History of Anaesthesia – Dr Edward (Ted) Ward

Joyce Barry: Welcome everyone, thank you for coming. Anaesthesia: you’re going to know a lot more about it when you go home tonight. I have great pleasure in introducing Dr Ted Ward; he’ll be enlightening, I can promise you that. I’m going to give you a little bit of background; Ted was born in Gisborne, raised in Canterbury; he’s a graduate of the Otago Medical School. He had three years as a junior and senior Houseman, then a Registrar post in the then Hastings Memorial Hospital. Then his Anaesthetic[s] training starts in earnest – four years as Paediatric and Anaesthetic Registrar posts, covering National Women’s, Princess Mary, Auckland, Middlemore and Greenlane Hospitals. These posts involved work in neonatal and critical care departments. Ted attained a Nuffield Dominion Fellowship [phone ringing] to the Radcliffe Infirmary in Oxford, followed by a Senior’s Registrarship at Alder Hey Children’s Hospital in Liverpool. Short-term posts followed in Sweden and an Assistant Professorship in Texas.

In the mid-1970s Ted returned to New Zealand and Hawke’s Bay as Director of Anaesthesia and Intensive Care under the Hawke’s Bay Hospital Board, as it was known in those days. His official title is, ‘A Specialist Intensivist Anaesthetist at the Regional Intensive Care Unit’.

Ted has been an ICI [Imperial Chemical Industries] travelling lecturer. He has experience shared at St Boniface’s and Winnipeg Hospitals, Canada. There’s still more. His sabbatical year covered terms in Terrace, [British Columbia] Canada and Guy’s Hospital, London. He holds his two terms at Guy’s as an unforgettable educational experience with neuro-cardio-thoracic and renal experience. His work has taken him to Sligo, Ireland, King Faisal’s Specialist Hospital, Riyadh, [Saudi Arabia] and St Vincent’s and several state hospitals across Australia. His Higher Fellowship in Intensive Care was endorsed in 1981, and the following years have seen him serve as an examiner with the Royal Australasian College of Anaesthetists, and an external examiner of the Hong Kong and Singapore Colleges of Anaesthesia.

We also discovered something which is a bit personal and he won’t mind me telling this. As a student, Ted took out and completely dismantled the engine from his little car. He dismantled it totally on the floor of his hostel bedroom, right down to the last bolt, and then put it together again. Then he walked in to his student mates and said, “I now understand the four-stroke engine.” [Chuckles] So that’s Ted. [Chuckles; applause]

Ted Ward: Thank you Joyce; a kind introduction. The problem with that car was it had the old cable brakes and they never worked properly in the hills in Dunedin, if you’re from there. [Chuckles]

Well, it’s a pleasure to be here tonight and talk about anaesthesia and particularly, its history. The contribution of anaesthesia to the practice of medicine and surgery has been immense, and it’s fortunate for all of us to live in a time of human existence when it’s available. The saga of anaesthesia development has been a gradual process. And anaesthesia is a word derived from two Greek words: ‘an’ which means ‘without’, and ‘aesthesis’ which means ‘sensation’, so it means ‘without sensation’. There are three requirements for anaesthesia to be successful in modern operating conditions; firstly, the patient must be asleep and unaware; there must be freedom of [from] pain; and the patient must be still … not moving; without reflex movement, that is, muscle relaxation. In the early days of anaesthesia, of course, the inhalation agents that required very deep anaesthesia were some of its dangers.

Adequate anaesthesia for surgical operations was first demonstrated publicly in October 1846. For this first time, effective anaesthesia with ether was proven. When thinking about what happened after that, I like to think of dividing the story of anaesthesia into two ages of enlightenment. The first age was the first hundred years or so until the end of the 1940s. During this period, anaesthetists developed techniques, machines and expertise to provide good, safe anaesthesia for the operating theatre. Surgical practice was able to expand into new fields. It became possible to open the abdomen safely for the first time in the 1960s onwards. Many anaesthetic skills were also forged [sneeze] by experience in the wars of the first part of the twentieth century. In particular, the anaesthetist became adept at life support during surgery, and artificial ventilation by manual squeezing of a bag in the anaesthetic circuit or machine, which became an integral part of anaesthesia. By the end of the 1940s anaesthetists had become experts in artificial ventilation of the lungs. This was from daily exposure of [in] doing it.

This skill set the scene for what happened in the second age – the time after 1950; the second half of the twentieth century. It was an amazing time in the development of anaesthesia and its [the] effect it had on medical and surgical practice in the emergence of intensive care units. Thinking of some of the world-wide influences in this time, 1950s onwards – influence on resuscitation; there was a widespread re-introduction of mouth-to-mouth breathing in collapsed patients. Up until that time, I mean many of you may well remember the old Silvester and Holger Nielsen methods of various pressures on the chest and lifting the arms and shoulders. And this was taught well into the 1950s until anaesthetist Peter Safar showed that there was a very efficient way of resuscitating people. It was reintroduced of course; midwives had been doing it for centuries with small babies who were having trouble, and they’re the ones who really probably kept it going. But [it] took a while for the doctors to relearn.

Think about improvement in operating theatre anaesthesia, which made sophisticated surgery possible such as the development of open-heart surgery. In post-operative care, recovery rooms appeared in the operating theatres – up until then patients had [been] sent directly to their ward beds, often after anaesthesia – and they started to appear, and patients could stay for a while before returning to their hospital ward. And of course in critical care came the development of intensive care units, and with it the arrival of special care, intensive care, medicine which sprung [sprang] from anaesthesia. So let’s look back to how this came about.

[Shows slides throughout; first slide] My apologies, I guess you’ve all had a good look at it now, [chuckles] but it makes a point before the advent of anaesthesia. This is a painting of a patient having an amputation in London at the turn of the nineteenth century – the end of the 1700s, just after the French Revolution – before the advent of anaesthesia. And certainly he is not without sensation. [Chuckles] In olden times various sedatives and medicines were used to help people tolerate, and of course, you know, the main operations prior to proper anaesthesia were amputations, dental extractions and perhaps the incision of abscesses. Various hallucinogenic agents such as the belladonna extracts, and extracts from the mandrake plant found along [the] Mediterranean, opium and alcohol were all used; and hypnotism, also called mesmerism after Mesmer who popularised hypnotism in medical practice. These all gave sleep to some degree but were largely ineffective in alleviating the pain of surgical incision. So you just had the first triad – sleep, but no pain relief and no muscle relaxation.

This is the old St Thomas’ operating theatre in London – this is before the arrival of anaesthesia; this theatre goes back [to] when the London Bridge Station was built. The old St Thomas’ was demolished and built opposite the Houses of Parliament. But for some reason this was just shut up, and it was found, you know, only a few decades again, [ago] and it had all the old instruments and everything there; but this shows you how stark it was. And of course they had these galleries where students could look and other surgeons could see what sort of operations were going on. It can be visited still in London, and the old instruments which were [there] can be seen.

This is what’s called Morton’s Inhaler; it was for the administration of ether. And Morton was a dentist who appreciated the properties of ether in the 1840s. Ether had, interestingly, been available and known since the 1500s but it was mainly used for all sorts of, you know, parties and [chuckles] [?] and things like that. Nobody realised how important it was. Anyway, this is his inhaler in which he administered a very important first public demonstration of anaesthesia. And there was an aperture in one end for the air to go in, and then a sponge which was filled with ether so that vapour arrived and the patient breathed through this end here. This is a simple draw-over Anaesthetic inhaler. And this is a painting of the first ether demonstration in October 1846, in Massachusetts General Hospital in Boston. This is Morton standing with his flask; the patient’s anaesthetised. He’s been applying this ether for considerable time ‘til the patient’s deeply anaesthetised. And interestingly, this is the surgeon operating on a vascular abnormality in the neck of this young man. And it took about forty minutes, so you can imagine that he had to continue just administering ether if the patient stirred, and that sort of thing.

It’s interesting that a few months before this, there was a dentist called Wells was also interested in anaesthesia. He used nitrous oxide, and he was demonstrating in this very theatre with all these people up in the galleries. Quite interesting, eh? They’re all in their street clothes – no gloves, no asepsis. And anyway, unfortunately he failed and the patient cried out, and of course all the people in the galleries called out “Humbug! Humbug!” [Chuckles] But Morton was lucky and he kept things going. It’s interesting, no gloves, no asepsis or anything. And anyway, the surgeon there was a man called Warren, and at the end of the procedure he said, “Gentlemen, this is no humbug.”

An American doctor, Oliver Wendell Holmes, at the time – he’s the senior of the great lawyers of American history … the dad I mean, sorry – he coined the term at that stage, “Anaesthesia”. [Background traffic noise] Now news spread rapidly world-wide, and ether was used that year for the first time in Britain in December [1846]; so about two months later. The surgeon is Liston, not to be confused with Lister, the founder of asepsis in surgical practice. These surgeons prior to anaesthesia, could be so fast they could take off a leg in less than a minute; again, of course, no asepsis. Anyway, the patient didn’t move, tolerated the procedure, and Liston was reported to have said, “This Yankee dodge beats mesmerism hollow.” [Chuckles] And he was actually using quite a lot of hypnotism in his department for his surgical operative.

The first anaesthesia in Australasia was May 1847, so about six months later; and in New Zealand in Wellington, in July 1847. They had to produce the ether themselves, and New Zealand had problems getting sulphuric acid, which was one of the important ingredients.

This is an interesting story. This is the Longfellow family; the American poet, Henry Wadsworth Longfellow. Mrs Longfellow was the first woman in America to have the pain of childbirth relieved with ether. Her words – and you know, a copy, it’s a little bit faint – but I’ll say what she says: “I’m very sorry you all thought me so rash and naughty to trying the ether. Henry’s” (her husband) “faith gave me courage, and I had heard such a thing had succeeded abroad where the surgeons extend their great blessings more broadly and universally than our timid doctors. And I feel proud to be the pioneer to less suffering for all womankind. This is certainly the greatest blessing of the age.” It’s interesting – there was a potential reason that she defied the strong religious leaders of the day against using analgesia in labour. The Longfellows were members of a precursor of the modern Unitarian Church, which did not believe that relief from labour pain opposed God’s will. And they also held enlightened views of a woman’s role in society. Longfellow wrote that he went to his friend’s house [?]; “The great experiment has been tried, and with grand success. My wife has a daughter, born this morning at ten. Both are well. The ether was heroically inhaled.” And of course there was another instance which put all the concern about women having pain relief in labour, and that was when Queen Victoria took the ether as well.

In 1947 Simpson, who was an Edinburgh obstetrician and surgeon, introduced chloroform, and again, chloroform had been around since 1830. But he used to have these parties too, and they’d lie under the table after the dinner, and [laughter] they started kicking somebody and they wouldn’t feel anything. [Laughter] Chloroform became quite a, you know, competitor to ether because it was so easy and quick to administer, but it was pretty fatal at times too, and caused cardiac arrhythmias, but anyway, he introduced chloroform into his obstetric practice, and he provided analgesia during labour to Queen Victoria for two of the children – Prince Leopold in 1853, and Princess Beatrice in 1857. So that really squashed most of the opposition.

A surgeon, Lister, around 1865 onwards, introduced asepsis in surgery. He used carbolic acid – phenol it’s commonly called now – and sterile dressings and eventually surgical gloves. And he had a little aerosol which he used to spray his carbolic spray over the patient during operations. And of course this followed on the advocation of hand washing by a man called Semmelweiss who was an obstetrician in the Hungary. Over the next few decades of course, anaesthesia enabled surgery to develop, and for the first time as I said, the abdomen could be opened safely. When you think for instance of the time of the American Civil War; there was about six hundred [thousand] Americans were killed in that war, so there must have been a lot of people who had surgery, and of course, mainly amputations. And the bullets in those days, if they hit your leg or shoulder or arm, caused tremendous damage – they just didn’t go straight through, and of course amputation was probably a big thing. Chloroform was used mainly in the American Civil War, but no asepsis. And it’s quite interesting, the Southern General, Stonewall Jackson died from a bullet wound in, I think his upper arm, and it must have been a bit delayed with amputation, and [he] developed sepsis.

This is sort of a painting from Australia of an anaesthetist in the early turn of the twentieth century, and I like it because he’s got his vaporiser there and you could notice the focused observation and the feeling of the pulse. That’s his monitor – himself.

I’d like to take you to what I think is one of the most interesting times of anaesthesia development. The central figure in the UK, [United Kingdom] Europe and the British Commonwealth was a New Zealander, Robert Macintosh. He is little known outside anaesthesia circles, but one of our most famous medical sons to leave his mark overseas. He was born in Timaru in 1897. He was christened Rewi Rawhiti Macintosh. He went to Waitaki Boys’ High School – it’s in Oamaru. He excelled in sport, and was Dux. He left school in 1915 so that would make him eighteen years of age – he was born in October, so towards the end of 1915 he was eighteen – and he went to England. Somewhere along the line he became known as Robert Reynolds. Now, I’m trying to sort that out, but I think there were no passports in those days; I think passports came in in about 1916, so I guess this young fellow went off, age of eighteen, got on a boat and then when he got to England he said he wanted to join the Royal Flying Corps. And they said, “Sorry, we haven’t got a place for you”, so he joined the Scottish Borders Regiment, [King’s Own Scottish Borderers] the infantry, and went to France. He was lucky I guess, because 1916 he was recalled to join the Royal Flying Corps. So he probably missed out on the Battle of the Somme, which we’re thankful for.

So in 1916 he trained as a pilot. I was disappointed; he didn’t fly the Sopwith Camel, which is the iconic fighter place of World War One. But this is the French plane, the Nieuport plane B1685. In May 1917, so this is when he was nineteen, he was shot down over Germany by a German Ace called Strähl. He was unhurt, but he managed to blow up the plane. This is his plane – amazing. And he was a self-destroyer of the plane; the Germans really wanted a copy of this plane if it wasn’t too badly damaged, but he destroyed it and was captured and he spent the rest of the war as a prisoner.

After the war he trained in medicine at Guy’s Hospital in London. He toyed for a while with becoming a surgeon, and took up anaesthesia instead. Most of his practice was in London, as a mainly dental practice. There were very few and very small departments of anaesthesia in those big London hospitals; mainly just part time, and people who came in and … people thought anybody could give an anaesthetic and you didn’t have to be a proper doctor. Interesting … he used to ride around in a car, and the front seat was taken out and a machine was there; and he had a chauffeur, and they would drive from hospital to hospital, practice to practice. His firm was called the Mayfair Gas Company. [Laughter] There was also another service in London called the Mayfair Light, Gas and Coke Company. [Laughter] Anyway, Macintosh’s rivals labelled Macintosh’s group as the ‘Mayfair Pipe, Gas and Choke Company’. [Laughter]

Anyway, it’s interesting how things happen in life. This is an interesting man, Lord Nuffield. And Macintosh got to know him because he first of all gave an anaesthetic to Nuffield’s wife. And she had had lots of bad experiences in vomiting and nausea after anaesthesia and everything went beautifully with Macintosh. Then Nuffield got appendicitis, and he wanted Macintosh to give his anaesthetic, which he did. So they became acquaintances and eventually played golf together and became friends.

If you really wanted to know an interesting story, you’d know the story of William Morris. I haven’t got time to tell it, but he started off building bicycles. And he built a bicycle for himself, and then the vicar wanted one, so he built one for the vicar and then the whole parish wanted to buy them, and in no time he had a business. He had it in a garage in Oxford in the early 1900s; and then the toffs come [came] with their cars, so he started looking under the bonnets and in no time he said, “I could do all that.” And this is what sort of turned out – the Morris cars – and in the 1920s, William Morris was a wealthy man. He was producing fifty to sixty thousand cars a year. Henry Ford tried to buy him out, but no way. He became Lord Nuffield, and he was knighted because of his generosity as a benefactor through his Foundation. The Foundation became known as the Nuffield Foundation.

Anyway, in 1935 Nuffield approached Oxford University to endow three professorships. He said, “I’ll give you £1 million. We’ll have one for surgery, one for obstetrics and gynaecology, and medicine.” So, at the golf club … interesting, eh? Nuffield was talking to Macintosh, and said, “Well, I’m going to do this thing.” Macintosh said, “Well, anaesthesia’s going to miss out again, is it?” So Nuffield took this up; anyway, he went back to the university and he said, “I want a fourth professor, and it should be anaesthesia.” And they said, “No deal – it’s not a proper specialty.” [Chuckles] Anyway, to cut the story short, he said, “Yes, there will, or you get nothing.” [Chuckles] And he eventually won, but it cost him another million; so he gave them £2 million. £2 million then … I don’t know, I’d imagine it’s about £300 million now, or it may be more. Anyway, it cost him; and of course he said to them, “And what’s more, the professor will be Macintosh.” So here was a man who was on the industrial side of Oxford, talking to all these toffs and professors and whatnot, and he’s telling them what they’re going to do; and also telling them who they’re going to appoint. [Chuckles] It’s unbelievable really, but it’s true.

Anyway, so he won out and as I said it cost him an extra million.

Macintosh initially, said, “I can’t do that”, but eventually he accepted. He’s been recorded as said [saying], “There was hell to play”; [pay] “there was no-one in that time in the country with the pretensions to fill a chair of Anaesthetics. The highest science I knew was that ether was inflammable.” [Laughter] He was a very humble man, and I think he probably hadn’t written a scientific paper. But eventually the Chair was established in 1937; Macintosh as professor. So it’s an amazing journey from Waitaki Boys’ High to Royal Flying Corps, through to medicine and seasoned professor.

There was another famous professor at Oxford at that time; it was pathology. His name was Florey, and he introduced eventually, penicillin into Australia.

Macintosh made a great choice and time proved it was right. The Chair was established in 1937, the first in Europe, and it did more for the specialty than ever can be adequately documented.

In 1937 there was a polio epidemic in England. This is in the 1950s [indicates slide] and this is the Los Alamos Hospital in California in 1953 [coughing] and you can see the massive number of people on [in] what’s called the iron lung at the time. Macintosh noted there were only seven iron lungs in the whole of England, and he persuaded Nuffield to manufacture the Both iron lung. The first iron lung was made in 1929 in America, and again the Cowley Works – car works in Oxford which Nuffield owned – manufactured eight hundred of these and offered one to any hospital in the Commonwealth that wanted one. There is to my knowledge, or there were, two in Hawke’s Bay. One is on display in the Faraday Centre in Napier. It belonged to Wairoa Hospital and was used in the New Zealand-wide epidemic for polio in 1948, and used in Wairoa Hospital. I remember going to primary school that year and we were closed down for the first three months because of that epidemic.

In 1938, Macintosh spent six weeks in Spain during the Spanish Civil War and anaesthetised [coughing] for the American plastic surgeon, Sheehan, who was operating on civil war casualties. The only anaesthetic apparatus was an outdated vaporiser so Macintosh improvised with his own Flagg Can – Flagg was an American. Holes were punched in the top of that and then the patient sucked in through the top end and air was sucked in, and the vapour anaesthetised the patient. This is just a diagrammatic representation of the way the Flagg can worked; now this is important, because this experience made Macintosh realise there was a great need for a simple vaporiser that would deliver known concentrations of ether under field conditions in wartime. And with the onset of World War II in 1939, this became more urgent.

This is the Epstein Macintosh Oxford anaesthetic machine. Anaesthesia could be given in remote conditions, and some three thousand of these machines were manufactured; again, as Nuffield’s contribution to the war effort. So air was sucked in over the vaporiser which controlled temperature. If the patient needed assistance with breathing they could be assisted with the bellows, and then an endotracheal tube into the trachea.

Another invention of Macintosh was the illuminoscope, which greatly facilitated visualisation of the larynx. To intubate the patient passed the tube into the trachea. It is still used thousands of times daily throughout the world, and has been further developed with fibre-optics and recently with video-laryngoscopy.

Macintosh was an adviser to the RAF;  [Royal Air Force]  here in his full Lieutenant Squadron Leader uniform – quite unique, because he had also a World War I Royal Flying Corps emblem, and a medical emblem.

This is the use of the EMO [Epstein Macintosh Oxford] anaesthetic machine in a field hospital in Burma during the war. Distribution of this system in the Forces began in 1942 and apparatus served in all the major theatres of the Second World War, and with medical missionaries in developing countries in the immediate post-war period.

With his Air Force connections, Macintosh was asked to look at life jackets for pilots who parachuted from planes in the North Sea and other oceans; and the idea was to modify the existing life jackets so that the pilot – if unconscious, as they often were – would keep his head out of the water and keep his airway and breathing. So experiments were made on a fully-anaesthetised member of his department; this man was Pask. [Chuckles] He’s a volunteer of course – he was, actually – but they asked Macintosh, “How did you get Parks [Pask] to do this?” And he said, “He was my houseman.” [Laughter]

This is a picture of a fully-anaesthetised Pask … great trust in his colleagues, really … with an [?] curved tube protecting his airway, and swimming in a swimming pool. And they did this in the Ealing movie theatre pool in London, which you know, you could do all sorts; it had all sorts of waves. This is the one they used for making movies of the sea in war.

Macintosh in ’56 was knighted for his contribution to the war efforts, and to anaesthesia; and Pask became a Professor of Anaesthesia in Newcastle in the UK, and received the OBE. [Order of the British Empire] Pask did all sorts of interesting other experiments; he joined the RAF and subjected his body to terrible all sort of trauma really; but anyway, interesting fellow.

During the war years there was a momentous change in anaesthesia; firstly, pentothal which put people to sleep easily; and then secondly, the use of muscle relaxants, curare. And in 1942 a Canadian anaesthetist by the name of Griffith introduced curare into anaesthesia. So this produced the muscle relaxant side of it; you were asleep, pain relief from the inhalation of volatile agents, and muscle relaxation. But they then had to have artificial respiration, and most of the time the anaesthetist was squeezing a bag in the circuit and was keeping the patient well-ventilated. Interesting – curare came from a tongue-twisting plant called chondrodendron tomentosum, and here’s a picture from Ecuador of a native Indian who’s using a blowtorch [blow pipe] for hunting. And this is how they prepared their poisoned darts; here’s the darts themselves, and they had this muscle relaxant medication which helped them to capture and kill animals. I like to think that’s probably the end of the 1940s and the end of the first stage of enlightenment. Anaesthesia perfected conditions for surgery; artificial and controlled ventilation was the daily bread and butter of anaesthetists.

And the second age of enlightenment soon came. In 1952 there was a major polio epidemic in Copenhagen. Vaccination for polio was not introduced until the second half of the 1950s, and in Copenhagen two thousand seven hundred patients were admitted to the Blegdam Hospital. Some thirty to fifty patients a day were admitted, and this occurred for over about six months. To extrapolate that, in Hawke’s Bay, I think … probably be about two hundred patients with population considerations. ‘Bout one in ten of these had quite severe paralysis involving respiratory muscles, and swallowing and protection of the airway. The mortality was high in these sickest patients, and there was some reluctance to do much about this because they … you know, only had one iron lung at the time. But there was a member of the medical department, a physician who persuaded the senior, whose name was Larsen, to invite an anaesthetist called Bjørn Ibsen to help out. It’s interesting it’s called infantile paralysis; I think it probably affected children more, but not really sure why it was called infantile … but I think probably adults would have some smaller infections which didn’t affect their weakness in lungs. It was quite interesting – it often used to affect one arm or one leg, and there are many patients who’re people still that suffer from that these days.

But Ibsen came, and he was presented with a real challenge – a twelve-year old child who was dying from respiratory failure; and unable to protect the airway; and rattling breathing. Things were very desperate, and he intubated the child, as one did with anaesthesia, and did a tracheostomy. This is the sort of situation they had – I don’t think this is the child; her name was Vicky. She survived for another … I think she eventually died in 1976. And a lot of these people had post-polio problems, but she had some life anyway.

This shows the technique; the patient with a tracheostomy, a tube in the neck; and the absorber for carbon dioxide, and somebody squeezing the bag because they didn’t have any ventilators. This child did very well, and Larsen was convinced; and one time there was a maximum of seventy patients in this hospital receiving this sort of treatment. About ten percent, one in ten, of the patients with polio needed some assistance like this.

And there was a hospital ward with a row of beds on each side – one of those old Nightingale-type wards – and next to each bed sat a medical student who every few seconds squeezed the bag, blowing air and oxygen through the tubing into the child’s lungs, and then letting go, and repeating this action for six hours at a stretch. Four times a day the shift changed. Dental students and nurses were also recruited. It’s been estimated by the time the polio epidemic was over, some fifteen hundred volunteers had squeezed these bags for a hundred and sixty-five thousand hours – about two and a half years’ time. The mortality of these sickest patients was reduced from eighty to ninety per cent, to thirty and forty per cent.

Now what this experience shows – and it was the birth of intensive care medicine really, and intensive care – what this showed was that artificial ventilation could keep a patient alive with a disease process, and could keep the patient alive until they healed themselves. Experience in this epidemic led to dedicated intensive care units established in Copenhagen. The world took notice, and intensive care then expanded to the management of many other conditions, [cough] such as neurosurgical conditions like the Guillain-Barré Syndrome which is in the news; extended to trauma, especially to chest injury, and in those days there was [were] no airbags and no seat belts, so trauma of the chest was a big problem; post-operative care; and enabled early open-heart surgery with good intensive care after surgical procedures.

This is a slide of a modern intensive care unit in our regional hospitals, and it shows many of the developments that have occurred over these years and the last few decades – good monitoring machine, good central provision of oxygen, suction, electricity, lights, infusion syringe pumps, the ventilators – very sophisticated ventilators now have tremendous software in them – so a big advance from those early days. I can remember some of the early ventilators we had. In 1976 I had a patient who was a farmer who had a bad chest injury, and the old ventilator chugged away and when he got better he said to me, “It was like being in the army – you had to do what the ventilator said.” But these ones interface with the patient, and they can trigger the ventilator and breath quietly and regularly and use less sedation. And then there’s a computer by the bedside, the nurse sitting there, and the renal replacement therapy.

They’re some of the great advances, but of course one has to remember that that’s not why patients get better in the ICU; they get better because they’ve got a nurse by the bedside. And the nurses of course become very experienced in looking after these people. Everything that’s needed for that patient is done by the nurse, and they get better I think largely because of that dedicated nursing care. And of course that’s always been so, so although we’ve got all these … you know, additions … the nurse is still that most important person.

So really, following these momentous experiences, development of anaesthesia – and I’ve sort of tried to make it more interesting because of New Zealand, and I think it’s an amazing story of Macintosh – following this and Copenhagen, the expertise of anaesthesia spread to stand-alone intensive care units and their contribution to hospital care over the last six decades. Thank you. [Applause]

Joyce: Questions please.

Ted: And of course is modern anaesthesia; and again, modern anaesthetic machines which have got everything that can monitor the patient, control ventilation, turn on controlled amounts of vapours to keep the patient asleep; and the anaesthetist setting the patient off to sleep at the beginning of anaesthesia. You can see the observations and concentration, and the friendly team from nursing. Sorry – forgot that side because that’s important to intensive care and anaesthesia [??].

Question: Is an anaesthetist a qualified doctor, or something different?

Ted: Yeah, proper doctor. [Laughter]

Question: But they specialised in anaesthetics?

Ted: Yes. It’s sort of the question that children ask if you’re a doctor when they’ve got a broken arm or … what’s that they say? “Are you a proper doctor?” [Laughter]

Joyce: I think it helps, Ted, just before we take the next question – just tell the years that you would’ve put in;  and an intensivist today has to put in before they do get their higher qualification. So they have six years of medicine …

Ted: Well, yeah. I get a bit embarrassed by the fact that, you know, we didn’t have to train for the days and years that we seem to have inflicted upon our juniors, really. We’re making it harder and harder for them.

Joyce: So it could be fourteen, fifteen years from starting as a student?

Ted: Well, I mean I graduated at the end of ’63, so 1964 – ten years, and I was back there as a specialist, but [it’s] pretty hard to do that now. And some people still train in anaesthesia and intensive care, and I mean … they graduate six years medicine; two years house surgeon; and take another six or seven years to train and fully qualify. And I was a bit lucky, you know – I mean I went to Auckland … at the end of ’66 I left here. 1967 I actually did a paediatric year in Auckland, I was initially going to be a Paediatric but I changed my mind because of the involvement in resuscitation that happened in Hawke’s Bay. So then I did a year’s anaesthesia; I got my first part, did a year in intensive care, then another ten months anaesthesia, and I was a specialist. Now, you know, you’re just not allowed to do that any more. [Chuckles]

So then you sort of learnt on the job. And then I had, you know, a great time … three years tripping around the world … fortunate enough to work in Oxford for a couple of years. And the other thing is, the competition – they’ve got to be standouts even to get into a training scheme now. So … had it easy, probably. [Chuckles]

Question: That’s a very sophisticated looking machine on the left. Have you any ideas as to what that would cost today?

Ted: I think they’re about $60,000, aren’t they? I often think about what Morton with his inhaler in 1846 would’ve even thought about the EMO machine that was giving an anaesthetic in the middle of the jungle in Burma, [a] hundred years later. But you know, it’s amazing how things happen. Here’s this guy Macintosh … simple man, very careful and humble; and he did things well, and he developed a great team around him; and then he influenced thousands of anaesthetists, and he influenced the practise of anaesthesia all round the world. Yeah, it’s amazing.

Question: Ted, are you training someone to take over from you?

Ted: Oh, there’s a lot of people around me. [Chuckles] No, there are over twenty specialist anaesthetists practising in Hawke’s Bay, and seven specialist intensive care doctors. So what we think, you know … some of the anaesthetists in this room would feel that at last we’ve got the working conditions we would’ve liked about thirty years ago.

Question: Yes – I don’t know how many of you realise that I [?used to be one of your?] senior nurses, and we were here when Doctor Ward started. And what he’s told you there is the conditions that we had in the Hastings Hospital when he arrived in 1974. We had one ventilator that ran off oxygen; we had only a hundred per cent oxygen out of the wall, and you can’t ventilate anybody with a hundred per cent oxygen, ‘cause what you breathe is twenty per cent. So he had to organise some sort of air system. He got a whole group of nurses who had no idea about intensive care at all; and every Tuesday or Wednesday afternoon he used to give us a lecture and he’s the first person who ever asked us – and I’ve never forgotten – he said, “What is an acid?” ‘Cause we all trained when we didn’t do any chemistry or anything; we all looked at each other and said, “It turns litmus paper blue.” [Laughter] And I actually thought he was going to turn around and go home. [Chuckles] He was by himself; I was there when he ventilated the very first patient. He didn’t have any other doctors there to help him; he had one afternoon off on a Wednesday afternoon when Barry Laidley, who was an anaesthetist, would look after the place. None of us liked that, because we didn’t know much and Barry knew even less. [Chuckles] When you were on night duty which many of us were, if we rung in the middle of the night – this is a man who’s been up all day – he would come and help us with whatever was wrong with the patient. Now while he was doing that, he was also re-organising the whole of the Anaesthetic department. When he said, “Anyone could do Anaesthetics” – at that stage a lot of the GPs [General Practitioners] did Anaesthetics. They weren’t trained specifically in anaesthetics; they just said, “Yes, I’d like to do this, so I’ll anaesthetise the patient.” I don’t think there was even a recovery room when he first came. The patients used to just come back and we used to just stand there and pinch their ears, ‘cause that would make them wake up. [Laughter] You were trying to get them awake, ‘cause you had tons of other things to do. When I look back, I do not know how he did it. And when he was talking about Doctor Macintosh and how humble and careful he was … Doctor Ward was exactly the same. [Applause]

Joyce: Ted, we can’t thank you enough. Ted was also hugely instrumental in not only doing the adult intensive care, but of course he was also a huge instigator, along with the paediatricians, of the neonatal intensive care – and these are the newborns – which is another specialist field again, and which Hawke’s Bay Hospital built up as well. Intensive care isn’t a booking; intensive care is twenty-four/seven all year and often – because I used to work in the hospital I know – that the middle of the night is often busier than the middle of the day, and time meant nothing. So many, many a night these guys worked all night but had to carry on all day as well … and often the next night as well. But that was life, wasn’t it? Before they got what he calls an optimum number of specialists. Ted, thank you so much.

Dr David Barry: I just need to comment a bit about the ventilation service [microphone interference] for babies. I think it was fantastic; that was only reason we got our unit going in the sense of ventilating, so I’ve got to mention a little anecdote, ‘cause I think, Ted, you had a bit of a Macintosh – you used to fiddle a lot. We had a Loosco – you remember this funny little ventilator we had? It didn’t do much, all it did was puff in and out … didn’t do anything. And Ted said, “You’ve got to make it get a bit of pressure on the end now, so that when the baby is breathing out … the machine is breathing out … you get a little bit of increased pressure.” It was called ‘peak’. He just cuts off a bit of plastic and jams it on the end of the expiratory … “Ooh”, he said, “that’s pretty good; that’s five centimetres.” So that was it. I thought, ‘That’s really sort of fiddling, and making something work where the machine isn’t doing it.’ And your talk was just … tell me, that was just Macintosh, wasn’t it? You used it and there you are [inaudible, chuckles] like that.

Ted: That’s right. You know, Epstein was a physicist, and they wrote in a magnificent book in his department on the physics of anaesthesia;  he wouldn’t let them use any complicated words, and that was the sort of guy he was. He wrote a lot of amazing books about local anaesthesia, and … just a man who loved travel; he used to go round the world and fix EMO machines, and give anaesthetics [in] all sorts of places.

Joyce: Thank you so much. I’m going to get another big round of applause.

[Applause]

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Landmarks Talk 13 September 2016

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