umes, Number 6
`
`csc
`
`ae
`TY
`MOAN
`NOY 13 1997
`
`November/December 1987
`
`unigal Science ¢
`
`Page 1
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`[> ASSOCIATE EDITORS. Richard Levy, MD, Univ of Cincinnati Meaical Center, Cincinnati, UH
`George Sternbach, MD, Stanford University, Stanford, CA
`
`[ ASSISTANT EDITOR Diana Doyle, Denver General Hospital, Denver, CO C) SECTION EDITORS
`
`Selected Topics:
`Radiology
`Original Contributions
`Jack Keene, MD
`John A. Marx, MD
`Chicago, IL
`Denver, CO
`Controversies in Trauma Management
`Clinical Communications/Pediatrics
`William H. Campbell, MD
`Roger Barkin, MD
`Denver, CO
`Denver, CO
`Computers in the Emergency Department
`Clinical Communications/Adult
`Stephen V. Cantrill, MD
`Michael Tomlanovich, MD
`Denver, CO
`Detroit, MI
`Techniques and Procedures
`Clinical Communications/OB/GYN
`George Sternbach, MD
`Stanford, CA
`Gail V. Anderson, Jr. MD
`Atlanta, GA
`Emergency Medicine in Review
`Ann Harwood-Nuss, MD
`Selected Topics:
`Jacksonville, FL
`Toxicology
`Emergency Case Records
`Kenneth Kulig, MD
`Michael Brunko, MD
`Denver, CO
`Denver, CO
`Prehospital Care
`Medical Classics
`Peter T. Pons, MD
`George Sternbach, MD
`Denver, CO
`Stanford, CA
`ECG Commentary
`Emergency Forum
`Ron Walls, MD
`G.Richard Braen
`Vancouver, Canada
`Boston, MA
`
`
`——e
`Administration of Emergency Medicine
`Ellen Taliaferro, MD
`Bakersfield, CA
`Ethics
`Jacek Franaszek, MD
`Oak Brook Terrance, [7
`Emergency Medicine and the Law
`Education
`Mary Ann Cooper
`Chicago, IL
`New Technologies
`Alexander Trott, MD
`Cincinnati, O#
`Humanilies and Medicine
`Richard M, Ratzan, MD
`Book Reviews
`Edward J. Otten, MD
`Cincinnati, O9
`Abstracts
`Suchinta Hakim, MD
`Chicago, IL
`Special Consultant
`Ernest E. Moore, MD
`Denver, CO
`
`(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 Iserson, MD
`Tucson, AZ
`Robert C. Jorden, MD
`Jackson, MS
`Gene Kallsen, MD
`Fresno, CA
`Alois F. Karlbauer, MD
`
`Martin S. Kohn, MD
`Far Rockaway, NY
`John Lyman, MD
`Panama City, FL
`Robert Margulies, MD
`Jacksonville, NC
`
`Vincent Markovchick, MD
`Denver, CO
`James Matthews, MD
`‘Chicago, IL
`Doug Mayeda, MD
`Colorado Springs, CO
`John W. McGill, MD
`Denver, CO
`Kendall McNabney, MD
`Kansas City, MO
`John Moorhead, MD
`Portiand, OR
`Jack Peacock, MD
`El Paso, TX
`Bruce T. Rowat, MD
`Toronto, Ontario, Canada
`Ernie Ruiz, MD
`Minneapolis, MN
`Arthur Sanders, MD
`Tucson, AZ
`
`Daniel T. Schelble, MD
`Akron, OH
`John Schriver, MD
`0
`Portland, OR
`Jeffrey Schwartz, MD, Capt, MC)
`Greenley, CO
`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
`Los Angeles, CA
`Daniel D. Whitcraft, II, MD
`Long Beach, CA
`Albert Yee, MD
`Milwaukee, WI
`
`50%)
`
`Editorial Office: Peter Rosen, MD, Editor-in-Chief: The Journal of Emergency Medicine, Denver General Hospital, 777 Bannock Street, Denver, CO g0204-4
`USA.
`ton aA
`Publishing, Subscription, and Advertising Offices: Pergamon Journals, Inc, Fairview Park, Elmsford, NY 10523, USA; or Pergamon Journals, Ltd, Heading!
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`Published Bimonthly, Annual
`institutional subscription rate (1987): US $110.00; Two-year institutional subscription rate (1987/88): US $209.00;
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`Printes
`in the USbit
`Copyright © 1987 Pergamon Journals Ltd
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`Copyright Notice: It is a condition of publication that manuscripts submitted to this journal have not been published and will not be simultancausly #8
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`Je is wccePh
`elsewhere, By submitting a manuscript, the authors agree that the copyright for their article is transferred to the publisher, of and when the artic
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`TheItem-Fee Code for this publication is: 0736-4679/87 $3.00 + .00
`
`| s
`
`onal!
`tal
`t
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`
`
`
` z fhe Journator-
`
`
`
`Volume 5, Number6
`
`George T. Rodeheaver
`
`Michael D. Spengler
`Richard F. Edlich
`
`451
`
`E
`
`csc 1987
`CONTENTS
`NOY 1 9 1987
`OriginalComatepieveelads Libraary
`Performance of New eaeBisMeagison, WI 53705
`
`.
`
`David Schillinger 463; Nifedipine in Hypertensive Emergencies: A
`~
`°
`Prospective Study
`
`Clinical Communications
`
`Joseph C, Dell’Aria
`
`475 Acute Pseudotumorof the Orbit
`
`Brian O. Stephens
`Gail V. Anderson, Jr
`
`481
`
`SimultaneousBilateral Quadriceps Tendon
`Rupture: A Case Report and Subject Review
`
`Paul S. Auerbach
`J. Taylor Hays
`
`487
`
`Erythema Nodosum Followinga Jellyfish Sting
`
`Eric M. Koscove
`
`493
`
` Taser® Dart Ingestion
`
`Selected Topics: Toxicology
`
`499
`
` Falsely Elevated Salicylate Levels Due to
`Diflunisal Overdose
`
`Selected Topics: Prehospital Care
`
`505
`
`Paramedic Skill Decay
`
`Kurt R. Duffens
`Martin J. Smilkstein
`Howard A. Bessen
`Barry H. Rumack
`
`John L. Zauteke
`Ron W. Lee
`
`Nancie A. Ethington
`
`James E. Pointer
`Michael A. Osur
`
`513
`
`EMS Quality Assurance: A Computerized
`Incident Reporting System
`
`Selected Topics: ECG Commentary
`
`Steven R. Lowenstein
`Alden H. Harken
`
`519 A Wide, Complex Look at Cardiac Dysrhythmias
`
`INDEXEDINSafety Science Abstracts, Emergency Medical Abstracts, BIOSIS Database, Index Medicus,
`MEDLINE,Excerpta Medica, CABS, Internat’! Bib! Period Lit, Internat’l Book Reviews
`
`(Continued on next page)
`
`ISSN 0736-4679
`(716)
`
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`Medical Classics
`
`Kenneth V. Iserson
`
`545
`
`J.- E- B. Charriére: The Man Behind the “French”
`Gauge
`
`Humanities and Medicine
`
`Timothy C. Evans
`
`549
`
`Airplane Propellers and Cynicism
`
`George Sternbach
`
`D. Demetrios Zukin
`
`Mary Ann Cooper
`
`Raymond P, Ten Eyck
`Joshua S. Vayer
`
`John L. Lyman
`John B. McCabe
`
`Patrick Fennell
`Susan Wason
`
`Editorials
`
`“Tasering” the Literature
`
`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
`
`Administration of Emergency Medicine
`
`Emergency Department Care: Cost
`Awareness by Health Care Providers
`Abstracts
`
`Book Review
`
`Handbook of Common Poisonings in Children,
`2nd Ed by American Academy of Pediatrics
`
`Calendar of Events
`
`Classifieds
`
`List of Reviewers
`
`Volume 5 Index
`
`Instructions for Contributors
`
`551
`
`553
`
`555
`
`557
`
`S61
`
`563
`
`567
`
`573
`
`381
`
`583
`
`585
`
`587
`
`589
`
`607
`
`This issue of JEM was edited by Dr George Sternbach, Associate Editor.
`
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`The Journal of Emergency Medicine, Vol, 5, pp. 545-548, 1987
`
`Printed in the USA « Copyright © 1987 Pergamon Journals Lid
`Medical—
`
`Classics—
`
`
`J.- F.- B. CHARRIERE: THE MAN BEHIND THE ‘“‘FRENCH’”’ GAUGE
`
`Kenneth V. Iserson, MD, FACEP
`
`Section of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ 85724
`Reprint address: Kenneth V. Iserson, 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 makerof 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-
`mentsuch as catheters and probes. Unlike the
`gauge system adopted bythe British for mea-
`surement of needles and intravenouscatheters,
`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-
`riére madesignificant advances in ether admin-
`istration, urologic, and other surgical instru-
`ments, and the development of the modern
`syringe.
`
`O 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, werestill 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.! 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 Charriére (Figure 1), de-
`veloped this measurement system. Today,
`in the United States, this system is com-
`monly referred to as French (Fr) sizing.
`Charriére was born in 1803 in Cerniat
`in Gruyere, Fribourg Canton, Switzer-
`land. At the age of 13, he wassent 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. Charriére 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.
`
`Charriére 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 Sternbach, MD
`Stanford University Medical Center.
`0736-4679/87 $3.00 + .00
`RECEIVED: 23 March 1987; ACCEPTED: 16 April 1987
`545
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` LAU UL UPA Loves, Ursmeed CeLiws Wsaee
`
`thesia, 4 1/2 minutes was considered a
`long procedure), his observations had to
`be quick.3 These observations allowed him
`to see how well his instruments worked in
`actual practice, thus enabling him to de-
`velop new modifications quickly. One of
`his guiding principles (Table 1) was “Given
`an unusual, extraordinary or unexpected
`case, immediately create an instrument ca-
`pable of serving the situation.”
`By 1825, four years after obtaining the
`business, Charriére 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:
`
`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 cutler. It was
`an urgent case, a poor soul who wasbrought to
`the Hotel-Dicu, choking and groaning due to a
`coin that he had swallowed. It was lodged in
`the esophagus and was compressingthe larynx.
`Charriére, 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.2
`
`Charriére thereafter became Dupuy-
`tren’s private supplier of surgical instru-
`ments. They worked together developing,
`testing, and utilizing new designs for older
`surgical instruments as well as for innova-
`tions, Charriére was described as being af-
`fable, hard-working, and very mucha per-
`fectionist. He not only developed the
`instruments, but observed their use both
`in cadaver experiments and during sur-
`
`I have purchased for
`‘Here, as you requested,
`you the scalpels 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, Charriére opent the instrument case;
`one reads Charriere. The scalpels had been
`forged, tempered, and sharpened in Paris, by
`his workers.?
`
`This was the beginning of the world-
`wide Charriére reputation for excellence in
`the manufacture of surgical instruments,
`which wouldlast into the 20th century.*
`Charriére 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. Charriére
`
`
`Table 1. Charriere’s Guiding Principles
`
`on
`
`NOOO
`won
`
`. Simplification of the surgical instrument.
`. To unite in the same object—compactness, elegance, and solidness.
`. 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.
`. Closely observe actual use of these instruments—on cadaver experimentsor at surgery.
`. Given an unusual, extraordinary, or unexpected case, immediately create an instrument capable of
`serving the situation.
`. Investigate foreign manufacture; barrow that which is of use and succeedatdoingit better.
`. Furnish an arsenalof surgical supplies that could fill all of the needs, without being cumbersome, toall
`
`large users.2
`
`to all
`
`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.”? 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.”? 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.
`Charriére 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 makethe ivo-
`ry less rigid. He also began using nickel
`silver, originally developed by the English,
`to replace the morerigid nickel, and used
`temperedsteel to replace iron.
`im-
`Charriére 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
`madeof stiff leather. Charriére’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 Charriére was involved wasthat 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, Charriére 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, Charriére’s system has uniform
`increments between gaugesizes, 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 intravenouslines.
`During his lifetime, Charriére’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, Charriére, who had on-
`ly become a Frenchcitizen in 1841, was
`named to the Legion of Honor in 1843. In
`addition, numerousnational and interna-
`
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`BRUT ey Ne ee nee ery -
`
`of his sons, who were his heir apparents,
`he worked up to the end of his life. Char-
`riére died in 1876, leaving both his busi-
`ness and his legacy to two of his former
`pupils.
`
`
`
`Acknowledgment—The authorappreciates the assis-
`tance of Debbie Alonge, RN,
`in translating from
`source material.
`
`the Metric and Stub’s Gauge
`
`Systems
`
`
`Gauge No.
`Inch
`French*
`mm
`
`36
`28
`23
`19
`16
`10
`8
`
`0.0040
`0.0140
`0.0250
`0.0420
`0.0650
`0.1340
`0.1650
`
`0.102
`0.305
`0.356
`1.067
`0.635
`1.905
`1.067
`3.200
`1.651
`4.953
`3.404
`10.211
`4.191
`12.573
`4.667
`14.000
`5.333
`16.000
`6.000
`18.000
`6.667
`20.000
`7.333
`22,000
`8.000
`24.000
`
`36.000 12.000
`
`*Although the French gauge system is based
`on three times the measurementin 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. Iserson KV: The origin of the gauge system for
`medical equipment. J Emerg Med 1987; 5:45-48.
`2. Chereau A: Charriére. Bibliotheque Universelle et
`Revue Suisse. Lausanne, Bureau de 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-Benoit Charritre
`(1803-1876). Schweiz Rund Med Prax 1985; 74:
`181-184.
`
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