Sir Ivan Magill: Endotracheal Intubation

Sir Ivan Whiteside Magill is one of the best known names in British anaesthesia. He served in the RAMC during the First World War and in 1919 was posted as an anaesthetist to Queen Mary’s Hospital for Facial Injuries,  “with little knowledge and less experience in anaesthetics”. Working with pioneer plastic surgeon Harold Gillies, and fellow anaesthetist, Stanley Rowbotham, Magill developed endotracheal intubation a method of anaesthesia that allowed surgeons to work on the face and jaw without being impeded by anaesthetic facemasks or equipment, and which is still in use today.

In this interview from the Association’s archives and recorded in 1976, Sir Ivan discusses his work at Queen Mary’s and the role he played in establishing the Association of Anaesthetists and the first qualification in anaesthesia- the Diploma of Anaesthetics- in 1935. The full transcript is available here.

Medical School

I took up medicine because I lived in a small town of 7,000 inhabitants and when you’ve got a grammar school education you had to do something. Well there were only a few options. Either you went into the bank, which my father wanted me to do, or you became a parson or you did for the law or medicine. So I elected to go in for medicine and that’s how I started. I wasn’t particularly interested in medicine, but it was a job and you had to do something to make a living, and I qualified in medicine in April 1913… in the Queen’s University in Belfast, Northern Ireland.

I wasn’t particularly interested in medicine, but it was a job and you had to do something to make a living

And I took honours in medicine and I thought I would like to try my hand at general practice, so I took an assistantship there in Northampton, where I worked with an old gentleman and I got £4 a week… And I worked there for three or four months but I found that … 80% of the patients had nothing the matter with them really and the other 20% I would spot it as soon as anybody, so I did that for a while and then having collected a few golden sovereigns I then repaired [to] the North of Ireland where I enjoyed myself for some months, and then I thought it was time I began to work really and I took a job in Liverpool, as a house surgeon… with four other people… There was a senior surgical, a junior surgical and two physicians, and we got on alright.

But then one night it was an appendix came in, middle of the night, and they couldn’t get hold of the resident surgeon and the senior resident surgeon said, ‘I wouldn’t like to do this one.’ I said, ‘I’ll do it.’ So I removed the appendix, and the senior surgeon was promptly sacked about a fortnight after that and I got his job. And during the next few months I did many operations, and frankly I was rather crafty when I knew there was a case coming in that required surgery, if my visiting surgeon happened to be on the premises I kept quiet about this, but whenever he began to go home I rang up his house and of course his secretary said he hadn’t arrived and said, ‘Well you’d better tell him that I have telephoned to him to say there’s an emergency here that couldn’t wait,’ and that I was carrying on the job. And I got a fair amount of experience doing abdominal work and even going into a head. I did a lot of surgery in that way but I never touched anaesthetics.

“I did a lot of surgery… but I never touched anaesthetics”

The anaesthetics were given by the other chaps, they didn’t have any phobias about it and so on. There was one very chloroformist there… and he anaesthetised the patient and himself, and he kept the thing going very well for …  the job in hand.

The Walton Infirmary

I eventually left that place and I went to the Walton Infirmary in Liverpool, and that was a wonderful institution. There were about 2,000 beds and there were only two medical officers in it. It was the senior one and myself, the junior. But I discovered that a large number of the people were chronic and it was a wonderful… land, where you could do surgery if you liked, like for instance a gangrenous leg’s got to come off and I made the other fellow give the anaesthetic for me to do.

“It was a wonderful institution. There were about 2,000 beds and only two medical officers”

But I discovered that it was interesting to see how this place was run. Now there were about 2,000 beds and yet there didn’t seem to be any more work in the various wards, and I tried to find out about this. But we had to do a round of the ward each day, you see, and I went to one ward and… somebody had come in in the night, I’d look at it and I would go round some of the other people, mostly chronics. But I remember very well going round the ward and I saw a rather dirty-looking cash sheet and I said to the Sister, I said, ‘This patient with the pleurisy – where’s he?’ She said, ‘Oh, that’s the bath man!’ I said, ‘What do you mean? He’s got pleurisy.’ ‘Well,’ she said, ‘He’s been here seven years, he’s a very good bath man.’ I said, ‘You bring him up.’ So he came up and he said, ‘What do you want with me?’ And I said, ‘I want to know about your pleurisy.’ ‘Oh,’ he says, ‘That’s alright.’ ‘Well,’ I said, ‘You’re in the hospital here you know. I think that if your pleurisy’s alright, I think you ought to go down to the house rather than an institution.’ So he took his discharge, and I went around the place, clearing it up and I found one man who had been in 27 years with incontinence of urine. So I said, ‘Well, I’m going to cure you.’ I said, ‘You’ll have to go to bed, unfortunately.’ But I said, ‘I’m going to give you some medicine, take it three times a day,’ and I said, ‘You’ll have to use a bed pan and you’re not allowed to get up, because this treatment is very difficult and we want to get you right, you know?’ So I put him in bed and I gave him with a mixture… three times or four times a day, and he was on milk diet and not allowed to get up. So after about five days he took his discharge, after 27 years!

“I went around the place, clearing it up and I found one man who had been in 27 years!”

Well then I found you see that having sacked all these people that were really patients in the place, they found there was nobody to do the work and they had to put their ha’penny on the rates to employ char ladies to come in and do the work that the patients were doing!

Queen’s Hospital, Sidcup & Harold Gillies

I gave some anaesthetics in France in a base hospital there but I wasn’t interested, and when I came back, the story is this, that I was in charge of troops and the last job I did in charge of troops was at High Wycombe where I had 5,000 troops, all in billets all-round the place and then came the armistice, And I was fortunate enough to be in a place called Barnet War Hospital. Now there were two Fellows of the Royal College of Surgeons doing a bit of the odd surgery, hernias and this and that, and I gave the anaesthetics. And there came around an order from the ADNS for the people who were employed on the staff at the hospital and we sat round a table, four of us, the Commander… he was a relative of Chamberlain who did the raid in South Africa, and originally was in the Boer War. Well the two surgeons… they put down specialty: surgery, came to me and I put down a category and under specialty I put dash. And they said… ‘Oh, you’re an anaesthetist, why don’t you put that down?’ So I said, ‘Alright’ and I put down ‘anaesthetist’ and wallop… within 36 hours there was a telephone message came from the ADNS in Bedford to know whether I would be prepared to go to the Queen’s Hospital in Sidcup.

“I gave some anaesthetics in France in a base hospital there but I wasn’t interested”

In those days we had a bag, all your belongings went in that and then you went from one place to the other, so I said, ‘Sidcup? I know that is near London because I’ve seen it on the back of a bus.’ And I elected to take this job in Sidcup because my wife, you see, was qualified and was doing school work in the North London area, I said ‘I’ll be able to see her.’ So I packed up and I went to Sidcup.

Nice place, beautiful old country house with lawns and that kind of thing, I had a little mess and I said, ‘What kind of hospital is this?’ They said, ‘This is a facial hospital.’ I said, ‘What do you mean facial hospital?’ They said, ‘Well if you don’t know you’ll soon find out.’ So I didn’t bother, but the following day I did find out… Well, it was a job of work and I met a chap who was giving anaesthetists, told me how to do it.

“Within 36 hours there was a telephone message… to know whether I would be prepared to go to the Queen’s Hospital in Sidcup”

I didn’t like it very much and I applied for resignation out of my uniform but they wouldn’t grant it, we were short-staffed at the time, so I stayed on. And I got interested in it, and… Stanley Rowbotham and I eventually conquered the… airway problem which was the chief problem in those cases.

It was [Harold] Gillies who really encouraged [us] to conquer that problem… He said, ‘You ought to try this endotracheal insufflation,’ which… Kelly had introduced it in Liverpool. I didn’t start insufflation, it was done before, but well, Gillies helped me out occasionally and said, ‘This patient ought to have insufflation.’ I said, ‘I can’t put the catheter in.’ ‘Well,’ he said, I’ll do it.’ And he tried to do it, being a nose and throat man originally, and he failed, and we sent for a nose and throat surgeon and he failed to put the catheter in, so we had to carry on without the endotracheal anaesthetic, but that made me sit up and take notice, and eventually you see, Rowbotham and I, he joined me in it, we got to the place where we could intubate a patient through the mouth with the aid of a laryngoscope. You had to get ‘em down, and the laryngoscope was very powerful. The bulb was vulnerable. You had to have a resistance round it and by the time you got it into the patient’s mouth it would always be fused and you were in the dark.

“I didn’t like it very much and I applied for resignation out of my uniform”

As a matter of fact I didn’t like the shape of the laryngoscope so I published a laryngoscope for anaesthetists that I thought was the right shape and I told the people, I said, ‘You ought to be able to put a battery in the handle!’ They said, ‘It can’t be done.’ I said, ‘It can be done.’ But the trouble was that you had to have a resistance… so the original one, the one that I got made with the battery in the handle, had a rotary resistance on it, which you could turn the light up so far and I had no knowledge of that being done elsewhere.

Well Gillies was … very … pleased with his own importance. And it was very interesting, particularly after we established the endotracheal insufflation technique, where respiration was so different from the kind of thing that you saw before, the patient fighting for the airway and so on. This was so different, the people who came to see him at work, they very often, because he was a slow worker, they watched him for a while and got bored and then they’d come round to know what I was doing, and it annoyed him very much. He used to wiggle the patient’s head and make the patient cough so that he would call me back to my job, but I pointed out afterwards, I said, ‘He doesn’t like any conversation in theatre, you’ll see him wiggling the patient’s head to make him cough but they don’t cough now because I put a little bit of… preventative drain in.’ So he gave that up.

“It was Harold Gillies who really encouraged [us] to conquer the airway problem…”

I used that insufflation technique without a second tube for quite a while, and then we discovered the bad parts about it, the blood and so forth, and the surgeon being exposed to the expirations all the time. And we began to use a second tube. Then it was unnecessary to have a… through to drive blood away from the larynx.

I used to demonstrate the efficacy of the insufflation technique, true insufflation. You see during the period of inspiration there was still something coming out all the time and if you took a jug of water and poured it into the patient’s mouth, well it was alright! It simply got withdrawn.

Endotracheal Anaesthesia

A particular event in the technique of endotracheal anaesthesia… when I went into private practice I was still using insufflation with two tubes but I came on a patient [who] had an accident in Switzerland and she’d had several anaesthetics in Switzerland and when she came to Gillies to have it fixed up eventually in London, she said that on no account would she have any operation with ether or chloroform as an anaesthetic. She had already had them and she refused local anaesthesia. And I had to give her an anaesthetic for this job. And it was quite a problem, and I knew that I could control a patient with a gas bag, and nitrous oxide, semi saturation. I knew that if I could control her in that way, but I must intubate her, and I thought well the only way I could intubate her is with a rubber tube sufficiently wide in the bore to prevent two-fold respiration, and sufficiently consistent in its material that it would not be obstructed by any movement of the tube in position.

“On no account would she have any operation with ether, chloroform [or] local anaesthesia… And I had to give her an anaesthetic…”

I anaesthetised this woman with preliminary injection… and then I duly saturated her with nitrous oxide and oxygen and by direct vision I put this tube into the trachea. I had a very strong angle-piece which I made myself in case once the tube had been in position she might bite it, because she had all her teeth. Well the next problem of course was, that I’d thought out before, you cannot have a bag in close opposition to the patient’s face if they’re operating in that neighbourhood. You must have the bag at a distance. So I had a piece of tubing about, almost 5/8 of an inch in diameter, about a yard long, and the bag at the end. And an expiratory valve through to the patient’s face. That meant the bag was not obstructing the surgeon and… that was the first time I inaugurated what was popular known as the Magill Attachment. And the construction of that attachment was interesting. The bag was not a heavy bag. It was thin, thin rubber and the tension on the bag was equal to the spring on the expiratory valve. So if you delivered to the patient, in those days it was always an accident you see, you delivered to the patient the necessary mixture of nitrous oxide and oxygen for their respiratory requirements and there was a continuous flow business, but when you saw the bag swell it wasn’t necessarily rebreathing, it was simply that the bag was filling at that time and at the same time the tension on the bag lifted the spring, operated the spring on the expiratory valve. And that way we avoided a vast amount of rebreathing.

That was the first use of that. And I began to use that then on the soldiers because it meant that you did not have to saturate them very much. We used to saturate them with ether because they were tough guys… in order to intubate them.

“The first tube that I used… I got off an old Boyle’s machine”

Once we began to use nasal intubation with the two tubes, one down one nostril, one down the other, then we found that you could do that blindly. You put in the catheter, the other tube was guided in beside it. We did dozens of those. But then whenever it came to this wide-bore tube I discovered that I put it in, particularly through the right nostril as a rule, because the tubes have got a bevel on the left-hand side because the course of the airway from the nose to the glottis crosses the pharynx, you see. But you could observe that when you were using two tubes, you would find them crossing in the pharynx. So I always figured that if I put in a tube within the right side, which being right-handed, the right nostril, then it would cross the middle line with the pharynx and the bevel would hit the left vocal cord… That worked. And you put down the other nostril too. But that was the original origin of the bevelled side.

The first tube that I used for that purpose that I’ve described to you, I got off an old Boyle’s machine, because it was a hard rubber. See the rubber available in operating theatres was useless for the purpose of intubation. It was soft rubber, made for drainage tubes and that kind of thing. Quite useless for intubation for my purpose. So the first one I got off of an old Boyle’s apparatus and then I began to hunt around for pieces of tubing and that kind of thing, in other words what I call commercial rubber. And I got in touch with a man called Benson in Tottenham Court Road. He was bombed out eventually, but he had a rubber shop where he sold squeeze dolls for babies, footballs and coils and coils of rubber tubing. And I went into an arrangement with this fellow that he would let me have the tail ends of the coils after they’d sold off the lot, because rubber is a live stuff, it’s soft when it comes out of the extruder but when you keep it for a while it grades consistency. And I used to call on him and I would get odd bits of rubber from him that fulfilled the requirements that I wanted. and eventually when he stopped, I used to buy bits of tubing and store it on the roof of my house so that, lying out in the cold, it acquired the necessary consistency. And it was little coils.

“I used to buy bits of tubing and store it on the roof of my house so that, lying out in the cold, it acquired the necessary consistency”

That was extremely difficult, to get a fine tube for infants… in the case of infants I found that the only solution was to have a tube specially made of gum elastic. It was very, very thin-walled, and I used that for quite a while, until the manufacturers got busy and started to make the tube for us.

The small tubes of the automatic piano player I found very useful for very young children, children under one year or two years old. But it was not long after that that we got the manufacturers really to get done and be interested in tubing. You see whenever Charles King started this shop, that was the first institution dealing entirely with the requirements of anaesthetists. And Charles King knew about this tube business and I told him the difficulties I had with getting them and he approached a rubber company and they produced miles of tubing! And they had two ladies in the back of his shop… with soldering irons, cutting these tubes and they were hopeless. They were oval and they hadn’t got the consistency. But it was only in later years… and these days people have got interested in it and they could see that there was… a commercial aspect of it, and then they began to make them. And several firms making them now.

“The small tubes of the automatic piano player I found very useful for very young children”

I think 1923 when I was appointed to the Brompton… Westminster was somewhere about ‘22/’23. My only contact with children was giving anaesthetics for tonsils in Westminster, where I used to drown them with ether and then give them chloroform with a hood. And the surgeon, he liked chloroform, ‘cause they didn’t bleed very much you see. Another surgeon that I worked with at the nose and throat, he liked mostly gas and oxygen, I intubated there. That was through the nose.

I worked at Dollis Hill as well. That was… plastic again. Well, the last anaesthetic I gave up there was in one of the big air raids in the Battle of Britain.

Intravenous Anaesthesia

It was quite a revelation to me when in 1930, when John Lundy was experimenting with barbiturates and he gave me some Nembutal to bring back, and I brought that back to London, and I had a corner on Nembutal for about six months and that was very interesting indeed.

It was quite a phenomenal thing you see, because hitherto we’d been using nasal anaesthetic… Avertin, which was an infernal nuisance because they had to be given half an hour before… and if you were in private practice and had several cases to deal with, you had to depend on the nurses to do the thing, so it was quite a revelation, a remarkable advance to be able to give an injection, and intravenously, which put the patient off to sleep, and I gave Rowbotham some of this and I used it myself, and I had some interesting experiences because there was a vast antagonism to this kind of thing.

“It was quite a revelation, a remarkable advance to be able to give an injection, and intravenously, which put the patient off to sleep”

I remember one occasion, there was an equerry of King George V… he had to have his appendix out, and his GP, who was an FRCS from Mayfair, … said, ‘I want him to be put to sleep before he has the operation.’ So I said, ‘Alright.’ He was in a nursing home in Manchester Street, and the doctor came along before the operation, he said, ‘He’s not asleep!’ I said, ‘You wait.’ And I anaesthetised him with Nembutal and put him to sleep, and they took out a harmless appendix and he spoke to the King on the telephone the same night, and the King said, ‘This isn’t possible, is it?’.

I brought Arfonad back from the States in 1953. That’s right. And I also, for the first time, saw freezing… thoracic operation. I remember it was an infant of about two years’ old and it was filled with ice and eventually… it was a transposition of the main vessels and the surgeon operated and transposed them and the child recovered sufficiently to cry before it left the table. I talked about that at the RSM I think I thought that they had really got something, these Americans, and they had!

The Diploma in Anaesthetics

I was very much interested in the training of anaesthetists… because whenever I got into private practice and I went to Brompton Hospital I found that the complications were getting so great in the way of managing apparatuses and that kind of thing that it was becoming a veritable specialty in its own right! And that we could never obtain any status without a degree and that is when, in 1932, when I was the Secretary of the Section of Anaesthetics at the Royal Society of Medicine, I asked the Council to permit me to see if something could be done in the way of getting a degree or a diploma. And they gave me permission and I went to the Secretary of the Royal Society of Medicine, who informed me that under the terms of the charter that he could do nothing in that respect whatsoever.

“Obviously the thing to do is to establish an outside body with this purpose as their main objective… the Association of Anaesthetists was established”

I reported back to the Council at the next meeting and my friend Dr Harry Featherstone from Birmingham, he said, ‘Well, obviously the thing to do is to establish an outside body with this purpose as their main objective.’ And it was for that reason that the Association of Anaesthetists was established, and in due time we approached the Council of the Royal College of Surgeons, I went as a delegate and put the case to them, and they did not seem to receive it with any welcome. However, I said to them, I said, ‘I feel that this thing has got to come to pass because if the Council of the Royal College of Surgeons don’t agree to it, steps will have to be taken to establish an outside body if necessary.’ And then they began to take notice and of course eventually we got the fundamentals, they arranged for an examination for a diploma in anaesthetics. And the first rules were made for the entry to the examination by a subcommittee including myself in the chair… and we made the rules. And the first rules were that anyone entering for an examination should be qualified in medicine, that they should have given at least 1,000 anaesthetics, 500 of which must be of major surgical procedures. And if they could produce evidence to that effect then they would be permitted to enter the examination. But within this proviso we learnt people were going up for the examination who were bookworms without any practical experience or potentialities in the way of application. So that’s how it started.

“Anyone entering for an examination should be qualified in medicine… [and] given at least 1,000 anaesthetics, 500 of which must be of major surgical procedures”

Before the first war… there was a movement afoot on part of Sir Frederic Hewitt and various other people who were in a senior position, to have some evidence of training of the newly qualified practitioner, that he knew something about anaesthetics, and it was inaugurated that the certificate of some kind should be provided before a man could enter into the final examination. Of course the war came on and that was toned down, but I personally had a certificate to say that I had received instruction in anaesthetics and I had personally administered an anaesthetic!

“I had a certificate to say that I had received instruction in anaesthetics and I had personally administered an anaesthetic!”

Honours & Awards

I suppose the Henry Hickman Medal was the chief honour I got, but I’m not an MD, I’ll tell you the story of that, which is rather interesting. Whenever I was at Sidcup, 1920, and we got busy on this endotracheal thing, I thought that here was something that would be worthwhile working on for an MD degree. And I wrote a thesis on anaesthesia for plastic surgery and I sent this off to the university and was turned down. And some years afterwards the North of Ireland Society of Medicine up there, they invited me to come over to deliver a lecture, the Robert Campbell Memorial Oration… and when I went over there of course I was talking about anaesthetics, and in the front row was an old fellow with a beard who was the man who turned down my thesis for the MD degree.

Well after that the Professor of Medicine to whom the thesis was delivered originally, he didn’t know anything about it and he sent it to this old GP who gave anaesthetics and things, and the old GP said, ‘This fellow is mad!’

Anyway, they made their amends in the university because they felt that they had done me wrong so they gave me an honorary doctorate of science which I carried on with.

In 1960 I received the honour of a knighthood for services to anaesthesia the KCVO. That was an elevation from the CVO, Victorian order… I suppose it was the climax of my career.

‘This is the last anaesthetic I’m going to give’

1973, I think that was the last anaesthetic I gave, and I went to give an anaesthetic for a dentist who liked my work, and I said to him, ‘This is the last anaesthetic I’m going to give.’ And he said, ‘Why?’ And I said, ‘Well, it’s unjustifiable for you to employ anybody of my age to give anaesthetics. In any case you ought to be encouraging the younger generation of your own time. However,’ I said, ‘this is the last anaesthetic I’m going to give and just because it is the last one I will demonstrate to you the blind [intubation] technique… I haven’t done it for years. And at the end of it I’ll give you the tube.’

“It’s unjustifiable for you to employ anybody of my age… you ought to be encouraging the younger generation”

There are certain milestones in anaesthesia that I think… one of them I think was the … endotracheal tube. That was one of the main things. Mind you, it was not invented by me, it was developed by me. The next thing I think was basal hypnosis, which was established by Rowbotham, that is to say that the patient should be absolved from the unpleasantness associated with the induction of anaesthesia. And that could be achieved by basal hypnosis with paraldehyde. And then of course the next thing was the… relaxants, that solved many problems, and of course nowadays you don’t have to saturate patients with ether anymore, but one has to be a little careful dealing with relaxants and nitrous oxide, oxygen maintenance with a little bit of pentothal and so on, because it is possible for a patient to be conscious and unable to speak. That has happened.

“There are certain milestones in anaesthesia… one of them I think was the… endotracheal tube”

I think one significant development that I have seen in my time was the practice of assessing respiration. That is to say the sensitive hand on the gas bag. That made a big difference to accomplishing efficient respiration and keeping the patient oxygenated and would absorb the carbon dioxide. And that was an initial development before we employed a mechanical device to squeeze the bag for us, and I was completely won over to that before I finished.