In the beginning. The 1952-1953 Danish epidemic of poliomyelitis and Bjørn Ibsen

Full text

Occasional essay
(revised November 2003)
In the beginning.
The 1952-1953 Danish
epidemic of poliomyelitis
and Bjørn Ibsen
“The modern specialty of intensive care medicine
began with the poliomyelitis epidemic in Denmark”. That
quotation from the golden jubilee book of the Royal
Australasian College of Physicians1 is a characteristic
statement found in the limited writings on the history of
Intensive Care Medicine, because it was during the 1952-
1953 Danish epidemic of poliomyelitis that the foundations
of our specialty were laid. The epidemic was “unprecedented
in the history of Denmark, in size as well as severity…..and
by far the worst ever recorded in Europe”.2 Comprehensive
and excellent accounts of it have been published.2-5a
Now that the 50th anniversary of the end of the
epidemic has passed, at the variously given dates of
March 2nd 1953,6 or, it has been argued, May 1st 1953,7 it
seems an appropriate time to consider the epidemic’s role
in the development of our specialty. Further,
the anniversary allows us to honour the innovative
contributions made by the clinicians involved. They were
principally the anaesthetist Bjørn Ibsen and his multi-
disciplinary colleagues in H.C.A. Lassen’s Department of
Communicable Diseases at Copenhagen’s Blegdams-
hospitalet.
Ibsen’s introduction of new treatment methods
dramatically reduced mortality among those patients who
needed artificial ventilation for acute respiratory failure
arising out of breathing and/or swallowing deficits.2,3,5 His
ideas and practices during this time also started the
development of the intensive care unit towards what it is
today;4 and, together with the collaborative enthusiasm of
laboratory chief Poul Astrup, fostered the introduction of
regular blood-gas and acid-base analyses into daily
management of the intensive care patient.8,9
The novel approach at Copenhagen4,5,5a
Before Ibsen introduced his methods, infectious
diseases departments often treated respiratory failure in
polio patients with either a cabinet “respirator” or a body
cuirass respirator, both providing negative pressure
ventilation. Since 1948, tracheostomy had also been used
at Blegdamshospitalet, where indicated, although Lassen
found that did not improve mortality.2
At Copenhagen, for the month until Ibsen was recruited
to the Blegdam treatment team, the death of 27 of the 31
epidemic patients treated by negative pressure ventilation
(mostly by body-cuirass respirators) highlighted the
limitations of this form of treatment.10 With an inadequate
number of machines to supply negative pressure ventilation
(one Emerson cabinet and six cuirass respirators, probably
Kifas, were available)10 and because of the ineffectiveness
of this form of treatment, on 27th August 1952 Ibsen
demonstrated on an adolescent polio patient the benefits
of an alternative approach. He showed that patients could
be ventilated successfully by using a technique of manual
intermittent positive pressure ventilation (m-IPPV).4,10
The method used a rhythmical “bag-ventilation”, through
a Water’s to-and-fro’ carbon dioxide absorber connected
to a cuffed endotracheal (tracheostomy) tube. The
ventilation method was a known anaesthetic technique
used in the operating theatre and the same anaesthetic
system could be applied to critically ill patients.
To supply the labour for m-IPPV in the months ahead,
Lassen organised shifts of approximately 1500 volunteer
medical students,5 (later joined by dental students5), 600
trained nurses and hundreds of auxiliary personnel,2
student nurses and semi-retired nurses. They were
supervised by anaesthetists and assisted by each patient’s
‘special’ nurse. With these teams, “despite the unabating
severity of the fresh cases”,2 the mortality among ventilated
patients had decreased from 87% recorded prior to
introduction of the new system, to 26% for the sixth cohort
of 50 patients admitted after August 25 and treated by the
“new methods”11. By the time of these patients, much of
the mortality was obligatory (e.g. due to the severity of
necrotising brain lesions caused by the polio virus).12 For
the group with the combination of “paralysis of respiratory
muscles, pharynx and/or larynx and with cerebralia
…mortality approaches 100 percent”;2 also many of the
deaths occurred, with “catastrophic rapidity”,2 soon after
admission.11
At the end of this Denmark-wide epidemic, the 1953
provincial Denmark epidemic followed,7 and an out-break
also occurred in Sweden,13 where mechanical IPPV with
tracheostomy was successfully employed in 54 patients,
and the mortality among “55 cases of bulbo-spinal
respiratory paralysis” was 27%.13
Outcomes
Multiple factors contributed to Ibsen’s striking success.
These included his clinical and laboratory acumen regarding
the nature and origin of the clinical features in many of
the patients treated by negative pressure ventilation, and
his recognition of the essential nature of lethal problems,
which were fully detailed in the accounts of the epidemic.4,5
In addition, once Lassen was convinced of the efficacy of
Ibsen’s revolutionary ideas, he immediately accepted them.10
227
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2. Intensive care units
When polio patients were concentrated into “a
special department”5 for best management (at the
Blegdam the large number required three floors),
impetus was given to the development of these as
specific units. Because Ibsen could see the benefits
in always having an area with its own trained staff
and multi-disciplinary team, he was foremost in
advocating a separate location to be established in
hospitals where intensive care management could
be supplied to the critically ill.4,9 These dedicated
areas became known as intensive care units.
By demonstrating the success of a team approach
for such patients (the team at Blegdam had
anaesthetic, epidemiological/medical, “otolaryngeal”,
student, nursing, laboratory, and physiotherapy
components), the organisation needed to run such
a unit came to be determined.2,8 Ibsen established
his own intensive care unit, a general one and
Denmark’s first, at (Copenhagen’s) Kommune-
hospital in 1954.4 Though this lead was soon
followed in the United Kingdom,15 and in the mid
to late 1950s the United States, it was not until the
end of the decade that any kind of formal intensive
care unit was established in Australasia.21
3. Intensive Care Medicine
When serviced by staff trained and certified
in the specialty, the practice and success of what
rapidly expanded into early Intensive Care
Medicine opened the way for evolution to its
present state. For their polio patients, anaesthetists
had to go beyond applying just the basic principles
of anaesthetic4 and respiratory care for the
preservation of vital functions (airway, ventilatory,
circulatory and acid-base balance). With guidance
from their epidemiologist and physician
colleagues they became acquainted with, and
involved in, management of other complications
(e.g. “cerebralia,”2 sepsis, azotaemia, paralytic
ileus, myocarditis22) and saw how to extend their
particular skills to areas involving prolonged,
whole-body support. This started with an
expanded role for IPPV, exemplified by its use in
“vasomotor shock” and pulmonary oedema.3
Anaesthetists became intensivists and were now
involved in systems of treatment tailored to relieve
the physiological disturbances from spino-bulbar-
cerebral complications. For those 345 victims of
the epidemic who fitted the Blegdam criteria for
having “Life-threatening poliomyelitis”3 their
clinicians had devised a “mixed anatomico-clinical
classification” into six patient groups from A to
F.2 Specific treatments were determined and
applied to the needs of each group.
Besides saving many lives, the achievements of that time
produced important outcomes in three major respects:
1. Intermittent positive pressure ventilation
The successful use of m-IPPV resulted in a
changeover from manual to mechanical, longer-term
intermittent positive pressure ventilation (IPPV), a
concept that spread through Scandinavia, the United
Kingdom14,15 and elsewhere in Europe.5a,14 That change
was accomplished by the rapid development and
production of a range of new IPPV machines, dubbed
“mechanical students”,16 reliable for the task of
providing long-term artificial ventilation. Apart from
the Engström prototype, the European IPPV machines,
which were available before the time of the epidemic,
were primarily anaesthetic ventilators, and had not
been tried outside the operating theatre or for long
term use.14,18 These machines included the Blease
Pulmoflator, the Frenckner, the Aga and the original
Mørch-1 respirator (i.e. E. Trier Mørch’s original World
War II Danish modification of the Swedish Aga). The
Bang ventilator, which was developed provincially
during the epidemic and also used at the Blegdam
from 1953,3 could not compare with the Engström.
The Gullberg positive pressure attachment for the Kifa
cuirass also became available later in the epidemic,
although it was not used in the acute phase of the
illness and was only used for weaning.3
The sophisticated Engström volume-controlled
ventilator18 was foremost among these machines and
had been developed in 1950 after Dr Carl-Gunner
Engström realised that it was underventilation which
caused many of the polio deaths in Stockholm.18 His
ventilator was carefully evaluated at the Blegdam, and
was found to be the only one of several types of IPPV
machines that were tested, that functioned
satisfactorily.8 Its merits were also evident in Sweden’s
1953 polio epidemic.13
Further valuable developments from the epidemic
included humidifying systems,2,4 and non-rebreathing
valves19,20 enabling the soda-lime canister to be
dispensed with.
After the Danish epidemic, IPPV was not taken
up generally in polio units in the United States, despite
new designs from Mørch (the 1954 Morch-3 Piston
Ventilator) and from Van Bergen et al.14 Negative
pressure ventilation still reigned supreme for polio
patients for the rest of the decade in most of North
America as well as in Australia and New Zealand. In
the latter two countries this was largely due to the
ubiquity of a useful local product (the cabinet respirator
of the Both brothers of Adelaide), which was freely
donated by Lord Nuffield before World War II to
hospitals of the British Commonwealth.15
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228

Hospital, for large-scale and successful use in a
polio epidemic (e.g. “294 respirator cases” in 1948,
with 1949 mortality figures at 17% of 130
respirator cases). Ibsen, as he has already written
concerning the two papers of Bower et al,4
confirms that he “saw it in the library” (personal
communication). That was fortunate, because
although he had been in the United States of
America after the time the two relevant papers
appeared, he was not aware of them while he was
there. Also in North America, and prior to the
Copenhagen achievements, it was recognised that
“the all-important problem in life-threatening
poliomyelitis is respiratory”.2 In 1949, Sjøberg
introduced the treatment with tracheostomy and
bronchoscopic drainage to “maintain free airways
in these patients.”18 Nonetheless, Engström - an
epidemiolgist at that time - later lamented that
mortality figures still stayed high in the Stockholm
Hospital for Contagious Diseases.18 Before Bower
and Bennett’s work there had never been any long-
term use of IPPV for artificial ventilation.18
Prolonged artificial ventilation had been achieved
in polio units only with intermittent negative
pressure ventilation.14
3. A team effort
It should be acknowledged that the results
achieved could not have occurred without a team
of colleagues and supporting staff. The logistics
at the Blegdam were very impressive, coping with
the 31811 patients “treated according to the new
therapeutic principles” (from the hospital’s
epidemic total of 2,241 verified polio cases).3 Some of
the advances described can appear to be attributable
solely to Ibsen. Notwithstanding his inspired
innovations, what was achieved came from a closely
collaborative effort among many professionals.
The 50th anniversary of the Copenhagen polio-
myelitis epidemic has recently passed. On considering
the outstanding achievements towards the development
of Intensive Care Medicine, the epidemic needs to be
remembered for the influence it had on the
establishment of our individual specialty. At the same
time we acknowledge with gratitude our indebtedness
to these pioneers, Bjørn Ibsen and his colleagues, whose
fore-sight, dedication and application made the
development of Intensive Care Medicine possible.
R. V. TRUBUHOVICH
Department of Critical Care Medicine,
Auckland Hospital,
Auckland, NEW ZEALAND
Thus, during the poliomyelitis epidemic and
with a backing of “good clinical research” from
Astrup and his team,8 began the development of
Intensive Care Medicine.4 In anticipation of further,
perhaps irretrievable, deterioration, the principle
of preventive intervention was recognised and
developed. To quote Ibsen: “keeping the patient out
of the respirator [i.e. ventilator] as long as possible
can let pulmonary complications develop”.4
Management of patients during the epidemic
included the development of safe methods of
transportation to the Blegdam by road or air from
other hospitals or locations, rather than waiting for
the unsecured patient to arrive at the door of the
intensive care unit. Clinicians travelled out in
ambulances and aircraft to safeguard and stabilise
the patient for safe transport.4 Recognition of this
need was made at a time when Australia’s flying
doctor system was well established, which Ibsen
himself acknowledged.4
Intensivists were strategically placed to take
advantage of rapid developments in blood gas and
acid-base analysis, the value of which was
exemplified by successful ventilatory and clinical
practice during the epidemic.5a,8 Such application
gave a substantial boost towards further refinements.
Other considerations
Whatever innovative thinking Ibsen brought to
existing Scandinavian practice, certain considerations
should not be overlooked.
1. Previous manual-IPPV
Within the confines of the operating theatre,
anaesthetists were familiar with manual ventilatory
support, to the extent of controlling the patient’s
breathing completely. Credit for initiating this
technique is usually given to Arthur Guedel and
David Treweek,23 who in 1934 documented “four
years of clinical observation” of rhythmic manual
ventilation (with CO2 absorption) for ether-induced
apnoea. However, Engström pointed out that “In
Sweden, KH Giertz had, as early as 1916, advocated
the use of rhythmic insufflation ventilation in
intrathoracic operations and [at that time] had
made a critical review of all previous publications”.18
Before 1952, occasional use of various forms of
m-IPPV, often delivered through an external mask
when not by tracheostomy, had also occurred outside
the operating theatre for certain medical and surgical
conditions.21,24
2. Previous mechanical-IPPV for polio patients
A method of mechanical IPPV had already been
developed outside Europe in 1948, by Ray Bennett
for Albert Bower,25,26 at Los Angeles County
R. V. TRUBUHOVICH Critical Care and Resuscitation 2003; 5: 227-230
229

14. Historical background to automatic ventilation. In:
Automatic Ventilation of the Lungs. Mushin WW,
Rendell-Baker L, Thompson PW, Mapleson WW,
Hillard EK. 3rd ed. Oxford: Blackwell Scientific
Publications, 1980:p206-211.
15. Crampton Smith A. The Respiration Unit. In: The
Nuffield Department of Anaesthetics Oxford 1937-
1962. Bryce-Smith R, Mitchell JV, Parkhouse J (eds).
Oxford: Oxford University Press, 1963:p52.
16. Christie AB, Esplen JR. Poliomyelitis in Denmark.
Lancet 1953; 1: 492-493.
17. Engström C-G. Treatment of severe cases of respiratory
paralysis by the Engström universal ventilator. Br Med
J 1954;2:666-669.
18. Engström C-G. The clinical application of prolonged
controlled ventilation. Introduction. Acta Anaesthesiol
Scand Suppl 1963:13:7-10.
19. Rattenborg C. A non-return valve, designed to ventilate
polio patients with respiratory paralysis by manual
positive pressure ventilation. Acta Med Scand
1954;147:431-435.
20. Ruben H. A new non-rebreathing valve. Anesthesiology
1955;16:643-645.
21. Trubuhovich RV, Judson JA. In: Intensive Care in New
Zealand. A History of the New Zealand Region of
ANZICS. Auckland, 2001:p.1-2.
22. Bjerre-Christensen K. Electrocardiographic changes
in acute poliomyelitis. In: Lassen HCA (ed).
Management of Life-threatening Poliomyelitis,
Copenhagen 1952-1956. With a survey of autopsy
findings in 115 cases. London & Edinburgh: E&S
Livingstone Ltd, 1956: p.126-140.
23. Guedel AE, Treweek DN. Ether apnoeas. Anesth Analg
1934;13:263-264.
24. Colice GL. Historical perspective on the development
of mechanical ventilation. In: Tobin MJ (ed). Principles
and Practice of Mechanical Ventilation. New York:
McGraw-Hill Inc 1994: p.27.
25. Bower AG, Bennett VR, Dillon JB, Axelrod B.
Investigation on the care and treatment of poliomyelitis
patients. Ann West Med Surg 1950;4:561-582.
26 Bower AG, Bennett VR, Dillon JB, Axelrod B. Part II:
Physiological studies of various treatment procedures
and mechanical equipment. Ann West Med Surg
1950;4:686-716.
Regarding Reference 5a.
The writer regrets that at the time this essay went to printing he was
unaware of the admirable description of the Danish epidemic and the
consequences arising from it, contained within the paper now given
above as reference 5a. There are multiple sites in the essay where this
paper should have been cited. However, Poul Astrup - despite being
an active participant at Prof. Ibsen's demonstration with the test
patient5 – in collaboration with John Severinghaus, had earlier seemed
to imply,9 but now in this paper actually stated,5a that the date of Prof.
Ibsen’s initial demonstration was August 26. They wrote that date
notwithstanding previous papers by HCA Lassen himself2,10 (and later,
the 1994 paper from Ger Wackers5), giving the August 1952 date for
the Ibsen demonstration as the 27th. Which date is the one repeated
here in this Critical Care and Resuscitation essay.
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