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The Role of Anatomy in Anesthesia.* C. P. Martin, M.D.

, Montneal, Canada Professor of Anatomy, McGill University

IN SPEAKING of the r6le of anatomy in anesthesia I feel that all that I can do is to outline briefly the practice in the Anatomy Department of McGill University with regard to the teaching of anesthesia on both undergraduate and the graduate levels. Taking the und6rgraduate level first, I may perhaps remark that in McGill University, as in most other places, the time alloted to the teaching of anatomy has been curtailed; and more seriously still, has been condensed into one year of the medical curriculum. I feel that this is unfortunate. After all, anatomy is a practical subject, and the object of a medical student s time in the dissecting room is not to amass a vast detail of insignificant anatomical facts but to become familiar with the human body. A familiarity of this type can be acquired much more easily if the student s time is spread over a longer period. I feel that the actual number of hours alloted to anatomy is not the only factor to be considered,

but that much more useful practical results would be obtained if the hours were spread over two years instead of one. Another point worth considering, if I may be allowed to digress somewhat, is the staffing of an anatomy department. In many universities it has, I think, rather unfortunately happened that the anatomy departments are staffed mainly or indeed exclusively by Ph.D. s who have 291 Anesthesia and Analgesia-September-October, 1949 no training or experience in medical subjects. To such persons, of course, anatomy is really no more than a subdepartment of vertebrate zoology, and their interests tend to run into the fields of anthropology and comparative anatomy, fields which are fascinating and useful in themselves, but have no direct or immediate bearing on medical science. Since I came to McGill I have always made it a point that we must keep in mind our main function of training medical practitioners. To this end all or at least a great majority of the teachers must be men who themselves have

had some clinical experience. In all our teaching we must emphasize the points which are of practical clinical importance, and no question should be asked at any examination which has not some clinical significance. I grant it is sometimes difficult to draw the line between useful and academic knowledge, but I think that if this end is kept in view one can, at least, keep an anatomy department in close touch with medical and surgical science. The above principles have, of course, a bearing on the training of students in anesthesia. In the course of our lectures and dissections we try to point out the places where certain nerves can most easily be blocked and we try to lay emphasis on the anatomical facts connected with such emergency procedures as tracheotomy. But in our undergraduate teaching I think we should keep away from anything resembling specialist training and try in the first instance to impart a broad general knowledge of the subject. Here and there we may illustrate our teaching by drawing attention to the significance of the facts in connection with some

specialist procedure. Coming, to the level of graduate teaching our orientation is somewhat different. Here we endeavor, in the first instance, to give to the graduate student a thorough and reliable knowledge of the anatomy of all those structures with which they will be immediately concerned. By this, I mean they have to study thoroughly the anatomy of the vertebral column, the spinal cord, meninges, and all the parts concerned in spinal anesthesia and caudal blocks. In like manner they should have a thorough knowledge of the anatomy of the nose, throat, larynx, trachea and lungs. As concerns regional anesthesia, we give to all candidates a series of lectures on the distribution and relationships of the peripheral nerves. In doing this we deal with all the different nerve blocks separately, and we try particularly to train students in a thorough knowledge of one or two blocks for each nerve. Most books on the subject give a whole series of alternate blocks without pointing out the advantages, difficulties or relative ease of each. We try rather to pick out a few blocks which we have found to be most free from possible sources of error, and most

easily accomplished, and to concentrate on these. This means meticulous attention to surface landmarks, and a thorough knowledge of the relationships of the nerves at the site of injection. There are authors who ascribe the many failures in regional anesthesia to variations in the relationships and distribution of the peripheral nerves. We have not found that this accords with our experience. As a matter of fact variations in the nervous system are not many and are not usually of great significance. We 292
Sciences in Anesthesia-Bourne, Melville, Martin, Themson, Hoff have found that a rigid attention to surface landmarks and a thorough knowledge of the anatomy of the nerves produces almost uniformly satisfactory results. We make the candidates insert a needle at the sites which we advocate and in accordance with our directions. He then has to dissect down on the needle to observe its course, and in each locality we draw special attention to such surrounding structures as joint capsules, tendon sheaths and vessels which may be the cause of failure. I may add that during the war we paid special attention to this course on regional anesthesia and trained a great many officers who went overseas. We felt that this was a routine that could be especially useful in war conditions and might obviate a great deal of human suffering. I feel likewise

that it is a routine that can be of immense service to the general practitioner or country doctor. But like all other routines it has to be built on exact knowledge or it becomes uncertain and unreliable. I am glad to be able to say that I think the Anatomy Department at McGill University has been able to render that much assistance to the Department of Anesthesia. They try to provide us with the practical ends to be obtained, and we try to provide them withof how those ends can be best obtained the detailed anatomical knowledge

Anatomy of the epidural space (figure 1)

The epidural space is that part of the vertebral canal not occupied by the dura mater and its contents. It is a potential space that lies between the dura and the periosteum lining the inside of the vertebral canal. It extends from the foramen magnum to the sacral hiatus. The anterior and posterior nerve roots in their dural covering pass across this potential space to unite in the intervertebral foramen to form segmental nerves. The anterior border consists of the posterior longitudinal ligament covering the vertebral bodies, and the intervertebral discs. Laterally, the epidural space is bordered by the periosteum of the vertebral pedicles, and the intervertebral foraminae. Posteriorly, the bordering stuctures are the periosteum of the anterior surface of the laminae and articular processes and their connecting ligaments, the periosteum of the root of the spines, and the interlaminar spaces filled by the ligamentum flavum. The space contains venous plexuses and fatty tissue which is continuous with the fat in the paravertebral space.