medical University
Hoorn, The Netherlands Fengtai, China

Kasra Razmjou, MD Evan Sutton, MD

Assistant Professor of Anesthesiology Anesthesiologist
Medical Director, Acute Pain Service Bend Anesthesiology Group
MedStar Georgetown University Hospital Bend, Oregon
Washington, DC
Tiffany Tedore, MD
Bernard Roach, MBBS, PGClinUS, FANZCA Associate Professor of Anesthesiology
Specialist Anaesthetist Co-Director, Regional Anesthesiology and Acute Pain Medicine
Liverpool and Wollongong Hospitals New York Presbyterian Hospital
New South Wales, Australia Weill Cornell Medical College
New York, New York
Christopher B. Robards, MD
Assistant Professor of Anesthesiology Antony R. Tharian, MD
Mayo Clinic Florida Program Director
Jacksonville, Florida Advocate Illinois Masonic Medical Center
Assistant Professor of Anesthesiology
Steve Roberts, MBChB, FRCA University of Illinois
Consultant Anaesthetist Chicago, Illinois
Alder Hey Children’s NHS Foundation Trust
Liverpool, United Kingdom Luc Tielens, MD
Paediatric Anesthesiologist
Meg A. Rosenblatt, MD, FASA President of the Dutch Association for Regional
Professor of Anesthesiology and Orthopedics Icahn Anesthesia (DARA)
School of Medicine at Mount Sinai Radboudumc
Chair, Department of Anesthesiology, Perioperative Nijmegen, The Netherlands
and Pain Medicine
Mount Sinai St. Luke’s and West Hospitals Ban C.H. Tsui, Dip Eng, BSc(Math), B.Pharm,
New York, New York MSc, MD, FRCP(C), PG Dip Echo
Professor
Siddharth Sata, DO Director, Stanford University Pediatric Regional
Assistant Professor of Anesthesiology Anesthesia (SUPRA)
Duke University School of Medicine Director of Research, Division of Adult Regional Anesthesia
Durham, North Carolina Department of Anesthesiology, Perioperative and Pain Medicine,
Stanford University
Sebastian Schulz-Stübner, MD PhD Stanford, Calofornia
Privatdozent in Anesthesia
Chief Physician Vishal Uppal, MBBS, DA, EDRA, FRCA
German Consulting Center for Infection Control Assistant Professor & Staff Anesthesiologist Director, Regional
and Prevention (BZH GmbH) Anesthesia Fellowship Program Department of Anesthesia,
Freiburg, Germany Pain Management & Perioperative Medicine Dalhousie
University, Halifax
Ali Shariat, MD Halifax, Nova Scotia, Canada
Assistant Professor of Anesthesiology
Mount Sinai West and St. Luke’s Hospitals Sam Van Boxstael, MD
New York, New York Consultant in Emergency Medicine, Anesthesiology and ICU
Ziekenhuis Oost-Limburg
Uma Shastri, MD, FRCPC Genk, Belgium
Assistant Professor of Anesthesiology
Vanderbilt University
Nashville, Tennessee

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 xvi Contributors

Catherine Vandepitte, MD, PhD Tom C. Van Zundert, MD, PhD, EDRA, FANZCA
Consultant Anaesthesiologist Udayana University, Bali, Indonesia
Kritieke Diensten Ziekenhuis Oost Limburg
Ziekenhuis Oost-Limburg Genk, Belgium
Genk, Belgium
Alexandru Visan, MD, MBA
Cedric Van Dijck, MD CEO, Executive Cortex Consulting
Dept. of Anesthesiology, Emergency Medicine & Critical Care Miami, Florida
Ziekenhuis Oost-Limburg
Genk, Belgium Alexander Vloka, MD
Internal Medicine Resident
Pascal Vanelderen, MD, PhD Boise VA Medical Center
Head of the Emergency Department Boise, Idaho
Ziekenhuis Oost-Limburg
Genk, Belgium Philippe Volders, MD
Professor at the Faculty of Medicine and Life Sciences Department of Anesthesia and Critical Care
Hasselt University Regional Anesthesia
Diepenbeek, Belgium Algemeen Ziekenhuis Diest
Diest, Belgium
Astrid Van Lantschoot, MD
Staff member anesthesiology Christopher Wahal, MD
ZOL Genk Assistant Professor of Anesthesiology
Genk, Belgium Department of Anesthesiology
Sidney Kimmel Medical College at Thomas Jefferson University
Thibaut Vanneste, MD Philadelphia, Pennsylvania
Anesthesiologist
Hospital Oost-Limburg Takayuki Yoshida, MD, PhD, EDRA
Genk, Belgium Assistant Professor
Department of Anesthesiology
André Van Zundert, MD, PhD, FRCA, EDRA, FANZCA Kansai Medical University Hospital
Professor & Chairman Discipline of Anesthesiology Hirakata, Osaka, Japan
The University of Queensland—Faculty of Medicine &
Biomedical Sciences Adam C. Young, MD
Chair, University of Queensland, Burns, Trauma & Critical Care Assistant Professor of Anesthesiology & Pain Medicine
Research Centre Co-Director, Acute Pain Service Assistant Professor
Chair, RBWH/University of Queensland, Centre for Excellence Anesthesiology & Interventional Pain Medicine
& Innovation in Anaesthesia, Department of Anaesthesia & Rush University Medical Center
Perioperative Medicine Chicago, Illinois
Queensland, Australian

Hadzic_FM_p00i-pxx.indd 16 22/04/19 6:41 PM

 Preface
Regional anesthesia and acute pain medicine protocols are
rapidly changing. Introduction of ultrasound in interventional
pain management and regional anesthesia has led to substantial
changes in practice management, protocols, techniques, and
applications, and their effects on patient safety and efficacy.
Nearly all anesthesiology journals now incorporate a section
on regional anesthesia and acute pain medicine. This evolu-
tion of the practice and expansion of new knowledge mandates
frequent updates through continuous medical education.
While the didactic knowledge of regional anesthesia and acute
pain medicine is available in anesthesiology textbooks, a compen-
dium of information for the purpose of knowledge assessment
in the subspecialty does not exist. Hence, NYSORA’s Textbook of
Regional Anesthesia and Acute Pain Management aims to fill this
gap by providing a comprehensive databank of questions that
can be used to test students’ knowledge and clinical reasoning
regarding new developments in the field. In making this book,
we have selected a team of opinion leaders throughout the
world and paired them with students of anesthesiology in order
to prepare the questions and logical answers. The questions are
Hadzic_FM_p00i-pxx.indd 17
organized in specific sections, whereas the answers are provided
from NYSORA’s textbooks and relevant additional literature
citations.
To our knowledge, this is the first question book that focuses
on the rapidly developing subspecialty of regional anesthesia and
acute pain management and point-of-care ultrasound-guided
interventional analgesia and anesthesia. With this volume we
primarily aim at students of anesthesiology, but the question
bank can also be used to assess knowledge acquisition of fellows
in regional anesthesia and acute pain medicine, and/or to test
the knowledge of applicants for the diploma in regional anesthesia
(eg, EDRA, European Diploma of Regional Anesthesia, adminis-
tered by ESRA, the European Society for Regional Anesthesia).
We hope that this question book will be useful in assessing
knowledge acquisition. We invite comments and suggestions for
future editions and also look forward to developing this ques-
tion book into a global knowledge assessment test.
Sincerely,
Prof. Admir Hadzic
22/04/19 6:41 PM
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Hadzic_FM_p00i-pxx.indd 6 22/04/19 6:40 PM

 Acknowledgments
Writing a book is always a large undertaking that is
difficult to accomplish without collaboration and support.
I would like to thank all NYSORA team members who have
donated their time, knowledge, and wisdom to this volume.
I would also like to acknowledge the outstanding students of
medicine, anesthesiology residents of the Catholic University
of Leuven and Katholieke Universiteit Leuven (KUL), and
NYSORA Europe fellows in regional anesthesia at Ziekenhuis
Oost-Limburg (ZOL), Genk, Belgium. Several talented
and resourceful anesthesiologists are richly deserving of
specific mention: Drs. Angela Lucia Balocco, Ana Lopez, and
Catherine Vandepitte.
Special thanks to NYSORA’s research team: Drs. Ingrid Meex
PhD, Gülhan Özyürek, and Marijke Cipers. Likewise, a big
THANK YOU to Professor Marc Vandevelde, and Dr. Steven
Hadzic_FM_p00i-pxx.indd 19
Coppens at KUL, as well as René Heylen and the leadership of
ZOL, Genk, Belgium. Your wisdom and vision have created a
platform to make scholarly endeavors, such as completing this
book writing, possible.
I would also like to thank the entire Department of Anesthe-
siology, Intensive Care Emergency Medicine and Pain Therapy
at ZOL—your dedication to clinical care and teaching clinical
medicine is inspiring. Finally, much appreciation to Professor
Dr. Jan Van Zundert for his advice, wisdom, and coaching me to
join this inspiring group of anesthesiologists in bettering edu-
cation and clinical care in perioperative medicine and for an
opportunity to develop the orthopedic anesthesia and research
unit at ZOL, in Limburg, Belgium.
Prof. Admir Hadzic
22/04/19 6:41 PM
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 PART 1
History

Chapter 1 The History of Local Anesthesia 3

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 1
The History of Local Anesthesia
Alwin Chuan

QUESTIONS 5.   The first successful and reliable method to extend the

duration of effect of local anesthetic drugs was:
A. Adding epinephrine to cocaine, by Heinrich Braun
DIRECTIONS: Choose the one best response to each B. Using multiple tourniquets to stop redistribution of
question. procaine, by August Bier
C. Pressing proximally to the site of cocaine injections, by
1.   In 1653, the first person to describe the anesthetic J. Leonard Corning
effects of coca was: D. Doubling the concentration of injected cocaine, by
A. Blas Valera William Halsted
B. Bernabé Cobo
C. Pedro Pizarro 6. The basis for the modern method of spinal anesthesia
D. Paolo Mantegazza was:
A. Heinrich Quincke injecting cocaine via a paramedian
2. The local anesthetic properties of cocaine were first approach to treat hydrocephalus
appreciated, in 1884, for the treatment of: B. J. Leonard Corning injecting cocaine into the subarach-
A. Peripheral neuromas noid space of dogs
B. Cutaneous lesions C. August Bier and Rudolph Matas injecting morphine
C. Morphine addiction into the subarachnoid space of each other
D. Glaucoma D. August Bier and August Hildebrandt injecting cocaine
3. An important advancement in local anesthetic drugs into the subarachnoid space of each other
was due to the introduction of: 7. A 28-year-old primigravid patient is to undergo
A. Prilocaine, as it is metabolized to end products that are spinal anesthesia for an elective lower segment
nontoxic cesarean delivery. Which of the following is not a
B. Lidocaine, as it is an amide local anesthetic with lower potential complication of spinal anesthesia?
side effects A. Inadvertent change in the baricity of the solution when
C. Ropivacaine, as the racemic mixture reduces the risk of tetracaine is used
cardiac toxicity B. Paralysis of the abdominal and thoracic muscles that
D. Procaine, as there are fewer allergic reactions than are involved in respiration
tetracaine C. Sympathetic blockade resulting in vasodilation and
4. Tumescent anesthesia refers to: hypotension
A. Intraneural injections of local anesthetics into D. Painful spastic paresis
peripheral nerves causing swelling and conduction 8. Important steps in the evolution of continuous regional
block anesthesia included which of the following?
B. Use of large volumes of dilute local anesthetic solutions A. Description of prolonged subarachnoid anesthesia
for cutaneous procedures blockade by Leonard Corning
C. Cutaneous infiltration of physiologic sterile water B. Identification of the epidural space by Edward Tuohy
and local anesthetic solutions to effect conduction C. Using a catheter for labor epidural analgesia by Manuel
block Curbelo
D. Large volumes of a dilute solution of 2% cocaine with D. Fixation and tunnelling of indwelling catheters by
physiologic sterile saline for cutaneous procedures Lincoln Sise

Hadzic_Ch01_p001-004.indd 3 18/04/19 2:31 PM

 4 PART 1 History
9. Our understanding of pain has progressed over time,
through evolution of several influential theories. Which
of the following was not instrumental in arriving at
our current concepts of nerve conduction and pain
management?
A. Specificity theory
B. Choleric theory
C. Spinal gate theory
D. Intensive pain theory
ANSWERS AND EXPLANATIONS
1. B is correct. Bernabé Cobo, who spent his life bringing
Christianity to the Incas, was the first to describe the
anesthetic effects of coca.
2. D is correct. Carl Koller performed the first ophthalmo-
logic surgical procedure using local anesthesia on a patient
with glaucoma.
3. B is correct. Lidocaine is an amino amide derivative,
a stable compound not influenced by exposure to
high temperatures, and, most importantly, one that does
not have the allergic potential of the ester-type local
anesthetics. The metabolite of prilocaine is implicated
in methemoglobinemia. Ropivacaine is an S-enantiomer
formulation. Procaine has the same allergic potential as
tetracaine; both are ester anesthetics.
4. B is correct. Karl Ludwig Schleich’s approach still seems to
be relevant, particularly with the recent European enthu-
siasm for tumescent anesthesia, in which sometimes-huge
volumes of very dilute local anesthetic are used for surface
surgery.
5. A is correct. Corning’s successes with prolonging the
action of local anesthetic with a physical tourniquet
inspired Heinrich F. W. Braun to substitute epinephrine, a
“chemical tourniquet,” for the Esmarch tourniquet.
Hadzic_Ch01_p001-004.indd 4
6. D is correct. Bier was able to demonstrate that small
amounts of local anesthetic (cocaine) injected into the
subarachnoid space could provide surgical anesthesia
for over 67% of the body. Bier concluded that Corning’s
injection was extradural, and that he (Bier) deserved to be
acknowledged for introducing spinal anesthesia.
7. A is correct. Inadvertent change in the baricity of the
solution when tetracaine is used is not a potential com-
plication of spinal anesthesia. Lincoln Sise began using
tetracaine because of its longer duration of action but
was concerned about controlling the height of the block.
Following Arthur Barker’s recommendations regarding
hyperbaric solutions, Sise added 10% glucose with success.
Options B, C, and D are known complications.
8. C is correct. In 1947, Manuel Martinez Curbelo of Cuba is
credited with using the Tuohy needle and a small ureteral
catheter to provide continuous lumbar epidural analgesia.
Corning inadvertently described extradural anesthesia.
The epidural space was first described by Achille Dogliotti.
Sise experimented with adding glucose to tetracaine to
increase the baricity to control the block height after
subarachnoid blocks.
9. B is correct. The Choleric theory was not instrumental in
arriving at our current concepts of nerve conduction and
pain management. The Choleric theory is part of “The four
temperament theory” described by Hippocrates. Options A,
C, and D were instrumental theories in arriving in our
current concepts of nerve conduction and pain management.
Suggested Reading
Hadzic A.The history of local anesthesia. In: Chuan A, Harrop-
Griffiths W, eds. Textbook of Regional Anesthesia and Acute Pain
Management. 2nd ed. New York, NY: McGraw-Hill Publishing;
2017:chap 1.
18/04/19 2:31 PM
 PART 2
Foundations of Local and
Regional Anesthesia

Section 1
Anatomy and Histology of Peripheral
Nervous System and Neuraxis
Chapter 2 Functional Regional Anesthesia Anatomy 7
Chapter 3 Histology of the Peripheral Nerves and Light Microscopy 11
Chapter 4 Connective Tissues of Peripheral Nerves 15
Chapter 5 Ultrastructural Anatomy of the Spinal Meninges and Related Structures 17

Hadzic_Ch02_p005-010.indd 5 18/04/19 2:29 PM

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 2
Functional Regional Anesthesia Anatomy
Ana M. Lopez
QUESTIONS
DIRECTIONS: Choose the one best response to each
question.
1. Which of the following descriptions is correct about the
structure of the neuron?
A. A typical neuron consists of a cell body, which is also
called the soma, with a small or absent nucleus.
B. Many dendrites branch out from the cell body; their
main function is to spread out outgoing messages.
C. A typical neuron consists of several axons, which carry
outgoing messages. They can vary in length and are
also called nerve fibers.
D. Most neurons are incapable of dividing under normal
circumstances and have limited ability to repair them-
selves after injury.
2. The structure of a typical peripheral nerve is as follows:
A. The endoneurium is a resistant layer of connective
tissue surrounding each axon; its main function is to
deliver strength to the peripheral nerve.
B. The nerve fascicle is surrounded by the perineurium. It
protects the neural tissue from the surrounding tissue,
functioning as a blood–nerve barrier.
C. Fascicular bundles are continuous throughout the
peripheral nerve. Because of this, axons starting in one
quadrant of the nerve keep the same position distally.
D. The peripheral nerve is composed of three parts: (1)
somatosensory or efferent neurons, (2) motor or affer-
ent neurons, and (3) autonomic neurons.
3. Which of the following anatomical descriptions of the
structure of a peripheral nerve is correct?
A. The interfascicular epineurium consists of elastic con-
nective tissue fibers binding and maintaining the fasci-
cles in a consistent disposition along the nerve.
B. The perineurium is the loose connective tissue that
connects the nerve to the surrounding tissues, also
known as paraneurium.
Hadzic_Ch02_p005-010.indd 7
C. From inside to outside the nerve, the layers enveloping
the fibers are: endoneurium, epineurium, perineurium,
and paraneurium.
D. The fascicles divide and merge with adjacent bundles
redistributing the fibers alongside the nerves.
4. With respect to spinal nerve anatomy, it is true that:
A. The anterior rami of cervical and lumbosacral spinal
nerves coalesce to form plexuses.
B. The dorsal rami of the spinal nerves carry only sensory
fibers and innervate the skin of the back and limbs.
C. The motor fibers arise from neurons in the posterior
horn of the spinal cord.
D. The sensory innervation of the bones (osteotomes)
closely follows that of the overlying myotomes and
dermatomes.
E. The thoracic spinal nerves exit above their corresponding
vertebra, in contrast to lumbar spinal nerves which exit
below the corresponding vertebra.
5. The cervical plexus:
A. Is divided into the deep and superficial cervical plexus,
the superficial anastomoses with the brachial plexus
B. Innervates relevant structures for respiration such as
the interscalene muscles, the diaphragm, and infrahyoid
muscles
C. Forms the phrenic nerve by junction of fibers from
C3 to C5 and travels caudally and anterior deep to the
anterior scalene muscle
D. Forms cutaneous sensory nerves that innervate the
neck, face, scalp, and upper thorax
6. The architecture of the brachial plexus is as follows:
A. The roots of C5 and C6 form the upper trunk, C7 and
C8 the middle trunk, and T1 and T2 the lower trunk.
B. The anterior divisions of the upper and middle trunk
join to form the medial cord.
C. The posterior cord is formed out of all the posterior
divisions.
D. The distal nerves of the brachial plexus arise distally to
the clavicle except the suprascapular nerve that leaves
the upper trunk at the supraclavicular level.
18/04/19 2:29 PM
 8 PART 2 Foundations of Local and Regional Anesthesia
7. The median nerve innervates muscles that cause:
A. Abduction of the shoulder
B. Flexion of the elbow and wrist
C. Pronation of the forearm
D. Adduction of the thumb
8. The radial nerve:
A. Passes from the axilla to the posterior compartment
of the arm through the quadrangular space of Velpeau
where it gives a branch to the teres minor muscle
B. Receives fibers from C5 to T1
C. Descends along the shaft of the humerus in the spiral
groove innervating the triceps and brachialis muscles
D. At the elbow divides into a posterior and lateral cuta-
neous branch, which innervates the lateral aspect of the
forearm overlying the radius
9. The ulnar nerve:
A. Receives fibers from the upper and middle trunk
B. Along the arm, descends superficial to the fascia of the
triceps muscle and crosses the elbow posterior to the
medial epicondyle
C. Proximal to the wrist, sends a branch to innervate the
adductor pollicis muscle and the skin of the thenar
eminence
D. Innervates all the interosseous muscles in the hand
10. The cutaneous innervation of the lower limb is as
follows:
A. The anterolateral aspect of the thigh is innervated by
the lateral femorocutaneous and the genitofemoral
nerves, which branch off from the femoral nerve proxi-
mal to the inguinal ligament.
B. The anterior branch of the obturator nerve contributes
to the innervation of the medial aspect of the thigh.
C. The posterior aspect of the thigh is supplied by the
sural nerve, a branch of the sciatic nerve.
D. The anterior aspect of the leg is innervated by the
saphenous nerve, the distal sensory branch of the fem-
oral nerve.
11. The sciatic nerve:
A. Is made up of two distinct nerves, which travel together
in the same tissue sheath from the onset down to the
popliteal fossa
B. Exits the pelvis through the greater sciatic foramen
superior to the piriformis muscle
C. In the posterior thigh descends in between the
semimembranosus and semitendinosus muscles,
medial to the long head of biceps femoris
D. At the level of the popliteal fossa gives off its four ter-
minal branches: tibial nerve, deep peroneal, superficial
peroneal, and sural nerves.
12. Which description of joint innervation is complete?
A. The shoulder is mainly innervated by the suprascapular
and axillary nerves, which branch off the upper and
middle trunks of the brachial plexus.
Hadzic_Ch02_p005-010.indd 8
B. The elbow is mainly innervated by the radial nerve on
the posterior side and the median nerve on the antero-
medial side.
C. The hip is mainly innervated by branches of the femo-
ral and obturator nerves.
D. The knee is mainly innervated by branches of the fem-
oral and tibial nerves.
ANSWERS AND EXPLANATIONS
1. D is correct. In adults, most neurons are incapable of
dividing under normal circumstances and have limited
ability to repair themselves after injury.
A is incorrect. The cell body of the typical neuron has a
large nucleus.
B is incorrect. The function of dendrites is to receive
incoming messages.
C is incorrect. A typical neuron has only one axon.
2. B is correct. The nerve fascicle is surrounded by the
perineurium, which imparts mechanical strength to the
peripheral nerve. In addition to its mechanical strength,
the perineurium functions as a diffusion barrier to the fas-
cicle, isolating the endoneural space around the axon from
the surrounding tissue. This barrier helps to preserve the
ionic milieu of the axon and functions as a blood–nerve
barrier.
A is incorrect. The endoneurium is a thin and delicate
layer of loose connective tissue surrounding each fiber.
C is incorrect. The fascicular bundles are not continu-
ous throughout the peripheral nerve. They divide and
anastomose with one another as frequently as every few
millimeters.
D is incorrect. The peripheral nerve is composed of three
parts: (1) somatosensory or afferent neurons, (2) motor or
efferent neurons, and (3) autonomic neurons.
3. D is correct. The fascicles continuously divide and merge
with adjacent bundles redistributing the fibers alongside
the nerve.
A is incorrect. The interfascicular epineurium contains
adipose tissue, fibroblasts, mastocytes, blood vessels
(with small nerve fibers innervating these vessels), and
lymphatics.
B is incorrect. The perineurium surrounds the fascicles
and imparts mechanical strength to the peripheral nerve.
It also function as a blood–nerve barrier. The paraneu-
rium is the loose connective tissue that connects the nerve
to surrounding tissues.
C is incorrect. The correct order is endoneurium, perineu-
rium, epineurium, and paraneurium.
18/04/19 2:30 PM

4. A is correct. The anterior rami of cervical and lumbosacral
spinal nerves coalesce to form the cervical, brachial and
lumbosacral plexuses, respectively.
B is incorrect. The dorsal rami carry both motor and
sensory fibers and innervate muscle, bones, joints, and the
skin of the back.
C is incorrect. Motor fibers arise from neurons on the
anterior horn of the spinal cord.
D is incorrect. The innervation of the osteotomes, myo-
tomes, and dermatomes does not always follow the same
segmental pattern.
E is incorrect. The cervical spinal nerves exit cranially to
the corresponding vertebra, in contrast to the thoracic and
lumbar spinal nerves that exit caudally to the vertebra.
5. B is correct. The cervical plexus has important implication
in normal respiratory function. In addition to the dia-
phragm, it innervates the scalene muscles, which promote
inspiration by elevating the first rib, and the infrahyoid
muscles, which open the laryngeal aditus to facilitate
inspiration.
A is incorrect. There is no division of the cervical plexus,
although the plexus can be blocked at a deep, intermedi-
ate, or superficial level. C4 may contribute to the brachial
plexus and C5 to the cervical plexus, but it cannot be con-
sidered anastomosis.
C is incorrect. The phrenic nerve travels caudally and
anterior superficial to the fascia of the anterior scalene.
D is incorrect. The cervical plexus innervates the neck,
scalp, and upper thorax, but it is not involved in the inner-
vation of the face.
6. C is correct. The posterior divisions of all three trunks
join to form the posterior cord.
A is incorrect. The upper trunk is formed by C5-C6, the
middle trunk is the continuation of C7, and the lower
trunk is formed by C8-T1.
B is incorrect. The lateral cord is formed mainly by the
anterior divisions of upper and middle trunks, although it
may receive some fibers from the anterior division of the
lower trunk.
D is incorrect. Several terminal branches arise at the
supraclavicular level within the posterior cervical trian-
gle, such as the dorsal scapular, long thoracic, and the
thoracodorsal.
7. C is correct. The median nerve innervates the pronator
teres and quadratus responsible for pronation of the wrist.
A is incorrect. Abduction of the shoulder is provided by
the axillary nerve.
B is incorrect. Flexion of the elbow is provided by the
musculocutaneous nerve.
D is incorrect. Adduction of the thumb is provided by the
ulnar nerve.
Hadzic_Ch02_p005-010.indd 9
CHAPTER 2 Functional Regional Anesthesia Anatomy 9
8. B is correct. The radial nerve arises from the posterior
cord and receives fibers from all posterior divisions
(C5-T1).
A is incorrect. The axillary nerve, not the radial nerve,
passes through the quadrangular space of Velpeau and
innervates the teres minor.
C is incorrect. The musculocutaneous nerve innervates
the brachialis muscle.
D is incorrect. The sensory branch of the musculocutane-
ous nerve innervates the lateral aspect of the forearm.
9. D is correct. The ulnar nerve sends fibers to all interos-
seous muscles in the hand and to the lumbrical muscles
affecting the ring and little fingers. The ulnar nerve ends
by innervating the deep head of the flexor pollicis brevis
muscle.
A is incorrect. The ulnar nerve is formed mainly from
fibers of the lower trunk, C8-T1.
B is incorrect. At the axilla the ulnar nerve crosses the
medial intermuscular septum and descends deep to the
fascia of the triceps.
C is incorrect. Proximal to the wrist, the ulnar nerve sends
a cutaneous branch to the hypothenar eminence. In the
hand it gives a deep branch that innervates the adductor
pollicis muscle.
10. B is correct. The anterior branch of the obturator nerve
passes superficial to the obturator externus muscle,
descends the thigh in the muscle plane between the
adductor brevis and adductor longus, and terminates in
the gracilis muscle. En route, it innervates all of these
muscles and the skin covering the medial side.
A is incorrect. The femorocutaneous branch and the gen-
itofemoral nerves are branches of the lumbar plexus inde-
pendent of the femoral nerve.
C is incorrect. The sural nerve branches out the tibial and
common peroneal nerves at the popliteal fossa and inner-
vates the posterior aspect of the leg. The posterior femoral
cutaneous nerve supplies the posterior aspect of the thigh.
D is incorrect. The saphenous nerve innervates the skin on
the medial side of the leg, ankle, and foot. The anterolat-
eral aspect of the leg is supplied by the peroneal nerve.
11. A is correct. The sciatic nerve is formed by the junction
of the tibial and common peroneal nerves. These two
branches are distinct from the onset and travel together
enveloped in the same tissue sheath.
B is incorrect. The sciatic nerve exits the pelvis inferior to
the piriformis muscle.
C is incorrect. In the posterior thigh, the sciatic nerve
passes between the adductor magnus and the long head of
the biceps femoris.
D is incorrect. At the level of the popliteal fossa, the
sciatic nerve divides into the tibial and common peroneal
branches.
18/04/19 2:30 PM
 10 PART 2 Foundations of Local and Regional Anesthesia
12. A is correct. Innervation to the shoulder joints stems
mostly from the axillary and suprascapular nerves
(C5-C7).
B is incorrect. Nerve supply to the elbow joint includes
branches of all major nerves of the brachial plexus that
cross the joint: musculocutaneous, radial, median, and
ulnar nerves.
C is incorrect. Nerves to the hip arise from the femoral,
obturator, and sciatic nerves.
Hadzic_Ch02_p005-010.indd 10
D is incorrect. Knee innervation is obtained from
branches from the femoral, obturator, and sciatic nerves.
Suggested Reading
Hadzic A.Functional regional anesthesia anatomy. In: Carrera A,
Lopez AM, Sala-Blanch X, Kapur E, Hasanbegovic I, Hadzic A,
eds. Textbook of Regional Anesthesia and Acute Pain Management.
2nd ed. New York, NY: McGraw-Hill Publishing; 2017:chap 3.
18/04/19 2:30 PM
 3
Histology of the Peripheral Nerves
and Light Microscopy
Ilvana Hasanbegovic, Lejla Dervišević, and Alexander Vloka

QUESTIONS of nerve integrity during the procedure. Which of the

following methods is used for proper identification of
peripheral nerves during block procedure?
DIRECTIONS: Choose the one best response to each A. Nerve stimulator
question. B. Ultrasound
C. Injection pressure monitoring
1. Which of the following nerve fibers would be the first to D. All of the above
be blocked by local anesthetics?
A. Aβ fibers 6. During the performance of a peripheral nerve block,
B. Aα fibers the risk of intrafascicular injection differs from site to
C. Aγ fibers site in the peripheral nervous system. What peripheral
D. C fibers nerve block is associated with the highest incidence of
nerve injury?
2. Which of the following local anesthetics would you A. Interscalene block
choose for effective sciatic nerve block using Labat’s B. Supraclavicular block
posterior approach? C. Infraclavicular block
A. 30 mL of 1% mepivacaine D. Wrist block
B. 20 mL of 1.5% mepivacaine
C. 20 mL of 0.75% bupivacaine 7. High injection pressure and consequent nerve damage
D. 30 mL of 0.2% ropivacaine during peripheral nerve block indicate:
A. Intrafascicular injection
3. Peripheral nerve lesions can be classified in terms of B. Extrafascicular injection
their degree of functional disruption. Which of the fol- C. Perineural injection
lowing nerve lesions commonly occurs during periph- D. Intraneural injection
eral nerve blocks?
A. Neuropraxia 8. Which of the nerve connective tissue layers is the most
B. Axonotmesis important in preserving the integrity of the peripheral
C. Neurotmesis nerve?
D. All of the above A. Inner epineurium
B. External epineurium
4. Does intraneural injection cause irreversible nerve C. Mesoneurium
injury? D. Perineurium
A. Yes, always
B. No, never 9. The mechanism responsible for nerve injury following
C. Only with long-bevel needles intraneural injection of local anesthetics is:
D. Infrequently , but possible A. Needle trauma
B. Neurotoxicity
5. A good knowledge of anatomy is crucial for efficient C. Ischemic injury
execution of peripheral nerve blocks. There are several D. Multifactorial
methods used for nerve identification and preservation

11

Hadzic_Ch03_p011-014.indd 11 18/04/19 2:35 PM

 12 PART 2 Foundations of Local and Regional Anesthesia
10. An 80-year-old man with diabetes mellitus was sched-
uled for a surgical procedure on his lower extremity
with the use of peripheral nerve block. The resolution of
the ultrasound scan was poor and the anesthesiologist
experienced difficulties performing the block. What
could be a possible reason for the poor resolution on the
ultrasound image?
A. Age-related changes
B. Sex differences
C. Some morphological variations
D. Preexisting pathology
ANSWERS AND EXPLANATIONS
1. C is correct. Aγ myelinated fibers supply the muscle spin-
dles. They have a smaller diameter than other myelinated
fibers. Myelinated nerve fibers with a smaller diameter are
more rapidly blocked because the “critical length” of the
smaller nerve fiber contains a larger number of Ranvier
nodes than a larger myelinated nerve fiber.
A and B are incorrect. Proprioceptive afferent (Aα) and
motor efferent (Aβ) nerve fibers have the same diameter
and are therefore equally sensitive to local anesthetics. The
sensitivity of nerve fibers to local anesthetics is not deter-
mined by whether they are sensory or motor, but rather by
their diameter.
D is incorrect. C fibers have the smallest diameter. How-
ever, they are unmyelinated. Because myelinated fibers are
more easily blocked than unmyelinated fibers, C fibers are
more resistant to the action of local anesthetics.
2. B is correct. The dose and concentration of local anes-
thetic should be optimized for different nerve blocks. The
larger the nerve, the more concentrated the local anes-
thetic must be to obtain effective neural blockade.
A is incorrect. A high volume with a low concentration
of local anesthetic solution is associated with a lower
success rate and a delayed onset time compared to a
low volume with a high concentration of the same local
anesthetic.
C is incorrect. Bupivacaine provides longer duration of
nerve blockade compared to other commonly used local
anesthetics. However, it also has the worst cardiotoxic
profile. Bupivacaine carries a significantly higher risk of
cardiac arrest and difficulties in resuscitation. This is espe-
cially important because currently there is no monitoring
that could prevent systemic toxicity of local anesthetics.
Bupivacaine has fallen out of favor in many centers due
not only to its potential for serious toxicity, but also the
availability of ropivacaine, a local anesthetic characterized
by a slightly decreased duration of action and an improved
safety profile.
D is incorrect. Ropivacaine 0.2% is usually sufficient to
provide excellent sensory analgesia but spare any motor
blockade.
Hadzic_Ch03_p011-014.indd 12
3. D is correct. Injuries to nerves during peripheral nerve
blockade are usually of mixed type.
Neuropraxia refers to a mild nerve insult in which the
axons and connective tissue structures supporting them
remain intact. This type of injury is often associated with
focal demyelination and is generally reversible over the
course of weeks to several months.
Axonal interruption with conservation of the neural con-
nective tissues is termed axonotmesis.
Neurotmesis represents complete fascicular interruption,
including the axons and the connective tissue. Because the
nerve is severed, recovery depends on the surgical reap-
proximation of the two stumps. Even with prompt surgical
intervention, recovery is often poor.
4. D is correct. A needle placed intraneurally can be in
one of two locations: within the loose epineurial sheath
that surrounds the fascicles or inside the fascicle itself.
Intraneural needle placement with resultant injection
within the epineurium does not lead to an imminent
neurological injury. The reason why nerve injury is infre-
quent is that the vast majority of these injections do not
occur within the fascicle.
A is incorrect. It is well established that injection of even
a very small amount of local anesthetic within the fascicle
(intrafascicular) can lead to widespread axonal degener-
ation and permanent neural damage in animals, whereas
extrafascicular injection does not disrupt the normal neu-
ral architecture.
B is incorrect. Direct intrafascicular injection into the
peripheral nerve can result in nerve injury. Therefore it
is necessary to be aware of injection pressure in order to
avoid nerve injuries.
C is incorrect. Long-bevel needles are more likely to punc-
ture and enter the neural fascicle compared with short-
bevel needles. However, if the nerve fascicle becomes
accidentally impaled during a nerve block procedure, the
lesions induced by short-bevel needles tend to be more
severe and take longer to repair than those induced by
long-bevel needles.
5. D is correct. Nerve stimulators, ultrasound, and injection
pressure monitoring each have their own distinct set of
advantages and limitations. For this reason, these three
technologies are best used in a complementary fashion to
minimize the potential for nerve injury, rather than just
relying on the information provided by one monitor alone.
The combination of all three monitors is likely to produce
the safest possible environment in which to perform a
peripheral nerve block.
Peripheral nerve stimulators are used to localize nerves
in order to perform nerve blockade. However, it has
been documented that the needle tip can be already
in the nerve but may not elicit a motor response even
at customarily used low stimulating currents. Use of
ultrasound to visualize the needle position and injection
pressure monitoring increases the safety of the peripheral
nerve block.
18/04/19 2:35 PM
 CHAPTER 3
Ultrasound guidance may not always be a sufficiently
effective means of preventing nerve injury. The reliability
of ultrasound to keep the needle tip extraneural depends
largely on the skill of the operator and the imaging char-
acteristics of the needle and the tissue. Furthermore, at the
present time the resolution of the sonographic image is
such that it is impossible to tell if the needle tip is within
the intrafascicular or extrafascicular space, which is the
critical anatomic differentiation to avoid nerve injury.
Finally, by the time the nerve can be seen swelling on the
image, the damage may have already been done if the
injection is made with the needle tip inside the fascicle.
One shortcoming of injection pressure monitoring is that
although it is highly sensitive, it lacks specificity. In other
words, the absence of high injection pressure appears to
effectively rule out an intrafascicular injection. However,
the high injection pressure also can be caused by periph-
eral nerve block needle obstruction, attempted injection
into a tendon, or tissue compression caused by the ultra-
sound transducer. A “syringe-hand-feel” is a subjective
technique and is not reliable. Injection pressure should be
objectively monitored.
6. A is correct. The risk of intrafascicular injury correlates
with the cross-sectional fascicle to epineurium ratio. The
brachial plexus at the level of the trunks contains much
more neural than connective tissue. For this reason a
needle entering the nerve at this point is more likely to
encounter a fascicle on its trajectory. This may contribute
to the disproportionately higher rate of postoperative
neuropathy following interscalene block. The incidence of
nerve injury and neurologic symptoms from interscalene
block is 3%.
B is incorrect. As peripheral nerves move away from the
spinal cord, the ratio of connective tissue to neural tissue
within the nerves tends to increase. The brachial plexus
elements below the clavicle have a ratio of connective
tissue to neural tissue of approximately 2:1, whereas the
more proximal trunks and divisions have a 1:1 ratio. The
incidence of nerve injury and neurologic symptoms for
supraclavicular block is 0.03%.
C is incorrect. In the interscalene and supraclavicular
regions of the brachial plexus, the nerves are more densely
packed and oligofascicular, while more distally, they are
polifascicular with a large amount of stromal tissue.
D is incorrect. The wrist block technique involves advanc-
ing the needle toward the three nerves that supply the
hand: the median, ulnar, and radial nerves. In the vicin-
ity of joints, the fascicles are usually thinner and more
numerous and tend to be surrounded by a greater amount
of connective tissue, which reduces the risk of intrafascic-
ular injection and nerve injury.
7. A is correct. The injection pressure rises abruptly dur-
ing the intrafascicular injection of local anesthetic and
can remain higher than the capillary perfusion pressure
beyond the duration of the injection itself predisposing
to neuronal ischemia and inflammation. Furthermore,
pressure curves derived from intrafascicular versus
Hadzic_Ch03_p011-014.indd 13
Histology of the Peripheral Nerves and Light Microscopy 13
extrafascicular injection in canine sciatic nerves show that
a pattern of very high initial injection pressure followed by
a sharp drop to baseline is associated with poor outcome
and severe neuronal histological damage and may suggest
fascicular rupture.
B is incorrect. High force (pressure) is required for the
intrafascicular injection of local anesthetic compared to
extrafascicular injection.
C is incorrect. In contrast to the intrafascicular injection,
extrafascicular injection is associated with a minimal
rise in pressure, which can be explained by its loose and
accommodating stromal architecture.
D is incorrect. The intraneural injection is not always
associated with nerve injury. Extrafascicular intraneural
injections usually present with low injection pressures
indicating safe neuronal blockade.
8. D is correct. The perineurium is a sheath of connective
tissue consisting of several layers of perineural cells, which
surrounds each individual fascicle. It acts as a physical and
chemical barrier. Injection into that compartment will dis-
rupt the perineurium and result in neural injury.
A is incorrect. The epineurium is a condensation of loose
areolar connective tissue that surrounds a peripheral nerve
and binds its fascicles in a common bundle. Epineurium
that extends between the fascicles is called the interfascic-
ular or inner epineurium.
B is incorrect. The epineurium that surrounds the entire
nerve trunk is the epifascicular or external epineurium.
C is incorrect. The mesoneurium is a loose areolar tissue
covering the outside of the nerve, which extends from
the epineurium to the surrounding tissue. Mesoneurium
gives protection against nerve trauma and is a conduit for
nerve gliding during movement. It can accommodate the
injected volume of local anesthetic during nerve blockade.
9. D is correct. Most peripheral nerve injuries that are asso-
ciated with peripheral nerve blocks have a multifactorial
etiology. It is difficult to differentiate the relative magni-
tude of the contributing factors. Once the perineurium is
breached, the spectrum of the subsequent injury is wide
and multifactorial.
A is incorrect. Needle-related nerve injuries may result
from forceful needle nerve contact or intrafascicular injec-
tion. It has been postulated that an intraneural injection
may cause sustained high intraneural pressure, which
may lead to nerve ischemia and potential injury. One of
the main causes of block-related peripheral nerve injury
is injection of local anesthetic into the fascicle, causing
rupture of the perineurium and loss of the protective envi-
ronment within the fascicle with consequent myelin and
axonal degeneration.
B is incorrect. All local anesthetics are potentially neu-
rotoxic. The site of local anesthetic injection may be the
primary determinant of whether neurotoxicity will occur,
especially if the concentration is high and duration of
exposure prolonged. Most chemical substances, includ-
ing all local anesthetics, injected intrafascicularly lead
18/04/19 2:35 PM
 14 PART 2 Foundations of Local and Regional Anesthesia
to severe fascicular injury, whereas the same substances
injected intraneurally but extrafascicularly cause less
injury or no detectible injury at all.
C is incorrect. Damage to the nerve vasculature during
nerve blocks can result in local or diffuse ischemia and
occurs when there is direct vascular injury, acute occlu-
sion of the arteries from which the vasa nervorum are
derived, or from hemorrhage within the nerve sheath.
Local anesthetics and adjuncts can also potentially reduce
neuronal blood flow.
10. A is correct. Age-related changes in the peripheral nerves
result from the cumulative, lifelong effect of various
pathogenic factors modified by genetic determinants
and by the gradual decrease in the regenerative capacity
of peripheral nerves. Age-related changes of nerves and
surrounding tissues may be responsible for the typically
poorer ultrasonographic images of the peripheral nerves
and surrounding tissues in the elderly as compared to
younger subjects.
B is incorrect. There are few reports about sex difference
concerning the morphology of the human peripheral
nerves. All of them underlying that there is no statistically
significant difference in the total number, average trans-
verse area, or average circularity ratio of myelinated axons
between the females and males.
C is incorrect. In the case of suspected variations on one
side, the anesthesiologist should check the patient’s other
side and exclude existing variations.
D is incorrect. Patients with underlying nerve pathology
are more susceptible to peripheral nerve complications,
including prolonged duration of block and increased
neurotoxicity from local anesthetics. But in this case, pre-
existing pathology is probably not the reason for the poor
ultrasound picture.
Hadzic_Ch03_p011-014.indd 14
Suggested Readings
Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological com-
plications after regional anesthesia: contemporary estimates of
risk. Anesth Analg. 2007;104(4):965-974.
Gentili F, Hudson AR, Hunter D, Kline DG. Nerve injection injury
with local anesthetic agents: a light and electron microscopic, fluo-
rescent microscopic, and horseradish peroxidase study. Neurosur-
gery. 1980;6(3):263-272.
Hadzic A. Histology of the peripheral nerves and light microscopy.
In: Cvetko E, Meznarič M, Pintaric TS, eds. Textbook of Regional
Anesthesia and Acute Pain Management. 2nd ed. New York, NY:
McGraw-Hill Publishing; 2017:chap 4.
Hadzic A, Dilberovic F, Shah S, et al. Combination of intraneu-
ral injection and high injection pressure leads to fascicular
injury and neurologic deficits in dogs. Reg Anesth Pain Med.
2004;29(5):417-423.
Moriyama H, Hayashi S, Inoue Y, Itoh M, Otsuka N. Sex differences
in morphometric aspects of the peripheral nerves and related dis-
eases. NeuroRehabilitation. 2016;39(3):413-422.
Selander D, Sjöstrand J. Longitudinal spread of intraneurally injected
local anesthetics. An experimental study of the initial neural dis-
tribution following intraneural injections. Acta Anaesthesiol Scand.
1978;22(6):622-634.
Taboada MM, Rodriguez J, Bermudez M, et al. Low volume and
high concentration of local anesthetic is more efficacious than
high volume and low concentration in Labat’s sciatic nerve
block: a prospective, randomized comparison. Anesth Analg.
2008;107(6):2085-2088.
New York School of Regional Anesthesia. https://www.nysora.com.
18/04/19 2:35 PM
 4
Connective Tissues of Peripheral Nerves
Ana M. Lopez
QUESTIONS
DIRECTIONS: Choose the one best response to each question.
1. Which of the following descriptions is correct about the
structure of the nerve?
A. Along the nerve, the same axon can contribute to
different fascicles.
B. The location of nerve fascicles inside the nerve is
consistent along the nerve, with little variation.
C. The proportion of connective tissue in the nerve
decreases as it travels distally.
D. In the vicinity of a joint, the nerve has fewer fascicles of
larger size to offer more resistance to stretching.
2. The connective tissue layers of a typical peripheral
nerve are as follows from inside to outside:
A. Endoneurium - paraneurium - epineurium -
perineurium
B. Perineurium - endoneurium - paraneurium -
epineurium
C. Endoneurium - perineurium - epineurium -
paraneurium
D. Perineurium - endoneurium - epineurium -
paraneurium
3. Which of the following anatomical descriptions of the
structure of a peripheral nerve is correct?
A. The interfascicular epineurium consists of elastic
connective tissue fibers binding and maintaining the
fascicles in a consistent disposition along the nerve.
B. The perineurium is the loose connective tissue that
connects the nerve to the surrounding tissues, also
known as paraneurium.
C. The endoneurium consists of concentric layers of con-
nective tissue with tight cellular junctions that form a
blood–nerve barrier.
D. The fascicles divide and merge with adjacent bundles
redistributing the fibers alongside the nerves.
4. The outermost connective tissue layer enveloping the
nerve:
A. Is the perineurium
B. Is absent in multifascicular nerves
Hadzic_Ch04_p015-016.indd 15
C. Contains adipocytes, mast cells, lymphatics, and blood
vessels
D. Is the epineurium that can be distinctly identified by
ultrasound before injection
5. Which statement is true regarding peripheral nerve
blocks?
A. The local anesthetic reaches the axons through the
intraneural capillary network and is independent of the
size of the fibers.
B. The architecture of connective tissue layers in the
peripheral nerve influences the spread of local anes-
thetic and therefore, the onset of the block.
C. The proportion of local anesthetic that traverses the
connective tissue sheaths and reaches the axons is
about 50% of the injectate.
D. Despite substantial variability in the characteristics of
the connective tissue layers, the dynamics and quality
of neural blockade are consistent and reliable in differ-
ent patient populations.
ANSWERS AND EXPLANATIONS
1. A is correct. Inside each nerve, the axons form an intran-
eural plexus in such a fashion that one axon can contribute
to different fascicles along the nerve length.
B is incorrect. The number, size, and locations of fascicles
in peripheral nerves are also variable even within a single
nerve and can vary as much as 23 times along a 4- to 5-cm
length of nerve.
C is incorrect. The proportion of neural tissue is higher at
the origin of the nerve. Distally, the proportion of connec-
tive tissue increases and can reach up to 75% of the nerve
cross section.
D is incorrect. In the proximity of joints, the fascicles are
thinner, more numerous, and have a thicker perineurium,
which may confer better protection against pressure and
stretching.
15
18/04/19 2:36 PM
 16 PART 2 Foundations of Local and Regional Anesthesia
2.
C is correct. The endoneurium is a thin, delicate layer of
loose connective tissue surrounding each fiber. A group of
fibers forms the nerve fascicle, which is surrounded by the
perineurium. The epineurium is the outer layer of connec-
tive tissue. The paraneurium is the connective tissue that
binds the nerve to the surrounding tissues or more than
one nerve together.
A, B, and D are incorrect. These options don’t follow the
correct order for connective tissue layers from inside to
outside.
3. D is correct. The fascicles divide and merge with
adjacent bundles redistributing the fibers alongside
the nerves.
A is incorrect. The interfascicular epineurium contains
adipose tissue, fibroblasts, mastocytes, blood vessels
(with small nerve fibers innervating these vessels), and
lymphatics.
B is incorrect. The perineurium surrounds the fascicles
and imparts mechanical strength to the peripheral nerve.
It also functions as a blood–nerve barrier. The paraneu-
rium is the loose connective tissue that connects the nerve
to surrounding tissues.
C is incorrect. The above description corresponds to the
perineurium: It consists of concentric layers of flattened
cells separated by layers of collagen. Tight junctions in
the inner layers of the perineurium and tight junctions
in endoneurial capillaries form a blood–nerve barrier
structure.
4. C is correct. The epineurium contains adipocytes, fibrob-
lasts, connective tissue fibers, mast cells, small lymphatics,
as well as blood vessels and small nerve fibers innervating
the vessels.
A is incorrect. The outermost connective tissue sheath of
peripheral nerves is the epineurium.
Hadzic_Ch04_p015-016.indd 16
B is incorrect. The outermost connective tissue layer is
present in all multifascicular nerves, although it may be
absent in small monofascicular terminal branches.
D is incorrect. Ultrasound equipment currently used to
perform peripheral nerve blocks is not able to distinguish
the epineurium. However, the epineurium can be identi-
fied after unintended subepineurial injection, which may
not be uncommon. For that reason, the routine use of
additional monitoring, such as with nerve stimulators or
pressure indicators, is highly recommended.
5. B is correct. Diffusion of anesthetic into the axons is
influenced by the presence and characteristics of the con-
nective tissue sheaths (eg, perineurium, myelin) and the
size and location of the axons inside fascicles. The speed
and the amount of local anesthetic that comes into contact
with the axons determine the onset of the blockade.
A is incorrect. The local anesthetic injected perineurally
must traverse the epineurium, perineurium, and endo-
neurium. Local anesthetic injected intravenously for a Bier
block most likely reaches the nerve endings through the
intraneural capillary network.
C is incorrect. Only a small proportion of the injected
local anesthetic comes in direct contact with the axons. In
experimental studies the amount of local anesthetic inside
the nerve when the block was complete was 1.6% of the
injected dose.
D is incorrect. Due to substantial variability in the charac-
teristics of the connective tissue layers, the dynamics and
quality of neural blockade are inconsistent.
Suggested Reading
Hadzic A. Connective tissues of peripheral nerves. In: Reina MA,
Sala-Blanch X, Machés F, Arriazu R, Prats-Galino A, eds. Textbook
of Regional Anesthesia and Acute Pain Management. 2nd ed.
New York, NY: McGraw-Hill Publishing; 2017:chap 5.
18/04/19 2:36 PM
 5
Ultrastructural Anatomy of the Spinal
Meninges and Related Structures
Siddharth Sata
QUESTIONS
DIRECTIONS: Choose the one best response to each
question.
1. Which of the following statements is most accurate
regarding dural puncture?
A. The size of the lesion created by a 24-gauge spinal
needle is similar with both the pencil-point and
cutting-needle designs.
B. Cutting needles produce a greater and rougher-
appearing injury to dural fibers as compared to
pencil-point needles.
C. Sagittal bevel orientation of a cutting spinal needle is
less likely to produce postdural puncture headache
(PDPH) as compared to a transverse orientation.
D. The morphology of dural lesions is consistent between
different spinal needle designs.
2. A 23-year-old primigravid patient for cesarean delivery
receives a spinal anesthetic with a 24-gauge cutting
needle. Which of the following mechanical factors is
true regarding her spinal puncture?
A. Passing a needle into the dural sac creates a lesion in
the dura mater while sparing the arachnoid layer.
B. The dural layer will take at least 3 to 5 days to com-
pletely close.
C. Both the arachnoid and dural layers are violated; how-
ever, the arachnoid violation contributes more signifi-
cantly to cerebrospinal fluid leakage.
D. The U-shaped dural flap created by a cutting needle is
likely to lead to significant cerebrospinal fluid leakage.
3. Which of the following statements regarding the ana-
tomical and equipment-related factors of postdural
puncture headache (PDPH) is most accurate?
Hadzic_Ch05_p017-020.indd 17
A. Conclusive evidence exists to demonstrate that needle-
bone contact causes deformation of cutting needles,
which leads to increased incidence of PDPH.
B. Pencil-point needles lead to less traumatic violations of
the dural sac, leading to decreased incidence of PDPH.
C. Cutting needles cause a “burst”-type lesion of the dural
sac with unpredictable damage of the dura and arach-
noid layers leading to increased incidence of PDPH.
D. Increased tearing and trauma created by pencil-point
needles lead to inflammation of the dural sac, which
may be protective against PDPH.
4. Transient root irritation syndrome and cauda equina
syndrome:
A. Likely have a greater risk of incidence with spinal
microcatheter infusion versus single-shot spinal
injection
B. Are very unlikely to occur without direct needle or
catheter trauma to spinal nerve roots
C. Are likely to be caused by local anesthetic injection into
the dural sac of spinal nerves
D. Will likely not occur if the patient does not experience
a paresthesia or dysesthesia during spinal needle or
catheter placement
5. After placing an epidural catheter at the L3–4 inter-
space, you dose it with 15 mL of 2% lidocaine in three
divided doses to achieve surgical anesthesia. After
20 minutes have passed, the patient has a 10 cm circular
patch of skin that retains temperature and sharp pain
sensation. Which of the following anatomical features
is the most likely cause?
A. Anterior meningo-vertebral ligament
B. Lateral meningo-vertebral ligament
C. Ligamentum flavum
D. Posterior meningo-vertebral ligament
17
18/04/19 2:38 PM
 18 PART 2 Foundations of Local and Regional Anesthesia
6. Which of the following statements is true regarding
epidural fat?
A. Below L4–5 epidural fat is the main component sur-
rounding nerve roots within the dural sleeves.
B. Epidural fat adheres to nerve roots in the dural sleeves,
which limits movement of the dura during flexion and
extension.
C. Patients with spinal stenosis have increased quantities
of epidural fat leading to compression of the nerve
roots and spinal cord.
D. The quantity of posterior epidural fat decreases as you
travel caudally from the cervical region to the lumbar
region.
7. You inject an 8 mL bolus of 0.25% bupivacaine via a
Tuohy needle at the T12–L1 interspace prior to epi-
dural catheter placement. Within 5 minutes you notice
the patient rapidly develops upper extremity weakness
and apnea with sparing of abdominal dermatomal
anesthesia. Why do you suspect subdural spread of the
injectate?
A. A large volume of greater than 5 mL is required to
cause subdural spread with subsequent high blockade.
B. Iatrogenic creation of the subdural space leads to highly
unpredictable neuraxial anesthesia with unexpected
high-level blockade.
C. The spinal cord is still present at this spinal level, which
increases the likelihood of subdural injection.
D. The subdural space is a compliant, nonadherent, and
well-circumscribed layer between the dura and arach-
noid mater in most patients.
8. Which of the following spinal needle designs is least
likely to cause fiber tearing and damage with less subse-
quent inflammation in the dura and arachnoid, confer-
ring an increased risk of postdural puncture headache?
A. Quincke
B. Sprotte
C. Greene (noncutting)
D. Whitacre
9. The trabecular arachnoid sheath:
A. Is an integral component of all nerve roots in the cauda
equina
B. Is greatly adherent to spinal nerve roots, making it
impossible to insert a needle between the two
C. Is responsible for minimizing the movement of nerve
roots within the dural sac
D. Provides significant mechanical protection to spinal
nerve roots
10. Which of the following is true regarding epidural fat?
A. Epidural fat lies within a continuous circumferential
plane in the epidural space at the lumbar levels.
B. Excessive fat deposits, such as those seen in epidural
lipomatosis, are a generally harmless finding without
clinical sequelae.
C. The uneven distribution of epidural fat in the lumbar
area can lead to differential diffusion of substances
through the epidural space, potentially altering drug
kinetics.
Hadzic_Ch05_p017-020.indd 18
D. Patients with kyphoscoliosis are likely to have
decreased epidural fat, particularly in the concave areas
of curvature.
ANSWERS AND EXPLANATIONS
1. A is correct. The size of the lesion created by a 24-gauge
spinal needle is similar with the pencil-point and cutting-
needle designs.
B is incorrect. Pencil-point needles produce a greater and
rougher-appearing injury to dural fibers as compared to
cutting needles.
C is incorrect. Bevel orientation does not affect the size or
morphology of lesions when using cutting needles.
D is incorrect. The morphology of dural lesions is depen-
dent on the design of needle tip.
2. C is correct. The size and morphology of arachnoid
lesions seem to be more important for laminar sealing and
cerebrospinal leakage than the size and morphology of
dural lacerations.
A is incorrect. Passing a needle into the dural sac creates a
lesion in both the dura mater and arachnoid layer.
B is incorrect. The dural defect created by a cutting spinal
needle is almost completely occluded after approximately
15 minutes.
D is incorrect. After needle withdrawal, the U-shaped flap
created by a cutting needle returns to the original position
due to CSF pressure and the elastic properties of the dura.
3. D is correct. The increased fiber tearing produced by
pencil-point needles may promote greater inflammatory
response at the edges of the lesion that paradoxically
results in earlier occlusion and lower incidence of PDPH.
A is incorrect. The definitive impact of spinal needle
deformation from needle-bone contact on the incidence of
PDPH is difficult to study and remains hypothetical.
B is incorrect. Pencil-point needles lead to more traumatic
violations of the dural sac with ensuing inflammation that
decreases the incidence of PDPH.
C is incorrect. Cutting needles create a cleaner defect in
the dural sac with less inflammation, which leads to pro-
longed closure of the defect, possibly leading to increased
PDPH.
4. A is correct. Injections of local anesthetic through a
microcatheter into these arachnoid sheaths could be more
devastating than a single injection. This is because the
injection of a single large volume would eventually be
diluted by leakage outside the sheath, whereas repeated
doses of small volumes may be more likely to lead to neu-
rotoxicity due to the continuous or repeated exposure to a
high concentration of local anesthetics.
B is incorrect. Injection of local anesthetic within an
arachnoid sheath of a spinal nerve root can lead to pro-
longed exposure to high concentrations of local anesthetic
18/04/19 2:38 PM
 CHAPTER 5 Ultrastructural Anatomy of the Spinal Meninges and Related Structures
without dilution from CSF, leading to a nerve lesion with-
out direct needle trauma.
C is incorrect. Injection into the arachnoid sheath, not
the dural sac surrounding spinal nerve roots, leads to pro-
longed exposure to high concentrations of local anesthetic.
D is incorrect. A patient may not feel any symptoms dur-
ing arachnoid sheath injection of local anesthetic, and, as
explained above, needle-nerve contact is not necessary.
5. A is correct. The anterior meningo-vertebral ligament,
which connects the dural sac with the posterior longi-
tudinal ligament of the spine, is more compact. In some
patients, fibrous flaps that fix the dural sac to the posterior
longitudinal ligament may incompletely divide the ante-
rior epidural space.
B is incorrect. The lateral meningo-vertebral ligament
is thinner than the anterior and does not influence the
spread of fluids in the epidural space.
C is incorrect. Ligamentum flavum is superficial to the
dura and has not been identified as a structure that com-
monly creates septae in the epidural space.
D is incorrect. The posterior meningo-vertebral ligament
is thinner than the anterior and does not influence the
spread of fluids in the epidural space.
6. A is correct. Below L4–5 epidural fat is the main compo-
nent surrounding nerve roots within the dural sleeves.
B is incorrect. Epidural fat within the dural sleeves allows
for displacement of the dura within the vertebral canal
during flexion and extension.
C is incorrect. Spinal stenosis leads to decreased epidural
fat and is often absent at the stenosed levels.
D is incorrect. Posterior epidural fat increases as you travel
caudally and is most prominent around L3–4 and L4–5.
7. B is correct. Subdural anesthetic blockade, caused by inad-
vertent injection of local anesthetic partially or entirely
between the dura and arachnoid, results in highly unpre-
dictable spinal or epidural anesthesia and complications
due to an unanticipated high-level blockade.
A is incorrect. Even small subdural injections of a few
milliliters can lead to subdural spread with high-level
neuraxial blockade.
C is incorrect. The presence of the spinal cord at the
level of subdural injection does not necessarily have an
impact on the risk of iatrogenic creation of a subdural
space.
Hadzic_Ch05_p017-020.indd 19
19
D is incorrect. Contrary to classic teaching, the subdural
space is an iatrogenic artifact created by tearing of weak
cohesive forces between neurothelial cells, leading to fis-
sures between the dura and arachnoid.
8. A is correct. Quincke is least likely to cause fiber tearing
and damage with less subsequent inflammation in the
dura and arachnoid, conferring an increased risk of
PDPH.
B, C, and D are incorrect. Sprotte, Greene, and Whitacre
are all non-cutting pencil-point type needles that will not
create a clean cut in the dura and arachnoid leading to
some level of inflammation.
9. C is correct. During movement, these sheaths stabilize and
prevent excessive movements of the nerve roots within the
dural sac. However, the sheaths confer little mechanical
protection against trauma.
A is incorrect. Trabecular arachnoid sheaths variably
envelope nerve roots, and in some cases are completely
absent on nerve roots.
B is incorrect. Needles and microcatheters can and have
been placed between nerve roots and the surrounding
arachnoid sheath.
D is incorrect. Arachnoid sheaths confer little mechanical
protection to nerve roots.
10. C is correct. The distribution of epidural fat in the lumbar
vertebral canal is uneven, being more abundant in the
dorsal region than in the ventral and lateral regions. The
total amount, distribution, and morphology of fat in the
epidural space and nerve root cuffs affect the diffusion of
substances across these compartments.
A is incorrect. At the lumbar level epidural fat is separated
into anterior and posterior spaces.
B is incorrect. Epidural lipomatosis can lead to spinal cord
and nerve root compression with significant neurologic
symptoms.
D is incorrect. Kyphoscoliotic patients have asymmetri-
cally distributed epidural fat with a greater quantity con-
centrated in the concave portions of the epidural space.
Suggested Reading
Hadzic A. Ultrastructural anatomy of the spinal meninges and related
structures. In: Reina MA, Franco CD, Prats-Galino A, Machés F,
López A, de Andrés JA, eds. Textbook of Regional Anesthesia and
Acute Pain Management. 2nd ed. New York, NY: McGraw-Hill
Publishing; 2017:chap 6.
18/04/19 2:38 PM
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 Section 2
Pharmacology
Chapter 6 Clinical Pharmacology of Local Anesthetics 23
Chapter 7 Controlled-Release Local Anesthetics 27
Chapter 8 Analgesic Adjuvants in the Peripheral Nervous System 31
Chapter 9 Local Anesthetic Mixtures for Peripheral Nerve Blocks 35
Chapter 10 Continuous Peripheral Nerve Blocks: Local Anesthetic Solutions
and Infusion Strategies 37

Hadzic_Ch06_p021-026.indd 21 19/04/19 10:04 AM

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Hadzic_FM_p00i-pxx.indd 6 22/04/19 6:40 PM


Clinical Pharmacology of Local Anesthetics
Shaun De Meirsman
QUESTIONS
DIRECTIONS: Choose the one best response to each
question.
1. Which of the following is true regarding the history of
local anesthetics (LAs)?
A. Cocaine was the first applicable product used by Carl
Koller as a LA.
B. Ten years after the first introduction of cocaine as
a LA, the first successful brachial plexus block was
performed.
C. Leonard Corning was the first to perform a spinal
anesthesia with cocaine.
D. Esters occur naturally. The first synthetic local
anesthetic was an amide like lidocaine, which was
introduced almost 100 years later.
2. Voltage-gated sodium (Na) channels have a specific
structure. Which of the following statements is true?
A. They consist of two large α-subunits and two smaller
β-subunits. The β-subunit is the place of LA binding,
causing a blockade in neural excitability and impulse
transmission between neural fibers.
B. They consist of six transmembranous segments. A shift
in these segments causes inadequate transmission of
neurotransmitters causing an inexcitable neuron.
C. They consist of one α-subunit and two β-subunits.
The α-subunit is the site of ion conduction and of LA
binding. Sodium channels have at least three native
configurations.
D. The distribution between sodium channels in myeli-
nated and unmyelinated fibers is the same. The differ-
ence in conduction mechanism causes LA to be more
potent in the unmyelinated nerve fibers.
3. Potency of local anesthetics (LAs) increases with:
A. Decreased molecular weight, increased lipid solubility,
more protein bound, and decreased duration of action
B. Increased molecular weight, increased lipid solubility,
less protein bound, and increased duration of action
Hadzic_Ch06_p021-026.indd 23
6
C. Increased molecular weight, increased lipid solubility,
more protein bound, and increased duration of action
D. Decreased molecular weight, decreased lipid solubility,
less protein bound, and decreased duration of action
4. Speed of onset of local anesthetic increases with:
A. Decreased lipid solubility, high pKa value, more aque-
ous solubility, and increased molecular weight
B. Increased lipid solubility, intermediate pKa value, less
aqueous solubility, and decreased molecular weight
C. Increased lipid solubility, high pKa value, less aqueous
solubility, and increased molecular weight
D. Decreased lipid solubility, intermediate pKa value, more
aqueous solubility, and decreased molecular weight
5. Many factors can influence the effectiveness of local
anesthetic, such as:
A. Site of administration, temperature, pregnancy, addi-
tives, and dose
B. Site of administration, temperature, pregnancy, gender,
and dose
C. Site of administration, temperature, gender, age, and
dose
D. Pregnancy, additives, age, dose, and molecular weight
6. During pregnancy local anesthetics (LAs) can be used
safely. Which of the following statements is true?
A. Pregnant women are less neurally susceptible to local
anesthetics. Esters undergo a more rapid metaboliza-
tion through the liver during pregnancy.
B. Pregnant women are more neurally susceptible to local
anesthetics, so more LA is necessary to have the same
clinical effect.
C. Spinal spread of LA neuraxially will increase because
of the decrease in thoracolumbar cerebrospinal fluid
volume.
D. LA toxicity is more common in pregnant women
because protein binding and protein concentration are
increased during pregnancy.
23
19/04/19 10:04 AM
 24 PART 2 Foundations of Local and Regional Anesthesia
7. Which of the following statements is true, concerning
local anesthetic (LA) allergic reactions?
A. True immunologic responses to LA are rare. Esters are
more often the cause of an anaphylaxis compared to
amides.
B. When injecting a LA intravenously it causes more ana-
phylaxis when compared to locally. Amide LAs are more
often the cause of an anaphylaxis compared to esters.
C. Preservatives are the cause of the allergic reactions,
not LA. True immunologic responses to LA are
frequent.
D. LA skin testing has a high positive predictive value in
regards to allergic reactions. There are no cross reac-
tions between different LAs.
8. Neurotoxicity and local anesthetic (LA) are a cause of
concern. Which of the following statements is true?
A. Signs and symptoms of early LA systemic toxicity con-
sist of tremor, blurry vision, vertigo, nausea, vomitus,
tinnitus, convulsions, and hypotension.
B. In laboratory settings, the convulsive dose of LA com-
pared to the lethal dose is around five times higher.
C. Lidocaine is more cardiotoxic than bupivacaine due to
the more avidly and longer binding of lidocaine to car-
diac Na channels.
D. All of the LAs cause vasodilation of vascular smooth
muscle cells except for cocaine—it produces local
vasoconstriction.
9. Treatment of local anesthetic (LA) toxicity depends on
the severity of clinical symptoms. Which of the follow-
ing statements is true?
A. Minor reactions such as tinnitus and metallic taste
in the mouth should be treated by lipid infusions to
create a shift in LA concentration from intracellular to
extracellular.
B. Seizures due to LA should be treated with anticonvul-
sive therapy such as carbamazepine or valproic acid.
C. When toxicity from LA progresses to a level of myocar-
dial failure and rhythm disturbances, intubation and
resuscitation measures including lipid emulsion ther-
apy should be put into motion.
D. LA toxicity is common, due to the fact that local anes-
thetics are lipophilic and can pass easily through the
blood–brain barrier.
ANSWERS AND EXPLANATIONS
1. A is correct. Carl Koller and Joseph Gartner used cocaine
to produce topical anesthesia of the conjunctiva. The birth
of local and regional anesthesia dates from 1884, when
Koller and Gartner reported their success at producing
topical cocaine anesthesia of the eye in the frog, rabbit,
dog, and human.
B is incorrect. Only one year after the first introduction of
cocaine as a LA, the first successful brachial plexus block
was performed.
Hadzic_Ch06_p021-026.indd 24
C is incorrect. August Bier was the first person to use
cocaine for spinal anesthesia.
D is incorrect. Only cocaine is a natural occurring local
anesthetic ester. Others are synthetic variants. The first
introduction of an amide was in 1948, around 70 years
later.
2. C is correct. They consist of one α-subunit and two
β-subunits. The α-subunit is the site of ion conduction
and of LA binding. Sodium channels have at least three
native configurations.
A is incorrect. Sodium (Na) channels consist of one large
α-subunit and two smaller β-subunits in humans. The
α-subunit is the place of local anesthetic binding.
B is incorrect. The α-subunit has four homologous
domains, each with six transmembranous segments.
D is incorrect. The distribution between Na channels in
myelinated and unmyelinated is not the same. Myelinated
fibers have nodes of Ranvier, which are dense and packed
with Na channels. Unmyelinated fibers have more diffuse
dispersal of Na channels, which makes them difficult tar-
gets for LA.
3. C is correct. The rate of diffusion across the nerve sheath
is determined by the concentration of the drug, its degree
of ionization (ionized LA diffuses more slowly), its hydro-
phobicity, and the physical characteristics of the tissue
surrounding the nerve.
More lipid-soluble LAs are relatively water insoluble,
highly protein bound in blood, less readily removed by
the bloodstream from nerve membranes, and more slowly
“washed out” from isolated nerves in vitro. Thus, increased
lipid solubility is associated with increased protein binding
in blood, increased potency, and longer duration of action.
A, B, and D are incorrect. Nerve-blocking potency of
LAs increases with increasing molecular weight and
increasing lipid solubility. The increased lipid solubility
is associated with increased protein binding in blood,
increased potency, and longer duration of action.
4.
A is correct. The pKa value generally correlates with the
speed of onset of action of most amide LA drugs; the
closer the pKa value to the body pH, the faster the onset.
LA rate of onset is associated with the aqueous diffusion
rate, which declines with increasing molecular weight. The
relationship between concentration and block onset is log-
arithmic, not linear; in other words, doubling the concen-
tration of LA will only marginally speed up the onset of
the block although it will block the fibers more effectively
and prolong the duration.
B, C, and D are incorrect. See explanation for answer A.
5.
A is correct. Many factors influence the ability of a given
LA to produce adequate regional anesthesia, including the
dose, site of administration, additives, temperature, and
pregnancy.
B, C, and D are incorrect. See explanation for answer A.
19/04/19 10:04 AM
Another random document with
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with malaria of late, and spent whole days in bed, lying without a
book or even her knitting, staring darkly and silently into space.
This afternoon Gabrielle had escaped, to scramble for half an hour
along the shore, her busy eyes upon the twinkling low-tide life
among the rocks, her thoughts a jumble of strange apprehensions
and fears. Now she was lingering in the garden, reluctant to
surrender herself once more to all the shadows and unnamed
menaces of the house, picking a few of the brave bronze zinnias and
the velvet wallflowers; the floating pale disks of cosmos, on their
feathery leafage, were almost as high as her tawny head.
She started as David’s figure loomed suddenly through the soft veils
of the autumn fog, close beside her, and laid her hand with a quite
simple gesture of fright against her heart. The colour, brought by her
scrambling walk into her cheeks, ebbed slowly from beneath the
warm cream of her skin. Her eyes looked large and childish in their
delicate umber shadows. David saw the fine, frail linen over her
beautiful young breast rise and fall with the quickened beat of her
heart; the soft moist weather had curled her tawny hair into little
damp feathers of gold, against her temples.
An ache of sheer pain, the pain of the artist for beauty beyond
sensing, shook him. She was youth, sweetness, loveliness
incarnate, here against a curtain of flowers and gray mist, with
wallflowers in her hand, and the toneless pink and white stars of the
cosmos floating all about her head. David gave her his hand, and
she clung to it as if she would never let it go, as if she were a
frightened child, found at last.
“David—thank God you’re home!” she said. “But you’ve tired
yourself,” she added, instantly concerned. “You look thinner, and you
look pale.”
“I’m fine,” he said, with his good smile. “But why did you want me
back?” he asked, a little anxiously, in reference to her emotion at
seeing him.
“Oh, I don’t know. Things”—she said, vaguely, with a glance toward
the looming black shape of Wastewater, netted in its blackened vines
—“things have—made me nervous. I’m not sleeping well.”
“Aunt Flora looks like a ghost, too,” the man said, and Gay gave a
nervous little protesting laugh.
“Don’t talk about ghosts! But it’s only her old malaria, David,” she
added, frowning faintly.
“I don’t know. Her colour looks ghastly. And Sylvia seems twitchy,
too. What’s the matter with us all?”
“Us all?” She caught up the phrase accusingly. “Then you feel it,
too?”
“I think I have always felt—something—of it, here!”
“It?” Gabrielle repeated the monosyllable thoughtfully, and as they
turned slowly toward the house, “Horror——” she said, under her
breath. “David, David, can’t we all get away?”
“We must get away,” he amended. “It isn’t a good atmosphere for
any one! Perhaps next summer——”
He stopped. Sylvia had given him another significant hint a few
minutes ago. But he dared not ask Gabrielle to confirm it. No, he was
only a sort of big brother to her—she did not need him much now;
presently she would not need him at all.
“David,” she said, quickly and distressedly, when in their slow and
fog-enshrouded walk they had reached the little alley under the
grapevines where Gay had seen her mother almost a year ago, “will
you advise me?”
His face was instantly attentive; of the sudden plunge of his heart
there was no sign.
“Gladly, dear.”
“Tom has asked me to marry him, David,” Gabrielle said.
Their eyes met seriously; David did not speak.
“I have known for some time that he would,” Gabrielle added, with
the pleading look of a child in trouble who comes to an omnipotent
elder.
“You told him——?”
“I—didn’t say no.”
There was a long pause while neither moved. A bird, unseen in the
mist, croaked steadily, on a raucous note.
“You have promised him, Gabrielle?”
“No. I couldn’t do that. But—I couldn’t say no. I tried,” Gabrielle went
on, in a sort of burst, and quite unconsciously clinging to David’s
hands, “I did try to prevent it, David. You don’t know how I tried! He
has been talking about it—oh, since before you went away! He told
me he liked a girl, and he would tell me all about her, pretending that
she was not I. I—prayed,” Gabrielle went on, passionately, “that it
was not I!”
“Gabrielle, I would have spoken to him, saved you all this!”
“No, no, no, I know you would!” she said, feverishly. “Aunt Flora
would have told him. But, David, we couldn’t have that! Why, it would
have broken his heart! You see, he’s proud, and he feels—feels that
there is—a difference between us and himself. He has been like a
child about this, a child with a wonderful ‘surprise’ for me. I am to
have jewels and travel and cars—everything.”
“If you marry him?” David asked, slowly.
“If I marry him. And I like him, David—ah, truly I do! I feel so badly for
him. I feel as if it would be a real—a real life, for me,” persisted little
Gabrielle, gallantly, feeling for words, “to fill Wastewater with guests
and hospitality and happiness again. I can’t bear to have him feel
that, poor as I am, and—and nameless—and he knows I am
nameless!—still, I couldn’t love him. It will make him bitter, and ugly,
and he’ll go off again, and perhaps die. I’ve had to be kind, to put
anything definite off, and so I’ve said nothing to anybody—not even
Sylvia. I’ve had to—to—fight it out alone,” finished Gabrielle, with a
trembling lip and swimming eyes, “and it has made me—nervous!”
“My dear girl,” David said, slowly, heavily, “you’re sure you wouldn’t
be happy? You would be very rich, Gabrielle, and you could teach
him to make the most of his money. I think it would make Aunt Flora
and Sylvia very happy.”
Gabrielle was moving slowly ahead of him toward the house now.
She half turned to look at him over her shoulder.
“David, do you think I should say yes?” she whispered.
“I think perhaps you should consider it gravely, Gay. You say you like
him, and what other woman is he ever apt to find that would
understand him, or even like him, so well? Imagine what harm his
money is going to do to him, once he is better, mixing in the world
again!? All sorts of social thieves will be upon him——”
“That’s what I think of!” she responded, eagerly, so childishly, so
earnestly concerned that David felt his heart wrung afresh with a
longing to put his arms about her, comfort her, kneel at her feet and
put his lips to her beautiful young hands. “If—if only we can get out
of here!” she whispered, with another strangely fearful glance at the
old house, “his affairs straightened out, Sylvia and Aunt Flora and I—
going somewhere!—anywhere! David, we mustn’t spend another
winter here. And yet now, now,” she began again, with fresh
agitation, “I don’t know what Tom thinks! He may think—indeed, I
know he does think, that everything will be as he wishes! What could
I do? I couldn’t help—and indeed, I didn’t say anything untrue! I only
told him he must not think of such things until he was much, much
better, but he seems to have taken that as a sort of—as a sort of—
consent—in a way——”
“Shall I talk to him, dear? Tell him that you need more time?”
“Oh, no, please, David! Leave it to me!”
“Sometimes, I’ve been given to understand,” he said, with his quiet
smile, “that a girl feels this way when she really is sure, or when, at
all events, it develops that the doubt and hesitation were all natural
enough, and part of—of really caring. Take time about it, Gabrielle.
Money and position do count for something, after all, and he is a
Fleming, and he knew your mother. It isn’t,” added David, with a little
conscious change in his own tone, “it isn’t the other man of whom
you spoke to me last June?”
For a moment Gay did not answer. Then she said, in a peculiar
voice:
“I’ve often wondered what you meant by that conversation, David.
Whether you remembered it? What was it? Had you consulted Aunt
Flora and Sylvia as to my destiny—as to the problem of what was to
become of me?”
“I—yes, I had written Sylvia, or no—not exactly that,” David
stammered, taken unawares, and turning red. “I—it was just an idea
of mine, it came into my head suddenly,” he added, with a most
unwonted confusion in his manner, as he remembered that old bright
dream of a porch on the seaward side of the Keyport farmhouse, and
himself and poor little unwanted, illegitimate Gay breakfasting there.
“I wrote Sylvia about setting her free of a sort of understanding
between us,” David went on, with a baffled feeling that his words
were not saying what he wanted them to say. “As a matter of fact, a
letter from her, saying the same thing, crossed mine,” he finished,
again feeling that this statement was utterly flat and meaningless
and not in the least relevant to the talk.
“You didn’t say you—cared,” Gabrielle said, very low. “You simply put
it to me as a sort of—solution.”
“I see now that it was an affront to you, Gay,” David answered,
sorely. “I have regretted it a thousand times! I wanted to offer you—
what I had. But God knows,” he added, bitterly, “I have nothing to
offer!”
“So that you—would not—do it again?” Gabrielle said, hardly above
a breath, and breathing quickly, yet with an effort to appear careless.
“I would never offer any woman less than—love, again,” David
answered. “If I had not been a bungling fool in such matters, you
should never have been distressed by it!”
“You see, you did not care for me, David,” the girl reminded him, in a
low, strained voice, and not meeting his eyes, when they were at the
gloomy side door. The mist was thickening with twilight, and a fitful,
warm wind was stirring its fold visibly.
“I had been thinking about it for days,” he said, “it had—I don’t know
how to express it!—it had taken possession of me.”
Gabrielle, her shoulder turned toward him, flung up her head with a
proud little motion.
“Tom—loves me,” she said, steadily. Yet David saw the hand that
held the flowers shake and the beautiful mouth tremble.
“Tom,” his half-brother said, still unable to shake off the wretched
feeling that they were talking at cross-purposes, “would make you a
devoted and generous husband, Gabrielle.”
Neither spoke again. They went into the dark hallway, and upstairs,
and the gloom of Wastewater sucked them in and wrapped them
about with all its oppressive silences, its misunderstandings, and its
memories.
 CHAPTER XVI
The weeks that followed seemed to Gabrielle Fleming, even at the
time when they were actually passing, strangely and darkly
unnatural, and afterward they remained a fearful memory in her life.
Long before the tragedy in which they culminated she was quite
definitely conscious of some brooding cloud, some horror impending
over the household, she felt herself bound by a strange interior
inhibition, or by a hundred inherited and instinctive inhibitions, from
speaking freely, from throwing off, or attempting to throw off, the
fears that possessed her.
Outwardly, as the serene autumn darkened and shortened into
winter, the household seemed merely what the return of the heir had
made it; Tom invalided, restless, in love with his cousin Gabrielle;
Sylvia beautiful and confident, as she faced the changed future; Aunt
Flora silent, coughing with her usual autumn bronchitis, moving
about the house as the very personification of its sinister history;
David grave and kindly, managing, advising, affectionate with them
all; and the staff of kindly old servants duly drawing shades, lighting
fires, serving meals.
Actually, Gabrielle felt sometimes that they were all madmen in a
madhouse, and vague disturbing thoughts of her own unfortunate
little mother would flit through her mind, and she would wonder if her
own reason would sustain much of this sort of suspense.
For suspense it was. The girl knew not why or what she feared, and
they all feared. But she knew that their most resolute attempts at
laughter and chatter somehow fell flat, that they glanced nervously
over their shoulders when a door slammed, and that the shadows
and gloom of the half-used old place seemed, of an autumn evening,
when the winds were crying, to be creeping from the corners and
lurking in the halls, ready to capture whatever was young and happy
in dark old Wastewater and destroy it as so much youth and
happiness years ago had been destroyed.
Nowadays, she fancied, the very voices of the maids, as they talked
over trays or brooms in the hall, took on wailing notes, the clocks
ticked patient warnings, a shattered coal on the fire would make
them all jump. Gabrielle, with her heart beginning a quick and
unreasoning beat, would turn off her bath water lest its roaring drown
some warning sound, would stand poised, in her wrapper, as if for
flight from she knew not what, listening—listening——
But it was only the October winds, sweeping the trees bare of their
last tattered banners, only the fresh, harsh rush of the sea against
the rocks, and the scream of a blown gull!
“Sylvia, does it make you feel as if you would like to scream,
sometimes?” Gay asked one day, in the bare sunlight of the garden.
“Does what?” But in Sylvia’s dark eyes there was perfect
comprehension. “It is almost,” she added, in a low tone, “as if people
did really stay about a place to haunt it. That poor little shadowy
Cecily—the second Mrs. Fleming—who died, and your mother, and
my father, and Uncle Roger——”
“And all their passions and all their hates!” Gabrielle said, in a fearful
whisper, glancing up at the grim outlines of the enormous pile, “and
all those dusty, empty halls and locked rooms! To me,” she went on,
speaking with her eyes still on the black-brick, black-vine-covered
house, “it is all coloured by that horrifying experience, here in the
side lane, almost a year ago—when I first saw my mother——”
The mere memory of it frightened her. She seemed to see again the
gray whirls of snow in the shadowy lane, the writhing, huddled gray
figure among the writhing ropes and curtains of white.
“Gabrielle, don’t!” Sylvia said quickly, with a nervous laugh.
“No, but Sylvia, you feel it, too?”
“Ah, of course I do! Mamma so ill and silent, Tom so strange, David
not——” Sylvia’s lip trembled, as much to her own surprise as Gay’s
—“David is not himself,” she said, hurriedly. “He came back from this
trip—changed! Whether it is Tom’s return, with all the memories and
changes, I don’t know. Only,” added Sylvia, quite frankly blinking wet
eyes, “only I have noticed a change in him, just lately, and it has—
worried me! Perhaps it’s only a passing phase for us all,” she
interrupted herself hastily, “one of those wretched times that all
families go through! Partly weather, and partly nerves, and partly
changes and sickness——”
“And largely Wastewater,” Gay said, hugging her great coat about
her, as the girls rapidly walked about the garden. “There seems to be
an atmosphere about the place stronger than us all. We’re all
nervous, jumpy. Last night, just as I was about to turn out the light in
the sitting room, it seemed to me the picture of Uncle Roger was—I
don’t know! breathing, looking at me—alive! I almost screamed. And
the night after David came back, I picked up his letters, he had
dropped them in the hall, and when I knocked on his door with them
he fairly shouted ‘What’s that!’ and frightened me, and himself, too,
he told me, almost out of our senses!”
“I don’t sleep well,” Sylvia confessed. “I don’t believe any of us do. I
don’t think we should stay here. If Tom has to go away——”
She stopped. It was impossible not to assume now that Tom’s plans
depended upon Gabrielle. Yet there was about the younger girl none
of the happiness that comes with a flattering and welcome affair.
Gabrielle instead was quite obviously experiencing a deepening
depression and uneasiness. Every day showed her more clearly that
Tom considered her bound to marry him, interpreting everything she
said and did according to his own cheerfully complacent self-
confidence.
Her kindness had carried her too far, now, for honourable retreat.
She could not even get away from Wastewater, to think in peace, for
Tom would not hear of separation, they had known each other long
enough, they had “considered” enough, he said; when Aunt Flora
and Sylvia took the apartment of which they were always speaking
for the winter, Tom and Gabrielle would be married and go south
together—go anywhere she wanted to go, but together. Bermuda or
Florida or San Diego were all equally indifferent to Tom, as long as
he had his wife with him.
The very words made Gabrielle’s blood run cold. It was in vain that
she tried to imagine herself married, rich, going about the world as
Mrs. Tom Fleming. Every fibre of body and soul revolted; she liked
Tom, she would have done almost anything to please him, but
somehow the thought of him as her husband made her feel a little
faint.
Yet how, after all this kindly talk, after these hours of listening, of
companionship, suddenly break free? Gabrielle dared ask no help;
Sylvia or Aunt Flora would only hurt him a thousand times more than
she would, even David’s touch could not be trusted here. Besides,
she did not feel herself deserving of help or extrication; she had
brought this most uncomfortable state of affairs upon herself, she
had been too kind to Tom, she had let him drift happily into the idea
that they cared for each other.
The girl began to feel with a sort of feverish terror that she must be
free—free if she had to run away into the world alone. From a
distance she could write them, she could explain! But she could not
go on in this fashion, with every hour deepening the
misunderstanding between herself and Tom, tightening the net.
November came in bare and cold, with a faint powdering of snow
upon the frozen ground. Suddenly summer-time, and shining seas,
and sunshine seemed but dreams, life had become all winter, there
would never be warmth and flowers again. Wastewater was bleakly
cold; oil stoves burned coldly, like lifeless red-eyed stage fires in
mica and coloured glass, the halls were frigid, the family huddled
about fires.
Tools sounded metallically all day upon the new radiators, that, still
unconnected, stood about wet and cold and forlorn against the walls.
Tom spent most of his days upstairs in his “study,” where a roaring
airtight stove, connected with the old flue, made the air warm. He
must start southward soon, they all said, and yet there was no
definite plan of a departure.
David was still immersed in the business of the estate; Flora was
wretched with rheumatism and malaria; Gabrielle, of them all, was
the least anxious to suggest a change, and so precipitate a
settlement with Tom.
On the fourth day of the month came the Great Wind. Keyport and
Crowchester, and indeed all the towns along the coast for miles,
would long talk of it, would date domestic events from it. The night of
the third was cold and deathly clear, with a fiery unwarming sunset
behind sombre black tree trunks, and a steely brightness over the
sea. Gabrielle saw milk-white frost in the upturned clods in the
garden; the light was hardly gone when a harsh moonlight lay upon
the bare black world.
There was a good deal of air stirring in the night, and toward morning
it grew so cold that the girls, chattering and shaking, met in the halls,
seeking blankets and hot bottles. Gay and Sylvia knocked on David’s
door; he must take extra covering to Tom; David’s teeth clicked and
his laughter had a ghoulish sound as he obeyed.
The day broke gray and cold in a hurricane that racked and bowed
the trees and bushes, laid the chrysanthemums flat, rattled dry
frozen leaves and broken branches on the porches. Whitecaps raced
on the gray, rough sea, doors slammed, casements rattled, and at
regular intervals the wind seemed to curl about the house like a
visible thing, and whined and chuckled and sobbed in the chimneys.
Fires were kept burning, and Sylvia and Gabrielle, in their thickest
sweaters, stuffed the sitting-room window ledges with paper to keep
out the straight icy current of the air.
The family was at breakfast, with the lights lighted, when one of the
oldest maples came down, with a long splintering crash that was like
a slow scream. During the morning two other smaller trees fell, and
whosoever opened an outside door was immediately spun about,
and in a general uproar and rattle and flutter of everything inside,
was obliged to beg help in closing it. After luncheon, John came in to
say that his wife and little girl were so nervous that he was going to
take them in to Crowchester. He could get the papers——
“No,” David said, “I may walk into Keyport later!”
“You’ll never keep your feet on the roads, sir. I never seen such a
blow in my life. There was great gouts of foam blown as far back as
the cow barn,” John said, respectfully. “I tied up the mill.”
David only smiled and shrugged, and at three o’clock went down to
the side door, belted into his thick old coat. Sylvia and Gabrielle he
had seen a few minutes before established with Tom and Aunt Flora
in the comfortable study far upstairs, where there was a good fire
burning.
As he slipped out, and dragged the door shut behind him, the wind
snatched at him, and for a moment he really doubted his ability to
make even Keyport, less than three miles away. There was a
whirlwind loose in the yard; everything that could bang or blow or
rattle or shriek was in motion, and the roar of the sea was deafening.
The sun shone fitfully, between onslaughts from clouds that swept
across a low iron sky; there had been a cold rush of hail an hour or
two before; ledges and north fronts were still heaped white with it.
There was not a boat upon the running high waters of the sea;
David, letting himself out at the narrow back gate, saw the waves
crashing up against the Keyport piers and flinging themselves high
into the gray cold air.
Wastewater stood upon a point, and there was less uproar on the
highway than upon their own cliffs. The wind faced him steadily here,
stinging tears into his eyes, and pressing a weight like a moving wall
against his breast. There was no escaping it, there was no dodging;
David bent his head into it, knowing only that the road was hard and
yellow beneath his staggering feet.
He jumped and shouted as a hand touched his arm, and he saw at
his elbow Gabrielle’s blown and laughing and yet somewhat
frightened face. Unsure of her welcome, she caught her arm tightly
in his and pushed along gallantly at his shoulder.
“I couldn’t stand it!” she shouted, above the shriek of the wind, “I had
to get out!”
“What did Aunt Flora say?” he shouted back, moving ahead simply
because it was impossible to stand still.
“She doesn’t know! I only told Hedda—when I came downstairs!”
Gay screamed.
“Well—hang tight!” And together they breasted the wall of air.
“Gay, you were mad to do this!” David shouted, after a hard mile.
“Oh, I’m loving it!” answered her exulting voice, close at his ear.
“I’m loving it, too!” he said. And suddenly they were both human, free
of the shadows, able to laugh and struggle, to catch hands and shout
again.
On their left the sea raged and bubbled, above them swept the wild
airs; clouds and cold sunshine raced over the world, and the wind
sailed with foam and mad leaves. But perhaps to both the man and
the woman the physical struggle after these weeks of mental strain
was actually refreshing; at all events, they reached Keyport, after an
hour’s battling, in wild spirits.
The little town was made weather-tight against the storm, and
presented only closed shutters and fastened storm doors to the
visitors. Gabrielle and David made their way along the main street,
catching at knobs and corners, and were blown into the bleak little
post office, whose floors were strewn with torn papers and tracked
with dried mud. The old postmaster eyed them over his goggles with
mild surprise as he gave them letters from a mittened hand. The
place smelled warmly of coal oil and hot metal; its quiet dazed them
after the buffet of the storm.
The piers were deserted, except for a few anxious gulls that were
blown crying above lashing waves; a group of tippeted boys
exclaimed and shouted over the tide that had caught the end of
River Street. David guided his companion into Keyport’s one forlorn
little restaurant, and they sat at a narrow table spread with steel
cutlery and a lamp, spotted cloth, drinking what Gabrielle said was
the best coffee she had ever tasted.
“You crazy woman!” David said, affectionately, watching her as she
sipped her scalding drink from a thick cup and smiled at him through
the tawny mist of her blown hair.
He had, with some difficulty, made arrangements for their being
driven back in the butcher’s Ford, at half-past five, when the butcher
shop was closed. David did not dare risk the walk home in the early
dark, and Gabrielle now began to feel through her delicious
relaxation a certain muscle-ache and was willing to be reasonable.
So that they had a full hour to employ, and they spent it leaning upon
the little table, sharing hot toast and weak coffee, straightening the
thick table-furnishing, setting sugar bowl and toothpick glass over the
spots, talking—talking—talking as they had never talked before.
Gabrielle poured out her troubles like an exhausted child; her eyes
glowed like stars in the gathering dusk, her cheeks deepened to an
exquisite apricot-pink under their warm creamy colourlessness.
David watched her, listened, said little. But he began to realize that
she was genuinely suffering and depressed and in the end a clean
programme was planned, and David promised to put it into
immediate execution.
Gabrielle liked Tom, but not as much as he thought she did. She
wanted to get away, at once—to-morrow or day after to-morrow—to
straighten out her thoughts and to see the whole tangle from a
distance. Very good, said David, drawing a square on the tablecloth
with the point of a fork. Aunt Flora should be told the whole story,
and Gay should go in to Boston at once, to see—well, to see a
dentist. She must develop a toothache, to-morrow morning, or as
soon as the storm subsided. She could telegraph the nuns to-night,
and be with them about this time to-morrow.
When he saw how her eyes danced and how impulsively she
clasped her fingers together at the mere notion, David was able to
form some idea of the strain she had been under.
“Oh, David—to see the streets and—and people, again! To feel that I
needn’t face Tom——”
“Meanwhile,” David proceeded with his plan, “I’ll get Tom to go off
with me somewhere, just for a few weeks. Norfolk, maybe, or Palm
Beach—it may clear up his mind, too. And perhaps I can explain to
him that while you do like him, you don’t feel quite ready to be any
man’s wife. I can tell him that the thought of it upsets you——”
“Ah, David, what an angel you are! But then what about Sylvia and
Aunt Flora?”
“Well, they can follow you in to Boston. Sylvia spoke to me about
either doing library work or teaching in some girls’ school; they can
be looking about for an apartment. But the main point is,” ended
David, “that you get out of it at once, before you make yourself sick.”
“It seems so cowardly,” said Gabrielle, fairly trembling in her
eagerness and satisfaction.
“No, it’s not cowardly. I suppose it’s what all girls feel,” David said, in
a somewhat questioning voice, “before they get married——?”
“That’s just it,” Gay confessed, her cheeks suddenly scarlet. “I don’t
know what most girls feel, and I haven’t any mother——”
She paused. But David, looking at her over his cigarette, merely
flushed a little in his turn, and did not speak.
“But I know this,” Gabrielle went on, feeling for words, and ranging
knives and forks and spoons in orderly rows, very busily, as she
spoke, “I know that what makes me feel so—so doubtful, about
marrying Tom, isn’t—isn’t being afraid, David,” she struggled on, her
eyes pleading, and her cheeks childishly red. “It’s—not—being
afraid!”
Their eyes met across the sorry little board, and for a moment the
strange look held and neither spoke.
“I have been playing a part with Tom,” Gabrielle said, after a pause,
“and I could go on playing it. I could marry him to-morrow, and—and
still like him, and be kind to him! But, David,” she said, in a whisper,
“is that enough?”
“I don’t know, dear,” David said, with a dry mouth. “You mean, that it
could be different,” he added, presently, “that it would be different, if
it were that other man—of whom you spoke to me one day?”
The girl only nodded in answer, her eyes fixed with a sort of fear and
shame and courage upon his. If it were the other man! she thought—
if it were David! And at the mere flying dream of what marriage to
David would mean—going out into life with David—Gabrielle felt her
heart swell until something like an actual pain suffocated her and her
senses swam together.
He sat there, unconscious, kindly, everything that was good and
clever, handsome and infinitely dear, and she dared not even stretch
out her hand to lay it upon his. His black hair was blown into loose
waves, his old rough coat hung open, his fine dark eyes and firm
mouth expressed only sympathy and concern. She dared not think
what love might do to them.
“I want—to be afraid when I am married,” she said. “I want to feel
that I am putting my life into somebody’s keeping, going into a
strange country—not just assuming new responsibilities—in the old!”
“I think I understand,” David said. And feeling that further talk of this
sort was utterly unsafe for him and likely to prove only more
unsettling to her, he proposed that they walk to the Whittakers’, a few
blocks away, and see how the large and cheerful family was
weathering the storm.
The Whittakers, mother, two unmarried daughters, two young sons,
married daughter with husband and baby, were having a family tea
that looked enchanting to Gabrielle and David, coming in out of the
wind.
The big room was deliciously warm, and Mrs. Whittaker put Gay,
who was a little shy, beside her and talked to her so charmingly that
the girl’s heart expanded like a flower in sunshine. Mrs. Whittaker
had known Gay’s poor little mother and both of Roger Fleming’s
wives; she said that by a curious coincidence she had had a letter
that very day from Mary Rosecrans.
“But you don’t remember her, of course,” she said. “She was a lovely
nurse—a Crowchester girl, but married now and living in Australia.
Let me see—nineteen—Dicky’s eighteen—she must have married
when you were only a baby. But I had her when my Dicky here was
born, and poor little Mrs. Roger Fleming had her for months and
months at Wastewater. Now, Mr. Fleming, you’re going to let me
keep this child overnight? The girls will take good care of her.”
“Oh, do!” said Sally and Harriet in one voice. And the Whittaker baby
smiled up innocently into Gabrielle’s face. “And why didn’t you do
this long ago, Gabrielle?” they reproached her. “You’ve been home
almost a year.”
Gabrielle, kissing the top of the baby’s downy head, explained; David
thought her more than ordinarily lovely in this group of youth and
beauty. Harriet and Sally had been at boarding school, she reminded
them, and Mrs. Whittaker had been staying with Anna and the new
baby, and then Tom Fleming had come home——
“Ah, but now do do this again soon, you dear children!” their hostess
said, when Gabrielle had pleaded that she really dared not stay,
having run away for the walk in the wind as it was, and when the
butcher’s hooded delivery wagon was at the door. And Gabrielle
went out, clinging to David’s arm, into the creaking, banging, roaring
darkness, with the motherly good-bye kiss warm upon her forehead.
The delight of this long afternoon of adventure and the prospect of
escape to-morrow kept her laughing all the way home, and even
when they got there, she seemed to carry something of the
wholesome Whittaker fireside, something of the good out-of-doors
with her into Wastewater.
But swiftly, relentlessly, the chilling atmosphere of repressions and
fears shut down upon them all again; outside the night rioted madly,
and the old house creaked and strained like a vessel at sea. Indoors
lights seemed to make but a wavering impression on the gloom of
the big rooms, doors burst open, casements shook with a noise like
artillery fire, and voices seemed to have strange echoes and hollow
booming notes.
Once some window far upstairs was blown in, and the maids went
upstairs in a flight, exclaiming under their breath, and slamming a
score of doors on their way. Chilly draughts penetrated everywhere,
and the dining room had a strange earthy smell, like a vault.
The girls wore their heavy coats to dinner, and after dinner went up
to Tom’s study and built up the fire until the airtight stove roared and
turned a clear pink. Tom lay on his couch; he had been oddly moody
and silent to-night; Gabrielle played solitaire, talking as she played;
Sylvia scribbled French verbs in the intervals of the conversation.
David and Aunt Flora had been with them until something after nine
o’clock; then Flora had somewhat awkwardly and heavily asked him
to come down with her to the sitting room; she wished to talk to him.
This was a common enough circumstance, for business matters
were constantly arising for discussion. But her manner was strange
to-night, Gabrielle thought, and the girl’s heart beat quickly as they
went away. Now David would tell her that she, Gabrielle, wanted to
go into Boston for a few days—perhaps he was telling her now——
A quiet half-hour went by, and then Sylvia stretched herself lazily and
admitted that she was already half asleep. Tom had been lying with
half-shut eyes, but with a look so steadily fixed upon Gabrielle that
the girl was heartily glad to suggest that they all go downstairs.
There had been something sinister, something triumphant and yet
menacing in that quiet, unchanging look. She had met it every time
she looked up from her cards, and it had finally blotted everything
but itself from her thoughts.
Tom rose obediently, and Sylvia folded his rug for him, and went
about straightening the room. The girls were accustomed to perform
small services for Tom, who really was not strong enough to be quite
independent of them yet. All three went downstairs together,
Gabrielle loitering for a few minutes in Sylvia’s room, not so much
because she had anything to say as because the nervousness and
the vague apprehension, that possessed her like a fever, made her
fear her own company.
When she turned back into the hall again Gabrielle was surprised to
see Tom standing in his doorway.
“Did I leave my pipe upstairs?” he asked, in an odd voice.
“Oh, did you, Tom?” Gabrielle asked, eagerly, always glad to be
useful to him; the more so as she found it more and more difficult to
be affectionate. “No, let me! Let me!” she begged, taking the candle
from his hand. “I’ll not be two minutes!”
Again—she remembered afterward!—he was smiling his odd,
triumphant, yet threatening smile. But he said nothing as she took
the lighted candle and started on the long way upstairs to the study.
Guarding the candle in the savage currents of air that leaked
everywhere through windows and doors, Gabrielle had to move
slowly, and in spite of herself the swooping darkness about her, the
wild racket of the storm outside, and the shadows that wheeled and
leaped before her frail little light made her suddenly afraid again. She
was desperately afraid. David, Sylvia—all the human voices and
hands, seemed worlds away.
Tom’s study was two floors above Gabrielle’s room, three above his
own, and in a somewhat unused wing. The wind, in this part of the
house, was singing in half-a-score of whining and shrieking voices
together, and there was a thunderous sound, of something banging,
booming, banging again with muffled blows, as if—Gabrielle thought
—the house had gotten into the sea, or the sea into the house, and
the waves were bursting over her.
Just as she reached for the handle of the study door her candle went
out, and Gabrielle, with a pounding heart, groped in the warm
blackness for the table and the matches and blessed light again! She
was only a few minutes away from the protection and safety of the
downstairs room, she told her heart—just a light and the half
moment of finding the pipe again, and then the swift flight downstairs
—anyhow, any fashion, to get downstairs——!
Her investigating hands found the brass box of matches, she struck
one and held it with a shaking hand to her candle. There was no
glow from the stove now, and the feeble light broke up inky masses
of darkness. The square mansard windows strained as if any second
they would burst in; a charge of howling winds swept by the window,
swept on like a herd of bellowing buffaloes into the night.
Gabrielle, holding her light high the better to search the room for the
pipe, and swallowing her fears resolutely, turned slowly about and
stopped——
She thought that she screamed. But she made no sound. There was
a man standing behind her, and smiling at her with an odd, sinister
smile. But it was not that alone that froze her into a terror as cold as
death, that held her motionless where she stood, like a woman of
wood. It was that the man was Tom.
“Well, what’s the matter?” Tom asked, slowly and easily. His voice
restored Gabrielle to some part of her senses, and she managed a
sickly smile in return.
“You frightened me!” Gabrielle answered, her heart still pumping
violently with the shock, and with a sort of undefined uneasiness,
bred of the dark night, and the howling wind, and her solitariness far
up here in the lonely old house.
Tom had lighted the lamp.
“Sit down,” he said. “I want to talk to you!”
“Oh, Tom—it’s after ten!” Gabrielle said, fluttering.
“Well, what of it? Here——” He pushed an armchair for her, and
Gabrielle sat down in it, and blew out her candle. Tom opened the
stove, dropped wood and paper inside, and the wind in the chimney
caught at it instantly, with a roar. “I wanted to talk to you,” Tom
added, “without Sylvia or any of the others around. They’re always
around!”
One of them would be welcome now, Gabrielle thought, in a sort of
panic. For Tom’s face looked stern and strange, and there was a
rough sort of finality expressed in his manner that was infinitely
disquieting.
She did not speak. She sat like a watchful, bright-eyed child,
following his every word and every movement. Tom would not hurt
her—Tom would not kill her—said her frightened heart.
“Here’s what I want to know, Gabrielle,” he began, abruptly, when he
had taken a chair close to her own. “What’s the idea? You know all
about me—you can’t keep up this stalling for ever, you know.”