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

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 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

Hadzic_FM_p00i-pxx.indd 12 22/04/19 6:41 PM

 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

Hadzic_FM_p00i-pxx.indd 13 22/04/19 6:41 PM

 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

Hadzic_FM_p00i-pxx.indd 15 22/04/19 6:41 PM

 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
 This page intentionally left blank

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
Another random document with
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indistinct. Davies read it: “The enemy is in full retreat.” But for this
providential mistake, the battle of that day would have had a darker
record than we are making now; for the retreat, disastrous as it was,
would have been cut off, and Washington probably taken.
Believing the army victorious, these brave men bore the restraints
of their position more patiently, but still panted for a share in the
work.
At this time Beauregard’s telegraph, opposite the left of Davies’
position, had been working half an hour; and from lines of dust
concentrating there and at Davies’ front, he anticipated an attack,
and made disposition accordingly.
At five o’clock, the enemy appeared on the left, as Davies formed in
line parallel to Bull Run, and about eight hundred yards distant.
Between the hill which he occupied, and the slope down which they
came from the road, was the valley or ravine, about four hundred
yards from Hunt’s battery.
They filed down the road and formed in the valley, marching four
abreast, with their guns at right shoulder shift, shining like a ripple
of diamonds in the sunshine, and moving forward in splendid style.
At first Davies viewed them in silence, and standing still; but as the
column began to fill the valley, he changed front to the left, and
ordered the artillery to withhold its fire till the rear of the enemy’s
column presented itself, and directed the infantry to lie down on
their faces, and neither fire nor look up without orders. This was
done that the enemy might not learn his strength and charge on the
battery.
The rear of the column at last presented itself, an officer on
horseback bringing it up. Then an order to fire was given, and
Lieutenant Benjamin, a brave young fellow from West Point, fired
the first shot from a twenty-pound rifled gun.
A cloud of dust, with a horse rearing, and its rider struggling in the
midst, was all the result that could be observed. The rear of the
enemy’s column then took the double-quick down the valley, and six
pieces of artillery opened on them. The effect was terrible; at the
distance of only four hundred yards, the enemy took the raking
downward fire in all its fury. An awful cry rang up from the valley;
the men had been swept down like wheat before a scythe, and their
moans filled the air.
This murderous fire was repeated over and over again. There was
no waiting to swab the guns, but, fast as powder and ball could be
served, the ordnance sent out its volleys. The enemy made a
desperate stand, but every shot swept down the men in masses. A
vacant space appeared for a moment, then fresh men filed in. Twice
they attempted to reform and charge the battery, but the rapidity
with which the pieces were served, and the peculiar nature of the
ground, rendered every shot effective, and they were swept back, cut
down, speedily disorganized, and fled for the woods.
During all this action, Lieutenant-Colonel Marsh, of the Sixteenth,
and Colonel Pratt, of the Thirty-first (the former since killed, and the
latter wounded before Richmond), controlled their men perfectly.
Not an infantry shot was fired during the engagement. Balls from the
enemy struck the ground in volleys before the men, filling their eyes
with dust. No man gave way; they were compelled to change position
three times during the fight. Although so many of the enemy were
killed, this spot being named, in the secession reports, as giving the
heaviest mortality of the day, only two men of Davies’ command
were hurt. One man was wounded, and Lieutenant Craig, a brave
young officer from West Point, was killed.
This brilliant engagement, so important in its results, sprang out of
a singular series of accidents: first, in the mistake made in reading
Richardson’s dispatch, and again in a failure of orders. When the
main army began its retreat past Centreville, at four o’clock, Colonel
Miles sent his aid, Captain Vincent, to order Davies and his
command back to Centreville, but Vincent, instead of coming first to
Davies, stopped to give orders to Richardson, and two regiments of
Davies’ brigade, stationed to guard his rear. After ordering
Richardson back, Vincent came over the ravine to deliver his orders
to Davies, when he heard his firing on the extreme left, went back to
Centreville, to report, and returned just as the firing ceased, to direct
Colonel Davies to retire on Centreville.
Davies, ignorant that Richardson had already fallen back, rode
over to order his retreat, but to his astonishment, almost horror,
found that the whole brigade, with two regiments of his own forces
left to guard his rear, had been gone a full hour. Thus it happened
that this important engagement had been fought and won with a
single battery and two regiments of infantry, utterly alone and
unsupported on the deserted battle-field, against a large body of
men, endeavoring to sweep to the rear and cut off the army in its
retreat.
It was near six o’clock when this contest terminated—two hours
after the main army were in full retreat. If ever delay and accident
were providential on this earth, it was here; for brave as these men
were, no sane leader would have felt justified in exposing them to
such peril upon a deserted battle-field, and in the face of a whole
victorious army, after all chance of protection had been withdrawn.
When this band of victorious men reached Centreville, a stream of
jaded, wounded and heavy-hearted men were pouring through the
village, while General McDowell was making a desperate effort to
collect all the troops that still kept a show of organization, under his
own command. These troops were principally composed of the left
wing, which came off the ground in good order. McDowell, about
eight o’clock, left Centreville for Fairfax Court House. Before going
Colonel Miles was relieved from his command of the left wing, and
the following order, written on the back of a visiting card, was
handed to Colonel Davies:

Colonel Davies is consigned to the command of the left wing, as the troops are
now formed. By command,

J. B. Fry, a. a. g.

July 21.

Under this running order Colonel Davies assumed command of all

that was left of the army in Centreville, and marched them in good
order to Alexandria and Washington, Blenker’s division being the
last to leave the field. This gallant officer had been among the bravest
and most resolute in protecting the retreat, and had by his firmness
held the enemy in check during the afternoon and evening.
THE BATTLE-FIELD AT NIGHT.
At night the calm air, the gently falling dew, visited that blasted
earth sweetly as they had done the night before, when the valley was
fresh with verdure and beautiful with thrifty crops. But the scene it
presented was O, how different! In mercy the deep shadows cast by
the woods concealed its worst features, and the smoke had risen so
densely between earth and sky that the moon looked down upon it
mournfully, through a veil. The battle-field was still, save when the
solemn shiver of the leaves came like a painful and mighty sigh, or
the troubled waves of the Run continued it in hoarser murmurs. If
human moans broke the stillness, they were lost on that vast field,
and only heard by the pitying angels.
But solitary lights wandered over the field, like stars dropped by a
merciful heaven to light the departing souls through the valley and
shadow of death. They were indeed heavenly rays, for all that is
divine in human mercy sent them forth. Kind men, and more than
one heroic woman carried them from point to point over that dreary
battle-field, searching among the dead for those who, breathing yet,
might suffer for water or Christian comfort.
There was a house on the hill-top where Griffin’s battery had
stood, and where the Connecticut troops had planted the stars and
stripes in their last desperate charge. Through all the fight, a helpless
and frightened family had found precarious shelter in their own
dwelling. The household was composed of a son, a daughter, and the
mother, a gentle Christian woman, who had been confined to her bed
for years. There was no hopes of flight for her, poor soul, and neither
son nor daughter would abandon her when the storm of battle was at
their threshold. Hoping to find a place of safety, the devoted children
carried her to a neighboring ravine, sheltering her with their own
persons.
But this spot became at last more dangerous than the house. So
the harassed children took their parent back to her home, and
placing her in bed again, stood to screen her from the bullets that
broke like hail through the walls and windows. While her house was
riddled with cannon balls and musket shot, and the missiles of death
plunged through her chamber and into her bed, three bullets pierced
her frail person. Still she outlived the battle tempest that raged
around her, a tempest that she had not even dreamed of approaching
her dwelling when that fatal day dawned upon it. When the night
came on she died peacefully, and the troubled moon looked down on
a mournful scene here also. Within the riddled walls and under the
torn roof, this gentle woman lay, in a quieter sleep than she had
known for many a long night, and by her bed knelt the bereaved
children who had dared so much, weeping that a life so peaceful
should have met that violent ending. Painful as this was, there lay
many poor soldiers on the field that hour, whose children would
never have the privilege of weeping over them.
In an orchard of young trees, just forming their fruit, lay many a
prostrate Southron, sent to his long account; for the enemy had
suffered terribly there. The northern verge of the field was blackened
by a fine grove in which a Georgia regiment had fought, and under its
black shadows the dead lay thick and numerous. Here Lamar had
fallen, and many a brave Northman slept side by side with the foe he
had sent into eternity but a moment in advance of himself. The fatal
hill, scorched and blackened in every tree and blade of grass, was
strewn with the dead of both sections, among them some of the
bravest leaders that the enemy boasted.
There have been rumors of great cruelty on the battle-field after
the fight was over—of men prowling like fiends among the dead, and
murdering the wounded; but these things should be thrice proven
before we believe them of American citizens. Rumor is always triple-
tongued, and human nature does not become demoniac in a single
hour. One thing is certain, many an act of merciful kindness was
performed that night, which an honest pen should prefer to record.
Certain it is that Southern soldiers in many instances shared their
water—the most precious thing they had—with the wounded Union
men. A soldier passing over the field found two wounded combatants
lying together—one was a New Yorker, the other a Georgian. The
poor wounded fellow from New York cried out piteously for water,
and the Georgian, gathering up his strength, called out: “For God’s
sake give him drink; for I called on a New York man for water when
his column was in retreat, and he ran to the trench at the risk of his
life and brought it to me!”
One brave young enemy lost his life after passing through all the
perils of the battle, in attempting to procure drink for his wounded
foes.
If there were individual instances of cruelty on either side, and this
is possible—let us remember that there was kindness too; and when
the day shall come—God grant it may be quickly—when we are one
people again, let the cruelty be forgiven and the kindness only
remembered.
And now our record of the battle of Bull Run is at an end. It was
valiantly contended on both sides, and won only from superior
numbers and reinforcements of fresh troops, poured upon the
exhausted soldiery of the Union. To gain this contest the South sent
her best and very bravest generals. Her forces were led by
Beauregard and Johnston, both experienced officers. They were also
cheered by the near presence of Jefferson Davis, who came upon the
field when the victory was assured, amid the shouts of a soldiery, the
more enthusiastic because they had just been rescued from almost
certain defeat. They had the choice of position and had fortified it
with wonderful skill; a thorough knowledge of the country, and
troops unwearied by long marches—indeed, the advantages were
altogether on their side. The North, never dreaming that an open
rebellion would break out, was utterly dependant on undisciplined
troops; while the South, having premeditated resistance to the
Government, had been drilling men for months, if not years. There
was no one point except in the actual bravery of their leaders and
soldiers in which the enemy was not superior to the Union forces. In
personal valor the Southerners themselves have never claimed to
surpass that exhibited in this battle by their foes.
The smallest estimate of the forces actually engaged on the
Southern side is eighteen thousand—while the Union forces which
crossed Bull Run did not at any time count more than thirteen
thousand. One brigade of McDowell’s eighteen thousand was not in
the action, except in a vain effort to check the retreat. This brigade, of
General Tyler’s division, was stationed at Stone Bridge, and never
advanced upon the actual battle-field. The attack repulsed by Davies
on the left wing, at Blackburn’s Ford, took place nearly two hours
after the army was in retreat.
In the loss of officers, the enemy was even more unfortunate than
the Union army. The fall of General Bee, one of the bravest of their
leaders, Bartow, Colonel Thomas, Colonel Hampton, Colonel
Johnson, Lamar, and others, shed a gloom upon their victory, and
greatly weakened their cause in the future. The Union loss was
heavy, for the men who fell or were taken prisoners were among the
bravest that marched with the army, but the loss of officers by death
was inferior to that of the enemy, and though Corcoran and Wilcox
were wounded and taken prisoners, they were not lost to their
country. In ordnance and munitions of war the conquest was less
important than might have been supposed. Many of the Union guns
were rescued from the field during the next day. Of the fine horses
attached to the ordnance a large proportion were killed, and others
were saved by their drivers, who cut the traces, and rode them from
the scene of battle. The loss in killed and wounded on the Union side,
was 481 killed, 1,011 wounded, and 1,216 missing: total, 2,708. That
of the enemy numbered, by Beauregard’s report, 393 killed, 1,200
wounded.
The victory was a very important one to the South, as it gave
prestige and force to a rebellion which, had the position of things
been reversed, would, it is probable, have expired before the year
went out. But in the North it only served to arouse the people to a
pitch of excitement hitherto unparalleled; if troops had been sent
forth in regiments before, they came in brigades after that defeat.
 WESTERN VIRGINIA.

Virginia has three grand divisions, viz.: the Eastern Section,

extending from tide-water up to the Blue Ridge Mountains; the Great
Valley between the Blue Ridge and the Alleghanies; Western
Virginia, stretching from the Great Valley to the Ohio river.
The contest between the people of the eastern and western
portions of the State for supremacy had been one of long duration,
dating back for many years. Internal improvements appear to have
been the cause of this dissension—Western Virginia claiming that the
East had enjoyed and been benefitted by them hitherto exclusively.
In this jealousy the inhabitants of the Valley sympathized, and the
completion of the James River and Kanawha Canal to the Ohio
aroused a feeling of such bitter rivalry, that even the Governor
favored the project of a division of the State. Added to this was the
complaint of unequal taxation. The eastern portion being the large
slaveholding district, paid per capita, without regard to value, while
the wealth of the western, consisting of land and stock, was taxed ad
valorem. This strife, of necessity, was carried from the people into
the Legislature, and stormy debates followed. The feeling of the West
on the slavery question, also, added fuel to the flame, and the loyalty
of that section was attacked.
In the State Convention which passed the ordinance of secession,
the western delegates took a firm and bold stand against it. When the
Act was about to be consummated, great excitement prevailed in
regard to the action of the western members, both inside and out of
the Convention, and some of them were obliged to leave Richmond.
In May, when the ordinance was submitted to the people, the north-
western counties voted largely against it.
A Convention assembled at Wheeling, and a committee was
appointed, which called a General Convention to convene at the
same place on the 11th of June. Forty counties were represented
there, and an ordinance was passed for the reorganization of the
State Government, every officer to be obliged to swear allegiance
anew to the United States, and to repudiate the Richmond
Convention. A Governor, Lieutenant-Governor, and other State
officers were elected, and the Legislature was summoned “to
assemble at the United States District Courtroom in the city of
Wheeling, at noon, on the first day of July, 1861.” Both houses met
and organized. The Governor’s Message was sent intogether with a
document from Washington, officially recognizing the new
Government. The message recommended an energetic co-operation
with the Federal Government. United States Senators were then
elected.
On the 20th of August, the Convention passed an ordinance
creating a new State, to be called “Kanawha.” It included thirty-nine
counties, and provision was made for the admission of other
adjoining counties, if a majority of the people of each desired it. The
question of forming a separate State was submitted to the popular
vote on the 24th of October, and resulted in favor of the proposition
by a large majority. Since that time other counties have signified a
desire to be admitted.
Western Virginia became the scene of military operations directly
after the war broke out, following in close order upon the occupation
of Alexandria. On the 30th of May Colonel Kelly took possession of
Grafton, and the occupation of Phillipi followed but a few days
subsequently. Federal troops also crossed the Ohio and entered
Parkersburgh. General McClellan had command of this portion of
the State, it being included in the Ohio district, and issued his
proclamation to the Union men of Virginia.
A series of offensive and defensive events now followed each other
in rapid succession, exhibiting bravery and determination
unparalleled in history—individual heroism and uncomplaining
endurance of suffering—rapid marches and brilliant charges, that
shine in letters of fire upon the pages of our war history, and threw
the prestige of early victory about the northern arms. It was here that
McClellan won his first laurels—here that chivalric Lander met a
soldier’s death—here that Kelly was wounded, till for weeks and
weeks his life was despaired of. In fact, Western Virginia is covered
with victorious Union battle-fields. She has indeed given their
greenest laurels to many of our generals.
The military department of Ohio, in which Western Virginia was
included, was organized on the tenth of May, and Major-General
George B. McClellan appointed to the command. His headquarters
were at Cincinnati. On the 26th of the same month he issued his first
proclamation, declaring that his mission was one of fraternity, union,
and protection, and called upon all patriotic men to aid him in his
endeavors to accomplish this holy purpose. The proclamation
produced a marked effect. Colonel Kelly, of Wheeling, Virginia, had
prior to that date organized a regiment for the defence of the Union,
known as the “First Virginia Volunteers.”
On Friday, the 24th of May, about twelve hundred rebels had
assembled and marched from Harper’s Ferry to Grafton, a town on
the Baltimore and Ohio railroad, and forced many citizens to
abandon their homes and fly for safety, leaving their property to be
pillaged by the enemy. About one hundred of the fugitives reached
Morgantown. The inhabitants of that place, warned of their danger,
immediately flew to arms and prepared for a vigorous defence.
Finding that they were not to be molested, and burning for revenge,
they marched, 1000 strong—their ranks having been swelled by
friends from Pennsylvania—towards Grafton.
The rebels became alarmed and fled to Philippi, in Bourbon
county, about 17 miles southward. On Monday, the 27th,
detachments of Ohio and Indiana troops crossed the Ohio river at
Wheeling and at Marietta, on their way, also, to Grafton.
Simultaneously, Colonel Kelly’s regiment of Virginians moved
forward in the same direction, but the bridges having been
destroyed, their march was delayed. At every point, and especially at
Mannington and Fairmount, they were received with great
enthusiasm and hailed as deliverers.
 BATTLE OF PHILLIPI.

Brigadier-General Thomas A. Morris arrived at Grafton on the

evening of June 1st, and took command of the Union forces. An
expedition was immediately organized to surprise and attack the
rebels at Philippi, under the command of Colonel Porterfield. The
troops left in two divisions. The First Virginia regiment, part of the
Ohio Sixteenth, and the Seventh Indiana, under Colonel Kelly,
moved eastward, by rail to Thornton, a distance of five miles, and
from there marched on twenty-two miles, to Phillipi, reaching the
town on the lower side. The second division, consisting of the Sixth
and Seventh Indiana, the Fourteenth Ohio, and a section of artillery
under Lieutenant-Colonel Sturgis, met by detachments at Webster,
on the North-western Virginia railroad, and marched twelve miles to
Phillipi. The combined forces were commanded by Colonels Dumont
and Lander, and at eight o’clock on the night of the 2d of June
marched forward through one of the most overwhelming storms
known to our country that year. Lander had been detailed to a
special command by General Morris, and in the terrible march that
followed, through darkness, mud and rain he led the way, sometimes
exploring the route three miles ahead of his forces, in the midst of
profound darkness, and through mud so deep and tenacious that
every forward step was a struggle. The men followed, bravely toiling
through the miry soil, staggering forward in thick darkness, and
pelted by the rain so violently that they could not have seen the road
had it been daylight. Still, not a murmur was heard. Against the
whole force of the elements the brave fellows struggled on, eager for
the storm of fire which was soon to follow the deluge that poured
upon them. Now and then Lander’s majestic form, seated upon his
charger, would loom upon them through the darkness, returning
from his scouting duty to cheer them with his deep, sympathetic
voice, which aroused them like a trumpet. Thus they moved on,
supported by one stern purpose, through woods, across valleys, and
over hills, the storm drowning their approach till they drew up on the
edge of the town overlooking the enemy. But it was not altogether a
surprise. Just before they reached the town the troops had passed a
farm-house. A woman within that house sprang from her bed as she
saw the lines of troops filing slowly by in the misty gray of the dawn,
and guessed their object. She instantly aroused her little son and sent
him by a short cross-road to give the alarm. The boy was quick of
foot, but the hopes of conflict had so aroused the energies of these
jaded men that he was but a few minutes in advance of them.
Lander’s troops took position on a hill across the river and below
the town, commanding it and the encampments around. He at once
planted two pieces of artillery, and prepared to open fire at exactly
four o’clock, the hour agreed upon for the attack, which was to be
made at once by both divisions. Lander was to assault them in front,
while Kelly was to attack the rear and cut off all retreat. But Lander
found his division alone before the enemy. The terrible night, the
almost impassable roads, and a march of twenty-two miles had
delayed Kelly’s forces, and when he did arrive it was to come in by
mistake below the town.
The presence of Lander’s troops aroused the town and threw it
into terrible commotion. In vain Lander searched the distant hills,
impatient for Kelly’s appearance. The hour of attack had arrived and
passed. The men became impatient as their leader, who, in his
indomitable courage commenced the battle with a portion of his
forces.
When Lander gave the order his eager men sprang to their posts,
and the artillery opened fire. As the first gun awoke its thunder on
the encampments, Kelly advanced, but in the wrong direction. He
instantly comprehended Lander’s action, and with prompt courage
charged upon the encampments. The batteries had by this time
obtained the range, and were pouring in their messengers of terror
and death, tearing through tents and cabins, and scattering the
rebels like chaff in every direction. After firing a volley of musketry,
Lander advanced.
Colonel Kelly’s command was close upon the enemy, the Virginia
troops in advance, the Henry Clay Guards in front, and Colonel Kelly
and Captain Fordyce leading, while Colonel Lander’s force came
rushing down the hill to the bridge and joined in an impetuous
pursuit of the fugitives. Colonel Kelly, who, with a bravery
amounting almost to rashness, had been foremost from the very first,
was shot by a concealed foe, the ball entering the left breast and
lodging beneath the shoulder blade. As his men conveyed him to a
place of safety, this brave man, while in the agony of his pain,
exclaimed, “I expect I shall have to die. I would be glad to live, if it
might be, that I might do something for my country, but if it cannot
be, I shall have at least the consolation of knowing that I fell in a just
cause.” But he was not destined to be cut off in the zenith of his fame
and usefulness. After a few weeks of danger and anguish he was
again performing noble duty for the country he loved so well.
In this dashing victory fifteen of the rebels were killed, a large
number wounded, and ten taken prisoners, together with a quantity
of camp equipage, arms, &c. The organization of the rebels at that
point was completely broken up, and the men driven to the
mountains.
 GREAT DESTRUCTION OF RAILROAD
PROPERTY.

The bitter animosity of the rebel army was strikingly illustrated on

the 23d July, by the destruction of a large number of locomotives and
cars of the Baltimore and Ohio railroad by secession troops under
the command of Colonel Thomas J. Jackson. Forty-eight locomotives
and three hundred cars were blown up or burned, one of the engines
having been previously wrapped in our national ensign. The road had
been rendered impassable by the destruction of bridges, and,
therefore, the rolling stock could not have been rendered available.
The estimated loss was about three-quarters of a million of dollars.
 GENERAL McCLELLAN IN WESTERN
VIRGINIA.

General McClellan, during the time that elapsed since his

appointment, had been actively engaged in organizing his forces and
getting them ready for efficient service. Scouting parties—an
important feature of his department—were detailed for service, and
raw troops replaced by experienced men. Colonel Kelly, who was
now recovering from the wounds received at Phillipi, had been
appointed by Governor Pierpont to the command of the Virginia
brigade of volunteers. Gens. Morris, Hill, Schenck and Schleich were
assigned their respective positions—the telegraph lines were put in
order, and new ones for military purposes were constructed where
necessary. The arrival of fresh regiments, among which Colonel
Rosecranz made his appearance, added great activity to the
department. On the side of the enemy were Generals Robert S.
Garnett, Henry A. Wise, Ex-Governor, John B. Floyd, Ex-Secretary of
War, and Colonel Pegram.
Columns of Federal troops were dispatched to attack the enemy,
simultaneously, at three different points, and the first collision
between them occurred on the 10th of July.
 BATTLE OF SCAREYTOWN.

A brigade of rebels under Governor Wise, crossed the Alleghanies

to the head-waters of the Kanawha, with the intention of attacking
the rear of McClellan’s forces, while General Garnett was prepared to
meet him in front. General Cox had been dispatched to this section
with a considerable force of Ohio, Indiana and Kentucky troops, and
was encamped on the Kanawha about ten miles below its junction
with Scarey Creek. Hearing that a portion of the rebel force had
taken position at Scareytown, but four miles above his camp, on the
other side of the river, and were entrenching themselves there,
General Cox dispatched a force of about 1,000 men, consisting of the
Twelfth Ohio, a portion of the Twenty-first Ohio, the Cleveland
Artillery, and a detachment of cavalry, all under the command of
Colonel Lowe, to dislodge the rebels if practicable. The column was
ferried across the stream, and moved cautiously onward, the scouts
scouring the country as they advanced. The enemy was found to be
entrenched on the opposite side of Pocatallico Creek, here
intersecting the Kanawha, protected by breastworks, and also
sheltered by woods, about half way up a slope of high hills, having
two pieces of artillery in position, while a portion of their infantry
had possessed themselves of ten or twelve log huts, constituting the
village of Scareytown, in which they had improvised loop-holes. The
Federal troops were met by a discharge from the rebel battery as
soon as they made their appearance; but the artillery of Captain
Cotton soon got in position, and returned the fire of the enemy with
good effect. The infantry were now ordered to advance, and rushed
fearlessly across the stream, which was fordable, in the face of a
heavy fire. The left wing, composed of portions of the Twelfth and
Twenty-first Ohio, had reached the enemy’s entrenchments, but
being unsupported by the right, and a fresh regiment of the rebels
appearing on the ground, they were compelled to retreat, leaving
many of their dead and wounded on the field.
The loss of the Federal forces by this engagement was nine killed,
thirty-eight wounded, and three missing. Of the rebel loss we have no
record.
A great misfortune of the day, however, was the capture of five of
the principal officers of General Cox’s command, who were not
attached to the expedition.
Colonels Woodruff and De Villers, Lieutenant-Colonel Neff, and
Captains Austin and Hurd, prompted by an eager desire to witness
the engagement in which they were not assigned a part, rode up the
banks of the river to its junction with the creek, and hearing a loud
shout, were led to believe that the Federal forces were victorious.
They procured a skiff, crossed the creek, and inadvertently strayed
within the enemy’s lines, where they were all made prisoners.
 HOW THE ENEMY WAS TO BE ATTACKED.
General Garnett had at this time nearly 10,000 men under his
command, and occupied a position at Beverly, on Tygart’s Valley
river, Randolph Co., in a valley of the Alleghany Mountains. Two
good roads unite at an acute angle at this place, one leading
westwardly to Buckhannon, and the other north-west to Phillipi. A
mountainous ridge crosses both these roads in front of Beverly, and
at each point of intersection General Garnett had an intrenched
camp. The first was on the road to Buckhannon, called the Rich
Mountain Camp, under command of Colonel Pegram; and the
second, on the road to Phillipi, called Laurel Hill Camp, under
General Garnett’s personal command.
Early on the morning of the 11th of July, General Rosecrans was
dispatched to attack Colonel Pegram, and dislodge him from his
position. General Morris was to make a simultaneous movement on
the position held by General Garnett.
 BATTLE AT RICH MOUNTAIN.

July 12, 1862.

The rebel entrenchments at Rich Mountain were very strong in

their position, and were evidently to be taken only by a great sacrifice
of life. They had rolled great trees down the steep sides of the
mountain, and banding their branches into a general entanglement,
filled the open spaces with earth and stones. The dense forest on all
sides made the approach almost impassable. General Rosecranz was
accordingly directed to attack them in their rear. For this purpose he
took with him the Eighth and Tenth Indiana, and the Nineteenth
Ohio, and under the leadership of an experienced guide, started
about daylight to ascend the mountain. The path was exceedingly
difficult and tedious, most of the distance being through thick laurel
underbrush, almost impenetrable woods, and a broken, rocky region,
which gave them a toilsome march of nearly nine miles. Meantime a
courier from General McClellan with dispatches for General
Rosecrans, had been captured by the rebels, who instantly took the
alarm, and a body of 2,500 men were sent to the top of the mountain
by a short route which they commanded, and on the arrival of the
Union forces they stood ready for defence. The rebels had three
cannon in place, and awaited the troops, facing that part of the road
where they would emerge from the timber. For some time there was
skirmishing, the rebels firing their cannon into the woods at random.
The Union troops had no cannon, and left the sheltering trees only
long enough to deliver a volley at any one time, and then retired back
to the bushes. They thus succeeded in drawing the enemy from his
earthworks, and leading him into the open fields, where the
encounter took place.