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The Woolley and Roe case. A reassessment.

¹University Hospital, Queen's Medical Centre, Nottingham.

|October 1, 1990

Summary

A 1953 medical case revealed phenol contamination caused paralysis after spinal anesthesia. Re-examination identified the probable contamination source, explaining patient paralysis and other similar incidents.

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Area of Science:

Medicine
Anesthesiology
Medical History

Background:

The 1953 Roe v. Woolley case involved patients developing spastic paraparesis after spinal anesthesia.
The court initially attributed the paralysis to phenol contamination from sterilizing anesthetic ampoules via invisible glass cracks.

Observation:

Phenol, used for sterilizing ampoule exteriors, is implicated as the contaminant.
The study re-examines the historical case with new information to identify the probable source of paralysis.

Findings:

The most likely cause of paralysis in three patients was phenol contamination of spinal anesthetic solutions.
Phenol likely entered the anesthetic via microscopic, undetectable cracks in the glass ampoules.

Implications:

This re-evaluation offers a plausible explanation for the 1953 paralysis cases and potentially other similar incidents.
Understanding historical contamination routes can inform modern anesthetic safety protocols and prevent future adverse events.

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