| |
|
|
Lieutenant Arthur Guedel, "The motorcycle anesthetist
of World War I." Photo courtesy of Guedel Memorial
Center
|
|
Today anesthesiologists rarely examine a patient's eyes to determine
the depth of anesthesia. Our sophisticated monitors usually tell
us all we need to know. In the early days of anesthesia, however,
eye signs were enormously important. Physiologic monitors were
nonexistent then, anesthetic techniques were simple (usually only
one agent was used) and eye signs were easy to observe. This article
discusses how Arthur Guedel, M.D. (1883-1956) developed the eye
signs of anesthesia during World War I.
Dr. Guedel, who made many vitally important contributions to
anesthesia practice, equipment and knowledge, began his career
with severe handicaps. Born in Indianapolis, Indiana, to a poor
family, he had to leave school at age 13 to work. A machine shop
accident led to the loss of the first three fingers of his right
hand – and he was right-handed. Guedel dreamed of practicing
medicine, even though he had no high school diploma and no financial
resources. With the assistance of his family's physician, he was
able to graduate from the University of Indiana Medical School
in 1908. Dr. Guedel administered his first anesthetics while an
intern at Indianapolis City Hospital. This was a common duty for
interns at the time because there were so few physicians interested
or trained in anesthesia. Dr. Guedel established a practice in
Indianapolis in 1909 and earned additional income by giving anesthesia
in hospitals and dental offices.1
Part-time anesthesia practice was also common at the time.
From the earliest days of anesthesia, physicians had tried to
define the "stages" of anesthesia. When Dr. Guedel began
administering anesthetics, four stages of anesthesia were generally
accepted:
Induction: Beginning of administration until loss of consciousness.
Stage of struggling, breath-holding, delirium: From loss
of consciousness to onset of surgical anesthesia.
Surgical anesthesia: Characterized by deep, regular, automatic
breathing. Some authors also noted loss of the corneal reflex.
Overdose, or stage of bulbar paralysis. No exact signs
except shallow, irregular breathing and dilated pupils that no
longer reacted to light.2
Dr. Guedel was a careful observer. As he anesthetized his patients,
he tried to verify these observations and to look for other possible
signs, for example, the characteristics of respiration and what
was happening to the eyes. He then tried to organize these observations.
Dr. Guedel's contributions better defined stage III, the all-important
level at which surgery could be done, by further dividing it into
four planes and by adding the eye signs.
The eye signs were new2 and the most
significant contribution to Dr. Guedel's signs of anesthesia.
His eye signs included the activity of motor muscles of the eyeball,
pupillary dilatation and, later, the eyelid reflex. (The eyelid
reflex is tested by gently raising the upper eyelid with the finger.
If the reflex is present, the eyelid will attempt to close at
once or within a few seconds. The corneal and eyelash reflexes
are better known to us today but were not mentioned.)
|
|
Earliest version of Guedel's stages and signs of anesthesia.5
Courtesy of Guedel Memorial Center
|
|
The setting for these contributions was the great need for anesthesia
during World War I. When America entered the war in April 1917,
the U.S. Army had not a single trained specialist in anesthesia
among its 491 medical officers.3 Dr.
Guedel was called to service in June 1917 and arrived in France
in August. Due to a crush of casualties from a major battle, his
staff of three physicians and one dentist needed to run as many
as 40 operating room tables at a time. After working 72 hours
straight, Dr. Guedel decided that other staff would have to be
trained quickly to meet this overwhelming need. He developed a
school that trained physicians, nurses and orderlies in open-drop
ether.4 However, how could he help
these trainees work safely once they left the school and Dr. Guedel's
immediate supervision? He prepared a little chart of his version
of the signs and stages of ether anesthesia, the most common agent
in use at the time and an agent with a wide margin of safety.
This chart was a visual version of the concepts he had been developing
for himself before his Army service.
Armed with their charts, the trainees went out to nearby hospitals
to work on their own. Dr. Guedel was given a motorcycle to make
weekly rounds of the six hospitals for which he was responsible.
He would roar from hospital to hospital through the deep mud that
characterized WWI's battlefields, checking on his trainees. This
led to his becoming known as "the motorcycle anesthetist
of World War I."3
Dr. Guedel returned to the United States in April 1919.4 The
same month, he presented the chart at a meeting of the Indianapolis
Medical Society and later at the state medical society and the
Interstate Association of Anesthetists. In 1920, it appeared in
Anesthesiology, the only anesthesia journal of the time.5
There were still the four accepted stages of anesthesia, but stage
III had now been divided into four planes. There were only two
eye signs, eyeball oscillation and pupillary dilatation, in the
original chart. Entry into stage III, where surgery could be performed
safely, could now be determined by the onset of eyeball oscillation.
Eyeball oscillation indicated a safe plane; it meant the patient
could have surgery and was not too deeply anesthetized. A more
dangerous level began when the oscillation stopped. Pupillary
dilatation was an indication of deep anesthesia. Dr. Guedel also
emphasized the need for the lightest anesthesia possible and the
need for deeper anesthesia at certain points of the operation.
Because of their simplicity and usefulness, Dr. Guedel's stages
and signs became widely known.
|
|
Original hand-drawn copy of the 1937
version of Guedel's stages and signs of anesthesia.
Courtesy of Guedel Memorial Center
|
|
Dr. Guedel moved to Los Angeles, California, in 1929 because
of his health. In addition to practicing anesthesia, he continued
work in his research laboratory at home. Items to come out of
the home laboratory during this period were studies of cyclopropane
and CO2, the Guedel laryngoscope blade and the Guedel oropharyngeal
airway, which is still in use today. (Work in his home laboratory
in Indiana led to the cuffed endotracheal tube while in collaboration
with his close friend Ralph M. Waters, M.D.) Dr. Guedel continued
working on his chart, further refining it based on his careful
observations of clinical cases. A series of four articles on his
signs and stages of anesthesia appeared in 1935-36.6A-C
In 1937, this revised material appeared in his notable book, Inhalation
Anesthesia: A Fundamental Guide.7
There was now another eye sign, the eyelid reflex (previously
mentioned) and further refinement of pupillary dilatation. For
unknown reasons, the lash and corneal reflexes were still not
mentioned. This book went through three editions and was enormously
successful, further popularizing the chart. Copies of the chart
appeared in other anesthesia texts and also were used by the military
for teaching in World War II. A 1972 study of minimum alveolar
concentrations (MAC) of various anesthetic agents documented that
the pupillary changes of ether correlated with its alveolar concentrations,
confirming Dr. Guedel's observations. This was not true of most
other agents that were not available in Dr. Guedel's time.8
Although of little use to us today, the eye signs developed by
Arthur Guedel, M.D., were an important innovation for the time,
and their usefulness lasted for many years. They resulted from
his careful, precise observations of his patients in a time of
little or no monitoring and limited anesthetic agents. The eye
signs were one of the many contributions that led to Dr. Guedel
receiving the ASA Distinguished Service Award in 1950.
References:
1. Calverley RK. Arthur E. Guedel (1883-1956).
In: Anaesthesia–Essays in Its History. Ruphreht J, van Lieburg
MJ, Lee JA, Erdmann W, eds. Berlin: Springer-Verlag; 1985:49-53.
2. Gillespie NA. The signs of anesthesia. Anesth
Analg. 1943; 22:275-282.
3. Courington FW, Calverley RK. Anesthesia on
the western front: The Anglo-American experience of World War
I. Anesthesiology. 1986; 65:642-653.
4. Unpublished manuscript, no author. Arthur E.
Guedel, MD: Public Servant of Mankind. Guedel Collection, Guedel
Memorial Center, San Francisco:24-28.
5. Guedel AE. Third-stage ether anesthesia: A
sub-classification regarding the significance of the position
and movements of the eyeball. Am J Surg. (suppl) 1920; 34:53-57.
6. Guedel AE. Anesthesia: A teaching outline.
Stage of Anesthesia. Anes Analg. 1936; 15:1-4. 6a. Guedel AE.
Anesthesia: A teaching outline. Anes Analg. 1936; 15:55-62.
6b. Guedel AE. Anesthesia: A teaching outline.
Anesthetic depths, surgical reflexes, stages and various operations.
Anes Analg. 1936; 15:120-127.
6c. Guedel AE. Anesthesia: A teaching outline.
Preparation of the patient and mechanism of varying anesthesia
requirements. Anes Analg. 1936; 15:157-162.
7. Guedel AE. Inhalation Anesthesia: A Fundamental
Guide. New York: The Macmillan Co; 1937:25.
8. Cullen DJ, Eger EI, Stevens WC, et al. Clinical
signs of anesthesia. Anesthesiology. 1972; 36:21-36.
| |
|
Selma
Harrison Calmes, M.D., is Clinical Professor of Anesthesiology,
University of California-Los Angeles, Department of Anesthesiology,
Olive View-UCLA Medical Center, Sylmar, California. |
|
return to top
|