The King's anaesthetic

Introduction

The late Dr William Pallister (1926–2008) (WKP) used to tell the story of how as a junior doctor in 1951 he had anaesthetised a patient. ¹ On moving his patient, pharmacologically paralysed and with an oro-tracheal tube in place from the anaesthetic room and, entering the operating theatre, he found it empty of personnel and equipment. Memorably, he had struggled alone to keep the patient alive until the muscle relaxant drug effects could be reversed and the patient woken up! He, like many in the Westminster Hospital, was not advised that Mr Clement Price-Thomas’s (1893–1973) ‘theatre’ had been moved to a room in Buckingham Palace.

To shed a modern anaesthetic light on historical incidents, data and technical information on early and influential anaesthetic deaths and key events of the kind so well described from a surgeon’s perspective by Harold Ellis in his book ‘Operations that made History’, has been collected. The latter includes the ‘Pneumonectomy of George VI’ in 1951. ² Dr Pallister has provided a copy of the reverse of the Nosworthy card (Figure 1) of the event. ³ OPEN IN VIEWER

The anaesthetic

A 55-year-old male, with a six-month history of ill health, cough and probably some haemoptysis, presented for surgery. On percussion of the chest there was diminished resonance to percussion at the back and base of the left side and, on auscultation, diminished air entry, bronchial breathing and rhonchi could be heard.

A chest X-ray reported by Dr Peter Kerley, a Westminster Hospital radiologist, showed the characteristic radiological signs of carcinoma of the left lung and this was confirmed by a biopsy taken at bronchoscopy and the tumour found to be operable. The patient was thin, cachetic and pale and had an exercise tolerance limited by the onset of intermittent claudication. A scar on his abdomen was a well-healed right lumbar sympathectomy wound from 1949 and his lower limb pulses notably were weak. ²

The history and physical examination would enable a future generation of anaesthetists to rate his fitness for anaesthesia as ASA 3 (American Society of Anesthesiologists Grading Scale); and his dental and mandibular characteristics to warn of a potential for ‘awkward oro-tracheal intubation’. Several units of blood were cross-matched and prepared by Dr Joseph Humble. ²

The patient was premedicated with Omnopon (gr1/6) and Scopolamine (gr1/100), which was administered at 9.25 am. Dr Robert Machray, Anaesthetist at the Westminster Hospital, and his assistant Dr Cyril Scurr, induced the patient in his bed at 10.20 am with thiopentone to a running total of 13 cc as the patient was transferred to ‘theatre’ and placed supine on the operating table.

In theatre, Mr Clement Price Thomas and his assistants, Mr Charles Drew and Mr Peter Jones, were ready scrubbed. Dr WH Jayne performed a cut-down for intravenous access and after curare (10 mg) had been given, with a further 3+5 mg administered because of continuing muscle ‘twitching' [sic]. A rigid bronchoscopy was performed. A Thompson blocker was positioned in the left main bronchus and a size 9.0 Magill oro-tracheal tube inserted, and the patient turned on to his right side (Figure 2). OPEN IN VIEWER

A blood pressure cuff was placed on the left arm, and ECG leads strapped on all limbs. Considerable 50 Hz cycle interference was noted on the Sanborn electrocardiographic unit (Figure 3) printouts. OPEN IN VIEWER

Sir Horace Evans, King’s Physician, arranged the position of the legs. Machray and Scurr were now administering an anaesthetic from a MIE Boyle’s machine with a gas flow of six litres per minute of 50% oxygen in nitrous oxide. A Waters Canister (a customarily used carbon dioxide absorbing device containing soda lime) was in circuit (WKP quote – ‘presumably’). On respiration stopping, ventilation was controlled by hand and continued to be so until between 1.30 and 1.45 pm and the re-onset of self ventilation.

The operation started on the dot of 11 am. Over the next two hours the analgesia was supplemented with five aliquots of pethidine to a total of 105 mg. Thiopentone aliquots (3–5 cc) were administered on three occasions – when the tracheal tube cuff had ‘gone’ [sic], when extra rib retraction was required and when the bronchus and vascular clamps were removed – manoeuvres generally producing vasoactive responses. A further dose of curare was administered at the start of chest closure at approximately 1.30 pm.

The first unit of blood was administered at 11.30 am by which time the chest was open and a second pint started at ligation of the pulmonary artery at 12.20 pm. The Thompson blocker was withdrawn at 11.35 am and the bronchus clamped; the bronchus was divided at 12.25. The chart recorder, presumably Machray, has marked ‘LUNG AWAY’ [sic] as an event at 12.35 pm. By 2 pm the patient was self-ventilating, his pulse rate was 80 bpm; his blood pressure 120/70 mmHg and he was returned to bed with a BLB oxygen face mask and capacity bag in place.

The pulse rate had been in the range of 80–100 bpm; blood pressure ran at a 120–140 mmHg systolic range throughout operation. Three critical events are recorded. Systolic pressure dropped below 100 mmHg before surgery and was related to the large dose of thiopentone being administered at the onset of manual controlled ventilation and adoption of the lateral thoracotomy position, and countered with a bolus dose of the pressor drug, Methedrine (methylamphetamine). The relatively high fresh anaesthetic and oxygen gas flow is because of ‘leaks +++ [sic] and it would seem these became a particular problem later when the tracheal cuff burst and the throat had to be packed to reduce the loss of gas. The developments of the extrasystoles around the clamping and dividing of the bronchus are noted as ‘few’ and ‘transitory’.

An evening bulletin stated ‘His Majesty’s postoperative condition is satisfactory'. The two surgical assistants remained resident to supervise his early recovery. ²

Discussion

Without sight of the other paperwork, this interpretation of the event on Sunday 23 September 1951 is on a typical and general rather than on an actual basis, with the addition of the patient being the Royal and an operation within Buckingham Palace. A quarter of century later, it was still possible to see technique and consideration translatable to the setting and setting-up of a modern operating theatre outside of a hospital (c1975).

Only specialist units had the wherewithal and physician oversight to have cumbersome machines for ECG monitoring during surgery: mains cycle interference was a significant deterrent to the use of those available. Measurement of blood pressure was commonly dispensed with: devices for operating theatre use even in 1975 being marketed as ‘blood pressure estimating instruments’: monitoring done at the most with observation and a finger on the pulse –‘if you feel one then it is at least 100 systolic’– something of a taught mantra.

Record keeping, in a 21st century sense, often was minimal: a short note and rough range of a few vital parameters on a small anaesthetic section of shared operation record sheet, the norm with the exception of complex major operations.

In a context that precedes the routine use of diathermy and of plastics and fibreoptics revolutions, it is easy to understand ‘cut downs’ for intravenous access, red rubber tubing, rigid instruments with battery operated distal lighting, manual ventilation, glass bottles and significant blood loss requiring transfusion before the chest is surgically fully open.

A copy of the obverse of this particular Nosworthy card was in the hands of a colleague of Dr Pallister and the complete original is in the Machray family.⁸ Other memorabilia of the occasion have been the operating table at Westminster Hospital; a temporary display in the foyer of the Royal College of Surgeons, Lincoln’s Inn Fields; and the ECG machine that was donated to the British Oxygen Company Museum at the Association of Anaesthetist’s of Great Britain and Ireland by Dr Cyril Scurr. ²

The King, according to bulletins, underwent an earlier bronchoscopy, almost certainly under local anaesthesia, and for diagnosis, biopsy and surgical assessment: a bronchogram might well have been considered. ² The second bronchoscopy, under general anaesthesia, was the routine for the insertion and placement of a Thompson blocker immediately before thoracotomy. With an anaesthetic team of colleagues including Sir IW Magill (1888–1986), and with regard to the importance of the patient, it is possible to see the ordeal of the first event – which even 20 years later was considerable – being reduced to that of the personal experience described by another, and later famous, member of the same anaesthetic school, Sir Geoffrey Organe (1908–1989). In his words The local anaesthesia option better than a, in his words, “sledge hammer blow of curare”, and such that “I much prefer it to a visit to the dentist!”. ⁴ (for extraction of upper molars to enable rigid bronchoscopy).

Though Dr Robert Machray developed his own endobronchial tube (Figure 4), it was essentially designed for tuberculosis pathology, insertion in the left main bronchus and for right-sided surgery. ⁵ OPEN IN VIEWER

The use of a Thompson blocker, aligned outside the tracheal tube and its withdrawal before main bronchus clamping, was an alternative to an endobronchial tube for one lung ventilation for left-sided surgery: it would be expected that airway system leaks would occur while the blocker was in situ and this would occur even after its withdrawal from the left main bronchus into the distal trachea, where it would remain for access to remove blood and secretions.

The anaesthesia too, in terms of drugs, agents and techniques again was standard for the surgery of tuberculosis, cancer then not being the dominant indication for surgery it was to become with the advent of anti-tuberculous therapy.

It is not recorded but likely that the room in Buckingham Palace being used as an operating theatre would have had an open fireplace and this would be a factor for the preference for nitrous oxide maintenance of anaesthesia to be supplemented with intermittent thiopentone rather than the commonly used alternative and explosive volatile agents, ether or cyclopropane. ⁶ This anaesthesia ‘school’ (the Westminster) was notoriously sceptical of the ‘curare, hyperventilation, hypocarbia with nitrous oxide’ techniques promoted by another contemporary school and anaesthetic philosophy – that of Liverpool – as adequate to protect from awareness phenomena when neuromuscular blocking drugs were used.

This author does not recall operating theatres with open fires but does recall anterooms warmed with coal fires and used for everything from changing, eating, and smoking, and without any shielding of the anaesthetic machine with its highly explosive orange cyclopropane bottle, liquid filled glass vaporisers, oxygen cylinders and attached patient.

Of the critical incidents reported on this card, the burst cuff on the tracheal tube is perhaps most worthy of comment. It was a common enough experience that this was a surgically induced event. Indeed, among innovations in surgery credited to Sir Clement Price Thomas is the ‘sleeve resection’ for carcinoma of the lung. So invariably did he puncture the tracheal or bronchial cuff at distal tracheotomy when doing this operation, it stimulated Dr Pallister to modify – with a reserve bronchial ‘cuff-within-a-cuff’ – the Machray endobronchial tube just for such a usual eventuality (Figure 5). ⁷ OPEN IN VIEWER

However, a surgical cause for cuff trauma is unusual with left-sided pneumonectomy as the endotracheal tube cuff is clear of the surgical field. In this case the incident reads as though it was torn on insertion (no record of the state of His Majesty’s dentition) or a faulty cuff. After he retired, Dr Pallister reported he no longer had any samples of his tube in his possession. A colleague found him one. Dr Pallister was rather shocked to find it was size 9.0 – a manufacturer’s addition to the range: he had no liking for the large sized Magill tubes, feeling these were more appropriate for veterinary than human use. Machray, it can be assumed, had fewer qualms for his special patient!

With the left recurrent laryngeal nerve sacrificed at surgery, the voice assumed a slow, muted and husky character that the Nation and Empire heard for first and last time from a tape recording of the King’s Christmas Speech on 25 December 1951. ² George VI retired to Sandringham for the short span left of his life and, when out shooting, the King’s speech was amplified with a loud hailer fitted to a Land Rover!⁸