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September 2002
Volume 66 |
Number 9
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Monitoring in the 19th Century:
From Blood-Letting to Blood-Flow Measurements
Doris K. Cope, M.D., Trustee
Wood Library-Museum of Anesthesiologyg
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The 44-year-old John Snow, M.D., in 1857, one year
before his death.
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Prior to the advent of anesthesia, surgery was accomplished by
either brute force or life-threatening efforts to subdue the surgical
patient. In 1819, James Wardrop, Esq., an English surgeon proposed
some alternative methods to accomplish surgery. In patients with
"irritable minds" who disrupted the operation procedures
by wresting themselves away from the surgeon, he proposed enclosing
the nonoperative parts of the body in a wooden box or bag and
binding the patients' hands and feet. For unruly or difficult-to-manage
patients, however, syncope could be induced by blood-letting.1
This he described in detail, adding that, in his opinion, exsanguination
also was advantageous in minimizing surgical pain and was distinctly
superior to large doses of laudanum for intraoperative pain.2
Another surgeon, James Arnott, M.D., created a vacuum around extremities
that were bled until fainting resulted with the salutary results
purported to be both muscle relaxation for the reduction of joint
dislocations as well as a bloodless surgical field. This practice
was described and advocated in a widely used surgical text published
in Philadelphia in 1823.3
In this context, the discovery of surgical anesthesia within
the ensuing two decades was a remarkable phenomenon indeed. Once
the amazement that surgical anesthesia was "no humbug"
was over, a debate, which continues to this day, ensued over the
safest way to receive the benefits of this new invention. As originally
reported, the amazement that anesthesia actually worked superceded
any mention of monitoring the clinical state of a patient under
its influence. As news of the Boston public demonstration reached
London late in 1846, John Snow, M.D., personally adopted the technique,
publishing his series of 80 anesthetized patients ranging in age
from children to octogenarians in the Inhalation of the Vapour
of Ether in Surgical Operations. He mentioned the customary monitoring
under anesthesia to include respiration depth and frequency, muscle
movements, skin color and stages of excitation or sedation. Although
the pulse was continually palpated, its characteristics were not
considered worth studying.4 By 1855,
the Edinburgh surgeon James Syme, M.D., lectured on the importance
of monitoring respiration and explained in his surgical lectures
that, in his opinion, chloroform was safer than ether anesthesia
if it was administered properly. The key, however, to proper administration
was monitoring the patient's respiration.5
Joseph Thomas Clover, M.D., was the leading clinical anesthetist
in Victorian England during his professional life from the beginning
of his anesthesia practice in 1846 until his death in 1882. His
clinical prowess and teaching are commemorated in the Clover Lectures
of the Royal College of Surgeons. In his anesthesiology career,
he rendered service to more than 20,000 patients, including many
socially prominent figures of his time such as the Princess of
Wales, Florence Nightingale, Sir Robert Peel and Napoleon III.
In the notes of Sir Henry Thompson regarding the latter case,
it was noted that the patient "recovered consciousness gradually
and was watched by [Dr.] Clover until his intelligence had fully
returned."6 In 1864, the Royal
Medical and Chirurgical Society established a committee to investigate
chloroform fatalities, and as an expert assistant to that group,
Dr. Clover described his innovations in apparatus and animal experimentation
with anesthetics. He strongly advised that the pulse be continuously
observed during an anesthetic and that irregularities such as
a diminution should alert the anesthetist to discontinue the anesthetic.
He also advised monitoring the pulse continuously while administering
an anesthetic [see NEWSLETTER cover]. "If the finger
be taken from the pulse to do something else, I would give a little
air."7
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"Dr.
Clover strongly advised that the pulse be continuously
observed during an anesthetic and that irregularities
such as a diminution should alert the anesthetist
to discontinue the anesthetic."
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Much of Dr. Clover's clinical practice was based on the systematic
discoveries of Dr. Snow, the pioneer British anesthetist. Dr.
Snow emphasized the importance of measuring the pulse as well
as respiration – techniques that were advanced beyond the
common practice. James Young Simpson, M.D., also voiced caution
during the administration of chloroform when snoring ensued and
the pulse became "languid."8 Yet,
even as late as 1889, the second Hyderabad Chloroform Commission
reported that anesthetists should be guided entirely by respiration
as the commission deemed pupil size and pulse not significant
enough to monitor.9
Once again, Americans demonstrated their Yankee ingenuity in
developing a desire to quantitatively and qualitatively measure
the pulse. An American surgeon in Philadelphia, Professor D.H.
Agnew, in a textbook from 1881 discussing the relative safety
of ether and chloroform, demonstrated his point by showing a diminished
pulse waveform after chloroform anesthetic. His readings also
captured a premature cardiac contraction10
– a major milestone in operative monitoring. Later
studies invalidated these measures due to, among other difficulties,
variation in skin thicknesses and the operative techniques.
This measurement of pulse curves by early sphygmographs was based
on the earlier work of scientists Karl von Vierordt in 1854 and
Etienne Marey in 1863. Etienne Marey developed a device made of
brass, steel, ivory and wood. A steel spine tipped by an ivory
plate was applied to the skin above the radial artery that magnified
and recorded pulse waves. He correlated the pulse-wave progression
and the relationship between heart sounds and the cardiac cycle
with Auguste Chaveau, M.D., in Lyon, France, in the early 1860s.
They correlated changes in duration of the cardiac cycle with
cardiac function.11 J.B. Sanderson,
M.D., refined the sphygmograph with a more effective wrist attachment
and the ability to record the tracing on smoked glass, which could
be varnished and shown as a glass lantern slide.12
The history of these cardiac measurements from experimental methods
to more modern recapitulations of these innovations can be found
in Anesthesia From Colonial Times13
(1966) by James E. Eckenhoff, M.D., and Schneider and Redford's
special article in Anesthesiology, "Historical Pulse Tracing
Made During Anesthesia" (1979).14
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Laünnec Stethoscope instrument and case in the
collection of the Wood Library-Museum of Anesthesiology,
American Society of Anesthesiologists, Park Ridge,
Illinois.
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Unlike pulse and blood pressure measurements, direct chest auscultation
along with documentation of medical history were the mainstays
of physical diagnosis in the 19th century. Réné
Théophile Hyacinthe Laünnec, M.D., graduated from
medical school in 1803. Direct auscultation with the ear on the
chest was considered to be unethical in female patients and distasteful
in others. Dr. Laünnec improvised with a paper rolled into
a cylinder for this purpose and later experimented with other
materials, including Indian cane and wood.15
(An early Laünnec stethoscope is currently on display in
the collection of the ASA's Wood Library-Museum of Anesthesiology.)
His treatise "De l'Auscultation Mediate" was published
on August 15, 1819, in two volumes and packaged with a wooden
stethoscope.16 Despite Dr. Laünnec's
detailed descriptions, many physicians thought the device too
troublesome to transport or even ridiculous and undignified, and
the sounds emanating from it were described as too vague or obscure
for this device to have any practical use. As late as 1837, stethoscopists
were a minority group against which there was considerable prejudice.17
Yet with the practice of anesthesia in the mid-19th century, there
was a generation of physicians with exposure to this type of monitoring.
The earliest clinical account of auscultation in the operating
room was reported in 1896 by Robert Kirk, M.D., of the Glasgow
Western Infirmary. An ordinary binaural stethoscope lengthened
by Indian rubber tubing was first used. Later, 200 patients anesthetized
with chloroform were auscultated using a phonendoscope with timing
of heart rate and rhythm by a watch.18
Dr. Kirk was involved at the time with the Glasgow Committee on
Anesthetic Agents and saw the stethoscope as a clinical research
tool to assess the effects of chloroform on cardiac physiology.
It took the strong advocacy of routine, continuous monitoring
of cardiac and respiratory sounds under anesthesia by Harvey Cushing,
M.D., to give impetus to the widespread clinical use of the technique.19
While an esophageal stethoscope was described in 1893 by Solis-Cohen20
for diagnostic purposes, it was almost three-quarters of a century
later that stethoscopy under anesthesia by precordial or esophageal
stethoscopes was considered standard care.
Once the idea that monitoring patients under anesthesia was clinically
useful and early tools were developed to do so, the anesthetic
record could not be far behind. B. Raymond Fink, M.D., credits
the first anesthetic record to A.E. Codman, M.D., at the Massachusetts
General Hospital in 1894.21 Dr. Codman's
chief, F.B. Harrigan, M.D., recommended recording the patient's
pulse during an anesthetic. This practice was encouraged by Dr.
Cushing who published a classic paper in 1902 reproducing an actual
patient's anesthetic record.22 Dr.
Cushing also brought the sphygmomanometer cuff invented in 1896
by Scipione Riva-Rocci, M.D., to the Massachusetts General Hospital
in 1898. This instrument allowed a systemic pressure measurement
by palpation of the radial pulse. Dr. Cushing's initiatives were
not accepted easily, and opponents to the newer devices to measure
temperature, pulse, blood pressure and the auscultation of the
heart were castigated by an editorial in the British Medical Journal
claiming that "by such methods we pauperize our senses and
weaken clinical acuity."23 Thus
it is yet again confirmed that paradigm shifts, however salutary,
are never easy. In this 100-year period, the transformation from
blood-letting to blood-flow measurement was nearly complete, and
anesthesiology emerged as perhaps the clinical discipline that
most utilizes physiological monitoring, which continues to this
day.
References:
1. Wardrop J. Some observations on a mode of
performing operations on irritable patients with a case where
the practice was successfully employed. Medico-Chirurgical Transactions.
1819; 10:273-277.
2. Wardrop J. Lectures on surgery delivered by
Mr. wardrop. On surgical operations. Lancet. 1833; 11:591-598.
3. Dorsey JS. Elements of Surgery. E. Parker:
Philadelphia, 1823.
4. Snow J. On the Inhalation of the Vapour of
Ether in Surgical Operations, John Churchill, London, 1847; reproduced
by Lea & Farbigen, Philadelphia, 1959.
5. Syme WS. Essays on the First Hundred Years
of Anesthesia. Chapter 8: The Scottish Chloroform Legend Syme
and Simpson as Practical Anesthetists. Robert Kreiger: Huntington,
NY. 1972.
6. Cope Z. The Versatile Victorians: The Life
of Sir Henry Thompson. Harry and Blythe: London, 1951; 56-60.
7. Clover JT. Lancet. 1868; 1:23.
8. Simpson WG, ed. Works of Sir J. J. Simpson.
Appleton & Co.: New York; 1872.
9. Pierce EC, Jr. Does monitoring have an effect
on patient safety? Monitoring instruments have significantly reduced
anesthetic mishaps. J Clin Monit. 1988; 4(2):111-114.
10. Agnew DH. Principles and Practice of Surgery.
Lippincott: Philadelphia; 1881.
11. Marey EJ. De l¹emploi du sphygmographe dans
le diagnostic des affections valvulaires du Coeur et des aneurisms
des arteres; extrait d¹une Note de M. Marey. CR Acad Sci. (d)
1860; 51:813-817.
12. Sanderson JB. Handbook of the Sphygmograph.
Robert Hardwicke: London; 1867.
13. Eckenhoff JE. Anesthesia From Colonial Times.
Lippincott: Philadelphia. 1966; 41.
14. Schneider AJL, Redford JE. Historical pulse
tracings made during anesthesia. Anesthesiology. 1979; 51:242-244.
15. McIntyre JWR. Stethoscopy during Anaesthesia:
Past, Present and Future, The History of Anaesthesia, 4th International
Symposium on the History of Anaesthesia Proceedings, J. Schulte
am Esch and M. Goerig, eds., Lübeck: Dräger Druck; 1998.
16. Keers RY. Laennec: His medical history. Thorax.
1981; 36:91-94.
17. McIntyre JWR. Stethoscopy during anaesthesia.
Can J Anaesth. 1997, 535-542.
18. Kirk R. On auscultation of the heart during
chloroform narcosis. BMJ. 1896; 2:1704-706.
19. Cushing H. Technical methods of performing
certain cranial operations. Surg Gynecol Obstet. 1908; VI:227-234.
20. Solis-Cohen S. Exhibition of an oesophageal
stethoscope, with remarks on intrathoracic auscultation. Trans
Cell Physicians Philadelphia. 1893; 3.5 XV:218-21.
21. Fink, BR. Times of the Signs, The Origins
of Charting, The History of Anesthesia, 3rd International Symposium
Proceedings, B.R. Fink, L.E. Morris, C.R. Stephen, eds. Chicago:
Wood Library-Museum, 1992.
22. Cushing HW. On the avoidance of shock in
major amputations by cocainization of large nerve trunks preliminary
to their diversion, with observations on blood-pressure changes
in surgical cases. Annals Surg. 1902; 36:321-343.
23. Major RH. The history of taking the blood
pressure. Ann Medical Hist. 1930; 2:47-55.
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Doris
K. Cope, M.D., is Professor of Anesthesiology and Critical
Care Medicine, University of Pittsburgh Medical Center (UPMC),
and Clinical Director of UPMC St. Margaret Pain Medicine Center,
Pittsburgh, Pennsylvania. |
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