The development of endotracheal anaesthesia (1965)

[Music] at the time of the first world war specialization in anesthesia was not recognized as it is today that being so sir Ivan why did you decide to devote your whole time to giving anesthetics well it's a very simple story uh so as a student before qualification I was interested in anesthetics because I could see that once one was qualified as a doctor you were expected to give an anesthetic for any kind of operation no matter how serious it was although you might not be expected to do the surgery you know of course that uh when you qualified in those early days the amount of training you had was negligible and I myself can produce for you here a certificate to show that on qualification as MV I had administered one anesthetic that gives you an idea of the amount of training we had in those days and what a formidable proposition it was in the future for me at the end of the uh first war um I was posted to a small Hospital in Barnett for lack of a better job to do and I got to giving the anesthetic for some simple procedures there with uh the oldfashioned methods of the drop bottle and the The Mask there were no complicated cases to deal with but it so happened that there was a demand from the adms to know whether he could post an anaus from this hospital to a place called sidcup but I got there I found that um The Proposition was a formidable one because this Hospital contained some 700 beds occupied entirely by men who had been wounded in the facing Jews in the First wall and they were under the care of s the late sir Gilles who did so much in the plastic field the methods of giving anesthetics were very simple at that time in that hospital even they used um ship The Operators to vaporize ether and a huge Airway but the difficulty of maintaining an airway over a period sometime of 4 hours was a very strenuous business for the anesthetist for the surgeon and for the patient because you see with the airway not completely free it meant that you were encroaching very often an aseptic field well RAM and I discovered that the the answer was complete control of the airway and we achieved this by means of uh the endot tube I do not claim that we invented endot anesthesia but it was not in common use when we joined the hospital there however we used this U method uh namely a insation technique with a catheter and a motor to blow ether vapor into the patient's lungs after the catheter had been inserted at first we passed the catha through the mouth and there was a certain amount of outflow from the tra with the plum system as you can imagine and the surgeon was very often Us by the spray of blood which was necessary to keep the blood from entering the tra we solved that problem by putting a second tube into the tra to provide for expiration and in that manner we could divert the patient expirations entirely away from the surgeon and the firings could be packed with G which meant that there was no spray of blood that was the first Technique we used but there was a demand for nitrous oxide and oxygen and and uh we found that it was expensive to use it by the insulation technique it required so many gallons and N that it was quite expensive eventually however we found that the solution of the matter was the use of one white board tube passed into the tra and connected by means of a wide boore corrugated tube to a gas bag and uh an expir valve Incorporated and in that way you could use um gas and oxygen for maintenance of anesthesia as well as for induction blind intubation which you introduced there had other advantages as well yes it had a very different Advantage at first as you know we pass the tube through the uh nose in order to give the surgeon free access to the floor of the mouth and the lower jaw without encumbering them in any way but we find that with the patient's head in the right position you could put the tube into the tra through the nose by what I called the blind method and that became very very popular indeed the tube could be passed into the Tura without the use of lingos scope at all the advantage of that was very obvious because in order to pass the tube into the turqua by direct vision of the lingos scope in those days when there were no muscular relaxant that meant inducing a depth of anesthesia in the patient which was really greater than that required for the operation itself so that it was particularly advantageous to the patient what sort of machines did you have at that time uh the machines were all there was a boils machine which operated with a water sight feed which was not by by no means accurate and did not provide for the necessary flows and there was a bottle uh an ether bottle on that so that you could add the VAP ether Vapor if you wished was nitrous oxide readily available at that time it was available and of course we used it in the hospital but uh when eventually I went in private practice I found that the the the price of it at 8 and6 p 100 gallons was prohibitive when you consider that the fees that we uh we got as a recompense in those early days it was not a paying proposition however there was a demand for it as you know for induction as opposed to the oldfashioned method of giving ether and uh one had to use it so my solution of it was having no Motorcar I borrowed two 100g c cylinders weighing 11 each and uh I took these down in the same way as one enters the jugg and bottle counter and I took them down to baths in Poland Street they were the people who made the gas in those days and I got them filled and I took them out all hot and I took them away onto my over coat and I was then able to give gas and oxygen at any rate for induction of anesthesia where did you get your indal tubes well at first it was very difficult to get material that was suitable for um passing into the traa you see you take ordinary greenage tube which is soft it was hadn't got the necessary qualities but I found that Commercial Rubber tubing which is used for gas and that kind of thing uh had the necessary characteristics it was thin in the wall and at a certain amount of resistance to external pressure I had to get this from an old rubber shop and Tottenham Court Road and these people stood me in good stead moreover the uh rubber was was stored in coils which gave it a natural curve as you see which lent itself uh very well to the air passages and to make a tube was a very simple matter all you had to do was uh cut off the end at an angle of 45° like that and um take a piece of any rough stuff like Emy paper and take off the edges like that and uh when you got it smooth off well you had an in ke tube you cut off the necessary length if you like you could put it into the broncus or you could simply put it into the tea but these tubes had the necessary qualities well of course there was a demand for these tubes and uh it was difficult at first to um get the manufacturers to uh deal with the situation Charles King of the British oxygen company now he was very helpful in that way and he Enlisted the help of the rubber companies who produced miles of tubing which was of no use whatsoever he had some girls cutting off the pieces and soering the ends and smoothing them off of that kind of thing and we sold them but they weren't very good however the rubber companies eventually tumbled to the fact that this was a saleable proposition and I can tell you it is the net result is that tubes are not available all over the world uh not only cut off a coil like that but molded as any other rubber appliances properly molded and vulcanized to the right degree the control of the larynx opened up a completely Fresh Field in surgery now for example you take children I was quite afraid at first about incubating children and there was a lot of difficulty in getting tubes of the right size for the very small opening of the ls however I was um a supported by Sir H Gillies he was always intent on you methods if they were in use and I can remember uh on one I think it was in 1924 I gave an anesthetic at Great Omen Street for sir Harold to do a hair Li and cleft pallet uh with an end anesthetic and I believe it was the first time that it had been used in that hospital well nowadays you find that intubation is uh used for practically every operation in great Omen Street then of course in other fields you take um the surgery of the chest in in thoratic work it was highly important to have some control of a LX during these endothoracic manipulations in those early days when I was at bump in the hospital the patients were very often full of secretion they were very wet I felt at the time that when the patient was in the operative position there was always a risk that the secretions would be driven by the surgeon manipulations from the affected lung over to the signed one for that reason I developed um a suction catheter with with a a balloon mounted on it and that was passed into the tequa independently of the Enda tube this worked very well it was a simple device and I believe it is still used of course there have been other developments since then and even so the necessity for a device of that kind probably no longer holds good because we do not get the same kind of clinical situation with a large amount of secretions doing to uh postal drainage and antibiotics and so forth were any complications blamed on intubation yes of course they were instrumentation of any kind involves the risk of trauma doesn't it so that if you pass an instrument into the tur whether it be a soft tube or a for or metal tube doesn't matter what it is if there's any reaction afterwards it's sure to be blamed on the intis however with practice of course you you find that the more experienced the nadis is the less of the incidence of complications of that kind however in the early days of incubation with this wide board tube that I have shown you um I used to find that it was advantageous to have control of the larynx and many and abdominal operation but at that time the surgeons were averse to any complicated method of anesthesia they preferred the open mask and the drop bottle very simple method which was of course effective but I used to cheat a little bit because I passed the chewed blindly when the surgeon was not looking or the attendant general practitioner I put on on the mask I nzed the patient with an endale to and fr anesthetic and at the end of the operation I removed the mask and the tube at the same time and nobody knew the patient had been incubated uh so I got the benefit of uh control of the larynx in that way yes it's quite clear that endot tral intubation is one of the most valuable assets that we have in modern anesthesia but of course advances in drugs and Equipment were not sufficient in themselves there had to be people trained to use them that's quite true in fact it occurred to me that we must depart from the basis where any newly qualified doctor should be deemed capable of giving an anesthetic for any operation for that reason I thought that the only thing we could do was to establish ourselves ESP Specialists this is in 1931 I was Secretary of the section of anesthetics in the Royal Society of medicine which was the only body devoted to Anesthesia in the British Islands at that time uh and I approached the council asking a permission that I should explore the possibility of having a diploma established the council granted me permission and I went to the Secretary of the Royal Society of medicine who dismissed me courtly with the information that under the terms of the charter nothing could be done through the Royal Society of medicine I reported back despondently to the council and at this juncture Dr Harry Fone said uh oh obviously the solution of the problem lies in the establishment of an outside body with that object in view the association of anesthetists was established and the diploma eventually came into being in 1935 I can well remember the rules for the deploma being made by the late Joseph bronfield and the late John chalice and myself as convener we made the first rules for the diploma in anesthetics so that by the beginning of the second world war there was already available in this country a substantial body of train Anis and it made a vast difference to the condition of casualties who wed in in the field there's no doubt about it that many lives were saved because we had expert anista available to deal with them uh on the spot it's amazing to reflect that incubation has now become a thing of the greatest ease even for the inexperienced ANS uh in fact it is interesting to reflect now that if you ask uh and a candidate for the da examination what are the difficulties of incubation he will say there are none they have been removed however I may tell you that whatever these developments may be there's no doubt about it that I will allow any surgeon I know to uh take off my leg if it were necessary or even remove my append takes but even with the modern appliances and drugs I should be very careful who I choose to be the anesthetist [Music] [Applause] [Music]