NovemberfDecen-Iber 1987
`
`
`
`PEHGAMON PRESS New York 0 Oxford 0 Beijing c Frankfurt - Séo Paulo ' Sydney 0 Tokyo . Toront
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`new nurturing-cs
`Clinical Communications/OB/GYN
`George Sternbach, MD
`Alexander Trott, MD
`Stanford, CA
`Gail V. Anderson, Jr, MD
`Cincinnati, OH
`Atlanta. GA
`Emergency Medicine in Review
`Humanities and Medicine
`Ann HarwoodiNuss, MD
`Selected Topics:
`Richard M. Ratzan, MD
`Jackson ville, FL
`Toxicology
`Book Reviews
`Emergency Case Records
`Kenneth Kulig, MD
`Edward J. Otten, MD
`Michael Brunko, MD
`Denver; CO
`Cincinnati, OH
`Denver, CO
`Prehospital Cure
`Alistntels
`Medical Classics
`Peter T. Ports, MD
`Suchinta Hakim, MD
`George Sternbach, MD
`Denver; CO
`Chicago, IL
`Stanford, CA
`ECG Commentary
`Special Consultant
`Emergency Forum
`Ron Walls, MD
`C. Richard Braen
`Ernest E. Moore. MD
`Vancouver; Canada
`Denver. CO
`Boston, MA
`
`__Jll
`
`[:1 EDITORIAL BOARD
`Tim Allen, MD
`Quebec, Canada
`Howard Bessen, MD
`Torrance, CA
`Joseph Clinton, MD
`Minneapolis, MN
`Robert Dailey, MD
`Oakland, CA
`Daniel Danzl, MD
`Louisville, KY
`Jan de Boer, MD, PhD
`Warnsveld, The Netherlands
`Peter Doris, MD
`Chicago, Heights, IL
`Peter Fass, MD
`Valhalla, NY
`Richard Feldman, MD
`Chicago, IL
`
`John Gallagher, MD
`Bronx, NY
`Jerris Hedges, MD
`Cincinnati, OH
`Kenneth lserson, MD
`fircsan, AZ
`Robert C. Jorden, MD
`Jackson. MS
`Gene Kallsen, MD
`Harm), CA
`Alois E Karlbauer, MD
`Austria
`Martin S. Kohn, MD
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`John Lyman, MD
`Panama City, FL
`Robert Margulies. MD
`Jacksonvllle. NC
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`Vincent Markovchiclr, MD
`Denver, CO
`James Matthews, MD
`'Chicago, IL
`Doug Mnyeda. MD—
`Colorado Springs. CO
`John W. Mchill, MD
`Denver, CO
`Kendall McNabney, MD
`Kansas City, MO
`John Moorhead, MD
`Portland, OR
`Jack Peacock, MD
`EIPoso, TX
`Bruce T. Rowat, MD
`Toronto, Ontario, Canada
`Ernie Ruiz, MD
`Minneapolis, MN
`Arthur Sanders, MD
`Tucson, AZ
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`Daniel T. Schclblc, MD
`Akron, OH
`John Schriver, MD
`.
`Portland, OR
`Jeffrey Schwartz, MD, Capt, MG-
`Greenley. C0
`Steven Silverstein. MD
`Newton Lower Falls, MA
`Robert D. Slay, MD, Col, MC
`San Antonio, TX
`T. D. Sosnowski, MD
`Edmonton, Alberta. Canada
`David Wagner, MD
`Philadelphia. PA
`Gerry Whelan, MD
`Lox Ange/er, CA
`Daniel D. Whitcraft, III, MD
`Long Beach, CA
`Albert Yee, MD
`Milwaukee, WI
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`Editorial Office: Peter Rosen, MD, Editor-in-Chicl: The Journal o/Emergency Medicine, Demcr General Hospital, 777 Bannock Strccl, De
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`
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`II I"
`
`Volume 5, Number 6
`1987
`
` E
`
`CONTENTS
`
`030
`
`NW .13 1987
`
`451
`
`-
`lSclence c
`'i
`-
`-
`.-
`Original-Cyanmgyig%d A
`enter Library
`Performance of New Woundvgiostrlviiea'fiiggn' Wl 53706
`
`George T. Rodeheaver
`Michael D. Spengler
`Richard F. Edlich
`
`David Schillinger
`
`:4635‘
`
`Nifedipine in Hypertensive Emergencies: A
`Prospective Study
`
`Joseph C. Dell’Aria
`
`Brian 0. Stephens
`Gail V. Anderson, Jr
`
`Paul S. Auerbach
`J. Taylor Hays
`
`475
`
`481
`
`487
`
`Clinical Communications
`
`Acute Pseudotumor of the Orbit
`
`Simultaneous Bilateral Quadriceps Tendon
`Rupture: A Case Report and Subject Review
`
`Erythema Nodosum Following a Jellyfish Sting
`
`Eric M. Koscove
`
`493
`
`Tascr"? Dart Ingestion
`
`Selected Topics: Toxicology
`
`499
`
`Falsely Elevated Salicylate Levels Due to
`Diflunisal Overdose
`
`Selected Topics: Prehospilal Care
`
`505
`
`Paramedic Skill Decay
`
`Kurt R. Duffens
`Martin J. Smilkstein
`Howard A. Bessen
`Barry H. Rumack
`
`John L. Zautcke
`Ron W. Lee
`Nancie A. Ethington
`
`James E. Pointer
`Michael A. Osur
`
`513
`
`EMS Quality Assurance: A Computerized
`Incident Reporting System
`
`Steven R. Lowenstein
`Alden H. Harken
`
`519
`
`Selected Topics: ECG Commentary
`
`A Wide, Complex Look at Cardiac Dysrhythmias
`
`(Continued on next page)
`INDEXED IN Safety Science Abstracts, Emergency Medical Abstracts, BIOSIS Database, Index Medicus,
`MEDLINE, Excerpta Medica, CABS, Internat’l Bibi Period Lit, Internat’l Book Reviews
`
`
`ISSN 0736-4679
`(716)
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`uun 5» u». mm“...
`
`D. Dcmetrios Zukin
`
`Mary Ann Cooper
`
`Raymond P. Ten Eyck
`Joshua S. Vayer
`
`John L. Lyman
`John B. McCabe
`
`Patrick Fenncll
`Susan Wason
`
`n..." ".5 ,7, , 7
`
`New Wound Closure Tapes
`
`Cost Ignorance: Not Cost Containment
`Letters to the Editor
`
`Letters of Reply
`
`Education
`
`Airway Management: A New Look at Old Models
`
`Administralion of Emergency Medicine
`
`Emergency Department Care: Cost
`Awareness by Health Care Providers
`Abstracts
`
`Book Review
`
`Handbook of Common Poisoning: in Children,
`2nd Ed by American Academy of Pediatrics
`Calendar of Events
`
`Classifieds
`
`List of Reviewers
`
`Volume 5 Index
`
`Instructions for Contributors
`
`553
`
`555
`
`557
`
`561
`
`563
`
`567
`
`573
`
`581
`
`583
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`585
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`587
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`589
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`607
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`This issue of JEM was edited by Dr George Sternbach, Associate Editor.
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`rm; material may be protected by Copyright law (TlIlE 17 us, Cede)
`
`
`Printed in the USA - Copyright 9 1987 Pergamon Journals le
`The Journal ofEme/gency Medicine, V0 5. pp 545548, 1987
`
`Medicaih
`
`
`J.- F.- B. CHARRIERE: THE MAN BEHIND THE “FRENCH” GAUGE
`
`Kenneth V. lserson, MD, FACEP
`
`Section of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ 85724
`Fteprintaddress: Kenneth V lserson, MD, FACEP, Section of Emergency Medicine,
`University of Arizona College of Medicine. Tucson, AZ 85724
`
`
`
`
` Abstract—Joseph-Frédéric-Benoit Char-
`riére, a 19th century Parisian maker of surgical
`instruments, has by virtue of his ingenuity and
`advanced thinking, continued to have his pres-
`ence felt in medicine throughout the 20th cen-
`tury. His most significant accomplishment was
`the development of a uniform, standard gauge
`specifically designed for use in medical equip-
`ment such as catheters and probes. Unlike the
`gauge system adopted by the British for mea-
`surement of needles and intravenous catheters,
`Charriére’s system has uniform increments be-
`tween gauge sizes (1/3 of a millimeter), is easily
`calculated in terms of its metric equivalent,
`and has no arbitrary upper end point. Today,
`in the United States, this system is commonly
`referred to as French (Fr) sizing. In addition to
`the development of the French gauge, Char-
`riere made significant advances in ether admin-
`istration, urologic, and other surgical instru-
`ments, and the development of the modern
`syringe.
`
`III Keywords—Charriére; French gauge;
`medical equipment; surgical equipment; ether
`anesthesia; urology
`
`In the first half of the 19th century, the
`British, in the throes of the industrial rev-
`olution, were still trying to adapt an arbi-
`trary sizing system (the Stub’s Gauge
`which was adapted to the manufacture of
`needles and catheters only in the 20th cen—
`tury) in order to standardize their manu-
`
`the
`facture of metal wires.1 Meanwhile,
`French had developed a uniform,
`stan—
`dard gauge based on the metric system.
`This gauge was specifically designed for
`use in medical equipment, such as cathe—
`ters and probes. The famous Parisian
`maker of surgical
`instruments, Joseph-
`Frédéric—Benoit Charriere (Figure 1), de—
`veloped this measurement system. Today,
`in the United States, this system is com-
`monly referred to as French (Fr) sizing.
`Charricrc was born in 1803 in Cerniat
`in Gruyere, Fribourg Canton, Switzer-
`land. At the age of 13, he was sent to Paris
`and apprenticed as a cutler (a maker of
`cutting instruments, such as knives). Four
`years later he became both a master cutler
`and the owner of his own business after
`the untimely and mysterious drowning of
`his former teacher, whose business he ac—
`quired. Charriere quickly developed a rep-
`utation among Paris surgeons as a skilled
`and innovative maker of surgical instru-
`ments. Part of this reputation stemmed
`from an incident that occurred shortly af-
`ter he opened his business.
`
`Charriere was hammering the metal and sharp
`ening the lancets and knives, when into his
`boutique flew a young man. By his white
`apron, his fine featured and intelligent face,
`and by his distinguished build he could recog-
`
`Medical Classics —is an ongoing feature of JEM, focusing on “classic” contributions
`to emergency medicine. This section is routinely authored by George Slernbach, MD
` Stanford University Medical Center.
`
`0736—4679/87 $3.00 + .00
`RECEIVED: 23 March 1987; ACCEPTED: 16 April 1987
`545
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`b
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`Figure 1. Joseph-Frédéric-Benoit Charriére
`(1803—1876). (Print courtesy of The New York
`Academy of Medicine Library.)
`
`nize this man as an intern at the Parisian hospi»
`tals who was urgently sent by the departmental
`head to ask advice of the humble eutler. it was
`an urgent case, a poor soul who was brought to
`the Hotel-Dion, choking and groaning due to a
`coin that he had swallowed. It was lodged in
`the esophagus and was compressing the larynx.
`Charriere, without even removing his apron,
`hastened to follow the young man, taking with
`him a Graefe’s hook. The ingenious instru-
`ment, under his timid direction, was used with
`great success;
`the patient was saved. Dupuy-
`tren was the departmental head}
`
`Charriere thereafter became Dupuy-
`tren’s private supplier of surgical instrur
`merits. They worked together developing,
`testing, and utilizing new designs for older
`surgical instruments as well as for innova-
`tions. Charrierc was described as being af—
`fable, hard—working, and very much a per—
`fectionist. He not only developed the
`instruments, but observed their use both
`in cadaver experiments and during sur-
`
`business, Charriere was_supplying the in-
`struments for twenty famous Parisian sur-
`geons, and his reputation continued to
`grow. However, no matter the quality of
`his wares, the surgical community, in gen—
`eral,
`felt
`that Parisian—manufactured
`goods should be used only if British
`equipment, especially knives from Lon-
`don or Sheffield, could not be obtained.
`In 1837, Charriere visited England to
`see the English manufacturing methods
`first hand. “Upon his return to Paris, he
`visited several of our famous surgeons and
`told them:
`
`‘Here, as you requested, I have purchased for
`you the scalpcls made in London.’ The profes»
`sional man examines them, raptures over their
`beauty, their grace, their excellent cutting edge,
`and proclaims: “Finally! This is what we need.
`You, the French workers, you are incapable of
`making us these little gems.’ Without saying
`a word, Charriere opent the instrument case;
`one reads Charriére. The scalpels had been
`forged, tempered, and sharpened in Paris, by
`his workers.2
`
`This was the beginning of the world-
`wide Charriére reputation for excellence in
`the manufacture of surgical instruments,
`which would last into the 20th century.“
`Charriere produced a wide variety of
`innovations in surgical
`instruments. He
`developed fine surgical scissors that op—
`erated without a screw to fasten the
`blades. This allowed the scissors to be dis-
`assembled for cleaning and reassembled in
`only a few seconds. He developed the
`
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`547
`J: F: B. Charriere
`
`Table 1. Charriere’s Guiding Principles
`
`1. Simplification of the surgical instrument.
`2. To unite in the same object—compactness, elegance, and solidness.
`3. Reduce prices as much as possible to make instruments available, as much as possible,
`practitioners.
`4. Never to back away from any experiment or expense that would make him the interpreter of the
`surgeon‘s imaginative innovation.
`Diminish size of instrument while rendering it more suited to all uses.
`\10391
`. Closely observe actual use of these instruments—on cadaver experiments or at surgery.
`. Given an unusual, extraordinary. or unexpected case, immediately create an instrument capable of
`sewing the situation.
`. Investigate foreign manufacture; borrow that which is of use and succeed at doing it better.
`_ Furnish an arsenal of surgical supplies that could fill all of the needs, without being cumbersome, to all
`
`large users.2
`
`to all
`
`LOCO
`
`forerunner of the modern hemostat that
`“were made capable of exerting a continu-
`ous pressure without the surgeon’s con—
`stant application (of force) by the addi-
`tion of a small system of notches.”2 In
`addition, he developed a nonrebreathing
`system for giving ether anesthesia at a
`time French surgeons were highly skepti-
`cal of “the new American invention.”3 His
`administration device allowed administra-
`tion of ether in a controlled, and much
`more effective manner than had previous-
`ly been available. The result was that ether
`anesthesia became an accepted modality,
`even by previous skeptics.
`Charriere also developed the use of sev-
`eral new materials with which to manufac—
`ture surgical instruments. These included
`flexible ivory, in which the inorganic ma-
`terials had been removed to make the ivo-
`ry lcss rigid. He also began using nickel
`silver, originally developed by the English,
`to replace the more rigid nickel, and used
`tempered steel to replace iron.
`im-
`Charriere also made significant
`provements in the medical syringe Al—
`though not in as common use as in current
`medical practice, the syringe was used to
`aspirate,
`inject a liquid, or to irrigate.
`However, using the syringes commonly
`available required a great amount of
`strength to move the plungers that were
`made of stiff leather. Charriere’s improve-
`ment was to develop a “double—parachuted
`piston,” otherwise known as a “double
`diaphragm, double valve” that allowed an
`
`efficient and less rigid movement of the
`syringe plunger.
`innovative areas in
`One of the most
`which Charriere was involved was that of
`the design and manufacture of urologic
`equipment. He developed the lithometer,
`used for measuring the size of bladder
`calculi and several types of lithotripsy for-
`ceps used to crush urethral and bladder
`stones. These instruments were in wide de-
`
`mand not only in France, but all of Eu-
`rope. However,
`the surgeons purchasing
`the tools needed to know exactly what
`sizes they were ordering.
`In 1842, Charri‘ere invented the system
`recognized today in the United States as
`French sizes, which was based on 1/3 of a
`millimeter (Table 2). Unlike the gauge sys-
`tem adopted by the British for measure-
`ment of needles and intravenous cathe—
`
`ters, Charriere’s system has uniform
`increments between gauge sizes,
`is easily
`calculated in terms of its metric equiva—
`lent, and has no arbitrary upper end
`point. The system is used today both for
`urologic equipment,
`including urethral
`catheters, and for large intravenous lines.
`During his lifetime, Charriere’s system
`of measurement allowed him to refine his
`
`quality control on equipment manufac-
`ture and to develop a brisk trade and
`thriving business throughout Europe. For
`his achievements, Charri‘ere, who had on-
`ly become a French citizen in 1841, was
`named to the Legion of Honor in 1843. In
`addition, numerous national and interna-
`
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`u .uu 1
`LUJJUU
`7.333
`22.000
`8.000
`24.000
`
`36.000 12.000
`'Ailhough the French gauge system is based
`on three limes the measurement in millimeters.
`some of the numbers appear to be other than
`exactly three times the millimeter equivalent
`due to rounding (adapted from Reference 1),
`
`REFERENCES
`
`1. 15erson KV: The origin of the gauge system for
`medical equipment. JEmerg Med 1987; 5:45748.
`2. Cltereau A: Charri'ere. Bibliullieque Universe/[c e!
`Revue Suissc. Lausanne, Bureau dc la Bibliothe-
`que Universelle, 1876, vol 57, pp 34—47.
`
`3. Des Inspirations de Vapeur Etheree. Gazette Med
`Paris 1847; 5 (January):81—82.
`4. Boschung U: Joseph-Frédéric-Benoil Charriére
`(1803—1876). Schweiz Rzmd Med Prax 1985; 74:
`181—184.
`
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