Anaesthesia, 2010, 65, pages 11331136

doi:10.1111/j.1365-2044.2010.06535.x
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Editor-in-Chief s note:
The following is the first in a new series, Classic Papers, in which invited authors select papers from the entire back-catalogue of
Anaesthesia and describe why they have special significance to them and or the specialty of anaesthesia. The Classic Papers feature
will be based at the Journals website (wileyonlinelibrary.com journal anae) and both the commentaries, and the original papers they
describe, will be freely available online, in fulltext.
To introduce the feature, this first commentary is also published in the Journal itself. Subsequent commentaries will be published on
the website on an occasional basis.

CLASSIC PAPER

Murphy P. A fibre-optic endoscope used for nasal

intubation. Anaesthesia 1967; 22: 489-91
I. Calder
Emeritus Consultant Anaesthetist, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Correspondence to: I. Calder

Email: icalder@aol.com

Murphy P. A fibre-optic endoscope used for nasal intubation. Anaesthesia 1967; 22: 48991 [onlinelibrary.wiley.
com/doi/10.1111/j.1365-2044.1967.tb02771.x/pdf ]
The significance of new technologies is not always
recognised. A lengthy period of development may be
required. Even when technical problems have been
solved it can be some time before practical applications
are identified and manufacturers can produce affordable
devices that can be used by less than expert operators. The
transmission of light through flexible fibreoptic cables,
which underpins so much of our experience of life (the
internet is the most important application of many that
we would now regard as vital), is an example.
It took some 40 years from the first suggestion of the
use of thin, flexible, glass fibres to transmit light by John
Logie Baird, the inventor of television [1], for usable
fibreoptic endoscopes to appear, and even more years for
the potential for information transmission to be realised.
Formidable problems, such as crosstalk between fibres
and maintaining the relationship between fibres throughout the length of a cable, had to be overcome. These
problems were largely solved by a remarkable collaboration between physicists and physicians in Michigan and
Alabama led by Basil Hirschowitz [2].
Basil Hirschowitz was a gastroenterologist whose
interest in fibreoptic technology was driven by the
deficiencies of rigid endoscopes for viewing the alimen 2010 The Author
Anaesthesia  2010 The Association of Anaesthetists of Great Britain and Ireland

tary canal. He reported the use of a flexible gastroscope in

1961 [3], and a flexible oesophagoscope in 1963 [4]. The
first report of flexible bronchoscopy was published by
Ikeda et al. in a Japanese journal in 1968 [5].
Peter Murphys report [6] preceded Ikedas publication
on the flexible bronchoscope [5], so what type of
endoscope did he use? In 1965, Dr Murphy was a senior
registrar in anaesthesia at the National Hospital for
Nervous Diseases (now Neurology and Neurosurgery)
in Queen Square in London. He saw an article in the
Lancet about the use of a flexible choledochoscope for
looking into the common bile duct at cholecystectomy
[7]. It occurred to him that the instrument might be
useful for laryngoscopy and tracheal intubation. Dr
Murphy contacted the manufacturers, the American
Cystoscope Makers Inc (ACMI) with his idea and was
surprised to be sent a choledochoscope (Fig. 1) with a
request that he let them know how he got on.
Dr Murphy used the choledochoscope to intubate a
patients trachea and as the instrument had a fitting that
allowed still photography, he was able to obtain the first
fibreoptic photographs of the trachea and include them in
his report in Anaesthesia. Dr Murphy later took the
choledochoscope with him when he rotated to the
Brompton Hospital and used it to confirm the placement
of double lumen tubes, although he did not report this
application (P. Murphy, personal communication, 1996).
1133

I. Calder
Classic Paper
Anaesthesia, 2010, 65, pages 11331136
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Figure 1 The choledochoscope and light source used by

Murphy. Courtesy of Dr P. Murphy. Reproduced from:

Murphy P. A fibreoptic endoscope used for nasal intubation.
Anaesthesia 1967; 22: 48991.

Shortly after the publication of his article, Dr Murphy left

London for Chicago, where he has practised ever since
(Fig. 2).
I asked Dr Murphy for details of how he did his first
fibreoptic intubation, and this was his reply:
You were probably taught, as I was, how to do a nasal
intubation in a patient put to sleep with halothane.
They breathe, not relaxed with any drugs, until they
are almost without a cough reflex. We were then
shown how to advance a tube through the nose and

Figure 2 Peter Murphy in 1967. Courtesy of Dr P. Murphy.

1134

listen for the breath sounds. At the point where the

noise vanished we were told to pull the tube back, out
of the oesophagus, for a half inch or so. Then, listening
carefully with the skull held off the table, we advanced
the tube, rotating back and forth, and if we were lucky
we pushed the tube onward, retaining the breath
sound. Voila, a so-called blind intubation.
I did the same thing but when I pulled back the
tube from the oesophagus I popped the choledochoscope down and there was the larynx straight ahead,
and now, by pushing the tube in and rotating a little I
was able to wiggle the scope into the trachea and push
the tube on further.
When an article was published in a journal in the preinternet days it was customary for an author to receive or
buy copies (reprints) of the article and to send them to
people who wanted to read the article but could not
access the journal. Dr Murphy did not receive correspondence from any anaesthetist, but there was a lot of
interest from ENT surgeons:
No-one in the world of anaesthesia wrote for a
reprint of my article on intubation. I doubt if they
saw the implications. Sounds very strange but if they
had, surely they would have contacted me. Anaesthesia
(the journal) surely did; they harassed me to get the
proofs back quickly and their reply was very, very
fast.
The otolaryngologists would have seen the practical
diagnostic value immediately. They now use a similar,
tiny scope to look at the glottis in the office setting.
They wrote for reprints from all over the globe (what
an idiot I was not to have kept them!). They knew this
technique offered the possibility of close glottic
examination for neoplasms as nothing else could, and
provided a means also to examine the nasopharynx
deeply, in an office practice. (P. Murphy, personal
communication, 2010).
Dr Murphy may be correct in assuming that anaesthetists (other than Dr Bryce-Smith, the then Editor of
Anaesthesia) did not see the implications, but the advent of
the flexible bronchoscope did result in further publications [8, 9], although it was a decade or more until the
advantages of a flexible endoscope for difficult intubations
became established [1013]. The first textbook on
fibreoptic intubation did not appear until 1990 [14].
The first dedicated flexible fibreoptic laryngoscope was
produced by the American Optical Company and a
report of 100 tracheal intubations was published in JAMA
by Stiles et al. in 1972 [15]. When Stiles et al.s article
appeared, Dr Murphy persuaded his department to
purchase a flexible fibreoptic laryngoscope, but despite
being the pioneer in the field his first attempts with this
device were embarrassing:
 2010 The Author
Anaesthesia  2010 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia, 2010, 65, pages 11331136

I. Calder
Classic Paper
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I lost interest in fibreoptics for a time and then an

Optical company, American Optical, mainly a manufacturer of eye glasses, marketed a battery handle
fibreoptic laryngoscope, of all things. The fibreoptic
bronchoscope had appeared by that time; thoracic
surgeons were learning how to use it in the US but
once again, anaesthesiologists in general were not
participating in its use very widely. It really seemed too
long, and too clumsy, meant more for viewing the
anatomical pathology of the bronchial tree. I persuaded
the Chairman to buy one of American Opticals shorter
scopes.
Now I confess the moment of truth had arrived. I
could not intubate with this thing! Although the end
wiggled up and down helpfully (the choledochoscope
was just a piece of spaghetti) I found the pharynx of a
curarised patient collapsed into my path so completely,
and I lost my way for so long, that the patient began to
suffer from lack of oxygen. All I could see was spit and
orange mucosa (there was no suction channel). Here
was the man who invented fibreoptic intubation but
couldnt even do it himself! There was no-one who
could tell me what was happening, of course. Everybody just stood around and watched curiously.
I did acquire some skill but not enough until I had a
new idea: why not try intubating in a patient recovering in the post-anaesthesia area? Justified sometimes
to evaluate post-thyroid glottic movement, for example. This was the opening of a door if ever there was
one: avoid muscle relaxants and the exercise became a
success. (Later on, I found out that tongue holding and
jaw lifting were even better). It was so wonderfully
simple I could not believe it. The moment the scope
went behind the tongue the glottis was there, lit like a
star! And then I became a star myself, flitting from one
room to another where difficult intubation situations
arose. Sometimes of course I was turned aside due to
the perception that my new skill might diminish
someone elses stature in the operating suite, but that
was a rare event. One patient died from complications
following a failed intubation during this time. I was
busy, but available close by. For some reason they
decided they could manage without my help.
From then on, my career became a joint venture
with head and neck cancer surgeons, who, in turn,
recognised in my skills someone who could readily
intubate the upper airway, past friable tongue cancers,
past and around vallecular cancers and over glottic
cancers invading the trachea.
These challenges have kept me interested and now
at an age of eighty-one I still do two days a week
teaching in this area. It has been very rewarding.
(P. Murphy, personal communication 2010).
 2010 The Author
Anaesthesia  2010 The Association of Anaesthetists of Great Britain and Ireland

Figure 3 Peter Murphy on his eightieth birthday. Courtesy of

Dr P. Murphy.

Peter Murphy is clearly a remarkable, and durable, man

(Fig. 3).
I wonder how many anaesthetic registrars read the
Lancet regularly these days. Having read Shore and
Lippmans article [7], Murphy did some notable lateral
thinking in perceiving that the choledochoscope might
be useful for laryngoscopy and intubation. He then
displayed considerable chutzpah in asking the ACMI
company for the loan of one of their instruments (Dr
Murphy thinks that the cost of the instrument was about
3000, which would have purchased a new RollsRoyce car at that time), and I applaud the ACMI
company for their faith in a relatively junior doctor in
another continent. The speed of publication is also
impressive as it was almost exactly 2 years between
Shore and Lippmans and Murphys publications. Ethics
and Research and Development Committees are necessary, but I suspect that Dr Murphys project would have
taken longer to complete today.
1135

I. Calder
Classic Paper
Anaesthesia, 2010, 65, pages 11331136
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Fibreoptic techniques are now well established, with

PubMed listing 52 publications on fibreoptic tracheal
intubation in 2009. Nevertheless, access to flexible
fibreoptic equipment and training is not universal outside
the developed world, and even in the developed world,
departments struggle with cost, cross-infection and training, but, as Andranik Ovassapian pointed out in the
preface to his textbook, virtually the same problems were
identified when direct laryngoscopy was introduced [14].
Dr Murphy was the first to realise that flexible
fibreoptic technology might be useful for airway management, the first to perform a flexible fibreoptic
intubation, and the first to publish a description. He
and Dr Bryce-Smith deserve recognition. Both of them
must have been disappointed by the lack of interest
displayed by their colleagues. When Anaesthesia decided
to reprint eleven classic papers in 1995 to celebrate
50 years of publication, Dr Murphys was not one of
them, which provoked a squeak of disappointment from
some of those involved in fibreoptic education [16]. It has
taken a long time for the significance of Dr Murphys idea
to be appreciated, but more than 40 years after publication, he and the Journal can be proud of an important
contribution to anaesthesia.
Competing interests

No external funding and no competing interests declared.

Some of Dr Murphys experiences related above have also
been described in reference 16.
References
1 Calder I, Ovassapian A, Calder N. John Logie Baird
fibreoptic pioneer. Journal of the Royal Society of Medicine
2000; 93: 4389.

1136

2 Hirschowitz BI. A personal history of the fiberscope.

Gastroenterology 1979; 76: 8649.
3 Hirschowitz BI. Endoscopic examination of the stomach
and duodenal cap with the fiberscope. Lancet 1961; 1:
10748.
4 Hirschowitz BI. A fiber flexible oesophagoscope. Lancet
1963; 2: 38898.
5 Ikeda S, Yanai N, Ishikawa S. Flexible bronchofiberscope.
Keio Journal of Medicine 1968; 17: 116.
6 Murphy P. A fibre-optic endoscope used for nasal intubation. Anaesthesia 1967; 22: 48991.
7 Shore J, Lippman HN. A flexible choledochoscope. Lancet
1965; 1: 12001.
8 Taylor PA, Towey RM. The broncho-fiberscope as an aid
to endotracheal intubation. British Journal of Anaesthesia 1972;
44: 6112.
9 Conyers AB, Wallace DH, Mulder DS. Use of the fiberoptic
bronchoscope for nasotracheal intubation: case report.
Canadian Anaesthetists Society Journal 1972; 19: 6546.
10 Mulder DS, Wallace DH, Woolhouse FM. The use of the
fiberoptic bronchoscope to facilitate endotracheal intubation
following head and neck trauma. Journal of Trauma 1975; 15:
63840.
11 Wang JF, Reves JG, Corssen G. Use of the fiberoptic
laryngoscope for difficult tracheal intubation. Alabama Journal
of Medical Sciences 1976; 13: 24751.
12 Messeter KH, Petterson KI. Endotracheal intubation with
the fiberoptic bronchoscope. Anaesthesia 1980; 35: 2948.
13 Ovassapian A, Doka JC, Romsa DE. Acromegaly use of
the fiberoptic laryngoscope to avoid tracheostomy. Anesthesiology 1981; 54: 42930.
14 Ovassapian A. Fiberoptic Airway Endoscopy in Anesthesia and
Critical Care. New York: Raven Press, 1990.
15 Stiles CM, Stiles QR, Denson JS. A flexible fiberoptic
laryngoscope. Journal of the American Medical Association 1972;
221: 568.
16 Calder I, Pearce A, Towey R. Classic paper: a fibreoptic
endoscope used for tracheal intubation. Anaesthesia 1996; 51:
602.

 2010 The Author

Anaesthesia  2010 The Association of Anaesthetists of Great Britain and Ireland