Medical School & Fire-Watching
I was born in Birmingham. Both sets of grandparents came over to this country in the early 1900s from what was the Russian occupied part of Poland and they settled here. My father served in the British Army during the First World War and automatically got British Nationalisation. It was an introduced marriage, my father was living in Leeds, my mother in Birmingham and they had a mutual friend who thought they were two nice people who would suit each other, really. I’m the oldest of three brothers; the middle one also did medicine; youngest – dentistry, all at Birmingham.
I hadn’t always wanted to study medicine. Actually I think it was much more my father’s urging because he wanted us to have, what he called, a portable career.
I went into medical school in 1940. In those days, everyone went to the local medical school, you didn’t leave home. I think what’s happening today when everyone whizzes off as far as they can from their homes is a post-war phenomenon, which I think has made life probably more difficult for a lot of people.
On the whole, I enjoyed medical school. I learnt later on that it was unusual in being very cliquey, there were groups of people who’d been at the same sort of prep school or whatever it was and they tended to stick together. I think we gradually got to know each other because one of our functions was fire watching and when we had our 50th anniversary reunion in ’95… that was the thing that people talked about, not about the lecturers or anything else but just that experience.
I can remember being on the roof of the medical school and seeing a great combustion going on, which was actually Coventry burning, and that was about thirty-odd miles away. So we were up there with our buckets of sand and stirrup pumps. Later on when we were into the clinical year… there was an emergency hospital in the basement of an old brewery in Aston, which was built on the side of a hill, and the basement had about 120 beds and a temporary operating theatre, a sort of make-do thing. And you went in at the top of the hill and you went down something like six floors to the bottom and that was where we were. There was a small little kitchen in one corner where we could make ourselves a bit of supper or breakfast, and there was a door and one day somebody decided to open this door and found themselves in the street, and in fact we were right down at the bottom corner of this hill and if a bomb had come down there the whole place would’ve gone up, you know we were not being protected by six floors at all!
Fortunately we never had to do anything, but there was one occasion when we acted as stretcher bearers- in ’41 I think it must’ve been- there was a big bad raid on Birmingham and they had an emergency operating setup in one of the department stores in the centre of town and we were drafted in there to just move patients around. I think they had about six tables going.
I graduated in June ’45. I was thinking of becoming a physician, so I got a house physician’s job at Selly Oak Hospital.
Now Selly Oak in those days, there was an acute part and an infirmary part which was a hangover from the old workhouse infirmary which had about 500 beds. And my chief was a sort of long-term locum for the chappy who’d been called up, and the other two physicians had dumped all the infirmary beds onto him. You were supposed to see every patient once a day so… you just sort of whizzed round, ‘Everything alright?’ sort of business. But it was an incredible treasure house of chronic conditions, multiple sclerosis, and all those sort of chronic neurological states for which there was no treatment at all, and very bad contractures, a lot of them.
And then on top of that, there the Relieving Officer – he had the authority to sign a Relieving Officer’s Order and the patient had to be admitted, no argument about it at all, so if old grandma or whatever, was getting beyond their care they would go along, get this order with no trouble at all and then you had to take these people in… and they were coming in in fairly regular stream.
There were three surgeons, each with a house officer, three physicians similarly, that was it, that was the total medical staff for virtually a thousand-bedded hospital. All the emergencies were anaesthetised by the house physician, who also were on casualty duty for 24 hours every third day… it was a completely different life and we loved it on the whole.
On the first Friday morning, I was having breakfast and the phone rang and the voice said, ‘Where are you? Has no one told you that [you] anaesthetise Mr Reading’s tonsil list on the Friday morning?’ When I got there, actually he’d started without me and he had anaesthetised the kid himself. He had a catheter in the nose and the plunger of the ether bottle was down to the bottom and it was bubbling wildly, and the sister was helping.
So she was handing him things off the instrument trolley, he was getting on with it… and the first thing I did was I pulled the plunger off the ether bottle, she sort of drifted round and pushed it down again with her elbow and when she’d gone back to the trolley I pulled it back up again, so she sort of shrugged and about two minutes later the kid started coughing so of course I… put it down. So that was a good lesson.
After he’d done the first case he said, ‘How much anaesthetics have you done?’ I said, ‘Well I did the obligatory 20 under supervision’ which we had to do in those days. He said, ‘Well if I’ve got you for six months I’d better started teaching you something.’ And it turned out that he was very interested in anaesthesia and very skilled in inhalation inductions and so on. So he taught me quite a lot there, then he showed me how to use the laryngoscope. I once went into Charles King’s shop and tried to buy a cuffed endotracheal tube and there were no such thing on the market, I mean they were in the books. The only thing I could get was a sort of free-floating cuff which sort of slid onto the tube which was jolly dangerous because when you pulled the tube out you could easily leave the cuff behind.
The youngest of the three surgeons was also a very friendly bloke and I hung around with him a little bit, he did all his work under spinals, all his emergencies, and one day he said, ‘Would you like me to show you?’ I said, ‘Yes please’ he said ‘It will be very good because once you are able to do it I can go and scrub up while you put the spinal in .’ So I learnt all about anaesthetics because of a certain amount of self-interest.
We used to do ECGs on Thursday mornings, once a week, in a dark, blacked-out basement, using a machine… well I suppose it was sensitised cardboard or something, but it went across on the little engines of the thing and had to be developed afterwards, and I think if we did three cases a week that was a lot. So the amount of ECGs recorded then was very little.
I gave my first anaesthetic at the age I suppose of 19 – virtually 70 years ago, in the casualty department of Birmingham General Hospital, using an apparatus which must have been at least 50 years old. It was a cylinder on the floor, a big capnography bag I think they called it, and a face mask, and a little valve… [so] a patient could either breathe air or he could breathe from the bag and out to the atmosphere or he could breathe back into the bag.
The cylinder was nitrous oxide and it was on the floor and you worked it with your foot on the pedal… I was taught by the chap who’d learnt it the week before. The instructions were ‘Give him pure nitrous oxide till his ears look blue. Then you give two breaths of air and then you go onto a three to one. If he starts jerking, give him a bit more air.’ No oxygen, air. And I eventually got quite good at this.
Because we did see quite a bit of anaesthetics given in the main theatres, almost invariably they were inhalational inductions. The Senior Resident was a chap called Murtheh. He did intravenous inductions. Thiopentone then was 5%. It was reduced to 2.5% by the manufacturers in the early fifties I think, largely because of local extravasation.
The technique was that you gave the thiopentone till the patient was unconscious. Then you gave the same dose again straight off, which stopped them breathing of course. You then put them onto gas, oxygen and ether and you just hoped that when they started breathing they didn’t go into laryngeal spasms! Quite often they did. And also I did wonder, although I knew nothing about anaesthetics, it seemed to me a slightly crackers sort of way to go about things. But everybody else did inhalation inductions and there was a chap called Dr Hassle, and he would start off with ethyl chloride and open ether always on a Schimmelbusch type mask put his hand in his pocket and he’d pull out a little bottle of chloroform and he’d look around and say, ‘Don’t tell anybody you’ve seen this.’ So he was giving a sort of combined ether/chloroform type of anaesthetic. And seemed to go alright. He was very … much trusted by the surgeons. They said he never flapped and he was a good steady pair of hands.
We had closed circuit. There was a separate outfit, there was an American neurosurgeon who had his own unit in one of the wards in the Queen Elizabeth, and he had a woman called Marion Green who did all the neurosurgical anaesthesia, so we didn’t really get very far into that so I don’t know what sort of techniques she was using. But I do remember the Coxeter-Mushin absorber coming out with the fluorescent knobs so you could see it in the dark if the light failed!
I have vivid memories of watching some chap sitting at the end of the table half asleep and thinking to myself, ‘Who would want to spend the rest of their life doing that?’ Having gone through the whole of medical training. I enjoyed it, once I’d got the grasp of the techniques. You felt that you were doing something useful that maybe other people weren’t and you were in a way part of a team.
Developments in Anaesthesia
Some things were incredibly primitive. I remember the first blood transfusion I ever saw was a large funnel-shaped glass container, open at the top, red rubber tube connected to the bottom of it which went into … in those days nearly all the drips were what were called cut-downs, you cut down onto the vein, you put in the cannula, could be either glass or metal and tied it in; and as the level of BP got lowered somebody tipped a bottle of blood in … and it was covered with a bit of gauze. Well after that, we gradually we got red rubber proper giving sets with rubber tubing. The received wisdom was that you couldn’t keep the system sterile for more than say 24-36 hours because patients invariably developed phlebitis. And so one was encouraged to change the site, perhaps every day or whatever. And then when the plastic giving sets came in they discovered that the patients didn’t get phlebitis once! And what was happening was that the plasticiser or something was being leached out of the red rubber tubing, which was causing…sulphur probably.
One other thing I learned was that all the worthwhile advances or developments were all due to the initiative of the commercial companies. One occasion where the Minister of Health got involved, they designed a giving set… but … this thing used to blow apart, and there was so much ridicule that the Department just decided it was never going to get itself involved in producing anything else again. So all the big advances are due to common sense.
The other big difference was that nothing was disposable. Needles were used time and time again. They were sharpened, quite often you might get a needle that was caked with blood on the inside. It really was ghastly and when the companies started trying to push disposable things, our reaction to start with of course was, ‘You can’t throw that away! You can’t just use it once!’ And they said, ‘Well you’re employing staff to do this, that and the other. It’s costing so much.’ And the comparison was always of course on their side, plus the tremendous advantage in not having to worry about infecting people with somebody else’s stored blood!
When I started giving anaesthetics, in the mid-40s, patients never asked how risky the anaesthetic was. It was accepted by the general public that some people couldn’t take the anaesthetic. If you had a death that was the accepted reason, excuse, ‘couldn’t take the anaesthetic.’ Nobody questioned it.
When I finished my first house job, a six month house job was it, I got called up into the RAMC.
Well we had a sort of six-week induction period in the wretched Barrack near Aldershot. We were sent off for about a week’s leave, and then… you crossed over to Calais and I think we were driving till we got to the German border, and the difference as we crossed… all we saw was total devastation… hardly a building standing for miles and miles and miles and miles.
I think we went over on 6 May, it would have been just about a year after the end of the war. I think I was posted to … I’m a bit hazy about this, I think it was a place called Iserlohn which was slightly south of the Ruhr.
And the amazing thing was that there was quite a large Birmingham contingent there. There was a girl who had been a registrar at Queen Elizabeth, a girl called Eileen McShane, who used to infuriate the surgeons because she insisted on reading the patient’s notes and they were furious. ‘What does she need to … she’s keeping us waiting!’ She had a DA so she was a Major automatically so she was the hospital anaesthetist. When I got there I was asked ‘What have you been doing?’ and I said ‘House physician, done quite a bit of anaesthetics.’ So I was given the option, ‘Either get yourself attached to her, or go and sit in the VD clinic this afternoon and see how you like it.’ And I hated it! It was really horrible! These poor chaps coming in, having whacking great … I think they did it sadistically. They used the biggest possible needle they could, they were giving penicillin at that time. Actually I was totally stupid of course, because those were the chaps who were making a fortune afterwards!
And then I was posted to 25 British Military Hospital in Munster, and I was there from probably June to December, but in between I was being sent off to do leave locums, and after about four or five months I suppose somebody was looking at names ‘cause they said, ‘Who is this bloke who’s going around doing locums, he’s not on our list of anaesthetists?’ So I was sent off to Hamburg for training, by a chap called John Boxton.
We were trained for four months. And then after that I was a fully-fledged graduate anaesthetist and I was sent off to a place called Wuppertal. And that was made up of two towns called Barmen and Elberfeld, and they’d been combined together round about 1930. So this was a very nice, modern, had been built as a civilian hospital I suppose, up on hill. Proper operating theatre suite and so on. By that time there were families coming out and staying, so we had a maternity unit.
I became interested in … we called them relaxants in those days. You couldn’t get them, they were not on the official list of drugs. So I wrote off, sent 30 bob to Duncan Flockhart and they sent me back a little box of six ampoules of Tuberine.
We had a case of a poor chap who had what was called a dish fracture, a face fracture. When they brought him in, I think he’d been driving a three-tonner or something. They just kept his face covered with a towel because nobody could bear to look at him. Rather stupid – we should have evacuated him straight away, except that there were no helicopters in those days. He decided he was going to pull it out and he was going to put a wire suture through the chap’s pallet and … my job was to keep the blood bank of two bottles of blood. Anyway, we started and I thought, ‘I’ve got to get a tube down this bloke, that’s the first thing I’ve got to do,’ so I started off with cyclo and then gave him some Tuberine, and he relaxed nicely and I got the tube in, that was OK, but he was bleeding a bit, and I put a big gauze pack in the back of the throat and then I relaxed … and that was OK … and then he started putting his wire suture through the pallet and as soon as he did that it was pouring with blood and to cut a long story short, the chap bled to death.
As it happened, when the PM was done I think he was probably irrecoverable, well certainly by us because I think his oesophagus was ruptured…. he had all sorts of other things, he had a haematoma going down the thorax, pretty horrid. I mean today he’d probably have been saveable, but not with the conditions we were working in.
The sequel of that was that every six months the surgical brigadiers, one was surgical, the other was medical, and they used to go round the BAOR checking up on the hospitals, seeing what they were doing, so this Brigadier, he came along and he was going through our book and saying, ‘What’s this stuff, Tuberine?’ So I explained, ‘Well I it relaxes the muscles’ and I explained why I used it. He actually was right, he said, ‘What does it do to the blood pressure? Does it relax the smooth muscles in the blood vessels?’ I couldn’t tell him. Next thing that happened was that a directive came out that this stuff is not to be used in BAOR. Now the funny thing about … I was telling this story to Jimmy Payne about forty years later and he said, ‘Oh, that’s why it came round!’ And he was in the RAF and he was stationed in the RAF hospital somewhere or other and they couldn’t understand why.
So at this stage I was a captain, I’d had an increasing amount of experience of anaesthetics, but no formal qualifications in anaesthetics at all.
In those days there were correspondence courses… so I signed up and worked my way through this… Anyway, I was working for the DA and that was before I was ready to take it they changed it into a two-part DA! So I had to do all the primary stuff. So I came on leave in May 1948 and I’d applied to take both parts and I got through part I and failed part II, which was a great shame because if I’d gone back with that I’d have become a Major automatically you see.
And when I was demobbed in August, I came back to Birmingham and there was supposed to be a scheme then to help demobilised doctors, so I went to see the chap who was the Dean and he said, ‘Well I’ve never been asked to help an anaesthetist before!’ So anyway, to cut a long story short, I got a job, in fact I was very happy to help the Birmingham Accident Hospital where there was a chap called Joe Wolfson. He was really, really good. And he taught me quite a lot.
He was the anaesthetist … there were three actually but he was the chief. They were doing all sorts of innovative stuff there and there was a burns unit there where they were doing instant grafts and things, and fractures were being plated as soon as they got through the door, that sort of thing. So it really was a forward-looking… We did a lot of stuff under local. I learned quite a lot of local techniques, because we were getting people coming in on Saturday nights absolutely blind drunk with cut scalp pouring blood and stuff, so we used to put in a ring block round that. We did a lot of local block for Colles fractures, haematoma block. And quite a bit of brachial plexus blocks. Probably [with] lignocaine. There was Desicaine I think was one of the things. Procaine was a bit too short but you might use Procaine with a spot of adrenaline. Thinking about Macintosh and Mushin’s little book about Brachial Plexus block, not a word about the complications. So that was something we had to learn the hard way!
Then I took the part II again and passed in October/November, which was nice.
At the end of the time Joe Wolfson said, ‘Look, if you’re going to stay in anaesthetics you’ve got to get off to London and get a job in a teaching hospital because there’s nothing going on in Birmingham’, which was true. It was still the same old gang, almost.
“Get off to London…”
So I went to Hammersmith as a registrar. That would have been ’49, spring of ’49. I think [it was] the least happy hospital I’ve worked in. Everyone was trying to stab everybody else in the back. The competition was incredible.
The thing was that they were working then on the beginnings of organ transplant and heart/lung machines and that sort of thing, so a lot of activity. Unfortunately it slowed everything down. I mean they would be doing measurements on straightforward gastrectomy would take seven or eight hours because they wanted to take blood samples all the time and this, that and the other.
Probably after about a year and it was suggested that I applied for a senior registrar job at Winchester. I got that job, which was a disaster. I was the only resident and I was a senior registrar, I was expected to be on call something like 28 days out of 30. There were a couple of GP anaesthetists, one of whom had got the DA, the other one was reputed to have come back from trying to take it and saying, ‘Ha, the exam is a farce! They failed me!’ So there was that. After six months I thought well this is no good. So I started looking elsewhere. I did some locums around North London, North Mid and so on. Then I got a phone-call from the senior consultant at the Whittington, and I don’t know how he’d heard of me but he said, ‘Look, I’ve got a senior registrar job coming up. Would you like to come and do locum for the time being and I’ll do what I can?’
That was how I became Senior Registrar at the Whittington. Then they said, ‘Look, it’s time for you to start applying for consultant jobs’… and eventually a job came up in Chase Farm and that was the one I got. That was one of the places I had done a locum at when I was going round, and I thought it looked rather a nice place and it was very nice to get to, because you were driving through bits of open country and in spring it looked nice, gorgeous. So that was it.
I was 32 I think. I was too young, two years too young to … because the baseline was 34, so they said, ‘OK, we’ll appoint you but we’re not going to pay you full rate for two years!’ Well I was just glad to get the job anyway! By that time I was married, I had a son. I got married between Hammersmith and Winchester… so that would have been 1950.
Chase Farm offered opportunities in a way of development, because for one thing the hospital management was absolutely primitive and ignorant, I’d put it that way. We had a medical staff committee and being the new bloke I was fairly quickly elected to be secretary of that! So gradually I got sucked into that side of things, and we persuaded them to put the, what you might call the medical running of the hospital, into the hands of a staff committee so that we were in charge of things like casualty department, appointment and staffing, that sort of thing. We managed to persuade them to provide us with an instrument technician and we had a very nice little workshop set up and that sort of thing as well.
On the whole it worked. Fairly shortly after I came there was a case where they’d sent an elderly person home without checking up that there was anybody, which they never would have done anyway. So there were complaints and all that sort of thing, so we decided that we needed to draw up a book of rules, book of advice if you like, and I got all the departments to put in their bits, any useful information that medical staff ought to have. And one of the very strict rules was that don’t discharge a patient until you’re sure that there’s somebody at home to see them. Nobody was ever sent out at midnight … it was daft anyway because statistics were being manipulated the whole time.
I managed to get Wednesday afternoons set apart… sometimes I would try and get one of the juniors to prepare a talk on something or other. Otherwise I would be doing something myself and usually it would be 1.5-2 hour session, and unless there was some emergency or other than all the juniors were expected to be there.
We’re talking about about 1970. Three consultants then … we got up to four eventually. I think they’d have had two registrars, four SHOs, something like that.
The History of Anaesthesia Society
I decided, I think it must have been ’75, that I wanted to do something serious in medical history, so I signed up for the Wellcome course for the Diploma in History of Medicine… We were all in the same sort of age-group and so on, and we all said afterwards that it was the exam that we worried most about throughout the whole of our careers, and it didn’t mean a thing really! The funny thing, of course, was there was a 100% pass rate and the reason for that, they said, was because ‘you are all self-motivated so you all did very high-quality work.’
You had to do a thesis of your own choice. They had to approve it, but mine was on Nooth who invented the soda water machine, the bottom part of which was used as an ether vaporiser for the first anaesthetics. I’d seen his name always as a footnote and no one had ever said who or what he was, so I thought well, this was an interesting one to have a go at, worked on it for the best part of a year but I found an awful lot of very interesting stuff about him. He became the senior medical officer of the British Forces during the American War of Independence. If he addressed his dispatches back to England in a certain way, the recipient, who was the Director General, he didn’t have to pay, but if he nobbled the address then he had to pay 40 bob which was a lot of money! And they always sent them in triplicate by three different ships, so if all three ships got through he really had a pretty big bill to pay!
I was trying to look up chaps who appeared as footnotes with nothing else about them. And then if we can jump to ’86, there was going to be an International History of Anaesthesia conference in England. The first one, I think, had been in Netherlands, in ’82, and then Adrian Padfield and Ian McLellan got on to Tom Boulton and said, ‘Look, we ought to have our own society as well, to sponsor this thing,’ so they called a meeting at Reading and I was only too keen to get along there, and they set up the History of Anaesthesia Society.
I think you were on the council for about three years and then … Aileen Adams phoned me one day, must have been in the early nineties, and said, ‘We’d like to nominate you for President.’ I was very flattered! So I did two years and it was incredible because … you were inheriting something from your predecessor that had all been organised, you were organising something for your successor, but you never actually organised something for yourself! You had a secretary who did a five-year stint, so he was the continuity bloke, and the other thing I realised, the moment the meeting started, you were actually on a treadmill, you couldn’t stop. Every minute of the day… It was two years of very pleasant work! It was very enjoyable. I mean I had jolly good chaps who were backing up.
I think actually this was Anna Maria Rollin, who said once, ‘Would you like to come and help to set up an exhibition?’ This was in Bedford Square, and then I was asked whether I’d like to become the official curator, and at that time I was a bit worried about my health, so I thought well I’d better not take up anything! So I said, ‘Well I’ll do it as an ad hoc’ and this went on for about five years, and it was a very enjoyable period because mounting an exhibition you’d be preparing perhaps for three or four months before you actually got into the museum at all, and then it was four weeks would be the rush period when you were getting everything, we were doing all our own labels and all the scripts and everything else. And so it was quite a hectic period, but I had Neil Adams and Geoff Hall Davis and we worked as a team.
The book- this is John Snow- that kept me going for six years at least. I’d forgotten all about that. I got this email from Peter Vinten-Johansen, asking if I was the bloke they’d been looking for for the last month! And … if I was, could they quote from this paper that I’d written about John Snow’s uncle, Charles Empson. And I wrote back and said, ‘I’m very interested in anyone who’s interested in John Snow, tell me more about it,’ and he said, ‘Well we’re a group of five, we call ourselves the Snowflakes and four of us are medical,’… and I said, ‘Have you got an anaesthetist?’ He said, ‘No’. ‘Well would you like one’ sort of thing. And they totally fell over themselves but they were very pleased, particularly to have somebody over here who could go and look up stuff for them! They kept me best part of six years.
It won the Wood Library prize for the best History of Anaesthesia book. It might be that there wasn’t much competition because there aren’t too many anaesthetic histories about! I think so, I think it’s recognised as the standard biography.
My proudest moment so far… I suppose probably getting either the Pask or the honorary membership I suppose. I had a very nice Presidential Commendation, which is still waiting to be hung up on the wall! That was from the College. That’s for As We Were.
I think I’d just completed about ten years of it. It was great fun actually. I loved doing that! One thing about the history of anaesthesia, that you just don’t know where you’re going to finish up. I started working on Hooper, who produced the very early ether vaporisers, and Hooper became interested in vulcanised rubber and he ended up putting in subterranean telegraph cables between Hong Kong and Japan. So when you follow this track and then eventually you’re reading all this stuff about things that I never had the slightest knowledge or interest in. And as I say, history of anaesthesia takes you all over the place.