BookPDF Available

History of British Intensive Care, c. 1950-c. 2000

  • William Harvey Research Institute, QMUL
The transcript of a Witness Seminar held by the Wellcome Trust Centre
for the History of Medicine at UCL, The Wellcome Trust, on 16 June 2010
Edited by L A Reynolds and E M Tansey
Volume 42 2011
©The Trustee of the Wellcome Trust, London, 2011
First published by Queen Mary, University of London, 2011
The History of Modern Biomedicine Research Group is funded by the Wellcome Trust, which is
a registered charity, no. 210183.
ISBN 978 090223 875 6
All volumes are freely available online at
Please cite as: Reynolds L A, Tansey E M. (eds) (2011) History of British intensive care,
c.1950–c .2000. Wellcome Witnesses to Twentieth Century Medicine, vol. 42. London: Queen
Mary, University of London.
Illustrations and credits v
Abbreviations ix
Witness Seminars: Meetings and publications; Acknowledgements
E M Tansey and L A Reynolds xi
Sir Ian Gilmore xxiii
Edited by L A Reynolds and E M Tansey 1
Appendix 1
Dr Alan Gilston’s draft structure for the Intensive Care Society, 1970 87
Appendix 2
Outline curriculum in general intensive care nursing
for State Registered Nurses, Course Number 100, c. 1974 91
Appendix 3
Excerpt from 'Priorities in the use of physiotherapy'
by the Chartered Society of Physiotherapy, c. 1970 103
Appendix 4
Intensive Care and High Dependency: definitions 105
Appendix 5
Twenty-four Nursing Times articles claiming a nursing contribution to
the establishment of intensive care units, arranged by date, 1965–98,
collated by Dr Tony Gilbertson 107
References 109
Biographical notes 135
Index 145
Figure 1 Coventry Alligator iron lung, c.1966.
Photograph provided and reproduced by permission
of Dr Geoffrey Spencer. 5
Figure 2 A cuirass shell ventilator connected to a 12 volt
alternating suction pump, in use in an Alvis car,
c. early 1950s. Photograph provided and reproduced
by permission of Dr Geoffrey Spencer. 6
Figure 3 Oxford ventilator: Radcliffe, Mark 1 prototype,
c.1955. Provided by Professor Sir Keith Sykes,
© Nuffield department of anaesthetics,
University of Oxford. 7
Figure 4 Anne Isberg, aged 8 in 1952, receiving artificial
respiration from a dental student. Provided by
Dr Geoffrey Spencer and reproduced by permission
of the British Polio Fellowship. 9
Figure 5 A British iron lung flanked by the Australian designer
E T Both (right), next to Lord Nuffield with Robert
Macintosh (1938). Caption and photo provided
by Sir Keith Sykes, ©Nuffield department of
anaesthetics, University of Oxford. 18
Figure 6 Local organizing committee of the First World
Congress on intensive care, London, 1974. Provided
by and reproduced with permission of Professor Iain
Ledingham. 25
Figure 7 Broadgreen Hospital Intensive Care Unit, 1964:
(a) floor plan; (b) view from nurses’ station. Provided
by Ms Pat Ashworth and ©Liverpool Regional
Hospital Board, East Liverpool Hospital Management
Committee. 28
Figure 8 Ron Bradley’s equipment in use on a patient
after cardiac surgery in St Thomas’ north theatre
recovery room, c.1964. Provided by Dr Margaret
Branthwaite and reproduced by permission of
Professor Ron Bradley. 31
Figure 9 Equipment that Ron Bradley and Margaret
Branthwaite wheeled round St Thomas’ before
the designated intensive care unit, the Mead ward,
was opened in 1966. Provided by Dr Margaret
Branthwaite and reproduced by permission of
Professor Ron Bradley. 31
Figure 10 The aftermath of a session investigating cardiac
output: Ron Bradley sterilizing the pressure
transducers and Margaret Branthwaite ‘counting
squares’. Provided by Dr Margaret Branthwaite and
reproduced by permission of Professor Ron Bradley. 34
Figure 11 Ron Bradley measuring a patient’s cardiac output
by thermodilution, assisted by staff nurse Douglas,
Mead ward, St Thomas’ Hospital London, c.1973.
Photograph provided by Dr Margaret Branthwaite
and reproduced by permission of the Royal College of
Physicians of London. 39
Figure 12 Floor plan of St Thomas’ intensive care unit, which
opened in September 1966. Provided by and
reproduced with permission of Dr Geoffrey Spencer. 40
Figure 13 The first council meeting of the Intensive Care
Society in 1973. Provided by and reproduced with
permission of Professor Iain Ledingham. 51
Figure 14 Meeting of the International Scientific Committee
of the Intensive Care Society at the Royal Society of
Medicine, 26 June 1973. Provided by and reproduced
with permission of Professor Iain Ledingham; names
researched by Ms Alice Nicholls and corroborated by
Professor Ledingham. 53
Figure 15 The technician at Royal Victoria Infirmary, Newcastle
upon Tyne, 1982. Photo provided by Dr J C
Stoddart, ©anaesthesia and critical care department,
University of Newcastle upon Tyne. 70
Table 1 Outline programme for ‘History of British intensive
care’ Witness Seminar. 3
AC alternating current
ARDS acute respiratory distress syndrome
APACHE Acute Physiology, Age, Chronic Health Evaluation critical
illness scoring system
BACCN British Association of Critical Care Nurses
BBC British Broadcasting Corporation
BTA Been to America
CoBaTrICE Competency Based Training programme in Intensive Care
Medicine for Europe
CVP central venous pressure
DC direct current
DIPEx Database of Individual Personal Experiences
ECCO2R extra-corporeal carbon dioxide removal
ECG electrocardiogram
ECMO extracorporeal membrane oxygenation
ENB English National Board for Nursing, Midwifery and Health
ENT ear, nose and throat
FICM Faculty of Intensive Care Medicine
GGHB Greater Glasgow Health Board
GMC General Medical Council
HBN27 Hospital Building Note 27 (Health Building Note after 1992)
HDU high dependency unit
HP house physician
ICNARC Intensive Care National Audit and Research Centre
ICS Intensive Care Society
ICU/ITU intensive care/therapy unit
IPPR intermittent positive pressure respiration
IPPV intermittent positive pressure ventilation
ITU intensive therapy unit
JBCNS Joint Board of Clinical Nursing Studies
MGH Massachusetts General Hospital, Boston, Massachusetts
NICG Nursing Intensive Care Group
NIPPV non-invasive positive pressure ventilation
NMC Nursing and Midwifery Council
PAC pulmonary artery catheter
PCO2 arterial blood partial pressure of carbon dioxide
PO2 arterial blood partial pressure of oxygen
PRCP President of the Royal College of Physicians of London
RAF Royal Air Force
RAP resident assistant physician
RCN Royal College of Nursing
RCP Royal College of Physicians of London
SCCM Society of Critical Care Medicine
TEG thrombo-elastograph monitoring equipment
UKCC UK Central Council for Nursing, Midwifery and Health
In 1990 the Wellcome Trust created a History of Twentieth Century Medicine
Group, associated with the Academic Unit of the Wellcome Institute for the
History of Medicine, to bring together clinicians, scientists, historians and others
interested in contemporary medical history. Among a number of other initiatives
the format of Witness Seminars, used by the Institute of Contemporary British
History to address issues of recent political history, was adopted, to promote
interaction between these different groups, to emphasize the potential benefits
of working jointly, and to encourage the creation and deposit of archival sources
for present and future use. In June 1999 the Governors of the Wellcome Trust
decided that it would be appropriate for the Academic Unit to enjoy a more
formal academic affiliation and turned the Unit into the Wellcome Trust Centre
for the History of Medicine at UCL from 1 October 2000 to 30 September
2010. The History of Twentieth Century Medicine Group has been part of the
School of History, Queen Mary, University of London, since October 2010, as
the History of Modern Biomedicine Research Group, which the Wellcome Trust
continues to fund.
The Witness Seminar is a particularly specialized form of oral history, where several
people associated with a particular set of circumstances or events are invited to
come together to discuss, debate, and agree or disagree about their memories. To
date, the History of Twentieth Century Medicine Group has held nearly 50 such
meetings, most of which have been published, as listed on pages pages xv–xix.
Subjects are usually proposed by, or through, members of the Programme
Committee of the Group, which includes professional historians of medicine,
practising scientists and clinicians, and once an appropriate topic has been agreed,
suitable participants are identified and invited. This inevitably leads to further
contacts, and more suggestions of people to invite. As the organization of the
meeting progresses, a flexible outline plan for the meeting is devised, usually with
assistance from the meeting’s chairman, and some participants are invited to ‘set
the ball rolling’ on particular themes, by speaking for a short period to initiate and
stimulate further discussion.
1 The following text also appears in the ‘Introduction’ to recent volumes of Wellcome Witnesses to Twentieth
Century Medicine as listed on pages xv–xix.
Each meeting is fully recorded, the tapes are transcribed and the unedited
transcript is immediately sent to every participant. Each is asked to check his
or her own contributions and to provide brief biographical details. The editors
turn the transcript into readable text, and participants’ minor corrections and
comments are incorporated into that text, while biographical and bibliographical
details are added as footnotes, as are more substantial comments and additional
material provided by participants. The final scripts are then sent to every
contributor, accompanied by forms assigning copyright to the Wellcome Trust.
Copies of all additional correspondence received during the editorial process are
deposited with the records of each meeting in archives and vanuscripts, Wellcome
Library, London.
As with all our meetings, we hope that even if the precise details of some of the
technical sections are not clear to the non-specialist, the sense and significance
of the events will be understandable. Our aim is for the volumes that emerge
from these meetings to inform those with a general interest in the history of
modern medicine and medical science; to provide historians with new insights,
fresh material for study, and further themes for research; and to emphasize to
the participants that events of the recent past, of their own working lives, are of
proper and necessary concern to historians.
Members of the Programme Committee of the
History of Twentieth Century Medicine Group, 2010–11
Professor Tilli Tansey – professor of the history of modern medical sciences,
Queen Mary, University of London (QMUL) and chair
Dr Sanjoy Bhattacharya – reader in the history of medicine, University of York
Sir Christopher Booth – former director, Clinical Research Centre,
Northwick Park Hospital, London
Dr John Ford – retired general practitioner, Tonbridge
Professor Richard Himsworth – former director of the Institute of Health,
University of Cambridge
Professor Mark Jackson – professor of the history of medicine and director,
Centre for Medical History, Exeter
Professor John Pickstone Wellcome research professor, University of Manchester
Mrs Lois Reynolds – senior research assistant, QMUL, and organizing secretary
Professor Lawrence Weaver – professor of child health, University of Glasgow, and
consultant paediatrician in the Royal Hospital for Sick Children, Glasgow
‘British intensive care’ was suggested as a suitable topic for a Witness Seminar
by Dr Tony Gilbertson, Professor Iain Ledingham and Dr David Wright, who
assisted us in planning the meeting. We are very grateful to them for that input
and to Professor Peter Hutton for his excellent chairing of the occasion. We are
particularly grateful to Professor Sir Ian Gilmore for writing the Introduction to
the published proceedings. We thank Professors Ronald Bradley, Iain Ledingham
and Sir Keith Sykes and Drs Margaret Branthwaite, Geoffrey Spencer and Joseph
Stoddart for their help with the photographs; and to Ms Alice Nicholls, who is
completing her PhD on the subject, for acting as reader and providing additional
information. We are most grateful to Professor Sir Keith Sykes for his expert
reading of the transcript. For permission to reproduce images included here, we
thank the British Polio Fellowship, the Chartered Society of Physiotherapy and
the Intensive Care Society. Permission was requested from the anaesthesia and
critical care department, University of Newcastle upon Tyne, the East Liverpool
Hospital Management Committee, Liverpool Regional Hospital Board and
the Nuffield department of anaesthetics, University of Oxford, as copyright
holders, but no reply was received. Additionally, we would like to thank Dr
David Morrison, whom one of us (TT) met while travelling in Northern
Russia on the way to Archangel. A dinner conversation in Yaroslavl revealed our
respective professions and he generously agreed to comment on, and add to, the
records of this meeting.
As with all our meetings, we depend a great deal on our colleagues at the
Wellcome Trust to ensure their smooth running: the Audiovisual Department,
Catering, Reception, Security and Wellcome Images; Mr Akio Morishima has
supervised the design and production of this volume; we thank our indexer,
Ms Liza Furnival, and our readers, Ms Fiona Plowman and Mrs Sarah Beanland.
Mrs Debra Gee is our transcriber, and Mrs Wendy Kutner and Ms Stefania
Crowther assisted us in running this meeting. Finally, we thank the Wellcome
Trust for supporting this programme.
Tilli Tansey
Lois Reynolds
School of History, Queen Mary, University of London
1. Technology transfer in Britain: The case of monoclonal antibodies
Self and non-self: A history of autoimmunity
Endogenous opiates
The Committee on Safety of Drugs (1997)
ISBN 1 86983 579 4
2. Making the human body transparent: The impact of NMR and MRI
Research in general practice
Drugs in psychiatric practice
The MRC Common Cold Unit (1998)
ISBN 1 86983 539 5
3. Early heart transplant surgery in the UK (1999)
ISBN 1 84129 007 6
4. Haemophilia: Recent history of clinical management (1999)
ISBN 1 84129 008 4
5. Looking at the unborn: Historical aspects of
obstetric ultrasound (2000)
ISBN 1 84129 011 4
6. Post penicillin antibiotics: From acceptance to resistance? (2000)
ISBN 1 84129 012 2
7. Clinical research in Britain, 1950–1980 (2000)
ISBN 1 84129 016 5
8. Intestinal absorption (2000)
ISBN 1 84129 017 3
9. Neonatal intensive care (2001)
ISBN 0 85484 076 1
10. British contributions to medical research and education in Africa
after the Second World War (2001)
ISBN 0 85484 077 X
11. Childhood asthma and beyond (2001)
ISBN 0 85484 078 8
12. Maternal care (2001)
ISBN 0 85484 079 6
13. Population-based research in south Wales: The MRC Pneumoconiosis
Research Unit and the MRC Epidemiology Unit (2002)
ISBN 0 85484 081 8
14. Peptic ulcer: Rise and fall (2002)
ISBN 0 85484 084 2
15. Leukaemia (2003)
ISBN 0 85484 087 7
16. The MRC Applied Psychology Unit (2003)
ISBN 0 85484 088 5
17. Genetic testing (2003)
ISBN 0 85484 094 X
18. Foot and mouth disease: The 1967 outbreak and its aftermath (2003)
ISBN 0 85484 096 6
19. Environmental toxicology: The legacy of Silent Spring (2004)
ISBN 0 85484 091 5
20. Cystic fibrosis (2004)
ISBN 0 85484 086 9
21. Innovation in pain management (2004)
ISBN 978 0 85484 097 7
22. The Rhesus factor and disease prevention (2004)
ISBN 978 0 85484 099 1
23. The recent history of platelets in thrombosis and other disorders
ISBN 978 0 85484 103 5
24. Short-course chemotherapy for tuberculosis (2005)
ISBN 978 0 85484 104 2
25. Prenatal corticosteroids for reducing morbidity and mortality
after preterm birth (2005)
ISBN 978 0 85484 102 8
26. Public health in the 1980s and 1990s: Decline and rise? (2006)
ISBN 978 0 85484 106 6
27. Cholesterol, atherosclerosis and coronary disease in the UK,
1950–2000 (2006)
ISBN 978 0 85484 107 3
28. Development of physics applied to medicine in the UK, 1945–1990
ISBN 978 0 85484 108 0
29. Early development of total hip replacement (2007)
ISBN 978 0 85484 111 0
30. The discovery, use and impact of platinum salts as
chemotherapy agents for cancer (2007)
ISBN 978 0 85484 112 7
31. Medical ethics education in Britain, 1963–1993 (2007)
ISBN 978 0 85484 113 4
32. Superbugs and superdrugs: A history of MRSA (2008)
ISBN 978 0 85484 114 1
33. Clinical pharmacology in the UK, c. 1950–2000: Influences and
institutions (2008)
ISBN 978 0 85484 117 2
34. Clinical pharmacology in the UK, c. 1950–2000: Industry and
regulation (2008)
ISBN 978 0 85484 118 9
35. The resurgence of breastfeeding, 1975–2000 (2009)
ISBN 978 0 85484 119 6
36. The development of sports medicine in twentieth-century Britain
ISBN 978 0 85484 121 9
37. History of dialysis, c.1950–1980 (2009)
ISBN 978 0 85484 122 6
38. History of cervical cancer and the role of the human papillomavirus,
1960–2000 (2009)
ISBN 978 0 85484 123 3
39. Clinical genetics in Britain: Origins and development (2010)
ISBN 978 0 85484 127 1
40. The medicalization of cannabis (2010)
ISBN 978 0 85484 129 5
41. History of the National Survey of Sexual Attitudes and Lifestyles
ISBN 978 0 90223 874 9
42. History of British intensive care, c.1950–c.2000 (2011)
ISBN 978 0 90223 875 6 (this volume)
All volumes are freely available online at
Hard copies of volumes 21–42 can be ordered from;; and all good booksellers for £6/$10 each plus postage,
using the ISBN.
1994 The early history of renal transplantation
1994 Pneumoconiosis of coal workers
(partially published in volume 13, Population-based research
in south Wales)
1995 Oral contraceptives
2003 Beyond the asylum: Anti-psychiatry and care in the community
2003 Thrombolysis
(partially published in volume 27, Cholesterol, atherosclerosis and
coronary disease in the UK, 1950 –2000 )
2007 DNA fingerprinting
The transcripts and records of all Witness Seminars are held in archives
and manuscripts, Wellcome Library, London, at GC/253.
Technology transfer in Britain: The case of monoclonal antibodies
Tansey E M, Catterall P P. (1993) Contemporary Record 9: 409–44.
Monoclonal antibodies: A witness seminar on contemporary medical history
Tansey E M, Catterall P P. (1994) Medical History 38: 322–7.
Chronic pulmonary disease in South Wales coalmines: An eye-witness
account of the MRC surveys (1937–42)
P D’Arcy Hart, edited and annotated by E M Tansey. (1998)
Social History of Medicine 11: 459–68.
Ashes to Ashes – The history of smoking and health
Lock S P, Reynolds L A, Tansey E M. (eds) (1998) Amsterdam: Rodopi BV,
228pp. ISBN 90420 0396 0 (Hfl 125) (hardback). Reprinted 2003.
Witnessing medical history. An interview with Dr Rosemary Biggs
Professor Christine Lee and Dr Charles Rizza (interviewers). (1998)
Haemophilia 4: 769–77.
Witnessing the Witnesses: Pitfalls and potentials of the Witness Seminar
in twentieth century medicine
Tansey E M, in Doel R, Søderqvist T. (eds) (2006) Writing Recent Science:
The historiography of contemporary science, technology and medicine. London:
Routledge: 260–78.
The Witness Seminar technique in modern medical history
Tansey E M, in Cook H J, Bhattacharya S, Hardy A. (eds) (2008) History
of the Social Determinants of Health: Global Histories, Contemporary Debates.
London: Orient Longman: 279–95.
Today’s medicine, tomorrow’s medical history
Tansey E M, in Natvig J B, Swärd E T, Hem E. (eds) (2009) Historier om helse
(Histories about Health, in Norwegian). Oslo: Journal of the Norwegian Medical
Association: 166–73.
You might ask what a gastroenterologist is doing writing this foreword when his
whole lifetime experience of intensive care medicine amounted to four months
at St Thomas’ Hospital in 1973, but it was a period that changed my life – for
several reasons.
The ‘Mead Job’ was the most highly sought-after post for aspiring physicians
(aspiring anaesthetists may have sought the post too, but very rarely passed
Ron Bradley’s critical assessment). The list of past SHO’s on Mead since it
opened about 1967 is a roll-call of honour in British medicine at St Thomas’
– I know, because Ron sent me the list when I became PRCP).1 I realised that
I had little chance of getting the job having failed to get a house physician
post at St Thomas’ (and my professorial surgical unit house officer post counted
for nought) – and so I went to the Whittington Hospital, famous for its ability
to get just about anyone through MRCP. This put me in the happy position,
just ten months after finishing my house jobs, of applying to Mead with ‘the
membership’ and this was sufficiently unusual for me to be allowed to fill an
unexpected vacancy. After the most frightening fortnight of my life, thrown into
the deep end, chance would have it that I was sent out of the front-line trenches
to fill a two-month slot at the South-Western Hospital (London, SW9) where
Geoffrey Spencer ran his internationally acclaimed unit for chronic respiratory
failure – usually as a consequence of polio. Although we were ‘on 168 hours
a week, the pace was slower and the clientele fascinating. Back to Mead ward
two months later and I was able to complete unfinished business by asking out
attractive staff nurse Douglas (now Lady Gilmore, see Figure 11) and apply
successfully for a registrar post (successful only because Ron Bradley was on the
committee and sitting next to David McBrien from Worthing Hospital, where
the rotation started, no doubt telling him whom he should appoint). So my
time as Mead SHO was cut short.
I would not have survived the 12 months at Worthing without the Mead training
– the sole medical registrar ran the intensive care unit (ICU) and the consultant
anaesthetist in charge called in once a month whether it was needed or not!
During the 12 months, Ron rang offering me a research post investigating the
1 The list of SHOs serving on Mead ward, 1966 to 1994, from Professor Ronald Bradley will be deposited in
GC/253, along with other records of the meeting, in archive and manuscripts, Wellcome Library, London.
haemodynamics of a brand new drug called dobutamine.2 After a sleepless night
I decided to stick to my career plan of hepatology rather than haemodynamics,
but when back at St Thomas’ soon found an excuse to team up with Ron again
performing liver biopsies via the internal jugular and hepatic veins on sick
patients with coagulopathies. Ron could never resist a new challenge and we
were soon writing up this first experience of the technique outside the US,
where it was pioneered.
Indeed my next stop was indeed the USA – on a MRC travelling fellowship to
San Diego to research liver function, a BTA. Although I was in a non-clinical
post, indeed had no licence to practice there, I was soon being sent up to the
ICU to see referrals on behalf of the head of the gastrointestinal division, who
was a wonderful researcher but ‘a little rusty on the clinical side’.
From San Diego, the next stop was Liverpool to my consultant post in 1980.
Cecil Gray was pre-eminent in anaesthesia at this time and Sherwood Jones was
doing great things in the ICU at Whiston Hospital.3 In no time I was invited
in to the ICUs of the Royal Liverpool and Broadgreen Hospitals by Tony
Gilbertson and Dickie Richardson respectively.4 I soon realized that the best
way to get my liver failure patients admitted to the ICU was to drop everything
when an opinion was sought on one of their patients. Liver patients had (and
perhaps still do have) a reputation for rarely coming out alive, and so I was
careful to give a box of chocolates to those that did survive so they could take it
up to the ICU staff when they came back to clinic. The intensivists at the Royal
Liverpool Hospital soon realized that I did a safari ward-round of the hospital
on Friday evenings starting about 6pm – cursed by generations of housemen
and registrars eager to start the weekend carousing – and so this invariably took
in the ICU about 9pm.
My involvement in the late 1990s became more cerebral than practical – when I
became registrar of the RCP, there were tensions within the intercollegiate training
board about the ease or otherwise of physicians getting the requisite training and
certification in intensive care medicine – but it was all sorted out amicably in the
end with great support from Presidents of the Royal College of Anaesthetists like
Peter Hutton and Judith Hulf. Indeed when I was Royal College of Physicians
President, it was a pleasure to work closely with Judith in the establishment of an
2 See page 59.
3 See pages 4, 24, 25, 48, 51, 52 and 58.
4 See page 4.
intercollegiate Faculty of Intensive Care Medicine, which will acknowledge the pre-
eminence of anaesthesia as a background for entering the specialty but also provide
very important access to physician trainees into it too.
This Wellcome Witness account shows brilliantly how multidisciplinary working
was crucial; for example, joint working between physician and anaesthetist, Ron
Bradley and Margaret Branthwaite or Geoffrey Spencer, in those early days.
There is perhaps some truth in Tony Gilbertson’s suggestion that support from
the rest of the hospital for setting up intensive care units in those early days
came easily as other staff were delighted to be relieved of the responsibilities of
looking after the most ill patients.
My story of intensive care ran through my personal and professional career and
came full circle as my son, training in acute medicine, is now starting a two-
year fellowship in intensive care under Professor Richard Griffiths at Whiston
Hospital, where Sherwood Jones was so important to the early years of the
specialty. I congratulate Professor Tilli Tansey (who became an Honorary Fellow
of the RCP during my presidency) and her team on the whole Wellcome Witnesses
series – so important in capturing what could be so easily lost as the pioneers
in various areas of medicine retire and pass away and this is very much the
case with this volume, where the crucial pioneers are now in their seventies and
beyond. They should look with great satisfaction on what has been achieved in
less than 50 years for the very sickest patients who have entered hospital over
this time.
Sir Ian Gilmore
Royal Liverpool Hospital and University of Liverpool
The transcript of a Witness Seminar held by the Wellcome Trust Centre
for the History of Medicine at UCL, The Wellcome Trust, on 16 June 2010
Edited by L A Reynolds and E M Tansey
Among those attending the meeting: Dr Jennifer Jones, Professor
Michael Worboys
Apologies include: Dr Richard Beale, Professor David Bennett, Dr Dennis
Coppel, Professor Tim Evans, Dr Clifford Franklin, Professor Richard Griffiths,
Professor Charles Hinds, Dr Jean Horton, Dr Roop Kishen, Dr Paul Lawler,
Dr Robin Macmillan, Dr Willie Macrae, Dr John Nunn, Ms Sue Porter, Dr Alfie
Shearer, Dr David Treacher, Professor Nigel Webster, Dr Sheila Willatts
Ms Sheila Adam
Dr Aileen Adams
Ms Pat Ashworth
Dr Carol Ball
Professor Julian Bion
Professor Ronald Bradley
Dr Margaret Branthwaite
Dr Doreen Browne
Dr Tony Gilbertson
Mr Graham Haynes
Professor Peter Hutton (chair)
Professor Iain Ledingham
Ms Alice Nicholls
Professor Mervyn Singer
Dr Brian Slawson
Dr Geoffrey Spencer
Dr Joseph Stoddart
Professor Leo Strunin
Professor Sir Keith Sykes
Professor Tilli Tansey
Dr David Wright
History of British Intensive Care, c.1950–c .2000
Professor Peter Hutton: Hello everybody. My name is Peter Hutton and I’ve
been asked by Tilli to chair this session, which I’m quite pleased to do, because
I think it could be extremely interesting. First of all, some thanks: the first
going to David Wright, Tony Gilbertson and Iain Ledingham for suggesting the
concept of this meeting and secondly to Tilli Tansey and the Wellcome Trust for
receiving the idea so positively and supporting it.
This is a unique opportunity for people to get their word in about how
it happened to them. This meeting will become part of a series of Witness
Seminars, which are written up so that they provide a permanent record of the
event. An earlier one on ‘Pain Management’, for instance, which is relevant to
many of us, is extremely good.1 There are lots of names in there that people will
know, and there is an interview with Pat Wall who, of course, sadly died a few
years ago. We do want people to speak and we’ve asked some people to speak on
specific topics to get things going from the outset. Once that person has made
a few introductory comments, I’m sure a number of people will wish to say
something, to add to it from their own experiences.
1 Reynolds L A, Tansey E M. (eds) (2004).
Table 1: Outline programme for ‘History of British intensive care’ Witness Seminar
Start of the specialty (c.1950–c .1960)
The 1952 Copenhagen polio epidemic and its consequences
The development of equipment and techniques, the conditions treated
Development of units (c.1960–c.1970)
Key individuals
Key places
Professionalization of staff and their careers (c.1970–c.1980)
e.g. societies; journals; qualifications, training
Resources and facilities (c.1980–c.1990)
Department, equipment, drugs
Record-keeping, scoring systems, transport
Other disciplines in intensive care
e.g. Physiotherapy, bacteriology, radiology etc.
Ethics, outreach, high dependency and follow-up (c.1990–c.2000)
Recording the history of British intensive care
History of British Intensive Care, c.1950–c .2000
The outline programme on your seats (Table 1) is meant to be flexible; I’ll do
my best to keep us to time and it’s meant to be friendly. So, if I could ask Tony
to kick off with the first item, which is to do with the Copenhagen epidemic.
Dr Tony Gilbertson: I was asked originally to speak about the Copenhagen
epidemic and I wrote a brief summary, but then I got another e-mail asking me
to reflect my views as a medical student during the 1952 Copenhagen epidemic
and how, if at all, it affected me then and later as a doctor. I’ve got to say that in
January 1953, when Lassen published his paper in the Lancet,2 I was just about
taking second MB and I certainly wasn’t reading the Lancet, and I didn’t read
that paper until exactly 40 years later when I was giving a lecture on the history
of intensive care at the Royal Society of Medicine, because nobody else had ever
talked about it, and I then found out about Lassen and his paper.3
But that’s not to say that it didnt influence me, because it did. It influenced
me indirectly, because Professor Cecil Gray, who was a reader in those days,
had actually been teaching in Copenhagen on the World Health Organization
anaesthetic course at that time.4 So he certainly knew all about Bjørn Ibsen.5
Dickie Richardson ran the intensive care unit (ICU) at Broadgreen Hospital,
2 Dr H C A Lassen (1900–74) was the chief physician at Blegdam Hospital during the 1952 epidemic. His
reports on the treatments used include Lassen (1953, 1956); see also Sykes and Bunker (2007): 163. For
an examination of the role of Bjørn Ibsen, see Wackers (1994a and b); see also note 7. The two forms of
ventilation in long-term use until the 1970s were those administered through a (permanent) tracheostomy
or using negative pressure ventilation applied via a tank ventilator, cuirass or jacket/poncho ventilators.
Correspondence on the spelling of Blegdam has been deposited in the Wellcome Library, GC/253.
3 Dr Tony Gilbertson wrote: ‘Lassen’s name is always given as “Lassen H C A”; his forenames have been very
hard to track down, but Sykes and Bunker reveal that he was called Hans Christian Alexander (Sykes and
Bunker (2007): 162). Trust Keith to know!’ Note on draft transcript, 20 August 2010. See also Gilbertson
(1995). Sir Keith Sykes wrote: ‘I consulted Dr John Zorab of Bristol who had spent six months working
in Copenhagen and who had interviewed one of the young patients treated in the epidemic. John noted
that in those days the organisation of the hospital was very hierarchical and most patients would not have
dared to question senior medical staff. This particular girl did, however, ask Lassen what his initials stood
for. She told John that she remembered that Lassen replied “Hans Christian Alexander” so I included this
in the book. Subsequent checking revealed that his names were indeed Henry Cai Alexander as recorded by
Wackers (1994a and b). Whether Lassen was trying to make himself seem more approachable or whether
the patient’s memory was faulty will never be known. Unfortunately the publishers ignored my corrections
when recently reprinting the book, so I have not been able to correct the mistake.’ Note on draft transcript,
6 March 2011.
4 See Gray and Halton (1946); see also Sykes and Bunker (2007): 169; Leuwer et al. (2008).
5 Bjorneboe et al. (1955).
History of British Intensive Care, c.1950–c .2000
Liverpool.6 Actually Pat Ashworth was the head sister so she was running it, but
Dick was allowed to have some influence. He’d visited Ibsen in Copenhagen
as well. So the influence it had on me was that I realized from a boy that the
treatment of respiratory failure was by intermittent positive pressure respiration
(IPPR) sorry Keith, but it was called respiration in those days, not IPPV
(intermittent positive pressure ventilation). Up to then treatment had been with
iron lungs using negative pressure (see Figure 1), but I realized you had to treat
respiratory failure with positive pressure.7
6 For the floor plan of the ITU at Broadgreen Hospital, Liverpool, see Figure 7, page 28. See also Ashworth
(1964); Edwards et al. (1965); Ashworth et al. (1973).
7 Dr Henning Sund Kristensen, an anaesthetist at the department for infectious diseases at Blegdam
Hospital from September 1952, disputed the ‘principal difference’ between ventilation by positive pressure
(pressure applied at the entrance of the airways) and negative pressure (pressure created in the alveoli by a
total body ventilator or iron lung) (Kristensen (1996): 134). Bulbar paralysis was then considered to be an
untreatable neurological destruction affecting the muscles controlling swallowing, talking, movement of
the tongue and lips, and sometimes respiration, caused by infection to the ‘bulbar’ (then comprised of the
medulla oblongata, pons and midbrain). Poliomyelitis was later recognized as the cause of this epidemic of
obstructed airways and muscular respiratory insufficiency (1994a): 421). For historical details of artificial
ventilation and equipment, see Young and Sykes (1990).
Figure 1: Coventry Alligator iron lung, c. 1966. See note 11.
History of British Intensive Care, c.1950–c .2000
Figure 2: A cuirass shell ventilator connected to a 12-volt alternating
suction pump, in use in an Alvis car, c. early 1950s.8
I qualified in 1956 and there was no intensive care in Liverpool at that time, but
when I went into the Royal Air Force in 1959 I found that the Royal Air Force
had embraced Ibsen’s views strongly.9 I say that because we had to bring back
patients with respiratory failure, usually due to polio or chest injuries, from
all over the world: from the Middle East, the Far East.10 We had a wonderful
system set up by Tony Merrifield and Colin MacLaren, where one of about
six of us would get a call: ‘You’ve got to go to Singapore tomorrow and bring
back a polio patient.’ We’d be met at RAF Lyneham by a technician from the
8 Dr Geoffrey Spencer wrote: ‘The Coventry Alligator (Figure 1) was widely used in the UK and other
countries and was designed by Captain G R Smith-Clarke, formerly chief engineer/designer to the Alvis
Motor Company, Coventry, in 1950. It was made by Cape Engineering Co. of Warwick with money raised
mainly by the Coventry Coronation Carnival Committee using a young lady dressed in a long blonde wig
who paraded the streets of Coventry on a white horse in 1953.’ Note on draft transcript, 2 March 2011.
9 For problems with transport, see Harries and Lawes (1955). National service (peacetime conscription or
call-up) for British men aged 17 to 21 existed between 1949 and 1962, with deferment for education or
apprenticeship. See also Royle (1986).
10 For a recent review of the Copenhagen incident and intensive care medicine, see Wackers (1994a and b).
History of British Intensive Care, c.1950–c .2000
medical rehabilitation unit at RAF Chessington where they had the equipment11
– ventilators and a whole box of equipment – and a sister would come with us.
It was very well organized, but I’ve got to say we hadn’t entirely abandoned
negative pressure respiration, because I remember bringing an army doctor back
from Singapore with polio. He had very much weakened respiration, but no
bulbar involvement and I had a cuirass (upper body shell, Figure 2) respirator
to bring him back. But the RAF had wonderful Oxford respirators (see Figure
3) with three motors: 12 volts for use in the ambulance; 110 volts for use in the
airplanes, which were Comets and Britannias; and 240 volts when we stopped
over. Comets were very short-range, so we stopped in Aden or Tripoli. These
were wonderful ventilators for the early 1950s with three motors.
To cut a long story short, after learning intensive care in a post-cardiac intensive
care unit at Broadgreen, I was appointed a consultant in 1965 at Sefton General
Hospital, Liverpool, and for four years I treated patients on the ward without
the usual disastrous consequences often described for those treated by IPPV on
general wards. What we treated in those days was barbiturate poisoning, asthma,
11 The RAF’s medical rehabilitation unit was in Chessington, joined there by the Army’s medical
rehabilitation unit to become the Joint Services Rehabilitation Unit after 1968. See Ward (1970); for a
more recent approach to critical care in the services, see Shirley (2009).
Figure 3: Oxford ventilator: Radcliffe, Mark 1 prototype, c. 1955.
The engine raised the weight and then allowed it to fall and compress the inflating bellows. The
inspired gas was delivered to the patient through corrugated tubing connected to a Stott non-
rebreathing valve. ©Nuffield department of anaesthetics, Oxford.
History of British Intensive Care, c.1950–c .2000
trauma and that sort of thing. But I did have to go in for every staff change
of nursing personnel to show them how to run the ventilators. Fortunately I
only lived five minutes away. What we specialized in eventually was treating
combined respiratory and renal failure, which was because my head nurse,
Colette Burrows, had previously been the head nurse on the dialysis unit and so
she taught us all to dialyse. The rest is history.12
Dr Geoffrey Spencer: I was very interested in what you say about the 1952
polio epidemic in Copenhagen. Dr Henning Sund Kristensen,13 the anaesthetist
who continued to run the Copenhagen unit after the acute epidemic, retired
in 1988 and six of the surviving patients living mostly in their homes around
Copenhagen transferred their care to me at the Southwestern Hospital in
Brixton, part of St Thomas’ Hospital, London. One had remained continuously
ventilator-dependent via tracheostomy since 1952 and remains so today. She
was hand-ventilated (Figure 4) by medical students both during the acute
epidemic and for months thereafter until a special ventilator, the ‘Pulsula’, was
developed for her. She found Danish winters too cold and used to spend her
winters in Texas until her Texan boyfriend died recently and since then she has
spent her winters on the Isle of Wight, evidently the next best thing to Texas.14
12 Dr Tony Gilbertson wrote: ‘The regional dialysis unit was up the corridor in Sefton General and patients
not infrequently developed pneumonia or pulmonary oedema. At first we ventilated them in the dialysis
unit but after the ITU was opened in 1970 we dialysed with full support from the dialysis team and reduced
the previously very high mortality rate to about 40 per cent. We developed the concept of severe combined
acute renal and respiratory failure (SCARRF) and participated in two conferences on the subject in Oxford.’
Note on draft transcript, 26 March 2011. See McClelland et al. (1990); Gilbertson et al. (1991); see also
Figure 7, note separate dialysis room. Dr David Morrison’s descriptions of the development of dialysis in
his intensive care unit in Crumpsall Hospital, Manchester, will be deposited along with other records of
the meeting in archives and manuscripts, Wellcome Library, London, at GC/253. See also Blagg (1967).
13 See note 7; see also Wackers (1994a).
14 Dr Geoffrey Spencer wrote: ‘It is essentially an improved, quieter and better engineered 24-volt modification
of the early Oxford Radcliffe machines (see Figure 3) and remains virtually unique. Her ventilator has been
adapted to run off aeroplane electrical voltages as well as US mains. This small IPPR machine made specially
in Denmark for replacing the medical students was designed by Jø Larsen, medical technician at the Blegdam
Hospital in conjunction with two anaesthetists, Dr H S Kristensen and Dr H Poulsen. Larsen made around
50 of these three types – 12-volt, 24-volt and mains for bedside and wheelchair use – which remained in
production until 1987. It incorporated a waterbath humidifier and a heated wire inside the single hose to the
tracheostomy, which reduced water condensation in the tubing and heated the inspired air. A great pity it was
not more widely produced and it probably remains to this day the most suitable IPPR machine for long-term
and wheelchair use.’ Note on draft transcript, 29 September 2010 and 2 March 2011. See also discussion on
page 6; for the personal reminiscence of one of the eight survivors, see Isberg (2005).
History of British Intensive Care, c.1950–c .2000
Figure 4: Anne Isberg, aged 8 in 1952, receiving artificial respiration from the black rubber hand-
squeezed bag, which the dental student stopped squeezing while the photo was taken,
via a Water’s canister containing soda lime for CO2 absorption connected to a cuffed
endotracheal tube. The oxygen is supplied from the long tube on the left.
The Copenhagen epidemic was said to have been the first use of tracheostomy
and intermittent positive pressure respiration (IPPR, Figure 3) in polio and
similar long-term conditions.15 This is only partly true. Tracheostomy, at least,
had been used for so-called ‘wet cases’ lacking saliva control from the late 1940s
in the polio centre at Rancho Los Amigos in Los Angeles, California.16 They
continued, however, to ventilate their patients in an iron lung with a metal
collar depressor to keep the tracheostomy outside the iron lung.17 They did
try simultaneously to make this arrangement work better by using a Bennett
attachment18 which gave positive pressure, which worked in synchrony with the
iron lung; a startlingly cumbersome system.
15 See note 7.
16 See (visited 14 March 2011).
17 See, for example, Baydur et al. (2000); Figure 2.
18 See Trubuhovich (2007a); and further discussion on page 13.
History of British Intensive Care, c.1950–c .2000
But to return to Copenhagen, the epidemic has been called ‘the 1066 of artificial
respiration.’ It resulted in the invention of pH, CO2 and oxygen electrodes
by Poul Astrup, a physiological chemist,19 which made it possible to monitor
the adequacy of the medical students’ bag-squeezing.20 It also resulted in the
development of the technique and suitable machines for long-term IPPR and
patients’ eventual home care.21
Another point of interest about Copenhagen is ‘who asked Ibsen to come?’
The people looking after these cases before anaesthetist Bjorn Ibsen appeared
were infectious diseases physicians. Professor Lassens first assistant at Blegdam
Hospital was Mogens Bjørneboe – a physician who had worked in the
commune hospital in Copenhagen – who suggested to Lassen that the methods
of tracheostomy and IPPR might have something to offer. Ibsen came to the
hospital and resuscitated a dying girl, one case. Having set her up using a Waters’
canister and rubber bag for the medical students to squeeze (see Figure 4), Ibsen
left.22 It is claimed that Ibsen never returned to the polio unit, although the new
method was dramatically successful and, with many improvements, still is.23
Lassen had to be persuaded to include Ibsens contribution to his 1953 report of
the epidemic. But his work was subsequently taken over by a young anaesthetist
called Henning Sund Kristensen, who was the person who looked after and
maintained the patients until a few years ago.24
Hutton: To broaden this a bit, Keith, would you like to say a few words on the
development of anaesthetic equipment and techniques at the time?
19 Bjorn Ibsen proposed in 1952 that the death of patients with high total carbon dioxide in their blood
at Blegdam Hospital, as measured by manometer, could have been the result of retention of CO2 from
inadequate exchange of air, and that manual positive pressure ventilation could reduce CO2 levels. Dr Poul
Astrup, director of the clinical laboratory, persuaded Radiometer A/S in Copenhagen to develop a smaller
pH electrode to measure the acidity of blood, which was delivered the following day. See www.radiometer. (visited 27 January 2011). For further details of
the effects of these measurements, see West (2005), particularly pages 426–8. Correspondence on the spelling
of Blegdam/Blagdam has been deposited in the Wellcome Library, GC/253.
20 See, for example, West (2005): Figure 3, page 425.
21 Home care was also important in improving the lives of those on dialysis. See, for example, Crowther et
al. (eds) (2009).
22 See Waters (1936); see also Severinghaus et al. (1998): S119–20, Figures 4 and 5.
23 Correspondence after publication from Professors Preben Berthelsen and Sir Keith Sykes and Dr Ron Trubuhovich Professor
to refute this claim and from Dr Geoffrey Spencer have been deposited with the records of this meeting in the
Wellcome Library, GC/253. For details on improvements, see, for example, Stott (2000); see also note 34.
24 See also note 7.
History of British Intensive Care, c.1950–c .2000
Professor Sir Keith Sykes: An interesting comment about Bjørneboe is that he
came back from the US in 1951 on the same ship as Ibsen’s wife and family, so
that is where the two families got to know each other.25
Before launching into the subject under discussion, I would like to thank the
Wellcome Trust, not only for funding our history of the Nuffield department of
anaesthetics, published in 1987,26 and for awarding me a number of grants throughout
my professional life, but also for being responsible for my entry into intensive care.
It all started one night in December 1958 as a result of a chance meeting with
Desmond Laurence outside the Lord Wellington pub (the Jeremy Bentham from
1982) near University College Hospital (UCH), London. Desmond was the clinical
reader in pharmacology at UCH and told me that he had just come back from
South Africa where he and Barry Adams, professor of medicine in the University
of Natal, were running controlled trials on the treatment of tetanus in the King
Edward VIII Hospital, Durban.27 They had been comparing chlorpromazine with
the conventional treatment with phenobarbitone and had found no difference in
mortality in neonates with severe tetanus.28 Jokingly I said to him: ‘Well, why dont
you get an anaesthetist to go out and treat the patients with curare?’ And he said:
‘Would you like to go?’ And I said, ‘Yes.’ I thought no more about it and some
two months later I got a letter from the Wellcome Trust saying they were going
to pay my fare out to Durban and were offering me £1000 for equipment. So I
went to see Charlie Newman, the dean of the Postgraduate Medical School, who,
much to my surprise and delight, offered me six months’ leave of absence with full
pay. I sold my car to pay for the travelling expenses of my wife and young family
and spent six months in 1959 setting up a small respiratory unit to investigate the
use of curare and mechanical ventilation in the treatment of adult and neonatal
tetanus. Two years later we were able to report a reduction in mortality in neonatal
tetanus treated with curare and mechanical ventilation from 84 per cent to 44 per
cent.29 By 1966 the mortality had been reduced to 36 per cent.30
25 Further examples of ‘Been to America’ or BTA, are mentioned on pages 41–2 and 59 and were an
important part of the professional development of a number of fields, see, for example, Reynolds and Tansey
(eds) (2009); Crowther et al. (eds) (2009); see also Sykes (2008).
26 Beinart (1987).
27 Laurence et al. (1958).
28 Adams et al. (1959).
29 Wright et al. (1961).
30 Adams et al. (1966).
History of British Intensive Care, c.1950–c .2000
When I returned to Hammersmith Hospital, I found that some of the open-
heart surgery patients were dying from what appeared to be respiratory failure,
and I made a number of critical remarks about their postoperative treatment. As
a result I was asked to join the anaesthetic team and began to initiate treatment
with mechanical ventilation after operation. I borrowed the large Radcliffe
positive-negative ventilator that Hugh-Jones31 had used in 1959 to treat asthma
and, fortunately, the first few patients survived.32 We continued to treat the
cardiac patients and some patients with tetanus in side wards over the next
year and opened a postoperative recovery unit in March 1961. By this time we
were treating other conditions such as asthma and acute-on-chronic respiratory
failure, so we soon became a general intensive care unit.33 That is how the
Wellcome Trust kick-started intensive care in Durban and in the Hammersmith
Hospital, London.34
I have been asked to say a few words about what happened before Copenhagen.
Polio was rife in the US and, in addition to local infectious diseases hospitals,
there were four big polio units using tank ventilators in Los Angeles, Boston,
Ann Arbor and Houston.35 Geoffrey Spencer has already mentioned the
groundbreaking papers of Bower and colleagues,36 in which there were
descriptions of some 40 new devices, largely engineered by V Ray Bennett,
which improved the care of patients in tank ventilators. As a result this group
had managed to increase the survival rate in tank ventilator patients from about
31 Dr Philip Hugh-Jones was on the scientific staff of the MRC Pneumoconiosis Unit, South Wales (1945–
55), and later was consulting physician and director of the chest unit at King’s College Hospital, London,
and part-time director of the MRC Clinical Pulmonary Physiology Research Unit at the Hammersmith
Hospital, London (1964–67). Professor Sir Keith Sykes wrote: ‘Hugh-Jones was one of the leading
respiratory physiologists of the day and, with John West, was responsible for initiating the use of mass
spectrometry in respiratory research and the use of radioisotopes for studies of regional ventilation and
perfusion in the lung.’ Note on draft transcript, 6 March 2011. See Fowler and Hugh-Jones (1957); see also,
for example, Hugh-Jones and West (1960).
32 Russell et al. (1956); Figure 3. See, for example, Gilson and Hugh-Jones (1949); Ness et al. (2002): 31–3.
33 Professor Sir Keith Sykes wrote: ‘We always used to call it acute-on-chronic respiratory failure, since
the admission to hospital was precipitated by an acute infection.’ Note on draft transcript, 6 March 2011.
34 Sykes (1964). Professor Sir Keith Sykes wrote: ‘Sykes et al. (1969) was the first book to provide a
comprehensive plan of treatment for all types of respiratory failure. It was translated into Spanish, Italian
and Polish and there were pirated editions in Russia and India.’ Note on draft transcript, 6 March 2011.
35 See, for example, Horstmann (1985).
36 Bower et al. (1950a and b).
History of British Intensive Care, c.1950–c .2000
20 per cent in 1946 to over 80 per cent in 1949. This was where Bennett
had developed his PR-2 ventilator – the forerunner of many other ventilation
devices designed by this brilliant engineer.37 So that was quite an important
development in the intensive care field, and Ibsen was aware of these papers
before he was called in to help at Blegdam Infectious Diseases Hospital in
August 1952.
I think the shock tents during the war were another important forerunner
of intensive care because that’s where anaesthetists learnt about triage, about
monitoring, about transfusion, and above all, about teamwork. I think we have
to realize that there was very little teamwork in medicine before Copenhagen and
this development represented a major change in the way doctors interacted with
each other. The care of the unconscious patient was also being refined, because
Carl Clemmesen, consultant psychiatrist at Bispebjerg Hospital, had started
to develop the idea of specialist poison units to treat barbiturate poisoning,38
and Erik Nilsson had produced his thesis on the benefits to be derived from
applying anaesthesia principles to the care of the unconscious patient in these
units. At this time, however, there were only a few intermittent positive pressure
ventilators and their use was largely restricted to the provision of controlled
ventilation during anaesthesia for thoracic surgery.39
There was one other interesting antecedent of intensive care and that was
a paper in the Lancet in 1934 by Howard Florey and his colleagues.40 They
had tried to treat experimental tetanus in rabbits with curare and small tank
ventilators without much success, but they made the comment that the best
way forward would be to create centralized units, where people with tetanus
could be taken to be treated. So in 1934 he and his colleagues anticipated
the concept of intensive care. Postoperative recovery wards of course, were, in
many cases, the immediate progenitors of intensive care units, but, as Geoffrey
Spencer has said, it was the people who went to Copenhagen and started using
IPPV instead of tanks (iron lungs) in their fever hospitals who spearheaded
37 In 1956, the Puritan Compressed Gas Corporation acquired V Ray Bennett and Associates, Inc., after
Bennett had constructed his first resuscitator unit for a Los Angeles hospital. For further details of the
company history, see (visited 7 September 2010). See also
Wilson and Roscoe (1958); Trubuhovich (2007a).
38 Jensen (1974).
39 See, for example, Nilsson (1951); see also Sykes and Young (1999): Ch 1, pages 1–19.
40 Florey et al. (1934).
History of British Intensive Care, c.1950–c .2000
the move to intensive care. Of particular importance were the Oxford group,
who established the principles of humidification and other aspects of care that
formed the basis of ventilator treatment.41
So that is, I think, the background to intensive care. We all know what
happened afterwards: Poul Astrup, Ole Siggaard-Andersen, John Severinghaus
and others developed apparatus that enabled us to obtain accurate blood gas
measurements.42 The participation of anaesthetists in cardiac surgery and
neurosurgery taught us to use other clinical measurements, and during the next
two decades we witnessed an explosion of knowledge about the physiological
aspects of mechanical ventilation. We then had the description of acute
respiratory distress (ARDS) by Ashbaugh and his colleagues in 1967,43 and the
introduction of positive end expiratory pressure. In the same year papers from
Nash and Northway and their colleagues alerted us to the problem of high
airway pressures and lung damage.44 Then, in 1971, the introduction of the
first microprocessor-controlled ventilator, the Siemens Servo 900, opened up
the possibilities of developing new techniques of respiratory support that have
culminated in the techniques used today.45
Hutton: Julian, I think you were going to add a few points.
Professor Julian Bion: Only in terms of downstream consequences from
Bjørneboe. I’m at the University of Birmingham and I come to this later than
previous speakers because I was born in 1952. We are now bordering on the
brink of the eradication of polio, I’m pleased to see.46 But thinking of Lassens
paper in the Lancet: one of the points that emerges from it is that although
41 See, for example, Marshall and Spalding (1953); Honey et al. (1954); Smith et al. (1954); Beinart (1987),
especially pages 118–23 for the ITU.
42 See for example, Siggaard-Andersen et al. (1960); West (1996): 100–5.
43 Ashbaugh et al. (1967).
44 Northway et al. (1967); Nash et al. (1967).
45 For a background to artificial ventilation equipment, see Young and Sykes (1990); see also Tobin (ed.)
46 In 1998, the Global Polio Eradication Initiative (GPEI), supported by UNICEF, the World Health
Organization, Rotary International and the US Centers for Disease Control and Prevention, Atlanta, was
established to immunize every child against polio until transmission ceased. On 27 January 2011 the US
government and the Russian Federation signed a protocol in Geneva to deepen this support. For further
details, see (visited 3 February 2011).
History of British Intensive Care, c.1950–c .2000
the mortality rate was reduced from 90 per cent to 40 per cent, of those who
died following the introduction of positive pressure ventilation, the time it took
them to die was very much longer – from three days up to many weeks – with
the new approach. I think that’s a theme that will come to inform some of our
discussions about rationing and the use of scarce resources.
Gilbertson: My comment was going to be about the long learning curve. It
wasn’t just a learning curve, as I see it. The delay in instituting intensive care in
this country had several reasons and the main one was that Ibsen was said to
have opened the doors of the operating theatre for anaesthetists. But talking to
people – and I’ve been interviewing them for the last couple of years – about
that time, the point they make strongly is that most anaesthetists didn’t want
to escape from the theatre. [Laughter] They were what Tom Boulton called
‘session anaesthetists’ – only in the hospital for a limited number of hours each
week and there was no way that they could look after patients for days on
end.47 Developments of the Health Service in the 1960s increased the number
of consultant anaesthetists and gave them competent junior staff so that they
could provide continuous care for intensive care units. For instance, there was a
37 per cent increase in the number of consultants – not anaesthetists – between
1952 and 1962, and the Platt report in 1961 had a great deal to do with that.48
I was appointed as a result of the expansion by the Platt report. I was told by
Cecil Gray that if I was ever going to come out of the Royal Air Force, I had
better come out now, because they were going to appoint a large number of
anaesthetists. In my particular experience, in my hospital, that was absolutely
true. After about five of us were appointed in 1964/5, there were no more
appointments for 12 years. So I think the ability of anaesthetists to respond to
Ibsen was delayed until political change in this country had taken place.
Dr Aileen Adams: I was interested in Keith’s comments about tetanus, because
this was indirectly why we at Addenbrooke’s had one of the earliest intensive
47 A twenty-first century description of a session anaesthetist in hospital policy documents is one who
will assess the fitness and suitability for anaesthesia for all patients undergoing general anaesthetic and will
be responsible for administering the anaesthetic and associated decisions. See also Boulton (1989, 2007);
Boulton and Wilkinson (1995).
48 Sir Robert Platt’s working party recommended that hospital boards should review medical staffing,
with advice from consultants, producing proposals for additional consultant appointments and for posts
in the medical assistant grade. The report urged the development of the ‘firm’ system, the reorganization
of the consultant service, the development of rotational schemes of training for senior registrars and the
establishment of regional advisory committees on senior registrars. Anon. (1961); Ministry of Health,
Department of Health for Scotland, Joint Working Party (1961).
History of British Intensive Care, c.1950–c .2000
care units. We were in an agricultural area, so we had an enormous amount
of tetanus. In fact they said up until the vaccination for tetanus came in, that
Addenbrooke’s was never without at least one case. In the 1930s 1934 –
Leslie Cole, who was the senior physician, took up a suggestion that had been
made in about 1811 and 1812 by Benjamin Brodie, the distinguished English
surgeon and physiologist, that maybe curare had a place in treating tetanus.49
That’s rather a long time ago, when you think of it. Leslie Cole got some crude,
gourd curare and he started to use it in tetanus in the 1930s and published
three papers, two in the BMJ and one in the Lancet.50 He didnt get very far and
was bothered, because, of course, his patients didn’t breathe properly. Harold
Youngman, who was the senior anaesthetist there, suggested that perhaps he
could help, because the anaesthetists were used to dealing with patients such as
this. Of course, being a physician, Cole rather pooh-poohed the idea. As you
say, he didnt like anaesthetists particularly; they were very low in the hierarchy.
But Harold again was unusual; he was quite prepared to spend his whole time in
the hospital; he remained a GP anaesthetist and started numerous other things
which I haven’t time to tell you about, but he kept at it.51 I think this was one
of the reasons – admittedly not until after the war – that we set up an intensive
care unit in Cambridge in 1959, which was quite early. Thanks to Harold
Youngman as anaesthetist and thanks to a very perceptive matron, Miss Mima
Puddicombe, who said she was fed up with nurses not being able to look after
patients properly, because they were scattered throughout the hospital.52 Her
own office was converted into an intensive care unit, which was referred to as
the Blue Room. Not because the patients were blue, but because the wallpaper
was. I think it’s interesting that in Cambridge it was tetanus, rather than polio,
that was the way into intensive care. I would like to end this by saying this is
not my research, it is Jean Horton’s research and she wasn’t able to be here today.
Professor Mervyn Singer: I’m from University College London – a long way
away that is, across the road. I even post-date Julian, being born in 1958.
About a year ago I had to prepare a talk, which prompted me to read the original
papers by Lassen, Ibsen, Engström and Astrup regarding the Scandinavian polio
epidemics of the early 1950s. For whatever reason, they seemed to target British
49 Brodie (1812).
50 Cole (1934, 1936, 1938); Cole et al. (1968); Cole and Youngman (1969).
51 See Horton (1992), freely available at: (visited
1 September 2010).
52 Puddicombe (1964).
History of British Intensive Care, c.1950–c .2000
journals such as the Lancet and BMJ for publication. There was a wonderful
coincidence of people and skills available in Copenhagen at the time. I had
the honour of being at Ole Siggaard-Andersen’s Festchrift in 1992,53 and was
then told that the reason they got into blood gas monitoring in Copenhagen
was because of the presence of Radiometer A/S, Copenhagen,54 an offshoot
of Carlsberg, that developed pH monitoring for the brewing industry. These
published papers emphasized the importance of multidisciplinary teamwork
and of the crucial role of physiotherapy. They also shot down the romantic
view of altruistic medical students bagging the paralysed polio victims by
stating they were paid 30 shillings (£1.50) per shift. They made the important
point, as did Julian, about the mode of death. A major advantage of blood gas
monitoring was the realization that either they were under- or over-ventilating
their patients. Over-ventilation caused haemodynamic compromise, so many
died from an iatrogenically induced haemodynamic collapse. After recognizing
this issue, patients survived, though a further group then suffered later deaths
from pneumonia. This was a very interesting shift and was rediscovered some
30 years later.55
Dr David Wright: I’m from Edinburgh. I’m going to ask one or two questions,
perhaps, rather than giving information. One thing that strikes me is that you
need a critical mass to start things off, and in Copenhagen that occurred with
the number of people involved in an epidemic. One question is: were there
other epidemics that produced that number of people elsewhere? If this was so
in Britain, before units were set up, patients must have been managed singly,
so which different places were patients ventilated in? Were they side rooms of
wards; were they the recovery rooms of operating theatres? But the first question
is: were there other epidemics?
Bion: I think there are others more expert than I here. North America is the
answer to the first question. The second one would be informed by those who
actually looked after the patients and that’s not for me to do.
Dr Margaret Branthwaite: This is a slightly flippant comment, and I’m not
sure that the word epidemic is correct, but the advent of cardiac surgery had an
enormous impact, at least from the mid-1950s onwards.
53 Anon. (1993); see also Burnett (1993).
54 Radiometer A/S, Copenhagen is a subsidiary of the Danaher Corporation. See
history.htm (visited 27 January 2011).
55 For further details, see Wackers (1994a and b); West (2005).
History of British Intensive Care, c.1950–c .2000
Professor Leo Strunin: I was a medical student in Newcastle from 1956
onwards, and there they used to ventilate patients with tetanus by hand. As
medical students, we got paid to do it, there was great demand, and you could
tell when there was a tetanus patient, because they were ventilated in a side
room off one of the wards on the ground floor, and carpets would appear in
the corridor to cut down the noise to prevent any seizures. When the carpets
appeared, everybody would queue up because one could get paid. [Laughter]
Sykes: There were lots of epidemics of polio that were documented from
the late nineteenth century onwards. I think Copenhagen took the record,
but polio was endemic in the US and, in 1955 for example, we had a polio
epidemic in Boston with some 30 patients nursed in iron lungs in a ward at
the Massachusetts General Hospital. There were many other cases treated in
the Haynes Memorial Hospital and the childrens hospital.56 Then there was the
56 Professor Sir Keith Sykes wrote: ‘There is a graphic description by a patient admitted to the Haynes
Memorial Hospital during the 1955 epidemic at:
b29cf014ab010ab257abf86752e4e006-0.html (visited 9 March 2011).’ Note on draft transcript,
6 March 2011.
Figure 5: A British iron lung (R to L) flanked by the Australian designer E T Both, next to Lord
Nuffield speaking to Robert Macintosh, Nuffield professor of anaesthetics (1938).
Macintosh drew Nuffield’s attention to the lack of iron lungs in Britain in 1938 and
thus Lord Nuffield arranged for production of the machines in the Morris Motors
factory in Cowley, Oxford.
History of British Intensive Care, c.1950–c .2000
1938 epidemic in Britain that precipitated the building of the Both ventilator
in Oxford (Figure 5).57
So, certainly there were lots of epidemics and the disease was greatly feared by the
general population. Most patients in Britain were treated in the special polio units.
Macrae in Bristol has written extensively about his unit, which had a number of
tanks and later he went on to design and utilize the Clevedon ventilator.58 But
even in Blegdam Hospital in Copenhagen, they only had one tank and six cuirass
ventilators, so there weren’t many machines around. In the US, however, the
National Foundation for Infantile Paralysis had collected enormous sums with
its March of Dimes Fund, and you’ve probably seen the pictures of 40 or 50
tanks in a ward at Rancho Los Alamos Hospital in California.59
Certainly in Boston, trying to work in that crowded ward was very difficult.
Three anaesthetists went to help out in the ward: Thorkild Waino-Andersen
from Denmark, Mike Andrew from the US and myself.60 We used to have to
bronchoscope the patients, but there wasn’t enough room because of the tank
right behind you. But there was one other thing that was interesting and that
was that some of the tanks had a Hoover vacuum cleaner on the top. Every hour
an alarm clock mechanism activated the Hoover, which increased the negative
pressure in the tank so that lung volume was increased for a minute before
returning to normal levels again. That was the influence of Ferris and Pollard
who believed that the artificial sigh prevented atelectasis.61
Dr Brian Slawson: I’m also from Edinburgh.62 It’s interesting that infection
seems to have been the origin of intensive care in some places – in Edinburgh it
57 See, for example, Sykes and Bunker (2007): 181–91; Trubuhovich (2006).
58 The Clevedon ventilator was designed to treat poliomyelitis by Dr James Macrae and his colleagues at
Ham Green Hospital, Bristol, in 1953 and built by Willcocks Engineering Co., Clevedon. See, for example,
Macrae et al. (1953); see also (visited 7 September 2010).
59 The ‘March of Dimes’ was an annual fundraising event of the National Foundation for Infantile Paralysis,
a US health charity founded in 1938 by President Franklin D Roosevelt, who had been paralysed by the
disease. This label superseded the original title of the charity in 1979. See
history.html (visited 1 February 2011); see also Paul (1971): 88. For a recent review, see Melnick (1996).
60 Sykes (2008); Sykes and Bunker (2007).
61 Ferris and Pollard (1960).
62 Dr Brian Slawson wrote: ‘Assisted ventilation was provided in an annexe of the postoperative recovery
room of the Western General Hospital from 1966 until the appointment of consultants with sessions
in intensive therapy and the provision of purpose-built accommodation there in 1988.’ Note on draft
transcript, 23 October 2010.
History of British Intensive Care, c.1950–c .2000
was crush injuries of the chest.63 Dr Harold Griffiths battled with the surgeons
as to what would be the best way to treat them.64 They wanted to sew the chest
together and he wanted to ventilate. He showed that those who were ventilated
survived more often than those treated surgically.
The final stimulus to setting up an ‘assisted ventilation unit’ happened one
day when we had to look after a patient with staphylococcal pneumonia and
the student ward in the Royal Infirmary was empty for a short time, and the
anaesthetists moved in patients and equipment, much to the annoyance of the
physician in charge of that ward. The professor of medicine expressed doubts
about whether the anaesthetists were fit to have charge of patients.
Professor Iain Ledingham: I’m from Glasgow, Dundee and various other places.
Could I follow David Wright’s example and ask a question. Keith, with regard
to these people performing hand-ventilating of polio patients or supervising, as
you described the procedures: what was the risk to those who were looking after
the polio victims? Were any records kept of the prevalence of acquired infection
among carers?
Sykes: I don’t know about that, but after I left Boston in September 1955 I did
hear that two doctors and a nurse had gone down with polio in that particular
epidemic.65 So it certainly was a risk and one accepted it, as you did with all
those things at that time.
Spencer: Just before we leave the subject of polio, I think we should mention
the pioneering work of the Oxford group, who extended the Danish work
and developed the simple East-Radcliffe ventilators.66 This was mostly due to
63 Dr Brian Slawson wrote: ‘Patients with tetanus were numerous in other places, such as Leeds and
Cambridge. Like them, Edinburgh is surrounded by rich agricultural land, but cases of tetanus were rare.’
Note on draft transcript, 23 October 2010.
64 Griffiths (1960); Bargh et al. (1967).
65 Emergency admissions for polio during the summer of 1955 at the Children’s Hospital, Boston, forced
doctors to triage patients in their cars. Several staff contracted polio, and two patients had babies while
being treated. Later it was discovered that some of the vaccine given in May 1955 to 6- and 7-year-olds in
Massachusetts contained live polio virus, which caused some cases of polio. See
newsroom/Site1339/mainpageS1339P1sublevel132.html (visited 4 February 2011).
66 Professor Sir Keith Sykes wrote: ‘The East-Radcliffe was introduced in 1961 and I adapted this machine
so that it could be used as an anaesthesia ventilator as well as in the ITU.’ Note on draft transcript, 6 March
2011. Sykes (1962).
History of British Intensive Care, c.1950–c .2000
the neurologist John Spalding and anaesthetist Alex Crampton Smith67 I
mention that specifically because Crampton Smith’s obituary is published in
The Times today.68
Gilbertson: Very briefly. Trubuhovich I never know how to pronounce his
New Zealand name – says in his review of Ibsen’s work that none of the students
in Copenhagen got polio. I dont know how he knows, but it’s in his paper.69
Dr Carol Ball: I’m from the Royal Free Hospital, London. From a nursing
perspective, I’m fascinated to find out if anybody knows what the nurses were
doing? Mervyn raised the issue of physiotherapists, but did you notice any
nurses around looking after patients on cuirass machines or with iron lungs?
Sykes: In Boston there was one nurse to every one or two iron lungs, but I
don’t remember seeing any physiotherapists. Physiotherapy was something that
I learnt from Alex Crampton Smith. I spent some time with Alex in 1957,
and he taught me how to remove secretions by manually hyperinflating the
lung followed by chest tapping and chest compression on expiration.70 When
we started the unit at Hammersmith, the physiotherapists were extremely
supportive and often came in voluntarily at weekends.71 The nursing staff also
helped with the bag-squeezing physiotherapy and suction. It all depended on
them. Now I gather that all that lovely tapping and slapping has gone by the
board, and you don’t do it any more, I made all our registrars do bag-squeezing
physiotherapy three times a day, with or without a physio, so that they knew
what the lung felt like and could see how the chest moved. I used to think
that was the best training that they had because it got them into contact with
the patient.
67 See note 41.
68 Anon. (2010); see also Sykes and Bunker (2007): 79–82.
69 Professor Preben Berthelsen wrote: ‘I have been looking through all the old papers on the polio epidemic.
Unfortunately, I can find only one paper – and it is Danish – where it is stated that none of the 1400–
1500 students and doctors who ventilated the polio patients contracted the disease (Maag 1953))….I am
convinced, however, that the myth is correct. Denmark is a small country. A polio victim among the medical
personnel would not have escaped the interest of the medias and would not have been missed by the medical
community in a “small provincial town” as Copenhagen was in the 1950s.’ E-mail to Dr Ron Trubuhovich,
copy to Professor Sir Keith Sykes, 11 March 2011, forwarded to Mrs Lois Reynolds. See, for example,
Trubuhovich (2004); see also Trubuhovich (2007a and b).
70 For the use of physiotherapy in the treatment of cystic fibrosis, see Christie and Tansey (eds) (2004): 5.
71 See Clement and Hübsch (1968).
History of British Intensive Care, c.1950–c .2000
Gilbertson: Back to nurses: I gave a lecture about a month or two ago, at the
Association of Anaesthetists. It wasn’t very well received, because I made the
point very strongly that nurses claimed to be the initiating factor – maybe not
in intensive care, but certainly in intensive care units because they were the
ones who had to try to nurse people and they didn’t feel competent to do it,
and they were all over the wards.72 I actually had to write to the archive of the
Nursing Timeswhich is in Edinburgh and they’re very good people – and I
sent them a list of 24 articles that I’d found written by nurses in the early days of
intensive care.73 In all of them, they claim that they started intensive care units,
and I think they make a very good point. I’m trying to raise the status of nurses
in the history of intensive care, but the Association of Anaesthetists wasn’t the
right place to do it. [Laughter]
Dr Joseph Stoddart: This point of nursing: when the Intensive Care Society
(ICS) first opened its doors, we had a message from a very senior nurse I
won’t say how senior she was – but she said she thought it was incorrect that we
should call ourselves ‘intensive care’, we should call ourselves ‘intensive therapy’,
because nurses always care intensively. [Laughter]
Hutton: Perhaps we should seamlessly slide forward to how intensive care units
developed across Britain over the next ten years from 1960 to 1970. Iain, I
think you were going to say a few words.
Ledingham: Thanks for inviting me to set the ball rolling on this particular
topic. My credentials are that I graduated from Glasgow in 1958, two years
post-Tony Gilbertson from Liverpool, and almost immediately found myself
involved in both clinical and laboratory work that set the scene for a lifetime in
the intensive care world. If time permits I’ll add a few words at the end about
the related medical influences in Glasgow at that time.
During the early 1970s, as those of us who were around at that time will
readily accept, the quality of care of patients, particularly for those with life-
threatening illnesses, was rudimentary by comparison with present state-of-the-
art practice. I’m thinking of a variety of things, but postoperative monitoring
and care, for example, contrasted unfavourably with the quality of care in the
72 See also Lynaugh and Fairman (1992); Crocker (2007). For a US perspective on nursing in the
development of the ITU, see Bulander (2010).
73 See Appendix 5, pages 107–08. Dr Tony Gilbertson wrote: ‘The 24 Nursing Times articles on intensive
care are rearranged in date order to simplify finding them.’ Note on draft transcript, 26 March 2011.
History of British Intensive Care, c.1950–c .2000
operating theatre, as people have touched on already. In the case of unstable
patients – here I’m drawing on my own experience, but I guess it’s not unique
this amounted to somewhat basic supervision of patients in the anaesthetic
anterooms, followed by transfer to the centre of a traditional Nightingale ward.
In the case of the Western Infirmary in Glasgow this meant around the coal
fire, which was in the middle of the ward, not so very far away from the oxygen
cylinders and so on.
Later, medical and surgical wards allowed some of their side rooms to be used
intermittently and, again, I have happy memories of pushing Cape-Waine
ventilators74 in and out of lifts and across corridors from one side room to
another. Medical staffing throughout this time was a very ad hoc arrangement.
There was no formalized provision for medical cover. There were exceptions,
and one or two of these have already been cited – I think it was one of Tony’s
papers on the subject that drew our attention to the work of Jolly and Lee
in 1957, who were, I believe, among the very first to set up a so-called post-
observation surgical ward.75 In that sense they were, I believe, well ahead of
their time.
Increasing awareness of the inadequacy and inefficiency of the care of patients
with life-threatening illness led slowly to the development of intensive care units
throughout the country. An influential report from the Department of Health
in 1962 facilitated this process to some extent.76 The Progressive Patient Care
document came out at that time.77 It encouraged the thought that intensive care
was at the sharp end of things, but the report wasnt very specific in detail and
merely made recommendations. Staffing arrangements, for example, continued
to be non-standardized.78
74 For details of the Cape-Waine ‘anaesthetic’ and Cape ventilators, see Mushin et al. (1969).
75 Jolly and Lee (1957).
76 Ministry of Health and the Public Health Laboratory Service (1962); Intensive Care Society (2003).
77 This concept was first described in the US; see, for example: Haldeman (1959). See also Ministry of
Health and the Public Health Laboratory Service (1962); Hartley et al. (1968). The Central Health Services
Council working party minutes, papers, self-care study, reports, intensive care units and action, 1961–67,
are held in BD18/2229, MH159/45–48 and MH133/365 at the National Archive, Kew, London. See (visited 4 February 2011).
78 Ministry of Health and the Public Health Laboratory Service (1962); Intensive Care Society (2003); see
also Hartley et al. (1968).
History of British Intensive Care, c.1950–c .2000
In those days small units were the order of the day. Gordon and Sherwood
Jones described the setting up of a four-bed unit in Whiston Hospital, Prescot,
Merseyside, and described the evolution of this unit from 1962 through to
1983.79 Touching on the topic of nursing, the emphasis in the Liverpool paper
was heavily on the importance not only of the nursing contribution to intensive
patient care, but also of training and specific training programmes were described.
Larger units tended to follow, often responding to specific stimuli. One example
was the Royal Victoria Hospital in Belfast, where a 12-bed intensive care unit
opened in 1970. This was partly in response to the civil disturbance problem
that began to present itself at that time. I remember Dennis Coppel telling
us at the time that up to a quarter of admissions there resulted from gunshot
wounds or blast bomb injuries, so it is easy to see where the stimulus came from
in this connection.80 Mention has already been made about the importance of
cardiothoracic and neurosurgical units, and also, to some extent, the respiratory
units for tetanus, polio and so on.
Finally, a quick word about my own introduction to intensive care in the early
1960s. This, I think, came principally from two factors: one was that I was an
assistant in cardiac surgery at that time and within about 18 months of starting
my training in that programme, I was given the responsibility for looking
after the cardiac surgical patients post-surgery the surgeon taking the view
that his work began and ended in the operating room, and his junior staff
in collaboration with the anaesthetists could do the honours thereafter an
interesting insight into the thinking at the time. The second was my involvement
with the MRC hyperbaric oxygen unit in the university department of surgery,
Western Infirmary, Glasgow.81 Some of you will recall that this was a large
surgical–medical walk-in facility that was used over something like seven years
for management and research of a whole host of acute medical and surgical
conditions. While at the end of the day, hyperbaric medicine proved to be
disappointing in terms of its effectiveness in medical practice, the experience
gave those of us who were involved at that time tremendous insight into the
79 Gordon and Jones (1998a and b); Gordon et al. (2000).
80 Coppel et al. (1973); Gray and Coppel (1975).
81 Professor Iain Ledingham wrote: ‘The first director of the MRC hyperbaric oxygen unit was Professor
George Smith (1960–62) – thereafter Regius professor of surgery in Aberdeen. I succeeded Professor Smith
in 1962 and remained director of the unit until my departure from Glasgow in 1988 to become dean of the
Faculty of Medicine and Health Sciences at the United Arab Emirates University.’ Note on draft transcript,
11 February 2011. See, for example, Illingworth et al. (1961); Ledingham et al. (1968).
History of British Intensive Care, c.1950–c .2000
care of acute illness of all sorts. Individuals who were key collaborators included
Bryan Jennett, Ian Donald and Sir David Cuthbertson.82 Bryan Jennett carried
out neurosurgical procedures in the hyperbaric chamber.83 His team was at the
same time developing the Glasgow Coma Scale84 that became a component
of the APACHE (Acute Physiology, Age, Chronic Health Evaluation) critical
illness scoring system.85
82 Professor Bryan Jennett (1926–2008) contributed to the Wellcome Witnesses to Twentieth Century Medicine
Witness Seminar on medical ethics education (Reynolds and Tansey (eds) (2007)) and vol. 5 in the series
described the work of Professor Ian Donald (1910–87) in obstetric ultrasound (Tansey and Christie (eds)
83 See, for example, Jennett et al. (1970); Ledingham (1968).
84 Teasdale and Jennett (1974).
85 Knaus et al. (1981, 1985). For the background of scoring systems, see Angus (2008): 449, followed
by classic papers. Professor William Knaus founded APACHE Medical Systems, Inc. in 1988, the first
commercial decision-support software and outcomes management company to disseminate and support the
APACHE approach to risk assessment and outcomes evaluation. For further details, see http://hsc.virginia.
edu/alive/phs/faculty_page.cfm?id=32 (visited 11 April 2011).
Figure 6: Local organizing committee of the First World Congress on intensive care, London,
1974. L to R: row 1: I McA Ledingham, Lord Brock, A Gilston; row 2: K D Roberts,
T J H Clark, G C Hanson, C B Franklin; row 3: M W McNicol, D Williams, J Jones,
J Gil-Rodriguez; row 4: A B M Telfer, J C Raison, J B Smith, E B Raftery; top row: J
Simpson, E Sherwood Jones, J C Stoddart, D Short, J Mathias.
History of British Intensive Care, c.1950–c .2000
To finish off, at the end of the 1960s a few of us got together and set up the
Intensive Care Society.86 The first challenge we undertook was the First World
Congress on Intensive Care, which I think helped to promote the concept of
intensive care worldwide (Figure 6).87 And I like to think that it helped further
development of units throughout the UK.
Hutton: Iain, could you comment on Margaret’s suggestion that advances in
cardiac surgery were one of the stimuli to the setting up of units? Would you
agree with that?
Ledingham: Yes, I totally agree with that and it isn’t difficult to appreciate why
this should be. The concept of tissue oxygen availability and consumption was
key to that whole process.88 So prevention and correction of disturbances in this
process were crucial to postoperative care of patients undergoing cardiothoracic
surgery. So I very much agree with Margaret’s comments.
Stoddart: The way in which the intensive care unit started in the Royal
Victoria Infirmary, Newcastle upon Tyne, in the 1950s was because, at that
time, Professor E A Pask was the king of all he surveyed.89 Consequently, if
anyone was very ill, or on a ventilator, the duty anaesthetist had to spend the
entire 24 hours with him and nothing was allowed to take him away from
that. So there had to be a second duty anaesthetist to look after the other
patients. Intensive care was very much regarded as being a responsibility of
the anaesthetist senior house officer and registrar at that particular time.
Everything else developed from there. Pask was certainly responsible for
developing the planning of the intensive care unit, which unfortunately
86 For further discussion, see pages 51–2, 56. Dr David Morrison wrote: ‘Such intensive care units
as there were were largely run by anaesthetists as a part-time hobby. In 1970 Alan Gilston of the
National Heart Hospital circulated those of us who he knew had an interest with a view to forming
an Intensive Care Society. I attended the inaugural meeting. At that time no-one knew for certain
how many units existed in the UK.’ Letter on intensive and high dependency care data collection,
4 August 1997. For the aims of the Intensive Care Society, see Appendix 1; for the distribution of the
units in England and Wales, see Gilston (1981): 189. The first directory of intensive care units (ICS
(1981)) was produced with the assistance of the industrial liaison group, later independently of the ICS
(Healthcare Industrial Liaison Group (1987)), along with an annual analysis of ICU statistics. Each
ICU received a free yearbook, subsidized by advertising. Letter to Mrs Lois Reynolds from Dr David
Morrison, 15 April 2011.
87 Gilston (1975).
88 See, for example, Ledingham (1972).
89 Conacher (2010).
History of British Intensive Care, c.1950–c .2000
he did not live to see.90 But intensive care was always something that was
regarded from the medical point of view as being the responsibility of the
duty anaesthetist.
Hutton: For the folks who were around in that period, was there any central
push or planning, or was it local enthusiasms in response to need that made
things happen?
Strunin: I worked at the London Hospital (1962–72) and during 1962–65 we
were ventilating patients on the wards with uniformly discouraging results.
Then Roy Simpson,91 the professor of anaesthesia, David Ritchie, the professor
of surgery, and David Pennington, a consultant physician, presented six of these
ventilated cases to a meeting of the medical staff one evening and said: ‘This
is what’s going on in the building. Do you think this is the right way to do it?’
Everybody said: ‘No.’ So Roy Simpson presented a solution. He proposed that
the six empty secretariesoffices next to the operating theatres should be used
as an ‘Intensive Therapy Unit’ and he said: ‘What we need is to put all the ill
and ventilated patients in there, and they will need one nurse each’. At that
moment there was a gasp around the room at the concept of one nurse for each
patient. I think the final point that made it work, was: ‘These beds must be
supernumerary to anything else in the hospital’, so nobody could just dump a
patient in there and forget about them. Therefore, it was agreed, that if whoever
was running the unit said the patient was better or worse and shouldn’t be there,
they went back to their ward. That’s what saved it, I think. I believe the unit got
going towards the end of 1966.92
Ms Pat Ashworth: At the time I was in intensive therapy, I was in Broadgreen
Hospital, Liverpool. Intensive care began there when one of the anaesthetists
came to the cardiothoracic ward that I was then sister of, and asked: ‘How did
we feel about our side wards being used for ventilating patients or anything that
90 Dr Joseph Stoddart wrote a protocol for the new 1970 Royal Victoria Infirmary ITU, Newcastle and this
was issued to every member of the hospital medical staff: ‘The intensive therapy unit provides facilities for
the care of patients who require, and would benefit from, more than ordinary ward care. The staffing, space
and equipment available enables more detailed observation, recording and treatment than is possible in the
busy general wards of the hospital, in which the nursing of the very sick or very dependent patients creates a
disproportionate disturbance to the ward routine and to the other patients.’ This is reproduced as Appendix
A in Stoddart (1975): 188–93.
91 Dr B Roy Simpson was head of the anaesthetics unit at the London Hospital until 1975 when he moved
to Baylor University Hospital, Dallas, Texas (1975–89). See Ramsay (2000).
92 Mason (1966); Salter (1966).
History of British Intensive Care, c.1950–c .2000
Figure 7: Broadgreen Hospital Intensive Care Unit, Unit, Liverpool, 1964:
(a) floorplan; (b) view from nurses’ station.
History of British Intensive Care, c.1950–c .2000
needed something beyond ordinary care?’ I think we had just combined two
wards and been very busy. They decided I thrived on organized chaos. So we
said: ‘Yes, we would do it.’ For the first four years the intensive care unit, not
only for the 100 cardiothoracic surgery beds, but also for the rest of the 600-bed
hospital, consisted of those two side wards. We had the usual two sisters, myself
and a junior sister, and a staff nurse. The remaining staff were all student nurses,
so it was quite usual for us to have a couple of patients across the corridor
in the side wards flat out, attached to ventilators, students looking after them
being end of first year, beginning of second year, while a senior student nurse
and junior were in the ward, and whichever of the qualified nurses was on, ran
between them dealing with whatever crisis there was.
So it began in a fairly basic way, but on the basis of that experience, I think
the primary initiator was the senior surgeon with his other colleagues, who
got money from the Nuffield Provincial Hospitals Trust, and some from the
Liverpool Regional Hospital Board, and we built the first – it was said by the
Ministry of Health nursing officer to be the first purpose-built UK intensive
therapy unit (ITU). It was semi-prefab and the 12-bed unit opened in February
1964 (see Figure 7).93
That unit was for cardiothoracic patients and then included open-heart surgery,
which began in that hospital after we opened the unit. We also had general
intensive therapy. The nurses, as I say, had up until that time largely been
pre-registration students. At that point we then had more qualified staff,
although we always still had three students for their ‘experience’. Although we
had lectures, I wouldn’t call it a course. I refused to call it a course until it could
be a proper educational experience. Whereas the hospitals that were running
courses very often admitted they were doing it to get staff and the courses were
of variable quality and not necessarily a good educational experience. But I
would say that we got quite a long way, even in the first four years, learning
how to nurse patients who needed ventilation and various other rather extreme
forms of treatment. Certainly once wed opened the 12-bed unit, we had a great
deal more experience.
In a way it is quite a surprise to me that so many of the patients survived, despite
the fact that they were nursed by inexperienced students with supervision from
such qualified nurses as there were. For example, somebody who fell 50 feet in
93 Liverpool Regional Hospital Board, East Liverpool Hospital Management Committee (1964); see also
McLachlan (1992).
History of British Intensive Care, c.1950–c .2000
Cammell Laird’s shipyard and ended up with a flail chest, where a segment of
the chest wall bones breaks and becomes detached from the rest of the chest
wall, and a head injury, went out of the hospital on his feet. Similarly, somebody
with multiple injuries with fractured ribs, pelvis, head injury, ‘tib and fib’ and
various other things, also went out on his two feet, eventually.
One of the big problems for nursing was getting the right equipment. In a
previous life, I had been running an ear, nose and throat (ENT) ward after the
war where we had laryngectomies among other things, and had had to use a
mutilated funnel in order to give inhalations to somebody after laryngectomy,
because we didn’t have tracheostomy masks in those days. By the time we
got to intensive therapy, we were beginning to get things like that. But some
equipment was still difficult to get. When I visited the US in the mid-1960s,
they were using the burettes, which were built-in to the disposable transfusion
giving sets, but we couldnt get them in England despite the fact that it was the
same firm that was making them.94 So getting equipment was quite difficult.
Branthwaite: There’s one other aspect of circulatory monitoring from that
period that I think is worth commenting on, because although a lot of what was
done emerged out of the operating theatres, and particularly cardiac surgery,
there was also the fact that Ron Bradley at Thomas’ in those days was trying to
use the techniques of the cardiac catheter lab in the acutely sick and developed
his float catheterization technique of the pulmonary artery.95 It wasnt a question
of bringing the patient to the set-up; you took the set-up to the patient. A large
trolley was wheeled around the wards (Figure 9), which had the monitoring
apparatus, the ECG, the blood gas analysis and so on, and much recording
apparatus. Ron and I I had the privilege of working with him then were
deemed the ‘death watch beetles’, because unfortunately we werent always
successful. You, Ron, may wish to add to this.
Professor Ronald Bradley: I came to this business from an almost
unrecognizably different aspect from all the rest of you. It had virtually nothing
to do with ventilators and that end of the business at all. Albeit, in 1956 I
was the houseman on the medical unit at Thomas’ and we had patients in the
open wards, Nightingale wards, on ventilators. People with Guillain–Barré
acute infective polyneuritis were ventilated, perfectly successfully, and it worked
94 For a report on clinical experiences of MRC plastic sets manufactured by Capon Heaton & Co. Ltd, see
Jenkins et al. (1959).
95 Bradley (1964).
History of British Intensive Care, c.1950–c .2000
Figure 9: Equipment that Ron Bradley and Margaret Branthwaite used to
wheel round St Thomas’ before the designated ICU, the Mead
ward, was opened in 1966.
Figure 8: Ron Bradley’s equipment in use on a patient after cardiac surgery
in St Thomas’ north theatre recovery room, c. 1964.
History of British Intensive Care, c.1950–c .2000
alright. That’s about all that I had to do with ventilators. I happened to be
the HP around at the time. It was later on that I fell into this business of
intensive care. What happened was that I spent a number of, not hours, but
many days, many months as the medical long-stop at Thomas’. You were called
the resident assistant physician (RAP). The day before you were the resident
assistant physician, you were an ordinary, ignorant, stupid registrar who was as
likely to foul everything up as anybody else. But the day you became the RAP
you could hear it around the hospital: ‘The RAP says this is such and such.’ And
that was it. Suddenly you had this sort of god-like touch and it was terrifying. I
sat there wondering what the hell they’d show me next.
Now the problem was when I grew up, you could be taught a great deal about
chronic medicine, but nobody ever told you how to deal with some acute mess
that arrived in casualty and nobody had the foggiest idea what was wrong with
the patient. And out of terror, I designed a logic system for myself to sort out
these acute messes, so that you could do it with a certain amount of equanimity,
and the terror level went down as the system got better. After some time doing
this I discovered that it was absolutely useless going and trying to root out help
from people like the cardiologists. If you were presented with somebody who
was palpably dying of some ghastly sort of circulatory nonsense, if you asked the
cardiologist to help, they said: ‘Oh, make him better, and then I’ll catheterize
him’. [Laughter] This was no help at all.
It gradually dawned on me that if only a few straightforward simple measurements
could be made, it might be vastly better for this chap when he was very sick, and
be more likely to make him better for the cardiologist. Well, Peter Sharpey-Schafer
asked me what I was going to do. Schafer had been the professor of medicine and
Schafer and Dornhorst were the two halves of the medical unit.96 They were both
remarkable men and very different. And Schafer said: What are you going to do?’
I replied: ‘It’s no good if you go to the cardiologist to ask to help you sort out the
acute problems that arise. They won’t do it. Whereas, with a few measurements,
you might be able to do something about it.’ Schafer actually rubbed the side of
his nose, I remember, and there was a long, long pause. At the end of it he said:
96 Professor Peter Sharpey-Schafer (1908–63) was professor of medicine in the university unit at St Thomas’
Hospital, London (1948–63); see McMichael (1964). Professor Tony Dornhorst (1915–2003) returned to
St Thomas’ hospital medical school, London, after the war as reader in medicine in 1949 and consultant
in 1951, later appointed to the foundation chair of medicine at St George’s Hospital Medical School
(1959–80). See Collier (2003). For further discussion about this partnership, see Reynolds and Tansey (eds)
(2008a): 11; for their contribution to clinical research, see Reynolds and Tansey (eds) (2000).
History of British Intensive Care, c.1950–c .2000
‘Take three years and see what you can do.’ So I found myself sawing up lengths
of steel tubing and making a scaffolding and putting wheels on the bottom of it
so that we could take four pressure heads, a set of gas electrodes and an ECG and
a recorder on which you could write the pressure records and everything else that
came out. One rather important bit of the kit was a centrifuge so that you could
tell what the haematocrit (erythrocyte volume fraction) was doing. All that was
on wheels and we went anywhere there was trouble: into the middle of the wards
or to the small wards where a lot of these patients were sequestered.97 I remember
sleeping on a sort of terrazzo floor of the old north wing theatres after the cardiac
surgeons had done their worst. We looked after those patients overnight with this
array of measuring kit. So, I came to intensive care from a very different aspect,
which had very little to do with ventilators.
After a time, I think it was about 1966, Geoffrey Spencer presented us with an
ideal place in which to work. He built this wonderful intensive care unit that had
no walls or very few walls. It was open-plan where you had plenty of space to do
almost anything you could think of. It was wonderful. It was a stroke of genius
for which I have never thanked him enough, I think. It was a very remarkable
place and it became a happy hunting ground for sorting out these circulatory
problems. We constructed a system of analyzing mathematically what was going
on in the circulation: how was the circulation misbehaving, not only in people
with various patterns of coronary artery disease, but also in people with big
pulmonary emboli? How was the circulation in people with chronic obstructive
airways disease? These people all had different patterns of circulation. Most
importantly, people talk of septicaemic circulations as though they were all the
same, but they aren’t; they’re wildly different. Unless you analyse them in this
sort of way, you won’t do very well for the patients.98
The last thing I would like to say is that built into this, there was a gradual
development of the kit we used. Most of it was built for us by a marvellous chap
called Tony Cowell, an electronics engineer, who built the things on circuit
boards. So there was a preamplifier for each of the pressure heads and so on.
By that time we’d developed a thermal dilution system for measuring people’s
cardiac outputs and so on.99 He put all that onto printed circuit boards and
97 See Figures 8 and 9, page 31.
98 See Figure 10.
99 See, for example, Branthwaite and Bradley (1968), which includes an image of Dr Margaret Branthwaite’s
neck to illustrate the technique for inserting a needle into the internal jugular vein (page 435).
History of British Intensive Care, c.1950–c .2000
Figure 10: The aftermath of a session investigating cardiac output: Ron Bradley sterilizing the
pressure transducers and Margaret Branthwaite ‘counting squares’.100
when I was chasing him for more and more and more of these things, this man
produced out of nowhere, the BBC Micro. This machine offered a measurement
system on an incredibly cheap basis. The BBC Micro would provide you with
preamplifiers for all the kit, four pressure heads, the cardiac output system,
everything. And, it only cost £350.101 If only the health service had a system
somewhere for producing kit for the hospitals, the whole thing could have been
done that way. It is still the case that if you go round to the Brompton, and in all
of these units, they have separate preamplifiers for doing absolutely everything.
Each one costs god knows how much. The opportunity was lost, because I
remember the boss of Simonson & Weel Ltd (Sidcup, Kent) in this country
coming round and saw this kit based around the BBC microcomputer and
said: ‘If this is put around and marketed, it will put us all out of business.’ We
wouldn’t be able to afford to send somebody around to all the hospitals to keep
100 Dr Margaret Branthwaite wrote: ‘Thermal dilution curves were originally drawn on graph paper and
the only way to determine the area under the curve was to count the squares.’ E-mail to Mrs Lois Reynolds,
17 June 2010; Figure 10.
101 BBC Micro: £235 Model A (16 KB RAM, 1981), £335 Model B (32 KB RAM, 1982) were designed
and built by Acorn Computers, Cambridge. Some documents from the BBC Computer Literacy Project,
are freely available at:
temid=69 (visited 31 August 2010).
History of British Intensive Care, c.1950–c .2000
the kit working if you could buy the machine to do all the processing for £350,
and anyone can pirate your programmes.’ So, that opportunity is still there, out
there somewhere, but it is totally lost now, I think, and it is a great pity.
Ledingham: A quick comment, following on from Leo Strunin’s reference to
how the unit in his hospital was set up. It reminded me that the way intensive
care came about in the Western Infirmary in Glasgow during the period from
1965 through to 1968 was partly as a result of the Progressive Patient Care
documentation,102 but also on the initiative of Sir Edward Wayne, Sir Charles
Illingworth and Herbert Pinkerton from medicine, surgery and anaesthesia,
respectively. These departmental heads got together and decided that the unit
would be multidisciplinary from the outset. It has remained so. The great
attraction to me, working there for the next 20 years, was that this approach
largely addressed the concerns that intensive care was going to take patients
away from physicians and surgeons. The referring clinicians had an input to the
system and there was a commitment from the start, in terms of both dedicated
medical and nursing staff. The unit was seen very much as a baby of the whole
hospital, not just an individual department.
Dr Doreen Browne: In 1968 Dr Hilary Howells set up the first three-bedded
ITU at the 1000-bedded Royal Free Hospital, London.103 They didn’t have a
cardiac surgical unit in those days, nor a neurosurgical ward that involved
ventilatory support for their patients. In the beginning it was very difficult,
because there was quite a lot of antagonism from clinicians who somehow
seemed to view the admission of one of their patients to the unit to be a
reflection of failed management on their behalf and so felt resentful. They
were always anxious for the patient to be discharged sooner rather than later.
The fact that their patient was now being managed by an anaesthetist with
their ventilatory expertise was a further cause for concern as they feared loss
of control of their patients.
In order to get the unit established at all at the Royal Free, it had to be agreed
politically that the patients would remain under the nominal care of the
admitting consultant. As time went on, a multidisciplinary unit was established
with a major input from the developing renal unit, the liver unit, neurology/
neurosurgical unit, cardiology, haematology, microbiology, chemical pathology
and radiology as appropriate, all coordinated by a consultant anaesthetist and a
102 See note 77.
103 For details of further developments, see Browne et al. (1974).
History of British Intensive Care, c.1950–c .2000
junior anaesthetic team with expertise in modes of ventilation and management
of the critically ill patient on a 24-hour basis.
Bion: I have one comment and a question. The comment is that in terms of
equipment, we mustn’t forget the humble syringe driver, without which we
would find things a lot more difficult. My question, which I’d like to direct to
Margaret Branthwaite and Ron Bradley – particularly with Mervyn Singer here,
who led the PAC-Man study,104 which demonstrated that pulmonary artery
catheters do not appear to improve patient outcomes – is as follows: would you
very briefly tell us the story of how the Bradley–Branthwaite catheter became
the Swan–Ganz?
Branthwaite: The technique of measuring cardiac output by thermal dilution
was reported in rabbits from some time back. We worked it up for use in man
using thermisters mounted in the end of Ron Bradley’s float catheters.105 Jeremy
Swan, as I understand it, was an Irish cardiologist who had emigrated to the US,
and during a return visit to the UK after the thermal dilution technique was in
use at St Thomas’, he expressed great interest and spent a long time with Ron
in the laboratory in Mead ward that Geoffrey Spencer had constructed to his
design. Jeremy Swan was full of enthusiasm. As he left, he asked that we should
send him the details of the technique. In those days, I was the scribe who typed
out in immense detail on a very old manual typewriter with a very grey ribbon,
how we made our own thermal dilution catheters. The letter was sent, and as far
as I know it was received, but unfortunately it was never acknowledged. It was
with some sorrow that shortly afterwards – within a year I think – we saw the
publication of a notice of this spectacular new device – the Swan–Ganz catheter
– which not only allowed you to measure the pulmonary artery pressure, but
also allowed you to calculate and measure the cardiac output as well. Sadly
credit was not given where credit was due; that is to Ron.106 The Swan–Ganz
catheter was much greater in diameter than Ron’s catheters – which were only
half a millimeter internal diameter – and had a balloon. The one disadvantage
of the Bradley catheter was that you often couldnt get them through a hugely
dilated right ventricle, because they would spin round and couldn’t get gripped
by the pulmonary artery. On the other hand, they were much less likely to
104 The pulmonary artery catheter (PAC) is also known as the Swan–Ganz catheter (see pages 39–40). For
the PAC-Man study, see Harvey et al. (2005).
105 Branthwaite and Bradley (1968).
106 Ganz et al. (1971). For further historical detail, see Swan (1991), one article in an issue devoted to the
Swan–Ganz catheter, including a reprint Amin et al. (1986a–d); see also Swan (2005).
History of British Intensive Care, c.1950–c .2000
do any harm, and there was no need to wedge them, because if you had a
good undamped pressure trace in the pulmonary artery, unless the pulmonary
vascular resistance was enormously high – you could tell from the shape of
the curve – you could get the left atrial pressure from the end diastolic. So the
Bradley catheters in their original form were, I believe, a very safe device, unlike
the Swan–Ganz, which was fatter and had a balloon. They did give us such an
enormous amount of information, which I think Ron has already tried to set
out.107 It does seem rather sad that yet another British invention crossed the
Atlantic and acquired a different pedigree as a result.
Bradley: Can I chip in a little bit? I’m sorry, but Billy Ganz was a marvellous
chap. He got out of Czechoslovakia as the Russian tanks moved in. He thought
up this wheeze of putting a balloon on the end of it. It is a remarkable device.
It’s lovely because the balloon does tend to float the thing in to the place you
want to get it; and it does give you a proper left atrial pressure even when
you’ve got a bit of hypertension. It doesn’t when you’ve got severe pulmonary
hypertension, but there it is. It was a great device and Billy was a great, good-
hearted sort of soul, who I didnt feel did us any injustice at all. No, I have great
sympathy with Ganz.
Singer: The question I have for those people working in the 1960s is how
knowledge was disseminated? Iain made the point that the Intensive Care Society
didn’t come into being until the end of that decade. How did practitioners learn
what constituted best practice? It seems like intensive care evolved in different
areas according to local need, but how did you learn what to do? [From the
audience: By mistake.] How did you learn from other people? There werent
many review papers, for example.
Mr Graham Haynes: I’m a nurse, not a doctor. I was in Leicester Royal Infirmary
in the 1960s. The majority of intensive care patients, or all of intensive care
patients, were trauma, particularly flail chest and multiple trauma. I’m going to
introduce the awful subject of children in intensive care, because to some it is an
anathema to have children in an adult intensive care unit. Children in Leicester
Royal Infirmary went to the Children’s Hospital. We specialled burns in side
cubicles, of which there were a significant number. On the adult general wards
we had ventilated patients; asthma and Guillain–Barré syndrome; and on the
trauma wards, ventilated patients were also there, a lot of whom would come
107 See Bradley et al. (1970, 1971); Jenkins et al. (1973).
History of British Intensive Care, c.1950–c .2000
out of mucky fields because of the surrounding agricultural area. As a student
nurse, we learnt by mistake, I regret to say. There was no body of knowledge, in
terms of available literature at that time.108
Spencer: I cannot let my great ex-colleague Ron Bradley get away with saying
that the unit at Thomas’ was a work of genius: the only work of genius that I did
was to ask Ron and Margaret to come and work in it (Mead ward, Figure 11).
[Laughter] I must, however, tell you how the unit came into being, because it was
very little of my doing. I came back from working in Shackletons tetanus unit
at Southampton to Thomas’ in 1960 and said that Thomas’ needed an intensive
care unit. I was told very firmly that Thomas’ could do anything anywhere and
didn’t need an intensive care unit. [Laughter] I noticed that Steve Semple, later
the professor of medicine at the Middlesex Hospital, and Ron, were treating the
acute exacerbation patients with chronic bronchitis by tracheostomy and IPPR in
general wards using Smith Clarke volume cycled ventilators and getting into all
sorts of difficulties. I tried to help and we published a paper in the Lancet describing
our results in 29 cases.109 The mortality was very high from various tracheostomy
complications and cross-contamination through the unsterilized ventilators, and
including cross-infections to adjacent patients in the medical ward.110 This reached
a point where we were granted two bed spaces for each of these patients, which
cost the physicians beds. The cardiac surgeons wanted some special units for their
postoperative work and the physicians agreed that an ITU was needed. There was
a discussion in the medical committees and everybody said: ‘Wonderful idea, but
not in my beds.’ Fortunately, the hospital was building its first significant rebuild
after the war – the east wing – and there was a 28-bedded ward planned to go on
the same level as the four operating theatres. The professor of surgery had decided
that that ward would be his. I was only a very humble senior registrar at the
time, and the hospital administration decided that they could quietly appoint this
senior registrar to turn this 28-bedded surgical ward into an intensive care unit
(Figures 11and 12).111 Because it was done under the counter, I had control and
108 Mr Graham Haynes wrote: ‘I have been reflecting on the seminar and have been somewhat happy and
sad since the experience, which I had not expected. My sadness was personal and coming to terms with my
advancing years, but happy that I made a contribution to ITU work through the 1970s–80s and stated so
whilst at the meeting. If you did a nursing/ITU seminar, you’d get another perspective and more nurses
attending.’ E-mail to Mrs Wendy Kutner, 21 June 2010.
109 Bradley et al. (1964).
110 Phillips and Spencer (1965).
111 Bell et al. (1974).
History of British Intensive Care, c.1950–c .2000
could do more or less what I liked, with a help of the planning nurse, a planner,
an architect and a couple of consulting engineers. And that’s how it happened. As
I said, the only thing that I did that was really useful was to ask Ron and Margaret
to come and work there, and to dump their trolley, which was hideously heavy, in
the laboratory. [Laughter]
Gilbertson: I’m having a delightful afternoon. I have never met Professor
Bradley before, but I’m actually his disciple. I read about his work with plastic
tubes being floated in to the pulmonary artery and I bought a drum with a
roll of some hundreds of yards of plastic tube – little minute stuff it was – and
then I had to try to sterilize it. I spent hours trying to drive the bubbles and the
germs out and when I read in the New England Journal of Medicine about the
Swan–Ganz catheter, I think that was the main reason that I imported some.112
Was it Seattle that they were in? I rang them up and bought six of them with
my own money. After 30 of these catheters had been used, I wrote a paper in the
British Journal of Anaesthesia.113 The first citation was Bradley. I’d never met him;
I didn’t even know where he worked, you know. The London teaching hospitals
to a Liverpudlian were these names, there’s Guy’s and St Thomas’ and all the
others. I wouldn’t even know where to find any of them. But I did acknowledge
112 Swan et al. (1970).
113 Gilbertson (1974).
Figure 11: Dr Ron Bradley measuring a patient’s cardiac output by thermodilution,
assisted by staff nurse Douglas. Valerie Arnold is monitoring the equipment, Mead
ward, St Thomas' Hospital, c.1973.
History of British Intensive Care, c.1950–c .2000
it. I was very pleased to hear you (Ron Bradley) mention what a nice chap
Bill Ganz was, because he and I used to do a double-act, sort of selling these
things for US hospital suppliers. He’d tell how he made them and I’d say what
you could use them for, and we went all over the place together. I remember
giving him some of my Valium on a particularly bad flight somewhere. But
I’ve watched with sorrow, in a way, the various reviews that have showed that
they were of no use.114 Certainly not as they were often used, particularly in
other countries. I saw one big paper in the American literature about the Swan–
Ganz catheter used for prostatectomy.115 Well, I can’t imagine why anybody
would want to use the Swan–Ganz catheter for monitoring perfectly healthy
people with prostatectomies. We used an awful lot at first, but gradually fewer.
The reason we gradually used fewer was that we had learnt by then what to
anticipate. Wed learnt about the circulation and particularly the pulmonary
circulation. The dangers of them: well, I must say I’ve seen some terrible tricuspid
granulations in post mortems on my patients, but we never burst a pulmonary
114 Pearson et al. (1989); Shoemaker (1990).
115 Garcias et al. (1981).
Figure 12: Floor plan of St Thomas’ intensive care unit, which opened in
September 1966. See note 111.
History of British Intensive Care, c.1950–c .2000
artery.116 And, we never got one knotted. We got a central venous pressure (CVP)
line knotted around a pulmonary artery catheter once – that was very tricky –
but I think if you followed the instructions, and it wasn’t all that esoteric, they
were on the box, just follow the instructions on the box – I think you can learn
a great deal from them. But, of course, you can measure cardiac output non-
invasively much more easily now and perhaps they’ve had their day. But at the
time, I think they were a great advance. I knew nothing about the left heart
pressures; I was great on CVP, but they told me a great deal and I think they
were for teaching as much as diagnosis.
Ms Alice Nicholls: I’m a PhD student at the University of Manchester, working
on the history of intensive care. I wondered if I could push Mervyns question a
little further and ask about how you learnt from each other in the 1960s? Did
you visit each other’s units? Did you visit units overseas? Could you say a little
more about that?
Strunin: Yes, we did quite a bit of travelling. We also presented papers at the
Anaesthetic Research Society, the Surgical Research Society and the Medical
Research Society.117 We went to all of them and presented cases that had occurred
in intensive care. I can remember travelling up to Iain Ledingham’s unit because
we did a bit of hyperbaric oxygen at the time; and we spent most of the meeting
trying to find out which was the best restaurant in Glasgow. It was obviously
an educational achievement. But we did do a lot of travelling, and people came
to visit us, of course. But writing major reviews and things like that was not de
rigueur in the 1960s. People didn’t do it.
Browne: We were very privileged to travel round to other units in the UK, and
to go abroad to gain further experience in the 1960s–70s. I was very fortunate in
1970/1 to go to Massachusetts General Hospital, Boston, to work as a research
fellow in the respiratory care unit run by Henning Pontoppidan for 18 months.118
116 Chun and Ellestad (1971).
117 Founded as the Anaesthetic Research Group in 1958, see Payne (1988), Nunn (1988); for details of
the Surgical Research Society, established in 1954, see Dudley (1976); the papers for the Medical Research
Society are part of the collected papers of Sir Thomas Lewis (1881–1945), who founded the society in 1930,
and are held in archives and manuscripts, Wellcome Library, London, as PP/LEW/D ‘Clinical Research and
Medical Research Society’.
118 See, for example, Pontoppidan et al. (1972), one of a three-part ‘medical progress’ report in the New
England Journal of Medicine, published as Acute Respiratory Failure in the Adult (Boston, MA: Little, Brown
and Co.) in 1973.
History of British Intensive Care, c.1950–c .2000
This was a most enlightening and unforgettable experience, for which I shall be
grateful forever. Such leave was allowed at senior registrar level and apart from
broadening the mind and obtaining insight into the culture of another country,
the ‘Been to America’ (BTA) label was thought to be a brownie point on your
CV for a consultant post in the UK.119 At the senior registrar level, the BTA was
almost obligatory. As an apprentice, would you were on the unit all the time with
your patients and learning from people who came in and the various consultants
who were involved.120
Sykes: At the Hammersmith we had 700 doctors and 700 patients [laughter]
and a huge number of visitors. In the cardiac theatre there was always a queue of
people looking into the mirror on the operating lamp, or the television screen.
However, there were very few people running intensive care units and we all
knew each other and visited each other’s units. That’s how we learned.
Ledingham: I’m pleased that Mervyn raised this topic. It has prompted
me to recall that in the early days we soon realized the benefit of having a
multidisciplinary approach to intensive care. We had inputs from medicine,
surgery, anaesthesia and nursing; and we set up a course, essentially presenting
the theory behind certain components of the care within the unit, together
with on-the-job training. In the process, I suppose we experienced what is now
called ‘cross-skilling’ as far as our clinical activities were concerned. Obviously
we benefited from travel elsewhere, but principally to address the point Mervyn
was making, we realized that we had a lot to learn from each other and between
disciplines, which tended to bond us together in the process.121
119 See pages 11 and 59.
120 Dr Doreen Browne wrote: ‘During my time at the MGH I learnt about a “mobile intensive care service”
that provided ventilatory care to patients on the wards outside the respiratory care unit. After I had returned
to the Royal Free from Boston in 1971, the three-bedded ITU had to close during the bed-gap period
1973/4 when the new hospital was being built. This meant that the six hospitals in the group were without
an established intensive care unit. To overcome this problem three special mobile intensive care unit trolleys
were designed to be stationed in the accident and emergency departments in three hospitals in the group.
Each trolley was thus immediately available for use in any ward in the three high-demand hospitals and
could also be easily transported to any of the remaining hospitals in the group.’ Note on draft transcript,
7 March 2011. See Browne et al. (1974).
121 Professor Iain Ledingham wrote: ‘As a footnote, prior to creation of the unit, the prospective nursing
sister-in-charge was funded to visit the few established units elsewhere in the country and benefit from their
early experience. See MacQueen and Kerr (1974).’ Note on draft transcript, 13 September 2010. See also
discussion from a nursing perspective on page 43; Salter (1966).
History of British Intensive Care, c.1950–c .2000
Bradley: Going back a step, about the catheters: we ended up virtually not
using the things. This was because, as I got older – and idler – and less inclined
to involve myself in work at all, I discovered with hands and eyes and ears and
stethoscope and a logic system, we could actually avoid putting catheters –
you had to have the right atrial pressure and you had to know the systolic and
diastolic blood pressure and the heart rate. But that apart, there were physical
signs there for the knowing eye which, if you fed a total of six things into a
calculator, you could know the strokework produced by the left ventricle and
the right ventricle and the pulmonary resistance and the systemic resistance. You
could know all these things, and I still carry it round with me in my pocket.122
And you can do it without too much effort. And it’s one of the benefits of
getting older and idler.
Ashworth: As regards exchanging knowledge for nursing: one of the things
that became important was the meetings at the King’s Fund. In 1965 there was
a multidisciplinary meeting on the design of intensive care units, held at the
King’s Fund, with about five or six nurses there. The staff there noticed that we
had plenty to talk about and so they offered to let us meet again. We started
having meetings twice or sometimes four times a year, for the next few years.
Those were very useful meetings, because it brought together usually the sister
in charge of each intensive care unit from various parts of the country. When I
say the country, I mean the UK, not just England. We talked about all sorts of
things, anything from the design of units, equipment, nutrition, other things
related to patient care, and things like difficulties of coping with matrons and
tutors, and so on, who didn’t understand what intensive care was all about. We
needed their help, but they needed our help too, and at least one representative
of each was invited to the next meeting. Those meetings were very useful. Peggy
Nuttall had been a nurse and used to attend.123 She was excellent at asking
pertinent questions to make us clarify what we were talking about and she also
wrote up the reports of those meetings. I think it probably happened to other
people, but I think I ended up writing at least a couple of articles,124 because
Peggy kept kicking me and saying: ‘When do I get it?’ So those meetings led
to a number of things that I’ll mention later, but they were very useful for
exchanging information, and some of us did visit each other’s units.
122 Bradley (1977).
123 Ms Peggy Nuttall (1917–2008) was editor of the Nursing Times (1959–73). See Dopson (2008).
124 See, for example, Ashworth (1966); Richardson and Ashworth (1966).
History of British Intensive Care, c.1950–c .2000
Stoddart: Nobody’s yet mentioned the very useful BMA publication from
its Planning Group No. 1 in 1967 called ‘Intensive Care’.125 It was very good
indeed; chaired by Henry Miller, a very good formative paper. But before we
change from ancient history, I might mention that one of the jobs that the duty
anaesthetist had to do when he went on duty, was to buy a dozen condoms at
the local chemist’s shop, because, at that time, tracheostomy tubes tended to be
very crude, and we found the best ones were silver tubes with a home-made cuff
made from a condom on the outside. These things did tend to burst from time
to time, but we always had half a dozen ready for changing over. [Laughter] It
was a very good way of keeping the tracheostomy tube clean, because, of course,
the inner tube was silver, it was taken out, and it worked as an airtight fit as well.
Wright: I’m interested in anaesthetic textbooks as one way of passing on
knowledge. My memory of intensive care textbooks is that there were anaesthetic
textbooks with chapters on intensive care. There were excellent cardiovascular
and respiratory physiology books, but what was the first textbook in intensive
Branthwaite: I’m not sure that I can answer that, but I would hazard a guess
that if we restrict ourselves to the UK, it might have been Mark Braimbridge’s
book on postoperative cardiac intensive care?126 Very early 1960s, I think, but I’d
have to go back to look at the dates.
Hutton: This is all interesting, but we need to try to keep to the outline
programme (Table 1). If we move on a bit now from the 1970s to the 1980s,
we’re going to look at the developments from there.
Professor Tilli Tansey: We havent really done the 1970s.
Hutton: We havent done the 1970s as fully as we might have but we must move
on. In moving on to different things, if we could slant a little bit more towards
the professionalism of staff in their careers. I think a number of people were
going to say a few words about this, starting, I think, with Sheila.
Ms Sheila Adam: I’m previously a nurse consultant to critical care and now a head
of nursing. I’m a little surprised to be asked to do this but I will say something
in terms of professionalization. I started as a student in intensive care in 1981
and at that time there was a Joint Board of Clinical Nursing Studies (JBCNS)
125 BMA, Planning Unit (1967).
126 See, for example, Braimbridge (1965); Fleming and Braimbridge (1974).
History of British Intensive Care, c.1950–c .2000
course,127 which – I’m looking at Carol Ball to see if she also undertook that?128
For the first time nursing had an accredited intensive care course. I’m interested
in Professor Ledingham’s comments about his course, because I’d be surprised
if that was accredited at that time? No? So, it was an internal course only. Very
early on, in the mid-1970s and early 1980s, there were clear courses that nurses
had to undertake and the course was accredited by, I think, the JBCNS at that
time.129 Moving on from that, we also had an association of nurses that met
in London and this was the London Intensive Care Nurses Group. This was
designed to improve understanding and share knowledge across the country,
not just in London itself when I joined it, and was led by a lady called Patsy
Barrie-Shevlin. She took this forward with sheer force of personality, as much
as anything else.
Haynes: Could I comment on that please? I undertook my intensive care course
at Westminster Hospital 1972 and we had an inspection. Pat Ashworth
was on that inspection panel. It was nine months long and we had to do a
further three months to gain our hospital certificate. We weren’t allowed a
JBCNS certificate at that time, and I cant remember when that commenced,
but I’m sure Pat can fill us in there.130 There was an informal group of London
intensive care-oriented nurses who began a group called the Nursing Intensive
Care Group (NICG) London, and this started in 1975. The key people who
started that were Pat McCann from the London Hospital; Sue Porter from the
Middlesex; Penny Irwin from St Thomas’ Hospital; we always tried to persuade
the late Jemma Boase to join us, but she was reluctant, Jane Cant from St
Thomas’ Hospital, plus myself. We were sponsored by Portex and they were
absolutely wonderful in the early days of us setting up the group.131 The London
group (NICG) became more nationally oriented and groups set up throughout
the country. Eventually we held national conferences based in London. We
127 The Joint Board for England and Wales was established in 1970 under the chairmanship of Sir Hedley
Atkins, with representatives from the nurses’, midwives’ and medical Royal Colleges, the Central Health
Department, and the health authorities to ensure a national standard in post-basic clinical education and
training for nurses. See note 141.
128 See page 47.
129 See note 143.
130 The curriculum was approved in 1972 and the first certificate was awarded in 1973. See Orme (1985).
131 Portex supplied plastic tubes for intubation and for ventilation and has been a registered trademark
used for surgical and medical apparatus and instruments since 1947, owned by Smiths Medical ASD, Inc.,
Keene, New Hampshire. See also pages 46 and 59; Healthcare Industrial Liaison Group (1987).
History of British Intensive Care, c.1950–c .2000
usually had about 400–500 attendees. That group eventually became the British
Association of Critical Care Nurses (BACCN).132
The push to start a nursing intensive care group came about because of
Virginia Henderson, who was the keynote speaker at the Royal Festival Hall
for the American Association of Critical-Care Nurses. The American nurses
like to hold a foreign jamboree once every five years.133 From that NICG, we
began a journal called Intensive Care Nursing and the editorial panel were as
stated: Sue Porter, Penny Irwin and myself, and later Nora Flannigan (Charing
Cross).134 Sally Nethercott from Great Ormond Street represented the children’s
faction. Again, Portex were very helpful. Going back to the literature: when I
undertook my course in 1972, there was no recommended reading, and Foyles
on a Saturday morning became the hunting ground for us all, which was quite
an undertaking knowing the Foyles referencing system.135 We used a Meltzer
handbook for coronary care; Braimbridge for cardiac nursing care – it was
post-surgery. We didn’t have anything at that time for renal, as I remember.136
For general intensive care there was a US text that came from the Beth Israel
Deaconess Medical Center, Boston, Massachusetts,137 and there was a cardiac
and general intensive care book from Green Lane Hospital in Auckland, New
Zealand. Those are the ones that stick in my mind.
Ball: Graham has covered quite a lot of the content I was going to mention, but
I’m not sure why as Graham was a contributor – he omitted what became
the bible for intensive care nurses in the 1980s, which was the publication
by Jack Tinker and Sue Porter from the Middlesex Hospital, London, called
Intensive Care Nursing.138 My course at Guy’s in 1978 was a JBCNS course,
132 The Nursing Intensive Care Group (London) was established in 1977, with the regional affiliation
dropped two years later. In 1982, it was decided a national group was needed and the inaugural meeting of
the BACCN was held in 1985, supporting 15 regions. Its journal was first published in 1985, later known
as Intensive and Critical Care Nursing from vol. 8 (March 1992). See Healthcare Industrial Liaison Group
(1987) and (visited 30 November 2010).
133 Mr Graham Haynes wrote: ‘Patsy Barrie-Shevlin represented the UK at the New Orleans conference in
the late 1970s.’ Note on draft transcript, 10 February 2011.
134 Haynes (1983).
135 Hoge (1999).
136 See, for example, Meltzer et al. (1965); Braimbridge (1972); see also Appendix 2, pages 91–102.
137 Pontoppidan et al. (1973).
138 Tinker and Porter (1980).
History of British Intensive Care, c.1950–c .2000
JBC N100 its number. When I started teaching in 1985, Tinker and Porter
was the bible – everybody had to have one. For some years it continued to be
so, I would say.
Ashworth: I’m about to talk about the foundations that went behind all that. The
meeting at the King’s Fund that I talked about continued until 1968; the group
of nurses went on meeting, usually about 20 odd of us. Then it became obvious,
because we were sometimes talking about things like salary and conditions
and work, the King’s Fund couldn’t accommodate that sort of meeting. It was
becoming obvious anyway that we needed to widen the meeting to include more
people. Rather than starting an independent association, the decision was that
we would go into the college, the Royal College of Nursing (RCN). At that time
about 30 per cent of nurses belonged to a professional organization of some sort,
and the College was much the biggest. The advantage of going into the College
was that we would have a much bigger voice in what we wanted to say about
intensive care nursing – if we could convince the officers and the council – than
if we were an independent association. Indeed, that was what happened.
Somebody mentioned the BMA report on intensive therapy from the medical
point of view;139 there was also a report from the Royal College of Nursing in
1969, which was written by several of the people, plus others, who had been in
this group at the King’s Fund.140 When the JBCNS was set up in 1970, a survey
found that there were 350 courses of various sorts in 47 different specialties,
and decided that some rationalization was needed.141 ‘Intensive Care Adults
was one of the first four topics where they set up a panel in order to devise a new
course. When the first group of us came together, there was a JBCNS clinical
nursing studies officer, another nurse educator, and seven other nurses, and six
medics, including people like Dr Sherwood Jones and Dr Eric Gardner. Our
139 BMA, Planning Unit (1967).
140 Royal College of Nursing (1969).
141 As a result of the 1966 report on the post-certificate training and education of nurses by a subcommittee
of the Standing Nursing Advisory Committee of the Central Health Services Council (Powell (1966)), the
Joint Board for England and Wales was established in 1970 to endorse a national standard in post-basic
clinical education and training for nurses. The background to two reports (Joint Board of Clinical Nursing
Studies (1972, 1975)) is described by the Board’s principal officer (Gardener (1977)). The Joint Board was
dissolved in 1983 by the Nurses, Midwives and Health Visitors Act 1979, and its papers are held as DY1
and DY2 in the National Archives; see
?CATID=95&CATLN=1&accessmethod=5&j=1#index (visited 22 February 2011). For an evaluation of
hospital nursing administration, see Dewar (1978). See also notes 127 and 143.
History of British Intensive Care, c.1950–c .2000
first task was to ask: ‘What is intensive care?’, because all the units that we have
talked about were different and we had to decide what general intensive care
involved; what would we put into this course? As recommended, we devised
the five major objectives and the required ‘skills, knowledge and attitudes’ that
went under those. As Graham Haynes mentioned, the first course outline for
JBCNS 100 contained a required reading list.142 Yes, the system was that when
the first courses had been approved in 1972, the first intensive care courses
were approved by a JBCNS nursing officer, who usually had worked with the
hospital designing the course, plus a nurse and a doctor from the specialty.
This was one thing that was very different from the usual way nursing course
initiation happened; these courses were written almost entirely by clinicians
and they were expected also to be approved by clinicians. We went on to design
a course for enrolled nurses as well as one for registered nurses, and then for
specialist areas like children, renal care and coronary care, etc. In 1979 when
the UK Central Council for Nursing, Midwifery and Health Visiting (UKCC)
was being set up, it was said that those courses became the English National
Board (ENB) courses. In Scotland there was a similar organization that also
authorized courses. The important thing was that these developments took
place at national level and were nationally approved. Previous to that, the
certificates issued from hospitals were only as good as the reputation of the
hospital they came from.143
I’d like to go a bit further on professionalization, because the question of
education remains.144 One of the things the Joint Board recognized was that
many clinicians were teaching on Joint Board courses, but did not have training
142 See Joint Board of Clinical Nursing Studies (c. 1974). A selection from the five objectives for skills,
knowledge and attitudes appear in Appendix 2, pages 91–102.
143 A committee (Committee of Nursing (1972)), chaired by Professor Asa Briggs, was set up in 1970 to
advise on the quality and nature of nurse training and recommended replacing the existing nine separate
bodies for the UK with a unified central council and separate boards in each of the four countries
with specific responsibility to improve standards of training and professional conduct, which eventually
formed the basis of the Nurses, Midwives and Health Visitors Act 1979. In 1983, the UKCC replaced
the Joint Boards (see note 141). Dissolved in 2002, its functions were transferred to a new Nursing and
Midwifery Council (NMC). The English National Board was also abolished and its quality assurance
function went to the NMC. For the background to nursing structure, see
The-history-of-nursing-and-midwifery-regulation/ (visited 30 November 2010); Gardener (1977). See
also notes 127 and 141.
144 See, for example, Atkinson (1987, 1990).
History of British Intensive Care, c.1950–c .2000
on ‘how to teach’. This applied both to medics and nurses. First of all the JBCNS
did two one-week courses, which were multidisciplinary. The first one, I think,
was held at the Royal College of Physicians so the doctors would go. [Laughter]
Unfortunately, the regional people did not take up this idea and continue it,
so after the first two, the courses were held just for nurses in various parts of
the country. These were to help people identify <