April 25, 1938
My dear Dr. Clement,
Thank you so much for your letter of March 28th.  The case you describe is most interesting, and the first of its kind in which pontocaine was the drug used.  Similar cases have been reported with all other drugs used in spinal anesthesia, i.e. procaine and its various combinations, nupercaine, stovaine etc.  May I suggest that you publish this case soon, so that others like it may come to light?
The mechanism of the paralysis is of course difficult to explain.  Your technic [sic] seems infallible.  Damage to the cord or its meninges from the drug itself is possible, but it should happen oftener [sic].  I do not know of any experimental work done with effect of pontocaine on the cord, as has been done with procaine and durocaine.  It should be done.  One possibility we overlook too often, is the presence of central nervous system disease before anesthesia.  A number of cases are on record in which preexisting C.N.S. disease has been made much worse by spinal anesthesia, irrespective of the drug used.  Autopsy might have decided this point in your case.
The analysis of 1100 pontocaine spinal anesthesias at the Presbyterian Hospital is in preparation at present, as is also a short paper on the "Late Effects of Oxygen Want in Spinal Anesthesia."  I shall be glad to send you reprints, when they are published.
Sincerely yours,
Virginia Apgar, M.D.
Director, Division of Anesthesia