Cyclopropane. C3H6. Trimethylene. A colourless flammable gas with a sweet petrol-like smell.
Guy’s Hospital, London
‘Just lie still, Peter, there’s a good lad.’
The anaesthetist gently stroked the top of the small head. The young boy was clearly anxious about what was going on around him, but his mother held his arm reassuringly and he did lie still for a moment.
‘I’m just going to hold my hand here like this, Peter. There that’s all right, isn’t it? We’ll soon have your nasty cut better.’
I watched the anaesthetist place his hand close to boy’s chin, the tube from the anaesthetic machine poking inconspicuously between his fingers. With his other hand he turned the orange knob at the bottom of the thinnest of the four flowmeters so that gas from the orange cylinder at the side of the machine flowed down the tube where it mixed with an equal amount of oxygen. This mixture of cyclopropane, with its faintly sweet petrol-like smell, and oxygen, which has no smell, seeped silently out of the end of the tube just beneath the boy’s nose.
‘I’ll tell you a story, Peter. Would you like that?’
The boy nodded.
I watched the small bobbin spinning in the thin glass flowmeter. It looked like a miniature cotton reel suspended in mid air as if by magic. The vertical position of the bobbin told them just how much of the gas, which was called cyclopropane, was flowing from the cylinder through the machine to the patient.
‘There once was a pretty young girl with long golden hair whose name was Goldilocks. One day she went for a walk in the woods and she came across a small cottage where the three bears lived. There was Mummy Bear, Daddy Bear and Baby Bear.’
A glazed look was already appearing in the child’s eyes and he yawned.
‘Mummy Bear had cooked some porridge.. too hot.. too lumpy.. just right.. upstairs.. three beds.. and soon she was fast asleep.’
The little boy was sleeping too. One of the nurses quietly led the boy’s mother from the room. The anaesthetist changed over from the ‘cyclo’ and oxygen to a mixture of nitrous oxide, oxygen and Trilene. Soon the wound was stitched and the bandage applied.
‘Wake up, Peter. It is all over. Your finger is all better now. That’s a good boy. Here’s Mummy come to take you home.’
‘That was a good way to get a child off to sleep,’ I said. ‘Why don’t people use cyclopropane all the time?’
‘I usually do,’ replied the anaesthetist, ‘but some people think ethyl chloride is safer because it isn’t quite so likely to explode. Still there are many ways to skin a cat.’
‘Well, I thought it was brilliant.’
‘So did I,’ said Peter’s mother.
I found it hard to get to grips with children’s heart diseases. For a start I had never been any good with the stethoscope, at least not where heart murmurs were concerned. Partly this was due to my lack of any natural sense of tone or rhythm, and partly because I did not believe in my ability to master it, so I had never really applied myself in a sufficiently disciplined and conscientious manner. Certainly I could appreciate and understand many of the noises that came from the lungs, ‘bubbles’ and ‘squeaks’ as I liked to call them, but timing and classifying a faint heart murmur was, I felt, beyond me. All of which made the job of children’s house physician, with its heavy emphasis on congenital heart disease, especially difficult for me. Of course, as a pre-registration houseman, it was not my role to make clever diagnoses, but rather to arrange the investigations so that other people could solve the riddles. Often I would need to liaise first with the X-ray department, then the anaesthetic department and finally the cardiac department. That way a child could go for a cine cardioangiogram under general anaesthesia and have a phonocardiogram at the same time, but it took a lot of to-ing and fro-ing and many telephone calls to get it all set up.
The cardiac physicians came round the children’s ward on a Tuesday morning. They would stand round the bed of each child in turn, discussing the various murmurs and the niceties of the electrocardiogram but they rarely involved me in their discussion and they would break off from one child to move onto the next without drawing things to any sort of conclusion.
When Sir Russell Brock and his surgical team arrived on the ward on the Thursday afternoon I could only report that Dr Baker had not left any comment about the child for him, and, no, he had not written anything in the notes. Really it was most unsatisfactory. The famous surgeon left no doubt in anybody’s mind that he, too, found it unsatisfactory.
‘They expect me to stand by this child with a knife in my hand, yet they don’t tell me where I should make the cut. If they can’t give me a proper diagnosis, I will transfer the child to the Brompton Hospital. Miss Jones, a note please.’
He never left the bedside before he had dictated a comment which she would type and put into the notes later the same day. If only the cardiac physicians would do this as well, how much easier my life would be.
‘Front surgery’, as the casualty department was always called, was on the phone. They had a child with abdominal pain and an extensive rash. Could I come down and see him. Yes, of course, I could. Abdominal pain and a rash, eh? What on earth could that be? I was slightly apprehensive as I walked down the stairs to the underground passage that linked the different parts of the hospital. Would I know what the rash was? Still if the child had a rash and tummy pain then perhaps I had better admit him to the ward and get Dr Smithells to see him.
When I got to Front Surgery it was clear that the boy was most unwell. Yesterday his knees had been sore and slightly swollen, and to-day he had some colic, a widespread rash that I thought looked like purpura and a temperature of 99.4oF.
‘What’s the matter with him, doctor?’ asked the anxious mother.
‘I don’t really know,’ I admitted, ‘but I think we had better have him come into the hospital so that we can find out.’ That way someone more clever would see him, I thought to myself. Perhaps they would say that I should have sent the child home and phoned his general practitioner who could easily have looked after him. Ah, well, at least this was the safe thing to do.
‘Johnny, don’t go yet’ said Tony, the casualty officer who had phoned me to come down in the first place. ‘I’ve another problem for you. The hospital chaplain’s thirteen month old baby has just swallowed the entire contents of a full ashtray. Apparently they had had a coffee morning and there were twenty or so cigarette ends in it. I’ve put a stomach tube down and washed most of them out but I think he should stay for observation. What do you think?’
‘Sounds as though it would be a good idea. I’d better phone Dr MacKeith and tell him about it. After all he is the hospital chaplain’s baby.’
Dr Mackeith said yes, we should admit the child and he would come and see him himself later on. Good, I thought, that’s one less worry
Back on the ward the senior registrar came to see the boy with the rash and confidently diagnosed Henoch’s Purpura.
‘Classical case,’ he said. ‘Good prognosis, but often relapses. Flitting arthralgia, abdominal colic, mild fever and purpura. Colic due to sero-haemorrhagic effusions; may mimic intussusception. Occasionally get renal complications, but not often at this age. ESR raised, and often the white count too, but platelets and bleeding time normal. Check the antistreptolysin titre but it will probably be normal. Tell the parents that everything will be alright.’
‘Are you sure?’
‘Yes, certain. By the way I’ve just admitted a child from out-patients. He’s got Fallot’s tetralogy and is getting frequent cyanotic attacks. I think the surgeons should be asked to see him with a view to early operation. Let’s go and look at him.’
We walked to the other end of the ward where we found a small boy squatting on a bed.
‘Hello, James. This is another doctor who wants to listen to your heart. Hello, Mrs Peters, everything all right?’
Mrs Peters nodded. The boy was clearly smaller than other children of his age. He was thin and scraggy with a blueness in his lips and cheeks, and also in his hands and feet. His nails were rounded in the strange way that I recognised as the condition called ‘clubbing’. He was breathing heavily though he did not seem particularly distressed by it. What a poor little fellow.
‘What should I do when he gets one of these attacks?’ I asked.
‘Well, the best thing is to give him some morphia and some oxygen. That’s the standard treatment anyway but I hear that Paul Wood has suggested that cyclopropane might be a good thing to relax spasm in the pulmonary infundibulum.’
‘Oh,’ I said. ‘Could you explain that? I don’t really understand it.’
‘Well, narrowing of the pulmonary outflow from the heart can either be at the level of the valve or in the muscle just below the valve. If it is the muscle there which is hypertrophied and goes into spasm then it may cause a cyanotic attack by increasing the right-to-left shunt. If that happens apparently you may be able to relax it with cyclopropane.’
‘Oh,’ I said, a second time.
‘Yes, but I don’t expect that anything as dramatic as that will be necessary. We’ll get the surgeons to see him as soon as possible.’
I was not very reassured. Still we would have to wait and see what actually happened.
‘What dose of morphia should I give?’
‘A tenth of one mg per lb. That usually works well.’
It was time now to talk to Dr Yates, a GP from Kent whose six year old son had been admitted earlier in the week for investigation of unexplained fever, or a ‘PUO’, as a ‘pyrexia of unknown origin’ was usually called. We had done every test we could think of, and the only abnormal thing, apart from a fast pulse rate, and the raised temperature, of course, was a raised ESR and a prolonged P-R interval on the ECG. The registrar had said on the ward round yesterday that it had to be rheumatic fever as an active carditis was the only common cause of a transient prolongation of the P-R interval in children. We should start the child on high dose aspirin immediately and a course of penicillin too. Dr MacKeith had suggested that it would be interesting to see if the new analgesic paracetamol would be as good as aspirin. Why didn’t I ask Dr Yates if he would agree to us trying it out? I had been reluctant but Dr MacKeith had insisted, perhaps in mischievous retaliation for the attempt to get him organized at the bedside of the previous child, when I had said
‘We have three things to decide for this child to-day: one, should we put her on high doses of Vit D?; two, are we giving her enough calcium?; three, shall we ask the urologists to see her again? Taking them one at a time, firstly should we put her on high doses of vitamin D? ‘
To which had come the reply
‘I’m not a slot machine, doctor; you can’t put pennies in one end and get answers out the other. Have you noticed,’ pointing across the room, ‘the size of that mother’s feet? Go and ask her what size shoes she takes.’
Now it was time to speak to Dr Yates. When I mentioned about the paracetamol. Dr Yates was clearly put out by the suggestion, and I could only agree with him, so I wrote up the conventional aspirin on the treatment card, as I felt I should have done in the first place.
I went to talk to Sister.
‘Is there anything that needs doing before I leave the ward? I thought I would try to get some of my discharge summaries written before the secretary went home. I still have some from last month to finish.’
That was from when I had still been a house surgeon, before I had moved across to be one of the two Children’s House Physicians.
Sister Crump smiled at me kindly.
‘No,’ she said, ‘everything’s under control. Go and do them while you have the chance.’
I hated writing discharge summaries. I was rather shy when dictating to the secretary but at least I had discovered the secret was to keep them as short as possible and stick strictly to the major details. Writing that ‘the postoperative course was uneventful’ was better than slavishly detailing every little spike of temperature or slight reddening around a stitch. And, of course, you should not try to be funny. I remembered how one of the physicians had referred a plump girl of eighteen to my surgical boss just before Xmas with an X-ray diagnosis of ‘partial volvulus of the stomach’. At laparotomy we had found that she only had gall-stones. I had not been able to resist adding at the bottom of the copy of the discharge summary that I sent to the physician the words of the famous dictat ‘common things commonly occur’. I had not heard what he had thought about this, but it seemed sensible not again to risk upsetting someone important.
I reached the secretary’s office only to find a message waiting for me. Could I contact Front Surgery where they had an infant who was seriously ill with pneumonia.
‘Please phone them and say I am on my way.’
When I arrived at Front Surgery and saw the small infant I was appalled; such a tiny little boy, such a fiercely high temperature and such a high respiratory rate. He looked so ill. Surely he would never survive the coming night. We would certainly need an oxygen tent for him, and plenty of antibiotics, perhaps even a drip as well. I phoned the ward to say the child was on the way and please would they get an oxygen tent ready, and some penicillin and sulphadimidine. ‘Stoss therapy’ Dr Smithells had called it: huge single doses of the two drugs: 1-3 grams of sulphadimidine, depending on the weight of the child, and a million units of penicillin, whatever its weight. The idea was to hit the infection on the head but still leave the child capable of mounting an antibody response against the next time he met the infection - if he survived this time, of course. I would get the registrar to see the child and decide whether we needed to set up a drip. It would mean a ‘cut down’ if we did. I went on ahead to the ward to see if they had got the oxygen tent ready.
When the registrar came to see the boy half an hour later he said
‘I see what you mean. He’s a very sick child. Yes, of course, we should put up a drip, and we should give him some chloramphenicol; probably some hydrocortisone too. I must get back to the clinic but give me a call if you have trouble with the drip.’
Cutting down on a vein proved to be quite a business. While one nurse kept the top half of the small child inside the oxygen tent as best she could a second nurse held his right leg firmly outside the tent. I carefully injected local anaesthetic solution beneath a wide area of skin both in front of and above the medial malleolus, the bony prominence on the inner aspect of the ankle. Then I took a scalpel from the silver box in which the cut down instruments were kept and made a small transverse incision through the thickness of skin. Luckily it did not bleed much as the pressure from the local anaesthetic had blanched it somewhat and the blade clearly had been freshly sharpened. I took hold of a pair of artery forceps and tentatively put the closed points into the side of the hole I had made and swept it deeply across to the other side hoping to pick up the long saphenous vein or one of its larger tributaries. Nothing. Where the hell was it? I repeated the manoeuvre, again unsuccessfully. The third time I pressed in deeper yet and now I felt my instrument pick up something. Could it be the vein I was looking for? It was nothing. Nothing that was except fat and fascia. No, there was something else.. a vein it must be.. yes, it was blue alright. Oh, dear it was rather small. I would never get a metal cannula to run up that little thing. Perhaps I would not be able to find a suitable vein at all. What would I do then? I felt break sweat on my forehead and hoped fervently that it would not drop into the incision I had made; that would be terrible
Try once more. Ah, this time I really had caught something. Here it was.. a great big blue shiny vein. Well, at least a sizeable vein. Probably not the main long saphenous but big enough. Thank Heavens Now to put two ligatures behind the vein. Tie the lower one.. pull the upper one upwards.. make a nick in the vein with the fine pointed scissors.. slide the vein spreader into the lumen.. oh. no The vein had snapped and the upper end retracted out of view. What should I do now? I pressed a swab on to the site which was bleeding quite heavily now. Pause for a moment and get my breath back. That’s better. I could see where the blood was coming from now. Clip it and tie it. Good. Now try and find another vein. Stick the forceps in and sweep deeply across once more. Ah, here it is.. a proper vein at last. This really must be the long saphenous. Two ligatures deep to it. Tie the lower one.. throw the other upwards .. nick the side of the vein.. in with the spreader.. slowly now.. carefully slip the cannula into the lumen.. there that’s it Now tie the ligature round the vein and the cannula, connect up the drip and the job is done. Must check the rubber tubing. Good, not perished anywhere.. put the gate-clip low down so that there will be a column of water above it and any hole in the rubber will leak fluid out rather than sucking air in.. now check the drip chamber.. looks O.K, no cracks in the glass.. undo the clip a little.. yes, the fluid runs all right.. what a relief!
It was probably too late to go back to the secretary. I looked at my watch. Goodness, how the time had flown It was six o’clock already; she would have gone home an hour ago. It was amazing how long it had all taken. Still the job was done at last and now we could only wait and see what happened. I tried to reassure the young mother and yet I myself was so full of doubt and dread about the outcome that I chose my words carefully half intending to prepare her for the very worst. She left the ward in tears and took herself off home to look after her other children. I was filled with sadness for her. When later it was time for supper I found that worry had driven away my appetite. I picked at my food but ate little.
Back on the ward after a second cup of coffee I looked once more at the small boy in the oxygen tent. The moist gas had misted up the inside of the tent so that I had to put my face close to the transparent window and peer though the droplets. Was it possible that the child was just a bit better? He was certainly breathing more slowly and somehow he seemed not to be struggling quite so hard to get the air in and out of his lungs. Perhaps things would work out alright after all How I hoped so. I noticed that I was hungry now. Why had I not eaten more supper? Rather furtively I looked into the ward fridge; there on the bottom shelf was a small pudding dish holding half an tinned apricot in thick juicy syrup. I stored the information away in the back of my mind resolving to eat the apricot if it was still there when it was time for bed. My mouth started to water at the thought. I had just closed the door of the fridge when the staff nurse on duty came looking for me.
‘Oh, there you are. What are we going to do with Charlie Deacon? He just won’t go to sleep. I’ve read so many stories to him that I am losing my voice. Anyway I’ve got other things I must get on with but he won’t let me leave him. Can we give him some sedation or something?’
‘Not unless we really have to. Tell you what, though, I’ll try to hypnotize him to sleep. We had a lecture on it last year and I’ve always wanted to give it a go. Leave him to me.’
Charlie Deacon was four years old. He had been admitted three months ago with collapse of the middle lobe of his right lung. After lots of investigations we had finally started him on antituberculous therapy nursing him on the balcony for several weeks before allowing him back into the main part of the ward. With his cheeky smile and plump face he had become everybody’s favourite.
‘Hallo, Charlie, I’ll tell you a story if you are a good boy.’
Charlie nodded approval. I looked at the little boy with real affection.
‘Come and sit on my lap, Charlie. There now that’s fine isn’t it? I’m just going to talk to you first before I tell you the story. Close your eyes and snuggle in to me. I expect you are feeling very sleepy, but it is warm and comfortable, isn’t it? Yes, you are really very sleepy. Just let yourself get sleepier and sleepier. You can feel yourself drifting off so quietly and gently. You are going to sleep now. You are going to have a wonderful sleep.’
I went on and on saying this over and over in a variety of different till I realised that I really had done it. It had taken four minutes by the clock. I looked up at the nurse.
‘There,’ I said, ‘I think he’s gone off.’
I was just congratulating myself, when Charlie opened his eyes, pointed across the room at some unspecified object and said ‘What’s that then?’.
We looked at him and laughed. I saw one of the medical students at the other end of the ward and called her across.
‘Be a good lass and sit with Charlie for us, will you? Thanks a lot.’
By nine o’clock there was nothing left to be done on the ward so I settled myself in an empty playroom at the end of the ward: a chance to get on with the summaries though I would have to write them out in longhand rather than dictate them. Still it would get them out of the way. I wished I was more organized; discipline that’s what I needed; self-discipline and a routine: two summaries every morning and another one after tea. I knew I would never stick to it, but wouldn’t it be nice? Even as I resolved to put just such a schedule into motion I remembered the words of Oscar Wilde: ambition is the last refuge of failure. How apt! Yes, I had been a failure in this respect. Perhaps I should go and get that apricot from the fridge. This would be just as good a time as any other to eat it. But no, I would complete the job in front of me first.
I worked steadily at the discharge summaries till nearly midnight. I was about to call it a day and go to bed when I was called back to the ward. James, the little boy who was prone to cyanotic attacks, had suddenly become very blue and breathless. The nurses were highly alarmed, and so was I when I saw him. The poor little fellow was squatting on the bed, his face and hands and feet a deep blue, fighting to get more air into his lungs. He looked to me as though he might die at any moment if I did not do something at once.
‘We must give him some morphia and oxygen.’
After a few minutes he did seem a little it better, but the improvement did not last. What was I to do now? I could not give him any more morphia and yet something had to be done I phoned the resident anaesthetist and explained the situation.
‘I was wondering if you would come and give him some cyclopropane. Apparently it can help sometimes, or so Dr Joseph says.’
‘I have never heard of anything like that,’ he replied. ‘Are you sure that it is a good idea?’
‘I am not sure of anything, but something must be done or he’ll die.’
‘Well, I’ll my registrar and ask his advice.’
The children’s ward was on the floor above the maternity department. I knew that there would be several anaesthetic machines there. I would bring one up in the lift so that it would be ready if we decided to use it.
The midwife I spoke to when I got to the labour wards was not at all keen on my taking a machine.
‘What if we need it ourselves?’
‘Well, you have two other machines and you are not busy anyway. This is a real emergency now, not just a possible emergency later.’
So she let me take one of them and I trundled it noisily out of the ward. As I pushed it into the lift the wheels got stuck. It took all my strength to free them, but eventually I arrived back at the children’s ward.
‘James is quite a bit better,’ the nurse told me. ‘He is still very blue but he is not so breathless. I think the morphia must be working at last.’
‘Thank Heavens for that.’
I went to see him for myself. I knew that patients with asthma, for example, sometimes seemed less breathless when they had reached the stage of exhaustion and that it could be a bad sign as well as a good one. But I was reassured when I saw him; he really did seem to be improving. Now the resident anaesthetist was on the phone.
‘I have spoken to my registrar and he has never heard of anything like it either. He says that if you really want the child to have some cyclo you must ask your registrar or consultant to phone him themselves.’
‘Actually the child seems a bit better, so I think we are going to be all right, after all. Sorry to have disturbed you.’
‘That’s OK. I had not gone to bed yet anyway. We still have another intestinal obstruction to take to theatre before I can get my beauty sleep. I hope your little boy is all right.’
He was. After another quarter of an hour he looked almost pink again and was sleeping peacefully. I was greatly relieved.
‘We’ll leave the anaesthetic machine here till the morning,’ I said to the nurse. ‘Good night.’
But I did not go straight to bed, for I still had a rendezvous with that single leftover tinned apricot. In the words of Oscar Wilde: the only way to get rid of a temptation is to yield to it.
My mouth began watering as I opened the door of the fridge. I was positively drooling as I lifted the glass dish to my lips. How I was going to enjoy it. I would have, too, had it been an apricot; unfortunately it turned out to be a raw egg, which had been in the fridge long enough for the exposed surface of the yolk to dry out and form a skin. I spat it back into the bowl and started to retch. I suppose it served me right.
The anaesthetists at Musgrove Park Hospital occasionally used cyclopropane, but not too often, except that is for Mrs Lailey. The problem was that the general surgeons always wanted to use the diathermy so explosive agents were out. In contrast the gynaecologists with whom Mrs Lailey worked (including her husband) tied off bleeding points with thick ligatures rather than ‘frying’ them with the diathermy, so she was able to use whatever she wanted to.
‘I like to use nitrous oxide with lots of oxygen and a little cyclo,’ she would say, ‘that way the patients stay pink and asleep, and the surgeon and I are both happy.’
It certainly seemed to work well, together with some tubarine, for the abdominal cases, whom we would ventilate by taking turns at squeezing the bag of the ‘closed circuit’, which we always used, of course, because cyclopropane was so explosive and expensive. For minor things, like ‘D & C’s, they just used a hefty dose of thiopentone, say 400-500mg, followed by nitrous oxide and a small dose of gallamine. The relaxant would ‘soften the patient up’ but was not enough to stop them breathing. However, for emergency gynae cases out of hours, like a D & C for an incomplete abortion when the patient had already lost a lot of blood, I would often revert to Mrs Lailey’s mixture of nitrous oxide, oxygen and cyclo, but without any relaxant, keeping the patients breathing normally while ‘pink and asleep’.
I liked the gynae lists with Mrs Lailey. She was a motherly sort of woman and we shared a deep appreciation of food in general, and of spinach in particular. When there was a quiet moment during the list the conversation would always get around to something edible. Also there was the excitement of never knowing exactly what the surgeon would find inside the abdomen. Strange things were always cropping up, even if they were only odd-shaped fibroids
The patients for hysterectomy always had high blood pressures, or so it seemed. I used to wonder if treating the blood pressure first might not actually cure the patient of her heavy periods even before she had her hysterectomy. Still it would never have worked out that way because the anaesthetists were very wary of patients on drugs for lowering high blood pressure as these often interacted with the anaesthetic in an alarming fashion. At least that was the theoretical worry, though I often found myself having to anaesthetise patients for emergencies when there was no time to stop these particular drugs and it never proved to be a problem in practice. Still it was the current teaching that anti-hypertensives, and also anti-depressant drugs, should be withdrawn two or three weeks before elective surgery. Occasionally this policy had disastrous results as when, for example, one patient had a stroke during the waiting period, and another committed suicide.
Although Mrs Lailey was the only person to use cyclopropane regularly the other anaesthetists would at times use it to induce anaesthesia in children in the way I had seen it used at Guy’s. I grew to enjoy this technique very much, though in the ENT theatre, which was where I met most of my younger patients, I continued to use ethyl chloride in the traditional manner. Nevertheless cyclopropane played a small but useful part in my own practice, and it certainly served both me and my patients well.
Catterick Camp, Yorkshire
Being on duty as Orderly Medical Officer (OMO) was certainly an interesting occupation. The weekend started with a complaint from the brigadier who had had his hernia repaired three days earlier. His supper was cold. He did not see why he should put up with it. He told the nursing orderly so in no uncertain manner.
The orderly, a quiet simple man, told the QARANC sister who reported it to the OMO, who was me. I felt quite unreasonably irritated. I marched down the corridor to confront the general in a mood and manner that could only belong to a national serviceman, or to someone who felt himself a national serviceman even if he had taken a short service commission.
‘I hear that you have been complaining about your supper,’ I said belligerently. ‘Surely you realise that the more important you are the more important it is that you do not complain. If you do, it all gets blown up out of proportion. I will have to put it into my report in the morning and some poor cook will get into trouble. I expect you didn’t know that most of the cooks are off sick and there are only four of them left to cook for the whole hospital.’ I did not add that the hospital was nearly empty. That was immaterial.
The brigadier was clearly taken aback by the onslaught, but his wife sniggered. Clearly she had never heard anyone talking to her husband in this way. I withdrew before a counter attack could be mounted.
Ten minutes later they brought in a soldier with ‘the DTs’ who started wrecking the reception department. I tried to reason with him at first but ended up injecting paraldehyde into his leg to quieten him, thrusting the needle through the cloth of his battledress trouser deep into the muscle of his thigh while three men restrained him. Unusual, but effective The smell of the paraldehyde would certainly hang around the room for the next two days.
Later in the day I got a call to visit a woman at home; she said she feverish and unwell, and her husband was away on manoeuvres. This was the life, I thought. Perhaps I should have been a general practitioner. I had a quick stitch or two to put into a cut hand and then I was on my way.
I pulled up outside the house, locked the car and walked up the drive. There seemed to be a sinister quietness about the place. I rang the bell. The woman who opened the door to me was in a thin pink dressing gown. She looked terribly ill. Her face was flushed and drawn, and her arms and body were trembling. She smelt of stale sweat.
‘Thank God you’re here,’ she said. ‘I feel so ill. It’s my own fault. I shouldn’t have done it. I hope I won’t die.’ She paused, and then ‘I think I am going to die.’
‘What have you done? Tell me.’
‘I used a knitting needle on myself to get an abortion. I did it this morning. I boiled it in Dettol first. I did this once before, two years ago, and it was OK then, but this time I must have done something wrong. ‘
I stepped into the hall and followed her into the sitting room. I opened my bag and got out the thermometer.
‘I’ll take your temperature, ‘ I said, and popped it into her mouth.
A minute later I looked at the thermometer in disbelief... 106.7oF! (we would measure this as 41.5oC these days). Dear God, I had never seen or heard of a temperature like that. 106.7oF? Surely it could not be compatible with life. I looked again. There was no mistake. If I didn’t do something this very moment the proteins in her brain would coagulate like the white of a boiled egg.
‘You will have to go to the hospital,’ I said, ‘but we will have to get your temperature down first. It’s very, very high. I think we should put you in a tepid bath and cool you down. Come on, let’s do that now, straightaway. Come on.’
I led her upstairs where I ran a tepid bath. I helped out of her dressing gown and into the water and I sponged her down for several minutes.
‘Let’s see if that has done the trick.’
I took her temperature again. 104o. Well, that’s a start. I continue to sponge her with tepid water until it had dropped another 2o, and then I dried her, got her back into her dressing gown, bundled her into my car and took her to the hospital. I wondered if she would need to go to theatre; if so I guessed I would give her some cyclo; that would be excellent. In the event the gynaecologists thought that she had not perforated her womb through into her abdomen and they treated her conservatively with massive doses of antibiotics.
Next there was a Sergeant Major with raging toothache. I said that we would get hold of the duty dental officer and get him to have a look. I guessed that I would be asked to give him an anaesthetic in due course.
The dentist proved difficult to contact. He had gone out somewhere but nobody knew where. We left messages for him everywhere we could think of; two hours later and we were still waiting for him to ring us back.
‘You’ll have to take this tooth out for me, Doc, if there isn’t a dentist. I can’t stand it any longer.’
The big, burly man looked so wretched that I decided that certainly I would have to do something for him. Where on earth had the dentist got to? He seemed to have vanished into thin air. Probably in a pub somewhere, I thought
‘Let me have another look. Just open your mouth wider if you can.’
Yes, the gum was altogether too swollen and inflamed to contemplate putting local anaesthetic into it. It would have to be a general or nothing.
Almost as though he could read my mind the Sergeant Major said
‘You can just put the forceps on it and pull if you like. The pain couldn’t be worse than it is now. I know you said you were not keen on giving me an anaesthetic and taking the tooth out yourself all at the same time. Well, why not just take it out without an anaesthetic. That’s what they would have done in the olden days, isn’t it?’
The logic seemed indisputable and anyway with an abscess like that the tooth might well be surprisingly loose. It was worth a try.
‘O.K., We’ll give it a go. Give me a few moments to find the right forceps and I’ll see what I can do.’
I went down the corridor to the dental surgery, and rummaged through the various instruments. There, this pair would do for an upper six, I felt sure. I found the switches for the overhead light and for the sucker, and worked out how the chair tipped.
‘O.K.,’ I said to the Nursing Orderly, ‘please go and get him.’
This was it, then. Let’s hope it won’t hurt him too much. Must wipe the sweat off my hands or they will slip on the handles of the forceps.
‘Come and sit in the chair. That’s right, but just tip your head back a bit more. Good.’
There’s the tooth.. carefully now.. up with the forceps, take a big breath and grip the tooth firmly.. don’t rush it.. pull It did not budge even the slightest bit. I knew that it must be excruciatingly painful and I felt desperate for the poor man. I gave it one last totally useless yank and stepped back. There were tears in the soldier’s eyes and sweat on his brow. He looked reproachfully at me.
‘You didn’t get it, did you?’
‘No, I’m sorry.’
‘Well, thank you for trying.’
I was wondering what to say next, when one of the nursing orderlies came into the room.
‘The duty dental officer is on the phone. He says do you still want him?’
‘Thank Heavens for that. Yes, I’ll come and talk to him.’
He said he was sorry that he had been so difficult to find but pointed out that he never held himself instantly available.
‘There are no such things as real emergencies in dentistry,’ he said. ‘I would never get any peace if I didn’t hide myself away for a few hours every now and then.’
I thought back to my childhood, when my father used to tell people with toothache to go Guy’s if they had pain as there was a dentist on duty there. It would not do for the doctors to take that line, would it?
Anyway, now we had found him he agreed to come and take the tooth out. Ten minutes later and the Sergeant Major was back in the chair, and I slipped a needle into a vein on his forearm.
‘‘Let’s get on with it then,’ I said to him, as I slowly injected 500mg of Pentothal into his vein.
‘What was it you were saying about Cyprus, sergeant?’ I asked.
‘Well, we were going down this street, and... I.... said..... to....... the....... cor........poral.....’. His voice faded away and he yawned; a slow extended yawn. He’ll be asleep in a moment, I thought, but he did not close his eyes; he just stared straight ahead for a moment or two and then ‘I...... am..... not.... go..ing... to.. go.. round the corner till I’ve looked with a mirror.’
Dear God, I thought, 500mg is enough to put an elephant to sleep and it has only made him pause in mid-sentence. I injected another 200mgs. He went off this time; the dentist slipped a prop and a pack into his mouth and picked up the forceps. I watched him apply it carefully and then he pushed rather than pulled, squeezing the handles hard as he did so; now he began to rock the tooth from side to side. A moment later he delivered the tooth sideways from the gum and dropped with a clang into the bowl.
‘Well, I hope the poor fellow feels a bit better for getting rid of that. It must have been hell for him when I tried it.’
‘Yes, but sixes can be brutes to move so you mustn’t feel too bad about it.’
‘Next time we have an extraction to do I’m going to try some cyclopropane mixed with oxygen in a six litre bag. I’ve been reading about it. It’s the idea of a anaesthetist from the London called Bourne. He’s the man who has written about fainting in the dental chair as a problem when patients are anaesthetised in the sitting position. He’s just got an M.D. from Cambridge University for his thesis.’
‘It sounds unusual. Tell me more.’
‘Well, he thinks that people can faint when sitting upright in the dental chair and that there have been one or two cases of delayed recovery from an anaesthetic because of this, as their brains don’t get enough oxygen during the faint. He also thinks that nitrous oxide is not necessarily the best thing to use in the dental surgery. He has been trying out cyclopropane mixed with oxygen, with some nitrogen added in to make it non-explosive. He puts it all in a six litre bag and gets the patient to breathe in and out of it. It seems to work really well, but it only gives a few minutes useful anaesthesia. I’ll read it up when I get a chance and, as I said, we’ll try it out next time.’
A few nights later I got Dr Bourne’s book down from the shelf. What a good project it had been. I could visualise Dr Bourne running around the hospital with his large black rubber bag, filled with his knock-out mixture. I turned to the chapter on Cyclopropane as I knew that his main thesis was that cyclo was the best alternative to nitrous oxide.
The chapter started by discussing cyclo’s potency as an anaesthetic. Ever since 1929 it had been considered a powerful agent because it acted so quickly. Dr Bourne argued that this speed was not due to high potency at all, but to its great lack of solubility and to the fact that it was non-irritant even when breathed in high concentration.
This places cyclopropane in a unique position amongst the available anaesthetics: it is a good deal more powerful than nitrous oxide, but compared with the other anaesthetics it is weak. Divinyl ether has more than twice its strength, ethyl chloride and ether about five times it strength, and halothane, chloroform and trichloroethylene about ten times its strength. Far from being extremely powerful it is in fact the second weakest anaesthetic. It stands alone in that wide gap that separates nitrous oxide from the others. Its potency is intermediate..... In ambulatory work, an anaesthetic of intermediate potency and very low blood solubility is precisely what is needed.
In the next chapter he described how he had first tried using a six litre rubber bag filled with 50% cyclopropane and 50% oxygen for a dental extraction in a large muscular man of 45 years, who was ‘accustomed to considerable amounts of alcohol’, and how well it had worked. It sounded just like my sergeant major
He had also studied the flammability of cyclopropane; apparently it was possible for sparks to be caused by forceps slipping on a tooth. If the concentration of oxygen was less than 30% it was unlikely that such a spark would cause an explosion. It was best therefore to wait for the patient to take five breaths of air after he had breathed the gas mixture before attempting any extractions. Alternatively the mixture could be made up with 25% oxygen and 25% nitrogen instead of 50% oxygen; this could be done by using two small disposable bulbs like those used in making soda water.
It was clear from reading the book that Dr Bourne was a man of great enthusiasm, and I warmed to him and his ideas.
I tried it out the next time I was asked to give ‘a gas’ for a dental extraction. It worked really well. I am sure that I would have continued using it if only it had not been quite so explosive.
Denver was an exciting mixture of brilliant sunshine and bitter cold. There were tall, tall skyscrapers and broad, broad highways. Despite what Derek had said about it, it was still a surprise to me when it turned out to be such a bustling modern city, with its huge international airport and its gigantic hypermarkets; not at all like a town from the old ‘Westerns’ that I had sat through at the Globe cinema when a boy. I had fully expected it to be years behind what I had thought of as ‘modern Bristol’. No wonder I felt foolish when I saw what it was really like.
I felt even more of a country bumpkin when I tried to insist to the telephone company just how urgent it was for me to have a phone installed before Thursday next week as I would be on call that night.
‘I really can’t take ‘no’ for an answer,’ I said as firmly as I thought necessary to make the point.
‘Gee, what’s your problem?’, he asked. ‘The average time we keep a new customer waiting for a phone in Denver is six hours. Isn’t that soon enough for you?’
The Medical Center was a striking building. In particular, each of the many glass windows was shaded from the almost constant sunshine by its own large screen that moved automatically to follow the sun across the peerless blue sky. Apparently it was cheaper to heat the building than to cool it.
The anaesthetic department, or rather the division of anesthesiology, was a curious mixture of the old fashioned and the bang-up-to-date. One of the former was the extensive use of cyclopropane in the gynae theatre. It was not used in the way that I had been taught in Taunton, as an adjuvant to nitrous oxide to provide an oomph that nitrous oxide alone could never possess; it was mixed on its own with oxygen in a low flow circle system just as Dr Ralph Waters of Wisconsin had described in the nineteen thirties. New anaesthetic residents were shown how to take a patient deep with a mixture of half a litre per minute of each of the two gases being added to the circle system. When they were deep enough for surgery to start the cyclo was turned off and the resident watched closely as the anaesthesia lightened gradually over the next ten minutes or so. Then the cyclo was turned on again. The resident watched just as closely as the anaesthesia deepened once more. The whole process was repeated as often as necessary till the operation was completed. After a week of administering anaesthesia in this way the young men knew all about the stages of anaesthesia. In addition, the professor insisted that record keeping was meticulous and changes in the patients’ condition were charted the moment they occurred. It was an excellent training exercise. I realised that in contrast I had learnt my anaesthesia largely by unsupervised trial and error. My overall experience at the end of my first year had utterly dwarfed my American counterpart as far as quantity was concerned, but in the quality of teaching and in exposure to the various branches of anaesthesia the Americans won hands down. But perhaps it was not so much a difference between the UK and the USA as between a university hospital and a small town hospital like Musgrove Park, Taunton. Yes, that was probably it.
At coffee-time one day I asked Dave about the role of the anaesthetic department in the maternity wards.
‘The obstetricians are not encouraging us at all to get involved with lumbar epidurals for relief of pain in labour. They like to put in caudals themselves; I guess its so they can bill the patient for it, rather than let us do a proper job and earn money for the anesthesiology department. There is nothing we can do about it at the moment, but I do think it is a pity. Still I do occasionally get asked to give a little cyclo in the second stage of labour if there is not a caudal already in place.’
‘Cyclo? I’ve not heard of that being used in labour. What concentration do you use?’
‘Oh, about 4%, which is just under half of MAC. It seems to work very well, I must say.’
I wondered what they would make of that in Bristol.
Southmead Hospital, Bristol
Ian looked up from the papers he was reading and called the meeting to order.
‘It is now five minutes past the hour and as there is a lot of business to get through I think we had better make a start.’
He paused for a moment whilst the hum of conversation died down and people settled themselves in the uncomfortable chairs. I spent this time looking out of the window. A strong feeling of nostalgia came over me for this was the same view that I had had from my office when I had worked for the university. Such a pleasant area of green grass; they were sure to build on it one day Still I would probably be retired before it happened.
Andy came dashing into the room. ‘Sorry I’m late, Mr Chairman.’
‘Not at all,’ said Ian. ‘We are only just about to get under way.’ He turned to Leila. ‘Are there any apologies for absence?’
‘Yes, I have received three.’ She read out the names. As she did so I could not help thinking what an exceptionally attractive woman she was with her silver hair and gentle Mona Lisa smile.
‘Thank you. You should have all received a copy of the minutes of the meeting on the 3rd of May. Is it your wish that I sign these as a correct record of the proceedings?’
‘I wonder could we alter the wording of Minute 676?’ said Tony. ‘I think it would be better if the fourth line of the second paragraph read ‘guidance on the routine care of intubated children’ rather than ‘routine guidance on the care of intubated children’.’
‘Yes, I see what you mean.’
The line was changed and the minutes signed with a flourish.
‘The next item on the agenda is ‘appointment of chairman’. As you know I have served my three years and now it is time to hand over to someone else. I would like to propose Ed as our next chairman.’
‘I second that,’ said James, and we all nodded our agreement.
‘Are there any other nominations? No? All those in favour please raise their hands.’
Everybody except Ed put their hands up in the air.
‘Carried unanimously. Before I step down there are just a couple of things I want to say. First, I think the Division has been particularly fortunate in the quality of the skills and enthusiasm of its new consultant members.’
There’s nothing wrong with the old ones either, I said under my breath.
‘Secondly, the University Department of Anaesthesia, and particularly its Southmead offshoot, is a vital addition to the Division and I hope to see the NHS and the University will each take full advantage of the opportunities and facilities offered by the other.’
What was he on about now? Hadn’t they done that ever since 1968? Ah, well, I guessed he knew what he meant.
‘Thirdly, I would like to see more recognition throughout the hospital of the vital role played by the ODAs in the work of the Division, especially in support of the junior anaesthetic staff in training.’
‘Finally, I thank everyone for their help and co-operation during my time as chairman.’
‘Now, Ed, please come and take the chair.’
The two men stood up and swapped places.
Ed then formally thanked Ian for his hard work on behalf of the Division. We went on to discuss ‘Matters arising from the Minutes’.
I listened closely at first: intravenous regional anaesthesia in the casualty department, new equipment for the theatre and the ITU, duties of the ward nurse in the anaesthetic room. It was not long before my attention began to wander and the doodles on my agenda sheet became uncontrollably elaborate. I had always been impatient at committee meetings; people were so predictably ponderous and stupid at them, though it had to be said that generally the Anaesthetic Division was more interesting than other committees and the level of debate far more satisfactory. Still it was good to ever let the fancy roam, or however the poem went. Perhaps I would write a poem. That would keep the mind active. Let’s see now
I must not shirk
It really is my duty.
Though it’s a bore
I’ll stay for more
‘Cause Leila’s such a cutie.
Suddenly I was dragged back to reality. They were talking about cyclopropane. Ian was holding the floor:
‘It really is a most useful agent and I would hate to be without it when inducing children. Even if you don’t keep it anywhere else in the hospital could we please retain it in the ENT theatre?’
He looked around the room for some support but it was not forthcoming. Nobody else but Shu used it at all, and he was not there. Still we were not in the business of denying him unnecessarily.
‘Do we know if the work of upgrading the ENT theatre is going to affect its anti-static status?’
‘Well, it’s O.K. to use inflammable agents at the moment, so surely it will be alright when they have finished. They can’t actually be downgrading the theatre, can they?’
‘No,’ said James, ‘they are not. I was at the meeting of the Working Party last month. The plans definitely include a check on the antistatic properties of the floors and appropriate action to be taken if necessary.’
‘Let’s agree then to keep cyclo on the machine in the anaesthetic room of the ENT theatre so that Ian, or anybody else, of course, can use it when they wish to. In main theatres it won’t be on the machines but it can be called for if it is wanted. How does that sound?’
There was general agreement so Ed moved them on to the next item - ‘Guidance to House officers on Preoperative Assessment’.
‘Tony, this is your item. Would you care to talk to it?’
‘Thank you, Mr Chairman. You have all had a draft copy of the handout that I writing for the housemen. It will, of course, only be a guide for them and in no way is it to be looked on as a substitute for discussing individual cases with the anaesthetist concerned, but it may stop important things being forgotten. I would be pleased to have any comments that anyone has, either now or afterwards.’
There were several comments and some discussion but after a few minutes my attention began to wander once more; it’s funny, I thought, I have not actually used cyclopropane since that poor man with liver abscesses whom I had to anaesthetise soon after I arrived at Southmead, fifteen years ago now. It had been only a few months after I had come back from Denver, and cyclo had seemed quite a good choice of anaesthetic to me at the time, though I guessed it would be difficult to justify its use to-day. After all this afternoon we had been talking only about using it during the very earliest moments in the induction of anaesthesia and the discussion had had nothing to do with using cyclopropane as a ‘stand alone’ anaesthetic. I wondered whether they were still using it in Denver. I must write to them and find out. Still, it would be strange not to have the friendly orange cylinder hanging silently by its neck at the side of the anaesthetic machine. I knew that I would miss it.
In the event the work on the ENT theatre did not live up to the Anaesthetic Department’s expectations. The original List of Work circulated by the District Engineer in May 1982 had clearly stated that ‘the anti-static properties of the floor need to be checked and action taken if necessary.’ Unfortunately by July 1983 this document had been re-written and it now contained the statement that ‘the flooring is not to be replaced but is to be made good. This is non-antistatic and it has been agreed by the committee that it shall remain so.’
Clearly during that fourteen months someone somewhere had confused ‘antistatic’ with ‘non-antistatic’. Everybody concerned (except the people who carried out the work) had continued to believe that ‘the antistatic floor would be checked and action taken if necessary’. The double negative had wreaked its havoc unnoticed. Red faces all round, but too late, or at least too expensive, to correct it now.
At the divisional meeting in January it was agreed to accept the unplanned fait acompli and not to use any flammable or explosive anaesthetic agents in the ENT theatre. A couple of cylinders of cyclopropane would still be available but for use in the main theatre suite only.
The division of anaesthetics met on the 6th of July with Colin in the chair. His ‘chairman’s report’ seemed never ending, but at least it was full of important items. He told us first about the Regional Specialist Subcommittee: how it had discussed the provision of skilled assistance for anaesthetists and also recovery wards - old chestnuts certainly, but important nonetheless. Southmead, he was happy to tell them, came near the top of the regional scale of provision in both respects. This satisfactory state of affairs was the direct result of the efforts of the Division over the years to provide a safe minimum standard in line with modern anaesthetic practice.
At this point James had chipped in to say that he understood the Faculty of Anaesthetists had advised the DHSS that it would be looking closely at the level of skilled assistance available to anaesthetists and that it would not in future recognize posts where this was absent.
There was general buzz of approval. Colin went on to tell them that the Regional Education Adviser had asked Divisions to review their practices in connection with visits to departments by applicants for Senior Registrar posts in an effort to be fair and humane to all. We discussed this at length and came down in favour of restricting visits involving formal discussions with consultant staff to applicants on the short list, though clearly there was no bar to informal visits to the premises or discussions with Senior Registrars already on the rotation.
Colin pressed on relentlessly: the JPAC report on the future needs of medical and surgical specialties; the Use of Trust Funds; a Consultation Document on the Transfer of In-patient Services from Barrow Hospital to Ham Green Hospital; the Avon FPC Profile and Strategy Statement; a draft paper on Care of the Dying and, finally, the Re-organization of the University Department of Anaesthetics. Andy, he told us, was withdrawing from Southmead to replace Griselda at the BRI while Nev would replace him at Southmead, with Chris as Lecturer.
I wondered where this business of ‘chairman’s report’ had come from. Was it really part of standard committee procedure or was it just something that Francis had invented when he had been chairman of the Medical Staff Committee? Whatever the explanation it seemed to have become a regular item in hospital committees ever since Francis’ time. Still it was probably a useful way of getting some of the things onto the agenda.
After chairman’s report the minutes were presented and signed. We went on to discuss the replacement for Heather when she retired; insurance cover for staff on the flying squad; the proposed new ‘on call’ rotas. Then James was asked to talk to the subject of ‘Efficiency Savings’.
‘Thank you, Mr Chairman. I must start by reminding the meeting that the financial situation of the Acute Unit is under severe strain. Any developments we might want to make can only be funded by our saving money from somewhere else. On top of this the Unit is under an obligation to make savings of 1% per annum over the next eight years. Personally I am strongly opposed to lowering our standards simply to save money but there a number of savings we could make by rationalising some of our practice. For example, if we were to withdraw our ‘anaesthetic packs’ from routine use and substitute clean laundered towels we could save £1,500 in a year.’
After discussion we agreed to do this.
‘Next, Astra are nowadays only marketing bupivacaine ampoules in individual sterile packaging. This is, of course, a most useful presentation for some specific situations, but, equally, it is often an unnecessary refinement. As it very much more expensive to buy an ampoule that is sterile on the outside as well as the inside I plan to talk to Pharmacy about the possibility of manufacturing our own ampoules of Bupivacaine. I estimate we might save £3000 in a year.’
‘Are you sure that it is a good idea to get into this sort of thing?’ I asked. ‘I seem to remember some years ago they got into terrible trouble with making their own intravenous fluids.’
‘That was quite a different set-up and certainly there were problems. This is a much smaller undertaking and with some help from Torbay it should be possible. Anyway, I don’t see that we have anything to lose by looking at it.’
‘No, of course not.’
‘Which brings me to cyclopropane. It seems that the British Oxygen Company has introduced new systems of quality control and as a consequence the minimum size of any order is to be increased. As I understand that nobody is using cyclo anyway, the cost of having it available in the hospital lies solely in the hire of the cylinders and not in their contents. I hope we can finally agree to get rid of our stock which, small as it is, will still save something approaching £300 a year.’
‘It will be a sad thing,’ said Ian, ‘but I suppose we will have to say ‘yes’.’
The rest of us nodded silently.
During the first weekend in April the new Ohmeda Excel machines were put into service, and those of the old Boyle Internationals that were being kept were modified. From this moment even had a cylinder of cyclopropane been available it would not have been possible to fit it on any machine within the Health District. Truly the era of cyclopropane at Southmead had ended.
 It is said that Russell Brock used to take his secretary with him on ward rounds even when he was a registrar; this must be considered highly unusual for that time, and even to-day it would single a man out from the crowd.
 Wood, Paul. Attacks of deeper cyanosis and loss of consciousness (syncope) in Fallot’s tetralogy. Brit. Heart J. 1958; XX: 282. I only know of one other case report of the beneficial effect of cyclopropane in this situation: Condon HA, Lee PFS. Functional infundibular stenosis treated by cyclopropane anaesthesia. Anaesthesia, 1960; 15: 45- 47.
 Paracetamol was not actually a new drug; it had first been used in medicine in 1893, but it did not become popular until 1949 after it had been discovered that it was an active metabolite of both acetanilide and phenacetin. Although it is aspirin-like in that it is both anti-pyretic and analgesic, it does not possess any anti-inflammatory properties so that it would not be appropriate treatment in rheumatic fever. These days, of course, aspirin is not used in children for fear of Reye’s disease.
 ‘Stoss’ is German for ‘knock, blow, jolt, thrust, shock , blast’. The idea of hitting the infection hard, but leaving the patient able to mount an immunological response against the residual infection, seemed a good enough idea; nevertheless, at one hospital, once the consultant had gone home, the junior doctors often could not resist writing up a maintenance dose as well, ‘just to be sure’ (Smithells RW, personal communication). If the patient did well the consultant would think it another success for ‘stoss therapy’, and would be keen to repeat it on the next occasion, so unwittingly demonstrating to his juniors the importance of properly conducted clinical trials.
 Disposables scalpel blades did not come into use until the late sixties
 Air embolism was a real hazard in the days of red rubber tubing and glass drip chambers; the position of the gate-clip was truly vital, as if air did get into the tubing it could not be seen through the rubber. After use on a patient these drip sets were rinsed out by the nurses and were boiled in the ward steriliser; it is hardly surprising that febrile reactions to transfusion were so common.
 Queen Alexandra’s Royal Army Nursing Corps. Alexandra (1844-1925), daughter of Christian IX of Denmark, married Edward VII ( then Prince of Wales) in 1863, and founded Queen Alexandra’s Imperial (now Royal) Army Nursing Corps in 1902.
 Bourne JG. Fainting and cerebral damage. Lancet 1957; 2: 499-505.
 Bourne JG. Nitrous oxide in dentistry - its dangers and alternatives. London: Lloyd-Luke (Medical Books) Ltd, 1960.
 It wasn’t! See my comments on American residency programme in chap 7, 1968b
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