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13 April 2020updated 29 Apr 2020 11:00am

How a polio outbreak led to the invention of modern intensive care

One doctor’s innovation saved a generation of children and changed medical practice.

By Paul Warwicker

A worldwide viral epidemic accelerating out of control, a health service on the brink, a critical lack of breathing apparatus: we’ve been here before. In 1952, an epidemic of polio led to the birth of intensive care, and the invention of the modern ventilator.

Poliomyelitis, or polio, is a paralysing infectious disease caused by the poliovirus. It most commonly affects children under the age of five. In temperate climates it occurs in the warmest months, which explains one of the names – the “summer plague” – that have been given to the disease in its long history of infecting humans. While it can be prevented – billions of people have now been vaccinated against polio – there remains no cure. In the first decades of the twentieth century, there was little that could be done to treat the most severely affected, who lost the ability to swallow, or even to breathe.

In 1928, the American medical pioneer, Philip Drinker, demonstrated that patients could be kept alive by a type of artificial ventilator, nicknamed the “iron lung”. The patient was sealed from the neck down in a metal tube, from which air was sucked, causing the chest wall to expand. This drew air into the lungs through the mouth and nose in a process called “negative pressure ventilation”. Mortality from polio remained high, but at least there was hope for those whose breathing muscles had been paralysed by the disease.

However, the need for the machines far outstretched their availability. From 1945 to 1949, Western countries saw an annual average of 20,000 new cases of polio. Just as today’s government has rushed to set up the new Nightingale hospitals, the countries that could afford it bankrolled huge suites of iron lungs. But in the austerity of postwar Europe, most countries had to go without. 

In Copenhagen, the summer of 1952 had begun like any other. The city expected a polio outbreak – in a bad year, a few hundred would contract the disease – and officials were not surprised when, in late July, the first case presented at the Blegdamshospitalet, the city’s main treatment centre for communicable diseases.  Within a month, however, the number of patients had reached an unprecedented 260. During the first three weeks, 27 of 31 severely paralysed children died, most within days of admission. During 19 weeks over 2,700 patients were affected, with 316 losing the ability to breathe. The hospital, and Denmark as a whole, had one iron lung.

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The senior physician at Blegdams was Henrik Lassen. Feared and respected by his staff, Lassen had risen rapidly through the medical ranks to be appointed chief of medicine at the early age of 38. On ward rounds, he half-jokingly referred to himself as “the emperor”.  Yet even he had no answers, and a sense of despair infected the staff.  Mogens Bjørneboe, Lassen’s deputy, urged him to call in help. He suggested a friend, an anaesthetist called Bjørn Ibsen. That April, Ibsen had helped Bjørneboe to manage an infant boy with intractable seizures caused by tetanus, using the paralysing agent curare. The treatment came at a price: the child was rendered unable to breathe without artificial respiration. The “iron lung” was unsuitable for such a small infant, so Ibsen had proposed a treatment hitherto only used for short periods in patients undergoing heart or lung surgery. It was called “positive pressure ventilation”. A tube was inserted into the infant’s windpipe, and a team of doctors, working in shifts, manually squeezed air in and out of his lungs using a rubber balloon for more than two weeks.

In the 1950s, anaesthetics was a low-status medical speciality. Anaesthetists were regarded as little more than technicians; the surgeon decided the anaesthetic, the anaesthetist administered it. Lassen, mindful of his international reputation, was offended by the suggestion that he take the advice of an anaesthetist.

As cases continued to rise exponentially, Lassen organised a gathering of the senior staff to review new initiatives. He agreed, reluctantly, to invite Ibsen, but only in order to humiliate the young anaesthetist regarding his lack of experience in polio. Ibsen’s forthright view, however, was that the iron lung was not up to the job, and the confident presentation of his positive pressure system won over the assembled physicians. Lassen, fuming, grudgingly agreed to a trial – on the most hopeless case in the hospital, a 12-year old girl called Vivi Ebert, who was considered to be in the terminal phase of the disease.

Ibsen began hand ventilations through a cuffed tube surgically inserted into Ebert’s windpipe. She did not improve at first, and one by one the watching physicians drifted away in embarrassment.  In a last desperate bid to save the girl, Ibsen administered a general anaesthetic. With the loss of consciousness, Vivi stopped fighting the manual ventilations. By the time the physicians returned from lunch, she had started to improve more dramatically than any of them had expected.

The news spread rapidly through the hospital. At a stroke, Ibsen had discredited the expensive, cumbersome iron lung, replacing it with a simple, cheap, and readily available form of artificial ventilation. Nonetheless, the logistics of hand-ventilating every critical case were daunting. Each patient required a team of four people to cover 24 hours, seven days a week, for up to three months, until recovery. There were only 20 anaesthetists in Copenhagen; hundreds would be needed.

Lassen’s leadership skills now came into play. He called up hundreds of medical and dental students, who often received less than ten minutes training before being given the responsibility for keeping a child breathing and alive throughout an eight-hour shift, day and night. By the end of the epidemic, 1,500 medical and dental students had put in over 165,000 hours filling the lungs of those who could not breathe for themselves.

The plan worked. The mortality rate of respiratory polio in Denmark fell from 90 per cent to 20 per cent, and the iron lung became a museum piece. The following year, the Swedish company Engström invented a machine that pumped the ventilations mechanically. The doctors nicknamed these machines “mechanical students”.

In 1954, the first polio vaccines were introduced into Denmark. The last polio case with breathing problems was treated in 1958.

We all owe a debt of gratitude to professor Bjørn Ibsen, the father of modern intensive care, who died in 2007. As the coronavirus pandemic stretches healthcare systems around the world, the inventiveness and dedication that he and 1,500 students used to saved a generation of children is needed once more.

This article appears in the 29 Apr 2020 issue of the New Statesman, The second wave