The British Journal of Anaesthesia

An informal history of the first 25 years

J. Norman

2 Russell Place, Southampton SO17 1NU, UK

Accepted for publication: November 8, 2001

Abstract

In 1961, some 7 months after starting anaesthesia in the Leeds General Infirmary, I took out a subscription to the British Journal of Anaesthesia. It cost £3.15s.0d (£3.75) a year. The publishers (John Sherratt and Son of Altringham) sent me the back numbers from the start of that year. I first had a paper published in the journal in 1965; first refereed a paper in 1969; joined the editorial board in 1975; and lasted there until 1998.

The following account of the early years of the journal derives from the journal itself, and from records, letters and minutes of meetings kindly given to me by Dr Edmund Riding and Professor Andrew Hunter when they demitted offices with the journal. The history cannot be complete. Sadly, the earliest minutes books are lost. But there is much of interest covering the times when anaesthesia developed from the rag-and-bottle inhalation era to the use of intravenous anaesthetics, neuromuscular blocking agents, ventilators and monitoring. Thoracic and neurosurgical anaesthesia were revolutionized; cardiac surgery became possible; and resuscitation with intravenous fluids, blood and plasma all developed. Antibiotics improved care. Anaesthetists pioneered intensive care and latterly extended their roles in pain relief outside the operating theatre. All these developments have appeared in papers at some time in this journal. This is a personal view of the journal over its first 25 years: there will be errors and misinterpretations – these are mine.

Br J Anaesth 2002; 88: 445–50

Keywords: history, British Journal of Anaesthesia; publications

The first years: 1923–1929

In 1923, the journal started as the second English language journal devoted entirely to anaesthesia. Current Researches in Anesthesia edited by F.H. McMechan beat it by a year. That journal was published in the United States and is now Anesthesia and Analgesia. This journal’s editor was also an American – Dr Hyman M. Cohen – but one who worked in Manchester. Others on the initial board were: Drs F. Shipway, J. Blomfield, H. E. G. Boyle, D. W. Buxton, all from London, H. B. Fairlie from Glasgow, S. R. Wilson from Manchester, and A. J. O’Leary from Liverpool. The journal was to appear quarterly and cost £2.0s.0d (£2.00) for the four issues. The volumes started in July – which makes citing references somewhat of a problem.

Dr Hyman Maurice Cohen (Figure 1) was born in New York on Christmas day in 1875. He chose a military career and was educated at military academies. After Harvard he went to Baltimore, where he gained his MD. He served with the United States Army, including a period of active duty in the Philippines in 1898. In 1904 he married a Manchester girl. In 1913, having resigned his commission, he came to the United Kingdom. Enrolling at St Bartholomew’s Hospital in London, he qualified MRCS, LRCP in 1916. Settling in Manchester, he became a full-time anaesthetist. He maintained contact with his American colleagues. One of his associates in Manchester, Dr S. R. Wilson, held the post of lecturer in physiology at the university there. Together with H. E. G. Boyle, they were the principal founders of the journal.



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Fig 1 Dr H. M. Cohen. Editor from 1923 to 1928. Reproduced with permission from the British Journal of Anaesthesia 1929; 7: 48.

 
Dr Cohen’s foreword to the first issue1 is fascinating. He introduces the journal as a publication ‘devoted entirely to the interests of Anaesthesia and its practitioners’. It is ‘hoped to be able to keep abreast of the times in all that appertains to Anaesthesia and reflect the progress our Speciality is making everywhere’. It was not only to be a ‘mouthpiece for those who desire to give public expression to the results of their research’ but to ‘place before its readers an account of what is being done generally in the anaesthetic world’. The foreword ends with a plea for an organization for the general body of anaesthetists. He noted that ‘with the exception of the Section [of Anaesthetics of the Royal Society of Medicine; RSM] in London and the Society [of Scottish Anaesthetists] in Scotland, the general majority of the something like 500 Practitioners of Anaesthesia have no affiliations with similar bodies’. Cohen concludes, ‘It is a self-evident fact that anaesthetists united in one large, virile body can do much to advance the science and practice of anaesthesia, and it behoves those of us who are alive to the possibilities of unity to give the matter attention and thought’. It was 10 years before the Association of Anaesthetists of Great Britain and Ireland (AAGBI) was formed, and 25 years before the Faculty of Anaesthetists was founded – two bodies, not one. As Dr Riding (personal communication) has commented, ‘this was a very far-sighted editorial’.

What was in the early journals?
I have counted 115 editorials and main articles in the time when Cohen was the editor. There were reviews and reprinted articles from other journals and reports of meetings. The correspondence section started, and there were even the odd humorous items. To wit, in 1925:

Visitor ‘Is your daddy in?’

Small daughter ‘No, he is out giving an anaesthetic.’

Visitor ‘An anaesthetic. That is a big word. What does it mean?’

Small daughter ‘Five guineas.’

That would have been a large fee then. In 1928, the editorial described the abysmal payments made to hospital anaesthetists.2 Other editorials discussed topics such as postoperative lung complications,3 and research.4

History played a large part, as did reports or notices of overseas meetings. Cohen kept up with his American colleagues. In 1926, a party from North America, including McKesson, Wesley Bourne and McMechan, visited the United Kingdom. Dr Cohen was the principal host. There was a joint meeting with the Anaesthetic Section of the RSM.5 The next year, Cohen visited the United States and at the meeting of the International Anaesthesia Research Society he gave a paper on the value of anaesthetic journals.6 At a formal session he was presented with a scroll ‘For Meritorious Services to the Specialty of Anesthesia’, which lists all the then current members of the editorial board of the journal. The scroll was reproduced in the journal in 1927.7 The other two people honoured at the same session were Arno B. Luckhardt, who had pioneered the use of ethylene as an anaesthetic, and Dr Carl Koller, who, in 1884, had studied the effects of cocaine and introduced it as a local anaesthetic for ophthalmic surgery. Good company.

The early intention was to produce an international journal. Of the original papers in Cohen’s time, 48 came from the United Kingdom, 34 from the United States of America, eight from Canada, four from Germany, two each from France, Austria and Italy, and one from Sweden. The North American authors included such pioneers as McKesson, Gwathmey, Leake, Labat, Pitkin, Bourne and McMechan. McMechan, a corresponding member of the editorial board, edited Current Researches in Anesthesia and Analgesia. The link between the two journals has been maintained. The journals worked together to initiate the production of the CD version (TEAL) together with Anesthesiology and the Canadian Journal of Anaesthesia in 1996.

Other early papers covered a variety of topics: obstetric analgesia, epidural block, lung problems, anaesthetic techniques, teaching of anaesthesia to medical students, the reflex basis of anaesthesia, anaesthetic history, and cardiac resuscitation all appear in the first volume. Later, there were articles on: acid–base balance, the use of acetylene and ethylene, the problems for diabetics, the risks of anaesthesia and surgery, the dangers of static electricity, body temperature during anaesthesia, the value of regional anaesthesia, ‘Avertin’ (tribromoethanol, bromethol) anaesthesia, the metabolic consequences of anaesthesia (blood sugar estimations), and premedication. Many repay reading and assessment in the light of modern practice.

In 1927, the editorial board lost its secretary and treasurer. Sidney Rawson Wilson was a Manchester graduate and an anaesthetist at the Royal Infirmary. He was the first appointed Lecturer in Anaesthetics at Manchester University. His physiological and pharmacological interests were well respected. At the time of his death, he was conducting experiments on himself on the effects of various mixtures of nitrous oxide and oxygen. It appears that with his last experiment at home, the oxygen cylinder ran out and he died from anoxia. He was born in 1882 and was obviously an outstanding student in his time at Manchester. As a student, he spent time coaching his fellow students. His interests at the time of his death also included the use of ethylene, and studies of unexpected deaths during ether anaesthesia. He thought these were due to ‘impure’ ether.

Dr Cohen suffered from hypertension and seems to have had at least one myocardial infarct. He died suddenly whilst motoring in Derbyshire on 31st August 1929. His obituary was written by Sir d’Arcy Power and appears in the next issue of the journal.8 That issue was delayed by 3 months whilst the new editor took over.

The years under Joseph Blomfield: 1930–1948

Joseph Blomfield (Figure 2) was one of the founders of the journal. When Cohen died, he became editor and stayed in post for the next 18 years. He was born in 1870, the son of Luis Blumfeld. His surname changed during the First World War. Marrying twice, his surviving wife, Kathleen, was the secretary of the Society of Genealogists and also of the journal for many years, finally ending her connection in 1967. There was a son by the first marriage. Blomfield died in 1948, aged 78 years, in harness as the editor of the journal.



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Fig 2 Dr Joseph Blomfield. The journal’s second editor, from 1929 to 1948. Reproduced with permission from Anaesthesia 1949; 4: 90.

 
Educated at University College School and Caius College, Cambridge, Blomfield completed his medical training at St George’s Hospital. He qualified MB ChB in 1894 and MD in 1897. He was awarded the FFARCS in 1948. After house posts at St George’s, he took up anaesthesia as a full-time career and joined the staff at a number of London hospitals, including St Mary’s and the Grosvenor Hospital for Women and Children. But his main attachments were at St George’s, where he remained on the staff until 1931, and the King Edward VII Hospital for Officers. In the latter post he seems to have been the principal anaesthetic adviser to Sister Agnes who ran the hospital as an autocrat.9 He was commissioned into the Army in the First World War but served in London hospitals.

The Society of Anaesthetists and the Royal Society of Medicine
The society was founded in 1893 and elected Blomfield a member in 1900. He had two papers in the Transactions of the Society, in 1902 and 1903. He became Honorary Secretary in 1905. That was the time of the formation of the RSM, with the amalgamation of a number of specialist medical societies in London. But there were problems for anaesthetists: some were women but the RSM rules did not allow women to be admitted as fellows. Blomfield conducted the negotiations. By 1908, the society agreed to amalgamate with the RSM to become its anaesthetic section, and women could become fellows. The section, and the publication of its proceedings, were the main ways of propagating news about anaesthesia, although proceedings were usually summarized in the Lancet and the British Medical Journal. One of Blomfield’s papers from the society appeared in full in the Lancet in 1902.12 It discussed the problems of producing relaxation for abdominal surgery. It makes interesting reading. Remember that the anaesthetics available then were nitrous oxide, ether and chloroform. Many techniques involved substantial rebreathing and what we would now regard as dangerously hypoxic gas mixtures. Blomfield emphasized ‘unimpeded breathing, complete absence of cyanosis and sufficiently deep anaesthesia’. Not a bad prescription, but he admits that success was not invariable. Blomfield became president of the Anaesthetic Section in the years 1911 to 1913 and vice-president from then until 1920.

In 1902 he also published a handbook of anaesthesia aimed at students and the occasional practitioner.11 It ran to four editions, with the last appearing in 1917. The interval had seen the first practical moves towards intravenous anaesthesia, the use of resuscitation fluids, and the wider use of local anaesthetics. But his emphasis in all editions was on the three first anaesthetics: nitrous oxide, ether and chloroform. The techniques must have worked, but might not necessarily be accepted by examiners for the FRCA these days.

The Anaesthetic Committee of the Medical Research Council
Early in the 1920s, the council of the Anaesthetic Section of the RSM was receiving complaints that nitrous oxide was not working properly. There were also complaints that some brands of ether were not as effective as others, and even one that very pure ether was not an anaesthetic! At the same time, Henry Dale from the Medical Research Council (MRC) was worried that there was no professional body in the UK that would enable anaesthesia to catch up with work done in America and in Europe. As a consequence, the Joint Anaesthetic Committee was formed by the Anaesthetic Section and the MRC. The anaesthetists appointed were Blomfield, Francis Shipway from Guy’s and Charles Hadfield from St Bartholomew’s hospitals. The MRC fielded Dale, Professor Donnan from chemistry at University College, and Professor Pembrey, a physiologist from Guy’s. All three were fellows of the Royal Society. Blomfield was elected chairman and Hadfield, secretary. The Committee lasted until 1948 and worked on the problems of nitrous oxide and ether, and on other anaesthetic gases and vapours, including ethylene, acetylene, propylene and cyclopropane. Mostly, the members of the committee did the work but they used outside experts such as Harold King at the MRC for the chemistry and Professor H. B. Dixon from Manchester when dealing with explosions. The committee persuaded the British Oxygen Company (BOC) to manufacture ethylene. Although it did not achieve much as an anaesthetic, ethylene was widely used elsewhere in the chemical industry. Imperial Chemical Industries (ICI) was also involved and set up a plant to make cyclopropane. The committee advised the British Pharmacopoeia Commission on the standards needed for medical nitrous oxide and other gases. Dale introduced other agents to the committee. Blomfield and Shipway pioneered the use of Avertin in the UK as a basal anaesthetic and published the results in 1929.12 Blomfield wrote a short account13 of one use for it: to anaesthetize a patient who would not consent to anaesthesia for an operation! In the 1930s, intravenous barbiturates were added to the armamentarium. The committee had access to hexobarbital (Evipan) and described its use in 1933.14

The committee also supported research by creating at least one fellowship. The MRC had been given an endowment to promote research in anaesthesia and analgesia. It managed to spend some, but by no means all, of the money. All the details can be found in the minutes books of the committee, which are stored in the Public Records Office at Kew. Towards the end of the 1930s, the committee had little to do and did not meet formally from 1938 to 1945. Anaesthetists were involved with research in the Second World War but not necessarily through this committee. Blomfield had a serious illness in 1945 and retired from the committee. Hadfield took over as chairman, with Geoffrey Organe as secretary.

The Association of Anaesthetists of Great Britain and Ireland
In the first issue of the journal, Cohen had asked for a national anaesthetic body for the UK. Although H.W. Featherstone was the prime mover in forming the AAGBI, Blomfield was a member of the provisional council in 1932 and elected the first vice-president at the inaugural meeting in 1933. Almost certainly, he wrote the welcoming annotation in the Lancet.15 The association also pushed for a Diploma in Anaesthetics, and noted the problems for teachers of anaesthesia – do they please the surgeon, the patient or the trainee? It concluded with pleas for expert anaesthetists in all parts of the country and for due reward for their labours! Some things do not seem to change.

The journal published accounts of the annual meetings of the association and, at that time, Featherstone was a member of the editorial board of the journal. In 1935, Blomfield became president of the association until 1938 and he remained on its council until 1943. He was also the honorary secretary from 1939 to 1941. The first honorary secretary was Howard Jones of spinal anaesthesia fame who tragically committed suicide in 1935. There is an editorial16 in the journal lamenting his passing and the reason for it – Jones could not make a living from anaesthesia, despite being one of the leading practitioners of his day.

What of the journal?
The journal continued its quarterly publication until the war years, when it came out only twice yearly until 1950. I counted some 255 papers, reviews and editorials in the 19 years under Blomfield. The topics were various and include political matters as to who should give anaesthesia for emergency surgery, and the problems of how anaesthetists should be trained. In 1937, the journal noted with pleasure the appointment of Robert Macintosh to the Nuffield Chair in Oxford.17 The journal published the regulations for the Diploma in Anaesthetics when that was founded in 1935.

Despite the recession, anaesthesia and surgery were changing. R. J. Minnitt from Liverpool had joined the editorial board. The journal includes a description of his apparatus for the self-administration of nitrous oxide in obstetrics.18 Obstetric anaesthesia and analgesia were continuing topics. In 1945, Crouch and Merry19 published their account of epidural anaesthesia for Caesarean section. Papers came in from all round the world. Mortality and morbidity were frequent topics. The physiology of pain was discussed in 1937 by Leriche.20 He makes many interesting points, particularly that chronic pain syndromes did not fit in well with the then current work on pain receptors and simple transmission systems through the peripheral nerves and main spinocortical pathways. The barbiturates appeared in the 1930s, with hexobarbital initially and later thiopental. Premedication, especially with atropine, had greatly reduced the problems of secretions. Oxygen was a great bonus. Curare made the first appearance in the journal for the neuromuscular blocking drugs in 1947.21 Michael Nosworthy described his method of using cards to record anaesthetics and their outcome.22 In 1945, E. Falkner Hill, a member of the editorial board since at least 1930, described the development of anaesthesia in the 45 years of his practice.23

Thoracic surgery was starting. Magill supplied a paper in 1936 on his technique for lobectomy.24 The problems of the poor general condition of the patients were noted, as were those of avoiding the contamination of the healthy lung with the infected secretions of the damaged lobes. The paper discusses use of spinal anaesthesia that may sound strange to modern ears but also includes the use of bronchial blockers and selective intubation. In 1938 Haslar described his technique for one of the earliest forms of cardiac surgery – O’Shaughnessy’s method of applying the omentum to the myocardium to relieve angina.25 Following premedication, anaesthesia was induced with ethyl chloride and maintained with ether and oxygen. The problem of the open pneumothorax was dealt with by adding some 5–8 cm of positive end-expired pressure (PEEP) by placing the expired limb of the anaesthetic circuit under the appropriate water level. At the end of the operation, the lung was re-expanded by increasing the level of PEEP. In 1944, Philip Ayre described his technique for neurosurgery.26 The breathing system employed the expected T-piece. Spinal anaesthesia was a popular topic. Howard Jones produced a splendid review in 1931 that detailed many of the myths and explanations of the technique.27

Death under, or associated with, anaesthesia was a common topic. Sykes in 1933 reviewed the results from a number of hospitals but was struck by the fallacy of small numbers and the problems of making comparisons.28 From Melbourne, Green and Kaye29 in 1934 noted that ‘every anaesthetic fatality is made the subject of an enquiry’ – an early foretaste of the Australasian interest in safety. In 1938, a lecture that Edwards from St George’s Hospital had delivered to the medical students was reproduced.30 It gives a splendid overall account of the problems.

The editorial board of the journal

There was a constant changing of the membership of the editorial board over the 25 years. Notable names at various times include: Dudley Buxton, Featherstone (the first president of the association), Magill, and Gillies from Edinburgh. But, at the end of the war, the journal was appearing only twice yearly, and there had been a suggestion of financial problems in the 1930s. The council of the association had made a grant to help keep it going. In 1945, Blomfield had his serious illness – he was 75 years old by then. Minnitt persuaded him to add some new members to the editorial board. T. Cecil Gray and R. P. (Jock) Harbord from Liverpool came on in 1948. The plan was to add other heads of departments in the several universities and medical schools in Great Britain.

Sadly, Blomfield died on 9 November 1948. His obituary appeared in the BMJ, Anaesthesia, the journal and in the Lancet. The latter31 gives probably the best picture of him and his work. The penultimate paragraph is worth quoting almost in full: ‘As an editorial contributor to our own columns, he was for many years a valued and entertaining colleague. In those relatively spacious times it was his habit to drop into the office after lunch, wearing a button-hole, smoking a cigar, and bearing a manuscript which could be deciphered only by the expert. (When he bought a typewriter the results were so remarkable that our printer begged him to return to the pen.) His notes on anaesthesia showed wit and judgement; and he was always prepared to write on other subjects, having a distinct journalistic talent as well as associations with Fleet Street. [. . .] He was, and remained, a companionable man, with a charm all his own.’

The editorial board of the journal needed to find a new editor.

Acknowledgements

I am most grateful to Dr Edmund Riding and the late Professor Andrew Hunter, who passed their files to me when they ceased being Honorary Treasurer and Chairman of the Board, respectively. The libraries at the Royal Society of Medicine and the Universities of Southampton and Leeds gave access to the early issues of the journal and of the Lancet, the BMJ and the Proceedings of the Royal Society of Medicine. The Public Records Office at Kew is a treasury with the old minutes of the Medical Research Council. The photographic section at the RSM undertook the copying of the two figures.

References

1 Foreword. Br J Anaesth 1923; 1: 1–3

2 Anon. Our hospital emoluments. Br J Anaesth 1928; 5: 107–8

3 Blomfield J. Some remarks on post-operative lung trouble. Br J Anaesth 1923; 1: 128–30

4 Anon. Anaesthesia and investigation. Br J Anaesth 1929; 6:153–4

5 Blomfield J. Recent investigations concerning nitrous oxide, and the ignition points of some anaesthetic vapours. Proc R Soc Med 1926; 19: 39–47 (This is an account of one of the papers given at the joint Anglo-American meeting.)

6 Cohen HM. The current literature of anesthesia. Anesth Analg Curr Res 1926; 5: 287–8

7 Anon. Special Honours Section. Br J Anaesth 1927; 5: 16–28

8 d’Arcy Power Sir. Obituary (Hyman Maurice Cohen). Br J Anaesth 1930; 7: 49–51

9 Mennell Z. Joseph Blomfield. Anaesthesia 1949; 4: 89–93

10 Blumfeld J. Complete relaxation of the abdominal wall under anaesthetics. Lancet 1902; i: 1523–5

11 Blumfeld J. Anaesthesia: a Practical Handbook. London: Balliere, Tindall and Cox, 1902

12 Blomfield J, Shipway FE. The use of Avertin for anaesthesia. Lancet 1929; i: 546–9

13 Blomfield J. A case illustrating the value of Avertin in unusual circumstances. Lancet 1930; ii: 689

14 The Anaesthetic Committee, Medical Research Council. A report on the clinical value of ‘Evipan’. Lancet 1933; ii: 42–4

15 Annotation. An Association of Anaesthesists. Lancet 1932; ii: 527

16 Editorial. Br J Anaesth 1935; 13: 1–2

17 Anon. The Nuffield Professorship of Anaesthesia. Br J Anaesth 1937; 14: 93–4

18 Minnitt RJ. Self-administration analgesia for the midwifery of general practice. Br J Anaesth 1934; 11: 148–52

19 Crouch DME, Merry ESM. Epidural analgesia for caesarean section. Br J Anaesth 1946; 20: 24–33

20 Leriche F. What is physical pain? Br J Anaesth 1937; 15: 9–19

21 Asquith E. Curarine chloride as an adjunct to general anaesthesia. Br J Anaesth 1947; 20: 106–11

22 Nosworthy M. A method of keeping anaesthetic records and assessing results. Br J Anaesth 1943; 18: 160–179

23 Falkner Hill E. The evolution of anaesthesia in Manchester, 1900–1945. Br J Anaesth 1947; 20: 115–21

24 Magill IW. Anaesthetics in thoracic surgery with special reference to lobectomy. Br J Anaesth 1936; 13: 92–109

25 Hasler JK. Anaesthesia in cardiac surgery. Br J Anaesth 1938; 16: 30–4

26 Ayre P. Anaesthesia for neurosurgery. Br J Anaesth 1944; 19: 17–31

27 Howard Jones W. Sub-arachnoid block; general analgesia; ‘spinal’ anaesthesia; respiratory paralysis; fallacies and methods. Br J Anaesth 1931; 9: 3–21

28 Sykes WS. Anaesthetic mortality. Br J Anaesth 1933; 10: 98–101

29 Green FW, Kaye G. Anaesthetic technique employed in two Australian teaching hospitals. Br J Anaesth 1934; 11: 56–65

30 Edwards G. ‘Death on the table’. Br J Anaesth 1938; 15: 87–103

31 Anon. Joseph Blomfield. Lancet 1948; ii: 833–4





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