An anaesthetist who missed a golden opportunity

Abstract

Richard Gordon (1921–2017) was a prolific writer of both humorous fiction and historical reviews. He trained in medicine at St Bartholomew’s Hospital (Barts) in London and specialised in anaesthesia working at Hill End Hospital, St Albans (where a large proportion of Barts work took place to avoid the impact of the Blitz during the Second World War) and at the Radcliffe Infirmary, Oxford with Robert Macintosh. He published multiple papers and a book on trichlorethylene anaesthesia and edited a textbook of anaesthesia for medical students which ran for 10 editions. His gift for writing and his prominent public persona placed him in a unique position to highlight the importance of the newly emerging speciality of anaesthesia. He did the exact opposite of this and instead created a representation of an uninterested spectator to surgical activity, a representation which still persists in some quarters today.

Early life

The author-to-be Richard Gordon was born Gordon Stanley Benton in Paddington, London in 1921. He went to school at Cliftonville School, Cliftonville, Kent and then at the Cours Moliere, Neuilly in Paris before starting as a medical student at St Bartholomew’s Hospital (Barts) in 1939. Due to the onset of the Second World War, he spent his preclinical time at Selwyn College, Cambridge before returning to Barts in 1942. ¹ In the summer holiday between Cambridge and London he changed his name to Gordon Stanley Ostlere as his mother had remarried. ² As a clinical student he became Deputy Editor and then Editor of the Barts Journal, a student-run publication.^3,4 His interest in anaesthesia was evident by the publication of a paper in that journal about a patient who was resistant to anaesthesia. ⁵ The case was a 19-year-old pilot who had suffered severe burns to his face and hands after a mid-air collision was followed by a crash landing. Before his admission to Hill End Hospital Plastic Surgical Unit (with the bombing of central London during the Blitz, the majority of the surgical specialties decanted out of the centre of the city to an old mental asylum near St Albans), he had been treated at another hospital where preliminary surgery had taken place, and during a three-month stay had received one-quarter grain (approximately 15 mg) of morphia four hourly for three months! His general health was noted to be poor, and the morphine dosage was slowly cut down; it was also noted that he was a heavy drinker of alcohol. After three months he had been weaned from the morphine and then underwent a further 14 anaesthetics over the next three years which all comprised a premedication of mist hyoscine ‘A’ four minims followed by a hexobarbitone (Evipan) induction and maintenance with oxygen-nitrous oxide and ether with spontaneous respiration. Morphia one-sixth grain (approximately 10 mg) was given postoperatively for pain. The first six procedures were uneventful but subsequent anaesthetics were marked by severe postoperative agitation often associated with violence and abuse of staff. He was returned to duty in the Royal Air Force, where he worked as a flying instructor and then returned for further surgery a year later. His health was much improved but after one further uneventful anaesthetic he required very high doses of drugs during further anaesthetics and exhibited more violent postoperative behaviour. Ostlere suggested that the problems were caused by his early dependence on morphine, fear of anaesthesia and heavy alcohol intake.

Developing career

Ostlere qualified in July 1945 MRCS LRCP, the Conjoint examination, and then took the MB BChir in December 1945, a University of Cambridge qualification. Following the Conjoint success, he started a house job in anaesthetics at Hill End Hospital in August 1945 which lasted six months. During the following year he became Senior Resident Anaesthetist at Hill End and then passed the Diploma of Anaesthesia in 1947. Curare had been introduced into clinical practice and Ostlere was soon writing about this new drug. In the first of these, a letter to the Lancet, he described how a fit 71-year-old man undergoing a partial colectomy had developed hypertension after the administration of 15 mg curare. ⁶ It could be argued, in retrospect, that the hypertension recorded could have been due to light anaesthesia with the patient having morphine one-sixth grain (10 mg) as premedication and then thiopentone 250 mg followed by blind nasal intubation under light cyclopropane anaesthesia followed by two and a half hours of surgery with the patient breathing spontaneously throughout. It was noted that the patient required ‘a little cyclopropane being added to the circuit from time to time for maintenance’. The hypertension settled towards the end of surgery.

His views on the risk that curare caused hypertension were not maintained, as he then published a paper in the British Medical Journal, in the same week, advocating the use of curare in poor-risk patients undergoing major abdominal or thoracic surgery. ⁷ The Nuffield Department had utilised four different curare preparations available; ‘Intocostrin’ made by Squibb, d-tubocurarine crystals, ‘Curarine’ and ‘Tubarine’ ampoules all made by Burroughs Wellcome. Only 15 mg of curare was given to the majority of patients, all breathed spontaneously and only one required assisted ventilation. Anaesthesia was maintained with oxygen-nitrous oxide and either trichlorethylene or ether for the abdominal cases and cyclopropane was used in thoracic cases. Later, a letter from Burroughs Wellcome objected to Ostlere’s use of the word ‘curare’ to describe different formulations of the drug. ⁸

In 1948, Ostlere reviewed the use of trichlorethylene at Hill End Hospital over the preceding eight years and estimated it had been used for over 40,000 cases without a single mortality attributable to the use of the drug. ⁹ He advocated its use at induction of anaesthesia, for maintenance and when curare was being used. It had not been used in closed circuit systems since 1943 after reports of toxic effects from the breakdown product, dichlorocetylene, created by the heat induced by carbon dioxide absorption in soda lime. ¹⁰ The following month a further insight into his personality could be seen when he wrote in response to a Manchester surgeon’s letter which described his use of direct intrahepatic injection of curare which thus avoided the nuisance created by the anaesthetist using an intravenous infusion as well as the inadvisability of ever leaving a needle lying in a vein. ¹¹ Ostlere describes the route of administration as ‘bizarre’ and cannot see any dangers in an intravenous infusion or the placement of an intravenous needle. He closes his letter by saying

‘If the effects of the curare persist for any reason, there is always prostigmin and atropine which may be injected into a vein or into the liver according to choice’. ¹²

Later that year he co-authored a major paper with Brian Rait-Smith (1903–1949) on the management of anaesthesia for patent ductus arteriosus surgery. This was published in the Lancet. ¹³ The authors reviewed 53 operations performed at Hill End Hospital in the past nine years; 43 of these had been for the treatment of persistent ductus and the other 10 for constrictive pericarditis. All patients were intubated ‘to maintain the perfect airway’ and not to facilitate ventilation, which was spontaneous in all cases breathing either oxygen-nitrous oxide-ether or oxygen-cyclopropane. Curare was used rarely when ‘considerable diaphragmatic movement is persistently troublesome’ and even then, spontaneous respiration was maintained. Their technique minimised arrhythmias and tachycardias, which always caused problems for the surgeons.

Career change

Ostlere was not settled in his role as an anaesthetist and so in 1949 after four years’ work, he suddenly moved out of hospital medicine and became an Assistant Editor with the British Medical Journal, where he was asked to focus on correspondence, book reviews and obituaries. This did not stop his contributions to other journals and in the same year he wrote to the Lancet, from Nottingham (where no record of any hospital position can be found), about the proposed rotation of medical students at the London Hospital to perform nursing duties under the management of the ward sisters. ¹⁴ Ostlere was not in favour of this and wrote:

‘If the student doesn’t appreciate the niceties of nursing at the time, he won’t be a houseman over a couple of weeks without realising all the difficulties the nurses have to put up with – the sister will spend most of her day telling him. The medical curriculum is already chaotically arranged and overburdened, so why inflict on the poor student, who has hardly time left to play rugger or Chopin according to taste, additional instruction in the work of related but obviously distinct hospital services?’

He continues to say that:

‘The signalman doesn’t have to drive an occasional engine, the editor isn’t expected to serve his time on the linotype.’

He goes on to wonder whether the students should spend a few weeks peeling potatoes in the hospital kitchens or polishing the hospital floors!

Ostlere was very interested in medical student education, and in 1949 the first of a long series of books on anaesthesia he wrote for medical students was published. ¹⁵ Anaesthetics for medical students was a small cheap book with no illustrations which Ostlere hoped would allow a student and later a newly qualified doctor to provide a safe basic anaesthetic. It was written in an amusing style and the foreword, written by Christopher Langton Hewer (1896–1986), ends with the words:

‘Most textbooks are intolerably dull; this one is frequently amusing and for this reason alone should prove popular.’

The series ran until 1989 with a 10th edition written by Thomas Babbington Boulton (1925–2016) and Colin Edward Blogg (1943–2015) under the title of Ostlere & Bryce-Smith’s Anaesthetics for medical students. Roger Bryce-Smith (1918–2006) had co-authored the book from its third edition in 1956. In the same year that his book for medical students was published, Ostlere published a book on anaesthetics for patients. ¹⁶ He had been approached by the publishers, Sigma, to write a monograph to add to their Introduction to Science series. It is a comprehensive book with accounts of history, drugs, apparatus and techniques. In the final chapter, titled ‘Anaesthetics and the patient’, he writes how:

‘the anaesthetist watches his patient carefully during the procedure and afterwards as he is transferred back onto his trolley, only leaving him as he hands over to the ward sister who escorts the case back to bed.’

At this time most patients recovered from anaesthesia on the ward, not in a special recovery area. Ostlere does stress that the patient is still seen on the ward postoperatively by the anaesthetist to ensure that all is well.

He also found time to contribute to Anaesthesia. In 1950 he wrote about anaesthetic rooms. ¹⁷ He would have seen the room designed by Hewer in 1946 at Barts, which had specially painted murals on the wall and ceiling of the anaesthetic room, and urges the creation of a room which is the domain of the anaesthetist and not a storeroom, a corridor or a place for the surgical team to congregate to talk! He urges that patients brought down to the operating theatre should enter a pleasant restful room without noise and alarming apparatus in view. He writes:

‘The surgical patient is given no choice over the timing of his slumbers, but at least he should be allowed to approach his abnormal and disquieting sleep in as natural surroundings as possible.’

Ostlere’s book reviews in the British Medical Journal are amusing and of value. He focuses primarily on anaesthetic texts^18,19 but is happy to pass comments on other topics such as the biography of Barnum and Bailey’s circus veterinarian. ²⁰ His time in these roles did not suit him although he later referred to how writing obituaries really honed his writing skills. He suggested in an interview with the London Broadcasting Company radio in 1986 that there were a series of phrases used which had very different meanings: ‘he suffered fools badly’ meant he was the rudest man in miles, ‘Hibernian temperament’ meant he drank a lot and ‘man with problems’ meant he drank alone. ²¹

Still not settled, Ostlere became a ship’s doctor and sailed to Australia via Newfoundland on a freighter. Somewhere in the Indian Ocean he realised that all the crew were fit and so there was nothing for him to do except either:

‘drink gin and whisky with the ship’s engineer or use the purser’s typewriter to write medical anecdotes about his life as a medical student.’ ²²

He chose the latter and Doctor in the house was the outcome, published in 1952. ²³ The book became a huge success and a film soon followed in 1954 in which Ostlere played a role of an anaesthetist in one scene.

Return to anaesthesia

He returned to the UK in 1951 and was appointed to the Nuffield Department of Anaesthesia in Oxford as a Research Assistant, which included considerable clinical anaesthesia. Here he met his future wife, Mary Patten, who was also a Research Assistant in the Department. He was soon back in print in the scientific literature when he wrote of his findings when trichlorethylene (Trilene) was left in an untinted bottle in light for three weeks. When the contents were analysed by Imperial Chemical Industries there was a considerable quantity of hydrochloric acid and phosgene in the bottle. ²⁵ He followed this with a paper in Anaesthesia on epidural anaesthesia used in the management of hypertension seen in pregnancy. ²⁶ He attributed the success, seen in his series of four patients, to the production of increased renal blood flow. The epidural was maintained for up to four days but a hazard with the polythene catheters then used was they became brittle and tended to break. He suggested that under these circumstances a superficial incision could be made in the skin and, if readily seen, the catheter may be removed. If not seen, he suggested that it could be safely left in situ – a circumstance seen in one patient who after a brief illness had had no more symptoms one year later!

In 1953, while Deputy First Assistant in the Department, he published a book on trichlorethylene anaesthesia ²⁷ together with a paper in Anaesthesia on the history of the drug. ²⁸ The 82-page book reviewed all current information on the effects of trichlorethylene. In 1953 Macintosh and Bryce-Smith published their book on local analgesia for abdominal surgery and in the preface thanked Ostlere for collating their writings and pictures into a form that could be published! ²⁹ In that same year Doctor at sea ³⁰ was published and, with its success, Ostlere gave up the practice of medicine and became a full-time writer. Robert Macintosh (1897–1989), the Professor of the Oxford Department, when informed of this decision is said to have remarked, ‘My boy, I think you made the right decision’. At this time, Ostlere, using the pen name Richard Gordon, was regularly contributing to Punch magazine, a weekly publication of humour and satire. In this he continued, at times, to not very subtly denigrate the role of the anaesthetist ‘when the anaesthetist strolled away for a cup of coffee and left his patient tranquilly freewheeling.’ ³¹

Full-time author

The level of success he was achieving with these books was noted in the Australian press in 1954. ³² This article stated that he was selling 5000 copies of Doctor in the house and Doctor at sea every week with a total sale to date of over 330,000. In 1955 Doctor at large gave further insight into Ostlere’s views of anaesthesia. ³³ Whilst the author is assisting rather unsuccessfully with a major surgical operation his ‘only consolation that morning was watching Grimsdyke out of the corner of my eye’.

He noted that at breakfast that morning Grimsdyke had given the opinion that

‘… there are only three stages of anaesthesia awake, asleep and dead.’

As the case continued it became apparent that Grimsdyke was becoming more concerned as

‘… every now and then he turned a coloured tap, or buried under the sterile towels to look up Macintosh’s Essentials of Anaesthesia, which he had propped against his unconscious nose.’

Towards the end of the case Grimsdyke fell asleep and the patient started to move, at which point the surgeon pronounced the fateful line:

‘Mr Anaesthetist if the patient can keep awake during the operation, don’t you think you might too?’

It has been suggested that Ostlere based the character of Richard Grimsdyke, the perpetual student who had a donation of £1000 a year while he remained a medical student, on his friend and colleague George Harold Ellis (1908–1998), who spent 13 years as a Barts student before specialising in anaesthesia.

The books were soon used by J Arthur Rank to produce very successful films which enhanced the further sales of Ostlere’s books. It is said that he followed the lead set by Hitchcock and played small cameo roles in the early films. In Doctor in the house, released in 1954, he played an anaesthetist. Doctor at sea, which followed in 1955, had Brigitte Bardot in the cast, in what was her first English-speaking role. Five further films in the ‘Doctor’ series followed and then in 1969 London Weekend Television started a series of five derived comedies which lasted until 1977. In 1979 the Australian Seven Network produced a sixth series entitled ‘Doctor Down Under’ and then in 1991 the British Broadcasting Corporation made a seventh, and final series, entitled ‘Doctor at the Top’.

Ostlere wrote another 40 books, both fiction and non-fiction (see Appendix 1), and in 1968 wrote in the St Bartholomew’s Hospital Journal how St Swithin’s Hospital in his ‘Doctor’ books was his view of St Bartholomew’s Hospital. ³⁴ His cantankerous senior surgeon, Sir Lancelot Spratt, was, he wrote, an amalgam of Sir William Girling Ball (1881–1945), Lord George Alwyn (1880–1967), Mr Harold William Wilson (1880–1959) (the surgeon not the politician), Mr Roberts of Hill End (who was possibly James Ernest Heleme Roberts (1881–1948), a thoracic surgeon) and Dr Geoffrey Evans (1886–1951); their views on this are not recorded! Ostlere continued to write, travel and enjoy gardening, fishing and cricket as leisure activities. In the three decades from the 1960s onwards, Ostlere wrote a series of historical fiction books about surgeons and more factual ones on the history of anaesthesia, ³⁵ and the private lives of Florence Nightingale, ³⁶ Jack the Ripper ³⁷ and Doctor Crippen. ³⁸

The sleep of life was published in 1975³⁵ and in it Ostlere reviews the history of anaesthesia as seen by a young journalist, Guy Romilly, whose father knew Sir Humphry Davy. This fictional young man had introductions which allowed him to meet with the surgeon Robert Liston and then he travelled to Boston to meet with the early experimenters who used nitrous oxide and ether to create an anaesthetic state. On his return to London, he is soon in contact with all the protagonists of anaesthesia in London, including Joseph Clover and John Snow.

In his book about Florence Nightingale, he suggested that she was a lesbian, which caused an indignant nursing officer to cancel a press conference due to be held at St Thomas’s Hospital and cause it to be held on the pavement outside the hospital. ²² He suggested that Jack the Ripper was an anaesthetist who used chloroform on all his victims and thus explained why no screams were ever heard. ²²

Ostlere made headlines in 1974 when Eamon Andrews (1922–1987) surprised him with his ‘big red book’ and said that tonight he was the subject of ‘This is Your Life’, a long running television show. Ostlere refused but reappeared the following week when the programme was broadcast. His friend and colleague George Ellis was one of the guests who recounted his views of Ostlere at that time.

In 1982 Ostlere wrote a book which provides a unique insight into his time in anaesthesia. Bedside manners; a patient’s guide to hospitals and doctors was written for patients. ³⁹ In this he writes about his time in medicine:

‘My own disillusionment was sharpened by the discovery that I did not really like patients, … I bolted into the one labelled ‘Anaesthetics’ where my patients’ conversation would be confined to a few drowsy murmurings on the theatre trolley, cut short at will with a syringe full of quick-acting barbiturate.’

He goes on to state some amazing thoughts about modern anaesthetists:

‘A common hazard of modern surgery is the anaesthetists’ reluctance actually to give anaesthetics at all. Instead, their patients are injected with a derivative of curare … So the patient lies awake on the operating table feeling the surgeon rummaging about inside and unable to raise a finger against it.’

He continues to reassure the prospective surgical patient with:

‘The anaesthetist’s life is agreeable enough. … He can slip out for a cup of coffee, leaving the patient free-wheeling.…He can quietly get on with the crossword behind the sterile towels.’

This was the scenario often shown in his humorous books, but this is a factual book for patients!

Personal life

In 1952 Ostlere married Mary Patten, whom he had met in Oxford. She continued in anaesthesia for a while after he had become a full-time author and she passed the FFARCS in 1954 before retiring in 1955. She co-authored, with Robert Macintosh, the excellent book on local analgesia for the head and neck. ⁴⁰ Ostlere and Patten had four children, two of whom went into medicine. Ostlere wrote a book with his wife about practical parenthood. ⁴¹ He was a very keen fisherman and watcher of cricket at Lord’s. He was a member of the Garrick and Beefsteak Clubs and the Marylebone Cricket Club and yet constantly claimed he was a shy person. He continued to write regularly for Punch magazine and was proud that his name was carved into a large desk there. He was a devotee of the author PG Wodehouse and was greatly moved by a tribute paid to him by Wodehouse in the ‘This is your Life’ programme. In 1971 he was invited to take part in ‘Desert Island Discs’ hosted by Roy Plumley. This radio broadcast invited personalities to choose eight records they would have if marooned on a desert island and these were played in between conversations. At that time, he said,

‘I wasn’t a very good doctor because I didn’t like patients – that’s rather like a man in the cavalry saying he doesn’t like horses, isn’t it? So, I became an anaesthetist, and all my patients were asleep’.

Ostlere continued to write and travel well into the 1990s. In 1981 he gave a talk to the Hobart Press Club luncheon while in Tasmania to present at the Sixth Australian Medical Congress on ‘Medicine and the Media’. The journalist who covered the speech likened him to ‘a cross between a pink-cheeked parish priest and an amiable leprechaun’; he was also described as a ‘monocled medico’. Once more he reiterated his dislike of talking to patients, which was only partially solved by his time in anaesthesia. ⁴²

Ostlere died after a stroke, in Kent, in 2017.

Conclusions

Gordon Ostlere was a reluctant doctor and anaesthetist who found his true career in writing. He was able to write excellent factual science, as can be seen in his published medical papers, as well as very popular works of fiction. In the years when he was an anaesthetist and in the decades that followed, the speciality of anaesthesia has been poorly recognised by both the medical profession and the general public. Ostlere was in a unique position to show the profession in a good way but instead depicted all who practised anaesthesia as alcohol prone, crossword-completing failures who often were not even present during the operation but were outside the room drinking coffee. Today, some 70 years after Ostlere started writing his novels, the profession of anaesthesia remains poorly recognised and understood by many. Numerous attempts have been made by professional bodies associated with anaesthesia on many continents to have some form of public relations day to illustrate the full contribution made by anaesthetists. These efforts have made some progress and the profession’s roles have been further illustrated by the current COVID-19 pandemic. The ensuing higher publicity for those working in intensive care medicine and anaesthesia has been welcome ⁴³ but still the role is seen by many in the same light as Ostlere wrote back in the 1950s. This very public figure missed a great opportunity to portray the art and science of anaesthesia in its correct light.