I: The date is August 19th 2011. My name’s Barbara Thornley and I’m at the Association of Anaesthetists in Portland Place talking to Dr Archie Brain. Thank you for coming to see us Dr Brain.
P: Good morning, it’s very nice to be here.
I: Can we start at the beginning and perhaps you could tell us a little bit about your early family life and where you were born and your parents?
P: I was born in Kobe in Japan, my parents were diplomats, in 1942.
I: And you stayed there?
P: I was there for about six weeks and then my existence in fact enabled my parents to be released because the Japanese didn’t want any more mouths to feed and we were able to escape if that’s the right word on a Red Cross ship and we went through war-torn… across the world, a fairly risky voyage I suppose at that time and there was an exchange of prisoners of war in Madagascar and it was there that I became a British subject. And then we also went back on a different ship and arrived in Liverpool the same year, 1942.
I: Did your parents talk about this experience a great deal because you wouldn’t have remembered it.
P: Not a great deal, I don’t think it was a particularly pleasant experience but they were not treated in the same way as the soldiers so they weren’t physically abused in any way; there wasn’t a great deal to eat. They made very good friends with fellow prisoners, there was a sort of camaraderie which develops as a result of being in this sort of situation but no, I regret not having asked them more but they didn’t really want to talk about it.
I: Did you go back to that part of the world?
P: I did many, many years later. I went back to Kobe to lecture. I can’t remember the year, it would have been more than 10 years ago and I certainly was not the most senior anaesthetist present but the Japanese had cottoned onto the fact that I was born there so I was quite surprised to find myself hauled up to give a totally peremptory speech. <Chuckles>
I: Do you have any brothers and sisters?
P: I had one brother. Unfortunately he developed muscular dystrophy and died at 23, he was three years older than me.
I: When you came back to the UK tell us a little bit about your schooling, where you went to school.
P: Well my parents being diplomats were most of the time outside of the UK so they put me in boarding school and I went to Ampleforth College in Yorkshire at nine years old.
I: Did you have your early schooling in the UK or was it abroad?
P: After my parents had been in Japan, they were for a short time, with the War Office and then they went to Singapore to work under Mountbatten to try and restore some sort of order to Singapore which of course had been overrun by the Japanese and I think we were there for four years, so I had nannies and some very early schooling in Singapore. Then we came back towards the end of 1940’s it would have been about 1948 I think. My parents bought a property in Bourne End in Buckinghamshire and I went to the local school until I was old enough to go up to Ampleforth.
I: Tell us about your time at Ampleforth.
P: I certainly hated the cold and I was very nostalgic for the tropics. In fact I think because of that early experience I’m always happier both in Asia and in tropical countries, so it was mostly memories of cold and rather severe monks. And the happiest day in my early schooling was the day my parents suddenly arrived after I’d been there I think about 18 months to announce that we were off to Japan again and I was to pack my trunk and off we went. And that was the most wonderful moment because I was united with the family who I hadn’t seen for a while and myself and my brother went off on this long sea voyage, in those days diplomats travelled by sea, six weeks back to Japan again.
I: How long did you stay in Japan then?
P: I stayed for two years, I had a governess, a half-French governess who was the reason I managed to learn French, well I learned French fairly early on because of that. I didn’t know any Japanese at that time because it was not considered appropriate to learn Japanese so soon after the War. I left my parents there, they sent me back to Ampleforth again because they thought that the British education was more important than staying with them, a point of view with which I disagreed…
P: … and I was again rather miserable at the school.
I: When you were at school were you interested in inventing things then?
P: Yes I was always interested in inventing things but there was no potential scene in that tendency as mine as I was also good at languages as had been my father and I was good at French because I already spoke a bit and so eventually I was streamed into the direction of taking a Degree in languages and I got a scholarship to Oxford.
I: That was your first Degree?
P: That was my first Degree indeed, yes.
I: What made you change to medicine?
P: I think the main influence was I had a friend who was very scientific and I was fascinated by his brain and I think it was the inventing side of me which is partly an engineering trait which was stimulated by this friendship and his family were all doctors. And I resolved that I definitely wanted to get inside this science and understand it, I’d been completely useless at science at school, nobody in my family was scientific apart from an inventor uncle on my mother’s side and an inventor on my father’s side and a brother of my father who died very young unfortunately, who invented one of the first radio valves. My father was not scientific at all, my mother was an artist. My father was an out and out musician, he played piano and I’ve inherited that from both sides, I love art, I love music.
I: Did you find the science side of medicine very difficult when you started?
P: Yes it was extremely difficult and what was most difficult of all was going against everyone’s opinion. My parents were very nervous about this, the head of my school house, we were in different houses, said that it was complete madness and I should never think about it and I should get on with following in my father’s footsteps but I think my memories of being a child of diplomats were memories of separation even when you were at home you were very much in the background and you couldn’t behave as a child, you had to be on your best behaviour. I’m very used of course now to dealing with people of high rank and so on because all my early life was like that but I think it was a kind of rebellion against a rather, I won’t say a loveless childhood at all, they were very loving, it’s just that there wasn’t much time with them.
I: A little distant at times?
P: Yes, yes. I mean I remember every family get together with great love and happiness but there were long stretches of time when either they weren’t there or if they were, I had to be in the background and seen and not heard, that sort of thing.
I: Are your parents still alive?
P: They’ve both passed away now.
I: Tell us about your time at medical school.
P: Well getting there was the most difficult thing, I was at Oxford and I was doing the modern languages and asked if I could change and start doing medicine and they said, ‘There’s absolutely no question of it, you’ve got no science qualifications at all but if you get a Degree in modern languages which is what you’re supposed to be doing, we’ll give you a chance to start at Oxford.’ I had to do something which then was called Prelim 4, which was a course designed for people in my position who were few and far between, I think there were in fact four of us who started doing that and it was something called Zoology for Medical Students and then ‘A’ level equivalents in physics and chemistry.
I: How long did the course last?
P: Well you went through it as fast as you could basically because I was aware that I was using up my parents’ funds to do this apparently crazy thing. I think that I did it in a year at Oxford, I hired my own tutors and was very much on my own. The Zoology for Medical Students was the quickest and easiest thing to do, the physics and the chemistry were a little harder for me but once I got the green light to go I was absolutely thrilled. I should add that I had been advised to apply to a medical school outside Oxford when I originally asked to change and was told I couldn’t, so I had already been offered a place at Bart’s with the proviso that I had to have a Degree first to show that I was serious. So that’s basically what happened. I took the first year to get the basic scientific background which I needed and then I started clinical work at Bart’s. Now, I’ll try to get a date for you <pause> this would have been ’66 I think or ’67.
I: And so you qualified in which year?
I: Where did you do your first post after that?
P: The first post was down on the coast in Folkestone because I love the sea. I don’t know whether it was because at the age of six weeks I was already on a boat, six weeks on a boat and my parents also liked sailing, so I think it’s a family trait as well. So Folkestone was a bit of a backwater. Again, why was I going down there? I think it was that, I didn’t really enjoy Bart’s terribly, it was rather rigid, you were not allowed to overtake the Matron in corridors; you had to wear a strictly sober uniform.
I: You mentioned sailing, did you have any other particular hobbies while you were at medical school and afterwards?
P: Well since the age of 17 I’ve been playing guitar, usually singing as well and I composed songs, I’ve got memories of playing in pubs with friends and that sort of thing. But as I perhaps mentioned I’m very single-minded and I was conscious that my parents had sacrificed quite a bit to get me through medical school and so I always kept it to one side. It came to a head when I did my first anaesthetist job in Hastings and there was a lot of live music in Hastings at that time and I remember hesitating really between the two careers because I loved music and composing very much and I came down on the side of carrying on because by this time I’d discovered quite accidentally that anaesthetists anaesthetics/anaesthesia was for me, so at that point I decided, ‘No I will leave that until I’ve got myself into this career of anaesthesia.’
I: What made you decide anaesthetists was something you wanted to do?
P: It was purely accidental. I was doing house jobs, I’d done the year in Folkestone as SHO, sorry the pre-registration jobs and I was applying for a job in gynaecology as a gynaecological SHO and I went down to Hastings because it was near… I liked the Kent area and I thought, ‘I’ll stay around here.’ I also liked to be by the sea, a job came up in Hastings and I went to the interview only to find that someone had just been given the job. They said, ‘Well sorry about that but there is actually an anaesthetist job going, why don’t you try your hand at that?’
In those days and certainly at Bart’s anaesthesia was very much the last thing anyone would consider but I met the anaesthetists and I thought they were a marvellous bunch of people, quite different to the consultants I’d met in other specialities up until then. So I said, ‘Well I might as well have a go, why not?’ It was only six months and it was good to have a bit of anaesthetics anyway and so I started. And basically as soon as I started doing anaesthetics I remember I anaesthetised a caesarean section six weeks after I’d started which of course these days would never happen and I just loved it. And they seemed to have confidence in me, so it was just great fun. At Christmas, one of the consultants would stagger up the stairs with a huge box full of whiskey and gin and all things one liked to imbibe in those days and it was in gratitude for us doing the on-call. In those days you did a huge amount of on-call and, well, perhaps you still do, but I think that was why one learnt so much so quickly, you were given a lot of responsibility very early.
It was considered very poor form to ask your consultant for help for anything that couldn’t be settled over the phone. I inserted my first chest drain in that way, you know, just saying, ‘What do I do?’ He said, ‘Well just stick it in boy.’ You know <chuckles> ‘All will be well!’ <laughs> You would watch it then go through and into the lung and all was well but I’ve always been very good with my hands I think I can say, so I think they had confidence that the mechanical side at any rate, I wouldn’t get into trouble.
I: How long did you stay in Hastings?
P: I was there, in the end I did a DA, I think I stayed a year actually instead of the six months; thoroughly enjoyed it and then I wasn’t quite sure what to do, I had my DA, I went through a period of really not being sure what I wanted to do. I had done a certain amount of accident and emergency work and I started to toy with the idea of doing that but again in those days that was not considered a career. So that was rather frowned on but having got qualified and having done some anaesthetics I went through quite a long period of not knowing really what I wanted to do. I think the inventor in me was beckoning but I didn’t know quite how to apply it or what relevance it had to what I was doing. The musician in me kept nagging away and I kept composing things which kept me awake because I wasn’t really playing for anyone, so I did a series of locums while I was trying to work out what to do.
And at this time I was also, of course involved, I was at the age of trying to find a wife and the long and the short of it was that I went through quite a long period of uncertainty and doing short jobs here and there around the country. And then I wound up going over to Holland because a girlfriend who I’d had in Uruguay, my parents were in Uruguay, my father was the Ambassador there, asked me if I would come and do a locum for her half-brother who was an anaesthetist. So I went over there, did the locum and he said, ‘Well we rather like you here, how would you like to take my job because I don’t like the surgeon and I want to go and work somewhere else.’ So I said, ‘Well I can’t possibly do that it wouldn’t be good for my career.’ And I went back to England but circumstances changed and I wound up actually taking this job in 1973. So I became a Dutch… well they don’t have consultants, they call them specialists, I became a Dutch specialist anaesthetist in 1973 and I stayed in Holland until 1977.
I: Did you have to take exams in Holland?
P: They at that time did not have a Fellowship and the DA was quite enough for them.
I: What were the other differences between Holland and the UK, can you think of?
P: At that time, I must say it’s not true today, at that time they were quite large differences in terms of the status of the anaesthetist which was much lower in Holland than in England and I think really the knowledge of the anaesthetist was much lower. Certainly the attitude struck me as astonishingly inappropriate and I immediately did battle with the surgeon who had caused the previous anaesthetist to leave and thoroughly enjoyed myself in gradually setting up a sort of British-style anaesthetist service there because coincidental with my arrival the old hospital was closed and we moved into a new hospital and I found myself setting up the anaesthetist department from scratch.
The other major difference between the two systems, the British and the Dutch, was that there was a system of nurse anaesthetist, not a nurse anaesthetist but nurse helpers and these people were variously qualified, to various levels, none of them very high because the anaesthetists themselves were not terribly well trained. So I was setting up a department which already assumed that there would be nurse anaesthetist-like helpers and I found myself running four operating theatres single-handedly, supervising these four. There was one very, very clever young man who was let’s call them nurse anaesthetists, it’s not quite the right word but and three girls and he gradually trained them up to the best of their ability which was actually quite high. If they were offered the training, they became very skilful. And this was necessary because if you’re running four operating theatres, you need to have confidence in the people who are actually in charge of the patient when you’re not in the room.
But that went on for four years during which time I managed to persuade the hospital to engage a second anaesthetist and a little bit of comedy entered at this point because I finally got a wonderful Scottish anaesthetist called Johnnie Walker who had done a lot of anaesthetics in Australia and had his Fellowship which I did not. But when he arrived I was supposed to be the Chief Anaesthetist but he was clearly much more senior than me. Clearly that is between he and me though not clear to the hospital, so we kept up the pretence of my being the chap in charge while over beers in the evening he would drill me in what I needed to know to pass the Primary and finally get the Fellowship, which I got in 1977.
I: That was from Holland?
P: From Holland yes and because at that time it was very much frowned upon to work overseas if you were still a junior anaesthetist I found that I was not welcome taking either the Primary or the Second part in England, so I wound up taking it in Ireland. That didn’t bother me because my mother was Irish, I love Ireland and I felt very at home there so I used to shuffle backwards and forwards between Holland and Ireland. I took the course in Hammersmith, the Primary course which was very good and very useful, although I raised a lot of eyebrows during the course when people talked about whether or not you should measure CO2. I said, ‘Well of course we do that all the time in Holland.’ We had huge old capnographs which were the size of a dining room table and this was not really very well regarded at the time. But I remember falling foul of people at the Hammersmith because I was using these things. Anyway I got the Primary and then I got through.
I: What brought you back to the UK?
P: Well I didn’t come back to the UK for quite a long time. In all of this the person who became my first wife played a part because initially I left England because I really wanted to end a relationship which was why I wound up working in Holland thinking that this would be a temporary thing. <chuckles> As so often happens, you go somewhere and suddenly a few years later, you’re still there, so I actually did stay in order to end that relationship and then I changed my mind and having flown her back to Guyana I then flew back to Guyana and married her. And when she got to Holland she didn’t like the cold and I’d already done everything in a sense, I’d got the hospital anaesthetist department running the way I wanted and I like challenges, I like doing new things, creating new things, and having got everything going and I’d got my Fellowship, I thought, ‘Right, this is time to leave, she doesn’t want to stay here, let’s go somewhere else.’ And she said, ‘Well it has to be somewhere hot,’ so I said, ‘Well I suppose I can afford a couple of years back in the tropics.’ You know because of my past history I was very willing to go back to if necessary a third-world country. I wanted to start a family by this time and so we wound up doing a two year stint in the Seychelles which was a WHO sponsored post where half your salary goes into the UK and the other half you use. And that was a wonderful time because it’s a beautiful place, I was again in the position of being a single-handed anaesthetist but this time with really very little in the way of reliable laboratory back-up, even the haemoglobin sometimes was untrustworthy. So you were developing other skills at that point, you’re really learning to fly by wire clinically and I learnt an enormous amount both in Holland and with my two year experience in the Seychelles. So I actually did a total of six years outside of the UK with really very little in the UK apart from the year in Hastings and several locums.
I: And after the Seychelles?
P: After the Seychelles, I said, ‘I really must go back and do the right thing,’ because I was conscious of the fact that my career was looking extremely dodgy in terms of the CV and so after two years, in fact two years in the Seychelles is too long because in those days you couldn’t have a break in the middle, you had to do two years straight and it’s a tiny community, 65,000 population, mostly black. A lot of very, rather like in Africa, the situations where people are in extremis, you would get almost exsanguinated patients arriving in the middle of the night for caesarean section. So it was a very valuable, practical, hands-on experience, very much emphasising the need I think to developing clinical skills without the benefit of back-up, colleagues to advise you and so on.
So I finally went back in 1980 to the UK having left in 1973.
I: And where did you work when you came back?
P: And then I went first of all, I felt that I could go for a consultant job which would obviously today be completely out of the question after what I’d done but I knew how to give an anaesthetic in pretty much any circumstances, so at that time it was almost acceptable and I almost got a job in Margate because again I wanted to be by the sea. And then the lady who, I’m sorry I won’t remember the name but who was a very nice consultant in Margate, who wanted to offer me the job but at the time there was beginning to be a tendency to want to favour apparently disadvantaged people and I think there was somebody from a third-world country who had some … somebody with influence And I also thought that Margate wasn’t quite right for me, even then it seemed a bit of a backwater and I wanted to get back into the thick of things. So this lady was a very nice consultant, sorry I can’t remember her name, she said, ‘Well I’m friendly with Professor Payne in the London Hospital, so go and see him and perhaps he’ll fix you up with something.’
The other point was that I had said to her that I was interested in research because this was the inventive bit wanting to come out in me and so when I went up to London again in 1980 still and I applied to see Professor Payne, he was actually busy and I saw his deputy who was a senior lecturer again, I’m going to have trouble with names, I’m sorry, I can supply afterwards but I’ve forgotten. And this senior lecturer liked the various ideas which I was proposing, I had various ideas of things I wanted to do in research and so they said, ‘OK you can have a job, we’ll give you a senior lecturer job,’ just like that. Sorry, not a senior lecturer, a lecturer job, so I became a lecturer in anaesthetics at the London Hospital in the later part of 1980.
I: What were these ideas that you were interested in?
P: I remember telling, I’m embarrassed I can’t remember his name, I’m so sorry, I remember telling him about an idea I had to bring up veins which was a simple hollow cylinder which was transparent, I used an old rubber facemask which was around the outer end and you put it on the arm and at the end there was a little nozzle which you attached to the suction, so that would suck the veins up in the arm. And this seemed quite fun really and I think John Bushman, I was trying to remember, I’m so sorry, apologies to John Bushman. John thought this was great fun but he told Jimmy Payne and he said, ‘I’ve never had any trouble getting a vein!’ <chuckles> So he wasn’t too keen on that.
I: So it was never developed?
P: Well I started making my own prototypes and I made one and used it and I don’t know if it would have had any application but it certainly worked and Professor Payne gave me as my first job to go and clear out Ashford Street which was full of laboratory equipment which had been discarded by various other pervious lecturers who’d done some research and in the course of doing this I realised most of it was going to go on a tip or several tips and most of it was unused laboratory equipment which had come from America. Massively expensive amount of equipment and he said, ‘You can help yourself to anything you want there because it’s all going to be dumped.’ So I found an empty room at the London and started putting all sorts of bits and pieces in there which became the basis for making my own prototypes for various different inventions which I was keen to try to make at that time. So I’d suddenly realised I’d actually found what I needed to develop my inventing interests and by this time I had the skills in anaesthesia to know what the problems were.
I: What made you think about airway problems?
P: Well I think then it became very much a question of what was really missing in anaesthesia and what was the bit that was really most unsure and I thought, ‘Well all this holding of facemasks does seem to me to be a bit awkward really.’ I remember all those years in Holland when I’d designed various things to pull the chin up, you know rushing from theatre to theatre and seeing the airway gradually deteriorate and of course that was my British training which was to use the facemask most of the time and you were intubating perhaps less than 40% of people that they would intubate in America at the same time.
Then I heard a lecture by a visiting American Professor in which he was saying, ‘Well what we really need to make a step forward in management of the airway in anaesthesia…’ and coincidentally I had been giving dental anaesthetics with the Goldman dental nosepiece for dental anaesthesia because it just went down the nose and they were just about to switch over to a disposable form. So I added to my collection bits and pieces of the remaining Goldman masks and started fooling around and seeing what I could make and it occurred to me that the anatomy surrounding the larynx was of similar proportions to the shape and size of this mask and that lead me to make the first prototypes of the laryngeal mask. And I actually had them in my car for six weeks before I dared to use one and then I thought, ‘Well I wonder what this feels like?’ and I tried putting it in my throat and I was rather excited because it seemed to go in, I coughed and spluttered a bit but I could breathe through it, it was a very exciting moment. So I went down to the photographic department and said, ‘Can we photograph this because this is quite interesting, I can breathe through this device?’ And they took some photographs of me doing this but unfortunately I lost the two main photographs where it was actually in, but I had the photograph of me with the Lignocaine, ‘cause I used to put Lignocaine, spray it, 2% and then put the device in my throat. So was it a party trick or was it something useful? Actually I didn’t dare to try it in a patient until I went down to my previous hospital in Folkestone to do a locum for one of the anaesthetists I knew well from my time doing my house jobs down there. And I was doing a list and there were some very simple cases and I thought, ‘Well why don’t I try it?’ No Ethics Committee approval, nothing like this! We might need to edit this out! <laughs> And so I tried slipping this thing in and having proved it myself, I thought, ‘Why not? It seems to be OK.’ And it was really a very, very exciting moment because they just breathed happily through this. And then I tried squeezing it a bit and then I found I could actually also ventilate.
I: Which year was this?
P: Now this was in, let me see, I think it might have been into 1981 by this time, yes, because then I very quickly started about how I could protect this idea and also who might be able to make it. And as I knew that Portex was down in Hythe only 10 minutes away from Folkestone, I thought, ‘Well while I’m there, let me go and see them and show them this.’ And in fact, I asked them if they wanted to come and witness a case and I showed the other consultant anaesthetists who were there and they all knew me and they all thought this was rather fun, you know. Nobody was saying, ‘Eureka!’ or anything, it was just quite fun. And Portex were unimpressed. The first question was, ‘Can it be made disposable?’ and I said, ‘Well I haven’t really thought about that but aren’t you interested?’ And they said, ‘Not really.’
So I was a bit disappointed, I went back to London and got on with my inventing various other things. I wanted to make an analgesia system in which you impregnated suture materials with an anaesthetic agent, an analgesic, and then the surgeon would just use it and you would have a high concentration of local anaesthetic where it mattered in the wound. And I approached several companies with this idea and nothing came of it. And that was true of several other things. I can remember one fact that after I’d been at the London a year, I had six patent applications which were in process but I didn’t have the money to keep them going, it’s an extremely expensive business, so i allowed all of them to lapse except for the laryngeal mask.
I: So that was the only one of your inventions?
P: That was the only one. Well the other thing that happened was once I had shown Professor Payne this device, he to his credit said, ‘This is important, forget the others.’ And so I did concentrate on that one. I agreed with him totally because I knew that it was important because I knew how important the airway was.
I: John Nunn was involved at this…?
P: Later on because he said and especially John Bushman said, ‘You’ve got to publish this.’ So I was already starting to realise that there was the invention side and the potential was there to make something which would become a product one day and on the other side, the need to actually establish a scientific foundation with a publication and so on. So John Bushman was actually very helpful to me and he said I should go for the BJA because at that time of course the College was inside, it was the Faculty wasn’t it, not the College? So he was of the College, The Royal College of Surgeons and he said, ‘We’ll try to get a publication and help you with this.’ So I get Ethical Committee approval, in those days a very loose-worded document which was open-ended in terms of the number of patients and thank God it was because had I been asked how many patients I needed to demonstrate that this device worked, we might actually never have had the laryngeal mask but the fact that it was open-ended meant that what started, I didn’t realise how long it would take, as just a question of a few patients. I remember Jimmy Payne said, ‘Well you’ll need 20 patients,’ actually turned into 7,000 patients and the fact that I could do things with my hands to make my own prototypes meant that I was literally at one time working deep late into the night making the next batch of prototypes and then during the day trying them out in an extremely large number of patients and virtually all the patients I was anaesthetising.
I: Were all your patients at The Royal London at that point?
P: No because, I’ll try to get the time sequence right, a consultant job came up at Newham and I applied for it, it was a part-time job which suited me very well because I needed a lot of time to do the other things. So I took that and I got that job and I think the Chair at that time was David Birt and so I became then a consultant on a part-time contract working at Newham. So I was actually doing a lot of these, acquiring all the clinical knowledge about how I should make this and how I should use it; the two things again are different, they fed into each other. You changed the design, you changed the way you used it and I was changing the design continuously over those years, right up until 1987 working at Newham. Yes, that’s right up until 1987 and at that time I had done an enormous number of cases and I knew basically what really worked well and what didn’t.
I had also got into and then got out of a contract with Portex because when I’d done the publication which came out in 1983, it was initially rejected by the way, the publication was not accepted they thought it was too dangerous and John Bushman again was very helpful because he persuaded the editor that this was something that should get published, so it was my first publication in fact, 1983. But it was as you know, it was a very small number of cases, 23 cases, but the actual experience was far greater than that and because of the lag in getting it published I just went on and on collecting these patients.
I: There was another more finite paper wasn’t there that came out later?
P: Well there were four publications earlier on in those years. There was one in the archives of Emergency Medicine because I also thought this might be useful in that department and there was one in Anaesthesia. There was one in something called Today’s Anaesthetist which was the first publication by somebody else because that was by Colin Alexander down in Hastings; that was actually a bit later, sorry. And there was another publication in Anaesthesia which I described an intubating laryngeal mask as well. There were three, I’m afraid I can’t remember the details now but they were all prototypes, so all of these early publications were prototypes therefore there was very little commercial interest and Portex really was losing interest, they really wanted a disposable device. So in I think 1983 I met a rather crazy individual who was, however, an extremely successful businessman, his name was Mr Gaines-Cooper and he subsequently became extremely important in my life because he was the first chap who said, ‘I will take this on. I don’t know what you’re talking about but it sounds interesting.’
I: He supported you to carry on.
P: He said, ‘I will fund this.’ And then I said, ‘Well Portex is not really doing anything,’ and Portex and I had an agreement whereby they paid for the initial patents for countries they thought were important which was the United States, the United Kingdom, Japan, England and France and so those five patents were the basis on which one could have the confidence to go ahead but when I met Mr Gaines-Cooper, he only could make a laryngeal mask for territories outside those because I still had the contract with Portex. But they made the mistake of paying a small retainer a few days’ too late which made them technically in breach of the contract. So Mr Gaines-Cooper who was always a very lucky man actually suddenly found himself with a device which could be sold everywhere and he had control of the whole thing. I had luckily arranged with Portex that although they were going to pay for the patents, they would remain in my possession so when they fell foul of the terms of the contract, they also lost the patents although they’d paid for them. So they didn’t do very well out of it, which they bitterly regretted later.
I: Was there any other particular obstruction to the development?
P: Yes there was a lot of clinical obstruction from people higher up in the anaesthetic hierarchy if you like who felt that this was dangerous but everyone who used it rapidly converted to it and once it was actually made available and people could try it which happened in 1988 in the UK only, then it spread like wild fire in the United Kingdom and six months after it was first launched in the United Kingdom, I’m told that it was in about 50% of NHS hospitals and an unknown number of private hospitals. So as soon as you had a device which was available on the market, it was distributed in England by a company called Colegate, they couldn’t make enough.
I: You’ve mentioned several names but is there anybody else that you feel has been very dominant in…?
P: Definitely yes I mentioned John Bushman who was very, very important to me and of course Professor Payne because he supported me. Later on I’d always greatly admired John Nunn, I’d heard him lecture and for me it was just magic. He was a wonderful lecturer and I thought that perhaps it was time for me to move somewhere a little bit more in tune with the way I was thinking because although London was great, I didn’t really feel that there were likeminded people around me and this was even more so of course when I went to Newham, where it was just basically routine stuff and although at the time I was there, by the time I left, I think my colleagues had come up with 23 cases of difficult airway which I’d resolved with a laryngeal mask, no one ever thought of publishing any of this, it was just, ‘Oh thank God for that then!’ <laughs> and we’d get on with the case. So at one point I went to see John Nunn and asked him if I could do a job at Northwick Park because it sounded like the kind of place that would suit me. And dear John was I still remember the moment when he asked me did I have anything special to offer, why was I applying for this job and I had a laryngeal mask in my pocket, so I pulled it out and said, ‘Well there’s this thing which I’ve designed which I’d like to do a bit more work with.’ And literally his feet left the ground, he was just so excited and he’s such a genuine man and I immediately felt very warm towards him. And it was mutual, we got on tremendously well although I was still totally in awe of him of course as I was unknown and very junior.
So he undertook a study which was the first independent study using my final prototypes, they were will my own homemade prototypes and that was the first independent study in fact on the laryngeal mask. 100 cases of breathing spontaneously which I think he put into Anaesthesia. And he never believed that the laryngeal mask should be used for positive pressure ventilation but of course he never was able to use the final version, he used my prototypes which definitely gave a lower seal. So John Nunn was enormously influential at that time and his word really opened the doors. It opened the door particularly to the commercial acceptance because although Mr Gaines-Cooper had taken the decision to go for it, I kept saying, ‘It’s not ready yet,’ and this irritated him enormously because he wanted to get on and start making money and when he got to know John Nunn, John’s enthusiasm very much influenced him and so he had to be patient and wait while I carried on until I felt it was ready.
I: So you’re more or less saying that John Nunn overcame the other obstruction?
P: I think this is true, yes. John was key really. I mean if John had said to this entrepreneur, ‘Well it’s all right,’ I think he would have immediately lost interest and we could never have had the laryngeal mask but his enthusiasm coupled with his obvious importance and charisma persuaded this businessman that this was a good thing to do and so he started putting serious money into it.
I should add that when I first met him, he said, ‘Well I’m just off to the Seychelles,’ this was over the phone, ‘I can’t talk to you now but get yourself a ticket and come over and we’ll talk.’ So I found myself going over to the Seychelles to meet him in February I think it was and it was just astonishing. I’d never met such an extraordinary man and I think he was fairly surprised by me too and we spent a week getting to know each other and walking up and down the hills in the Seychelles and I was trying to tell him what a laryngeal mask was and he said, ‘Well it sounds all fun to me.’ I was also talking about several other ideas I’d had at the time so he got fired up with enthusiasm and I can remember him saying as we parted at the airport and I went back to a cold London. He said, ‘I’ll be back in the UK, I’ve got to go to various other places and New York and so but I’ll be popping into the UK in a few weeks and I’ll go down to the city and raise a few million and I’ll get some sort of medical company in and we’ll see what we can do, because I need a cash stream.’ So this was all amazing to me, I’d never heard of anything like this, I was on my £13,000 a year or whatever it was and really living on a fairly basic salary. And I thought this man is either the solution to all my problems or he’s completely mad and I was extremely surprised because he said, ‘I’ll ring you in six weeks.’ I thought he didn’t sound like the kind of person who would actually ring you in six weeks but six weeks to the day I had a phone call from him saying, ‘OK I’ve bought this company,’ he couldn’t pronounce the word orthopaedic, so he was trying to say ortho-something or other, Orthofix in fact was what he was talking about, ‘I’ve bought this Orthofix company for 20 million, pretty cheap and we’ve got some cash now, so let’s go.’ I couldn’t say anything, I was just absolutely gobsmacked.
I: You’ve carried on developing the LMA since then haven’t you?
I: And you’ve done some work with Dr Verghese, is that right?
P: That’s right, yes. Dr Verghese came into the picture, he was the next important figure really after John Nunn because he had moved from Newham, he was a colleague in Newham and he had a magic pair of hands, he was very, very clever and he used to always make his patients go to sleep laughing, marvellous chap. And he said, ‘Why don’t you come and join me in Reading?’ At that time I was what they call a guest worker at Northwick Park but I was not giving lists there, I was actually working as a guest worker, playing around with the laryngeal mask, I was trying to develop one which would tighten up the upper oesophageal sphincter and we were using monkeys which were already anaesthetised with something else but that’s another story. So I didn’t have a job which tied me down and so Chandy said, ‘Why don’t you come over to Reading and I can give you as many clinical cases as you want to develop other forms of laryngeal mask?’ So I thought his sounded quite fun and John was retiring and what was clear was that without John the Northwick Park Research Centre would not be the same. Maggie Thatcher was already talking about closing down anything that didn’t make money and clearly it looked as though we were getting to the end of that experiment which was the Northwick Park Research Centre. So I went to join Chandy and because of his clinical expertise and the way he was able to make his largely private patients very enthusiastic about the work we were doing together, it was absolute magic for me, it was exactly what I wanted at that time.
So I became an Honorary Consultant at Reading General Hospital and I had rented a little house opposite the hospital which became my prototype making sort of research office. I had a secretary supplied by Mr Gaines-Cooper, he used to come in every morning and she worked downstairs and I had my little laboratory upstairs and that went on from 1990, I should add that I actually resigned my consultant job at the end of 1989 at Newham, so I was doing this research guest worker job with John Nunn between those years but it didn’t last very long because as soon as I realised I could work very productively with Dr Verghese, I spent a lot of time there and moved out of London.
I: So how long did you stay associated to Reading?
P: It was really up until the time that I left England which was in 2002, so it was quite a long time and basically I had to thank Dr Verghese for the enormous help that he gave me on the clinical side in helping me to test first of all the flexible laryngeal mask which was the next one that was made after what is now called the classic and then many years of work to produce the intubating laryngeal mask. That was all done really in association with Dr Verghese at Reading. And then finally the Proseal, so all of that was done there and there’s a huge debt of gratitude which I owe him for all that.
I: What happened to your clinical career at this time?
P: Well I was constantly in the operating theatre and when I resigned from Newham I basically was outside the NHS and I was not receiving money from anyone so I had to ask Mr Gaines-Cooper if he would compensate for me at the level of the salary which I would have been getting if I’d stayed, which he agreed to do. And that went on for some years until the company actually started making serious money and then I was able to get a little bit more but by that time I was married a second time and my second wife was very financially clever and she was also the sister of Mr Gaines-Cooper’s wife so a sort of…
I: You became a family?
P: It’s almost like a family, yes, that’s right, yes.
I: Do you still work with Mr Gaines-Cooper?
P: No I’ve now not seen him for more than a year I think. He is unfortunately, he’s quite unwell now and in December last year, I formally resigned my position with the company which of course now is a public quoted company, it’s on the Singapore Stock Exchange and there are 83 distributors around the world, so the whole thing is up and running. I’ve never been part of the company, I’ve always insisted on being outside it and maintaining clinical independence even though I don’t have a clinical position because in fact well before I resigned from Newham, I resigned because I was doing too much lecturing and it wasn’t really fair on my colleagues, they were always having to stand in for me and I think everyone understood that I had to do this. And really I can say since 1990 it has been more and more lecturing and teaching. First of all of course it was in the UK and then all around the world.
I: And you’ve never held another clinical position in the National Health Service?
P: No, never. It has not been possible, it has literally not been possible, I’ve got five Honorary Consultancies.
I should say that another very important help to me has been the Institute of Laryngology in London and that’s from quite early on because when I initially had the idea of making the laryngeal mask I thought to myself, ‘I really need to get to grips with the anatomy,’ because it’s one thing to put it in your own throat but you actually need to see what’s happening. So I went, I can still remember going on the tube to the Institute of Laryngology and getting to know people there and went to their anatomy department and getting specimens of the larynx and taking them home with me on the tube. And the smell of formalin was spreading around me <laughs> and it was slightly embarrassing. And then of course having to make prototypes, I also had to teach myself how to make rubber masks because I realised that the original prototype mask first of all I didn’t have very many of them and secondly, it wasn’t the ideal shape. So how do you change that? Well I went to get some liquid latex again from some shop in the East End and asked them how I’d turn this into solid rubber and I explained. So I then got some plaster of Paris and started making the shape which I thought was right and that was the reason I went to the Institute of Laryngology to get specimens of the larynx so that I could then put plaster of Paris against them and see what the resulting space was in terms of plaster of Paris solid. And clearly that produced a highly corrugated and traumatic shape which you couldn’t possibly put in the throat, so then I if you like, idealised that shape by smoothing out all the corrugations which were of course large post mortem in the specimens and produced a smoothed out shape which is what actually became the classic laryngeal mask.
I: Have you got any other inventions that you wish had taken off the way the LMA did?
P: Yes. I have for a long time had a lot of inventions which are completely outside this field and clearly really to get something off the ground, you’ve got to spend a certain amount of time within that field to which the invention applies.
I: These are outside anaesthesia?
P: Outside medicine even yes. So I’m hoping one day to get some of them off the ground but it’s quite difficult and now that I’ve as I said last year I actually in December I resigned from my consultant position with this international company and I’m trying to spend more time on music. So I’m not sure whether these inventions are ever going to get done.
I: Is there anything outside medicine that you wish you’d done differently?
I: That’s quite rewarding to say that isn’t it?
P: Yeah I’ve had a wonderful time, I’ve been very lucky.
I: You’ve been rewarded quite highly for your invention. Can you tell us a little bit about what awards and things you’ve got?
P: Well I think when dear Peter Baskett decided to put me up for the Gold Medal, that was a tremendous accolade and I was enormously proud and happy to receive that and in fact the Irish College struck a Gold Medal for me and I believe I’m going to get a Macewan Medal from the Difficult Airways Society which again will be a great honour, that’s another nice medal I think. <Chuckles> So I’ve had quite a few other medals and various honorary positions but it’s very nice to get these accolades but it’s not really for me what it’s all about. The greatest satisfaction for me is when I’m in different countries and people come up to me and say, ‘Last week I managed to save a patient using a laryngeal mask,’ I mean that’s really what it’s all about. That’s what I did it for and that’s tremendously satisfying.
I: During all the development of your product, you’ve obviously had to be quite involved in political areas. How did you deal with that?
P: I’ve tried to keep away from that. I think not having a position with the British medical establishment has helped to do that. I’ve never sought a professorial position, I don’t think it would help my work. I think I’m a little bit of a one-off in that way.
I: Do you think that’s caused resentment among some people?
P: It probably has but I’m not in the United Kingdom very much so I don’t <laughs> have a lot of confrontations if you like but I’m aware that this must cause resentment, yes, yes but what can I do about it?
I: You don’t feel that there’s anything that you could have done that would have changed that?
P: Well it seems to me I’ve always tried to put myself in a position where I can be most effective at doing what I know I do best, so I don’t know if you remember at one point Dr John Nunn was made a Dean and the result was not terribly to his satisfaction or perhaps to other people’s satisfaction and I think I would be even worse than him. So I think I’ve tried to steer clear of what I’m not good at and I don’t think that I would have produced any more had I have accepted some position in the College for example or in the Association. I’ve never been offered a position but I’ve never actually sought one, I don’t want one, I simply want to try to achieve something which will affect clinical practice positively. And I was also very conscious that you know life goes galloping by and I do have other things I really want to do and I’m really excited now about getting into music more seriously.
I: You’ve mentioned a lot of people that have obviously had a huge influence in what’s happened, have you forgotten anybody? Is there anybody that we need to…?
P: Oh gosh, I’m sure there are. I think what I’d like to do probably is to write a few names down later and think about then and then supply them to you.
I: Yes, that would be very helpful.
P: Clearly no man is an island and there’s a lot of people that have been great.
I: I know you have one daughter, have you got any other children?
P: I’ve got three daughters now, yes, I’ve been married twice and divorced twice.
I: Have any of them followed you into medicine?
I: What about music, have they followed you into music?
P: Actually funnily enough not, my daughter who was married yesterday, is into design, she likes to design, she’s been in theatre costume design and she’s artistic in that way. My second daughter was married two years ago and is living in Australia and she is into birthing hypnotherapy, so that’s the nearest to medicine. Very concerned that pregnant ladies are becoming medicalised or hospitalised, not hospitalised in the sense of going but feel that they can’t have their baby without medical help and she’s very against that and I actually rather support that. And my third daughter is becoming a Parisian I think, she’s bi-lingual and has just finished school in Geneva and is starting design again, a course of design in Paris.
I: So they’ve stayed in the arty side of the family haven’t they?
P: Yes, all.
I: You’ve mentioned music as one of your main hobbies and sailing.
P: Yes when I was the Seychelles I built an experimental catamaran <chuckles> and I still haven’t finished that, I’ve got to go back and finish that one day, yes.
I: What about any other hobbies, anything else?
P: I like particle physics, it’s difficult but I like to follow what’s going on in that world, a rather abstruse world. I love to learn languages, I’m currently learning Mandarin and Russian, more on the Chinese side because that’s more difficult, it takes longer. I’m just going to China now and I’m going to be there for a couple of months lecturing, also hopefully getting better at the language. There’s an enormous amount to do there in terms of teaching for my particular area, so that takes up a lot of time, it’s very fascinating there.
I: For someone who always had so little interest in science to start with, your life has changed considerably since.
P: Well it always strikes me as extraordinary that my ability with languages has actually been useful because when I started doing medicine, I agreed with everyone else, it didn’t seem to make any sense but when I invented the laryngeal mask I was almost immediately having to use my languages and I speak six and I use, I’ve actually lectured in eight languages because if you’ve got a bit of an understanding of language, you can often just speak to slides, for example Portuguese is close to Spanish; German’s close to Dutch; so having a linguistic ability has been absolutely fundamental.
I: It’s been fascinating listening to you talk about what you’ve done. Do you think there’s anything that we haven’t covered that we should have mentioned?
P: I can’t think of anything at this moment. <Pause> I’m very interested in literature, I like to compose and also to read, I like to write. A number of people have asked me if I want to write a book about all this and I said, ‘Well not yet, I’m not ready yet.’ <laughs>
I: There’s more to come.
P: More to come, yes, that’s right.
I: Thank you very much, it’s been very, very interesting.
P: Thank you.
I: Just before we finally finish perhaps you’d like to tell us if there’s any further developments in the pipeline that we can look forward to?
P: It became apparent in the early years that there are many different kinds of laryngeal masks possible and it’s really just lack of time and of course the enormous amount of development that has to be done before you can actually launch the device that has meant that we haven’t got these devices yet. I’ve always felt that it was possible to design a laryngeal mask which would offer substantially greater protection against the aspiration risk and that has always been a goal I’ve strived to fulfil. For the last few years I’ve been doing a lot of work in Houston using cadavers to explore this idea further and in fact I’ve just finished a very long series of experiments using the cadaver which had as their aim to actually finalise a design which would achieve this. So I think I’m about to rest on my oars there but there still remain other forms of laryngeal mask which would be less spectacular but still quite interesting which I am still working on.
I: We look forward to seeing what they are. Thank you.
<part 1 finishes>
<part 2 starts>
P: This is just a short section which I’ve added to my talk about things missed out and people missed out.
My first research project was not mentioned in the initial account. I found that I could reverse the inhibit, the compound action potential in a frog sciatic nerve muscle preparation using an electromagnetic apparatus which I designed and built myself. I was working alongside a Dr Wali from Turkey who was studying atracurium under Professor Payne using [67.10 chick embryos.] He observed the phenomenon I discovered and became very intrigued by it. He persuaded me to publish my results and helped me to write the paper which was submitted to the Japanese Journal of Zoology with Wali as author. For anyone who might be interested, the reference is Wali FA, Brain AIJ, Inhibition of Nerve Conduction by Electromagnetic Induction of the Frog Sciatic Nerve Gastrocnemius Muscle Preparation, Japanese Journal of Zoology, 1989, 39 pages, 303-310.
Subsequently I had some electro micrographic pictures made of the sciatic nerve used in one of the experiments and I found evidence of vacuolation in the axon. This persuaded me that the inhibition I had repeatedly demonstrated when the nerve was subjected to intermittent electromagnetic field stimulation from the coil wrapped around it, and which was reversible, was most likely the result of ohmic heating of the nerve. Consequently I felt that the phenomenon although interesting probably had no clinical application. Many years later, I was contacted by an anaesthetist working with the Ministry of Defence who had spotted the paper and was interested in possible military applications as a method of anaesthetising limbs requiring amputation on the battlefield. He later told me that he was unable to replicate my results and I heard no more about it.
Professor Ron Cass was one of several influential people who came to see me when I was working at Newham General Hospital in London’s East End to observe the prototype LM being used, following my first publication in the BJA in 1983 which he’d seen. Several of my first prototypes reached America and India in this kind of way, spreading news of the idea well before they were commercial products available but once the LM was being sold I think the main figure to emerge was definitely a young Yorkshire man who emigrated to Australia and who was ultimately to become the single most important researcher on the subject, producing many hundreds of peer reviewed articles on the LM. This was of course Dr, now Professor, Joseph Brimacombe. His greatest contribution will probably be his most recent one, a real labour of love I have to say, a single author 700 page text book entitled Laryngeal Masks Anaesthesia Principles and Practice 2nd Edition 2005. This was a greatly expanded version of the first edition, a book which we wrote jointly, published by Saunders. I’m told that both these books are now out of print.
In America, once the LM was commercially available which was in 1991, many influential people in the world of anaesthesia gradually became champions of the LM and many also became good personal friends. I can’t really name them all because I would have to add to these names the names of countless fine clinicians I have known from all over the world who’ve contributed to the spread of the idea of LM anaesthesia but I must mention my dear friend Professor Andranik Ovassapian from Chicago now sadly no longer with us, whom I often found myself lecturing in various parts of the world. He was of course founder of the American Society for Airway Management and he was a very great teacher. He had humility and kindness which are qualities often accompanying brilliance in my experience. He not only taught the use of the intubating laryngeal mask alongside the fibre optic skills for which he was justly famous but he also accepted my invitation to Chair the LM Companies Product Evaluation Committee, a position he held for many years to the enormous benefit of the LM Company and the other clinical members of the committee.
Another American clinician who was a close friend must also be mentioned, Professor David Houston an early convert to the intubating laryngeal mask and today my collaborator in the difficult but important task of designing the cadaveric model which is necessary to advance the design of the LM with a view to achieving the holy grail, that is to say a device which can reliably protect the lungs from aspiration whilst avoiding the need for tracheal intubation.
In the United Kingdom I have to thank amongst many others Dr Anil Patel from The Royal National Throat Nose and & Ear Hospital in Gray’s Inn Road, London, always of invaluable assistance to me during the development of the first disposable form of the LM Proseal device called the LM Supreme. His predecessor, Dr Paul Bailey, who’s now retired, was the first anaesthetist in Gray’s Inn Road to understand and promulgate the use of the LM principle for ear, nose and throat surgery. He taught generations of young anaesthetists this actually quite difficult skill, in fact he was soon fast to surpass my own skills. To him I owe my position as Honorary Fellow of the Institute of Laryngology.
Oh there are so many more. One day I’m able to write an account of all this at more leisure, I’ll try and connect the names of all who should be mentioned. For now I’ll just say that although the invention of the laryngeal mask has brought me many awards and allowed me to retire in comfort, it’s brought me far greater riches in terms of personal relationships and I’m tempted to conclude that anaesthesia seems to breed the qualities of modesty, altruistic dedication and humour wherever in the world it’s practised. It was a very happy accident indeed that allowed me the privilege of becoming part of this wonderful community.