affected testis is extremely tender and the patient resents any attempt at palpation. I inject 5 to 10 mL of i% xylo- caine around the external inguinal ring. Five minutes after the injection the patient is completely pain-free and will permit palpation. Palpation will show the affected testis to be tiding higher than the normal one, and the torsion of the cord can be felt as a distinct knot. Because the cremaster muscle spirals around the cord in a supero-lateral to infero-medial direc- tion, torsion will usually have occurred in external rotation. The torsion is undone by rotating the testis internally. A distinct "flick" is felt as the torsion is relieved. As in the case reported, the torsion may be 7200 rather than 360 ° and the cord should be carefully palpated for a residual "knot." If one is found, the process is repeated until the cord feels smooth. In the rare event in which torsion has occurred in inter- nal rotation, attempts to undo it by further internal rotation will give the sensation of overwinding a spring, and detor- sion by external rotation should be attempted. This method has the following advantages: it gives the patient immediate relief from pain; it permits the physician to perform careful palpation, allowing the diagnosis to be established; and it relieves the torsion without having to mobilize an operating room and a urologist and, thus, in- creasing the ischemic time of the testis. Following suc- cessful manual detorsion, the patient still requires an or- chiopexy to prevent recurrence, but this may be planned as an elective procedure rather than as an emergency, JM Davidson, MB, ChB, FRCS (Ed) Director, Division of Emergency Services University of Alberta Hospitals Edmonton, Alberta, Canada Author's Reply: The use of cord blocks or external inguinal ring blocks is a humane way to evaluate testicular torsion. The success of reducing the torsion manually after the block has been mixed in our hands. The Doppler ultrasound is useful in confirming the reestablishment of blood flow if one is suc- cessful. We would support all efforts to reduce ischemic tes- ticular time. As Dr Davidson States, orchiopexy is still indi- cated if manual detorsion is accomplished. Dale C Askins, DO Department of Emergency Medicine Grand Rapids Osteopathic Hospital Grand Rapids, Michigan Lidocaine Toxicity from Intraurethral Administration To the Editor: The toxicity of local anesthetics is well known, inadver- tent intravascular injection , rapid mucosal absorption, oral ingestion, and intentional overdose all have been shown to result in profound side effects. 1-4 Recently, however, we en- countered a possible case of local anesthetic toxicity from an unexpected sourcel as illustrated in the following case. A 77-year-old man was brought by ambulance after hav- ing been found unresponsive on the floor of his hotel room. Tile patient had a several-day history of deteriorating men- tal status, but little else was known. Physical examination revealed a cachectic, elderly man who appeared dehydrated and exhibited nonsensical speech marked by echolalia. Vital signs revealed a rectal tem- perature of 33.3 C, respirations of 24/min, pulse rate of 120/ min, and blood pressure of 160/86 mm Hg Supine with prominent orthostatic changes. Pupils were 3 mm and min- imally reactive. Chest was Clear, abdomen was normal, and rectal examination showed an enlarged prostate. Stool was hemoccult negative. Cranial nerves were grossly intact, and deep tendon reflexes were normal. The patient moved all four extremities spontaneously, but the left better than the right. He also tended to keep his head turned to the left. Passive rewarming and intravenous (IV)rehydration with normal saline were begun. Initial attempts at Foley catheterization were unsuccessful. Repeat attempts by the physician, after instilling a tube of Xylocaine jelly into the urethra, were again unsuccessful. A small amount of blood was evident on the catheter tip. A computed tomographic scan of the head was remark- able only for diffuse cerebral atrophy. Initial laboratory Stud- ies were significant for a sodium of 154 mEq/L; chloride, 120 mEq/L; BUN, 95 ng/dL; creatinine, 4.4 ng/dL; and WBC, 9,400 with 11% band forms. A urologist was successful in passing a Coude tipped uri- nary catheter after instilling a 30-mL tube of 2% Xylocaine jelly into the urethra. Urinalysis revealed more than 100 WBCs and more than 100 RBCs per high'powered field. Ultrasound of the kidneys showed hydronephrosis bilat- erally and a small renal stone on the left side. The patient became more alert and active as his rectal temperature warmed to 35.6 C and rehydration continued. Because of persistent disorientation and confusion, tox- icology screens Were ordered. Cultures were also drawn, empiric antibiotics were begun, and the patient was admit- ted for further care. During the next few hours he became very agitated and even transiently combative. By the follow- ing morning his mental status was improved considerably Not Unexpectedly the urine toxin screen was positive for lidocaine. A serum acid/neutral screen was negative, but the blood basic screen was positive for lidocaine. Close re- view of the case uncovered no IV administration of lido- caine in the emergency department or in the ambulance. No local anesthetics were used for starting IV lines or for laboratory tests. A careful drug history provided no likely outside source of lidocaine. Intraurethral administration of Xylocaine jelly for catheterization appeared to be the most likely source. Quantitative levels could not be obtained ret- rospectively. CNS toxicity due to lidocaine would be diffi- 13:6 June 1984 Annals of Emergency Medicine 483/1,19