Acta Anaesthesiol Scand 2014; 58: 503–507 Printed in Singapore. All rights reserved
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12311
Special Article
Manual positive pressure ventilation and the Copenhagen poliomyelitis epidemic 1952 An attempt at setting the record straight P. G. Berthelsen Private practice, Charlottenlund, Denmark
Accepted for publication 5 February 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
T
he story of the Copenhagen poliomyelitis epidemic in 1952–1953 has been told many times in books and journal articles.1–5 A short recapitulation is necessary, however, before I attempt to assess the
merits and demerits of the physicians involved in the treatment of polio patients during the severe Copenhagen epidemic. During the first 4 weeks of the epidemic, 27 of 31 patients with bulbar-spinal paralysis had died. With his back against the wall, the head of the Department of Communicable Diseases, professor Henry Cai Alexander Lassen, on the suggestion and urge of his senior registrar, Mogens Bjørneboe, reluctantly summoned a freelance anasthetist – Bjørn Ibsen. Ibsen had no experience with polio patients, but he recognized the clinical picture as one dominated by respiratory insufficiency with carbon dioxide retention – despite the use of negative pressure respirators. His advice was to tracheotomize the patients and use intermittent positive pressure ventilation (IPPV) afterwards. He demonstrated the feasibility of his method on a 12-yr-old girl in extremis on 27 August. Subsequently, he also demonstrated in the little girl, with carbon dioxide measurement (Brinkman’s carbovisor) and the Millikan oximeter that negative pressure respirators were of limited value in patients with bulbar-spinal respiratory insufficiency and that IPPV was what was needed.
Order of Merit Entertainment and manual positive pressure ventilation went hand in hand at the Blegdam Hospital.
At the top of the conventional list of physicians, involved in the saving of hundreds of lives during the devastating 1952–1953 poliomyelitis epidemic in
503 bs_bs_banner
P. G. Berthelsen
Denmark, one usually finds Henry Cai Alexander Lassen (professor, head of the Department of Communicable Diseases, the Blegdam Hospital, Denmark) and Bjørn Ibsen (freelance anesthetist). After having reviewed the medical literature, the personal, unpublished account from 1997 by Poul Astrup (chief of the laboratory, the Blegdam Hospital) and interviewed Ibsen in 2002, I present evidence for a new and more fair Order of Merit.
spasms. When the neuromuscular block occasionally became too pronounced (!), IPPV was used. The patient eventually died but Ibsen’s skills and methods had left a lasting impression. So when Bjørneboe came to realize the similarity between the curarized patient and polio victims, it was natural for him to think of Ibsen.
Mogens Bjørneboe (1910–2006)
Bjørn Ibsen is second on my list of merit. When consulted by Lassen, he almost instantly recognized, from his work in thoracic anesthesia, the clinical picture of inadequate carbon dioxide elimination. Furthermore, he also had a solution to the problem – positive pressure ventilation by hand with a simple to-and-fro system with a Waters’ canister for carbon dioxide absorption.5 And lastly, he was theoretically well prepared when he first met with Lassen at the Blegdam Hospital. For reasons I cannot imagine (unfortunately I never thought of asking him), Ibsen had requested reprints of two articles published by Bower in 1950 in a little known journal – the Annals of Western Medicine and Surgery – titled ‘Investigation on the Care and Treatment of Poliomyelitis Patients (I–II)’.6,7 Why he went to the trouble of writing to Bowers in Los Angeles (LA), without ever having been involved in treating patients with polio, is as I said beyond me, but it meant that he was well armed when he confronted Lassen, Bjørneboe, Astrup and Neukirch at the Blegdam Hospital in late August 1952. In the papers, Bower, Bennett, Dillon and Axelrod describe their experience with treatment of bulbar poliomyelitis using negative pressure tank respirators, positive pressure ventilation and the combination of the two modalities. They measured tidal volumes, vital capacities and blood gasses in 73 patients during the 1949 epidemic in LA. The patients were very ill with an average vital capacity of only 175 ml (0–900 ml) when not in the tanks. The LA experience demonstrated unequivocally that negative pressure ventilation was insufficient and resulted in carbon dioxide retention and acidosis. Only positive pressure or combined positive/ negative ventilation could secure sufficient tidal volumes. After the introduction of IPPV in LA, mortality fell from 79% in 1946 to 17% in 1949. Lassen and his colleagues were not aware of the papers. In the beginning, they viewed the findings of Bower with skepticism. They felt certain that the American patients were less sick and probably would not have been candidates for respirator treatment in
At the top of my list, I have Mogens Bjørneboe, MD – senior registrar in the Department of Communicable Diseases, the Blegdam Hospital in Copenhagen. To understand why I have ranked him as number one, it is necessary to recollect the hierarchical way the Department of Communicable Diseases (and most other medical and surgical departments as well) was run in the 1950s. The all-powerful chief of the department was professor H. C. A. Lassen. He was intelligent [‘actually damned intelligent’ (Ibsen 2002)] but also arrogant and self-reliant. His views were usually not challenged by junior doctors. Any disagreement with Lassen could easily wreck the future career of a dissident. Fortunately, it seems that Bjørneboe did not believe in respectful submission and that he was not unduly concerned over the possible consequences of a dissenting view. It was the common credo, in Lassen’s department, that polio victims died when the virus infection of the brain overwhelmed the patient. The clinical picture of cyanosis, hypertension, hyperthermia, respiratory distress and death [despite the use of negative pressure respirators (tank or cuirass)] was caused by the encephalitic state. In that situation, nothing more could be done.4 The reason I put Bjørneboe first on the list of merit is that he had the courage and acumen to challenge the prevailing view on the cause of death in patients with bulbarspinal polio. Furthermore, he had the audacity to suggest that an anesthetist (with no prior knowledge of polio) might be instrumental in saving patients who had hitherto died in great numbers during conventional therapy in a university Department of Communicable Diseases. When Bjørneboe suggested soliciting the help of Ibsen, it was not because they knew each other well. It was because he had once before seen Ibsen handle a patient with respiratory problems. In the summer of 1952 (while Lassen was away on summer holiday), Ibsen assisted Bjørneboe in treating a neonate with tetanus. Curare was used to alleviate
504
Bjørn Ibsen (1915–2007)
IPPV in bulbar poliomyelitis
Denmark. Fortunately, opinions changed after Ibsen’s one patient demonstration. At the time, expert opinion (Lassen’s) was enough so nobody requested a randomized controlled trial or further experiments. Positive pressure ventilation became the preferred method of handling respiratory problems in polio patients also in Copenhagen. And the mortality started to decrease from 87% before IPPV to 50% in the next 50 patients (27 August–7 September) and eventually to 26% at the end of 1952. Ibsen acted when called upon, but to top the Order of Merit, he should have volunteered his services. Copenhagen was not a big city and word got around. He must have known, also from the press, that the epidemic was unusually severe with many deaths. He had read the Bower papers, and therefore he knew the solution was IPPV and not ventilation with negative pressure devices such as tank or cuirass respirators. To oust Bjørneboe from the top of the Order of Merit list, Ibsen should have acted as boldly as Bjørneboe did when he confronted Lassen. It must however be realized that Ibsen was not the only one to commit this sin of omission. None of the world-renown and accomplished anesthetists, who were teaching at the World Health Organization (WHO) Anaesthesiology Centre Copenhagen, came forward with useful suggestions.
Henry Cai Alexander Lassen (1900–1974) H. C. A. Lassen is third and last in the Order of Merit. His all-important contribution was the way he organized the treatment of the many hundreds of patients with respiratory insufficiency. It was at his instigation that 1500 volunteers – doctors, trainees from the WHO Anaesthesiology Centre Copenhagen, and medical and dental students from the University of Copenhagen – were recruited to handventilate 333 polio victims with respiratory insufficiency, according to Ibsen’s scheme, for a total of 165,000 h.4 It is furthermore meritorious that Lassen (albeit without coauthors), already in 1952–1953, published extensively in English, French and Danish in many medical journals on the methods and results of the way polio patients were being managed at the Blegdam Hospital.1,8–12 This impacted the way polio patients were treated around the world, possibly saving thousands of lives. It is detracting, however, that Lassen found it quite difficult to acknowledge the essential contributions by Bjørneboe and Ibsen. In Lassen’s first paper on how to treat respiratory
insufficiency in October 1952 he writes ‘the situation has forced us to seek new ways – especially collaboration with anaesthetists’. In the more important Lancet publication 3 January 1953, Lassen states ‘At this point we consulted our anaesthetist colleague, Dr. B. Ibsen, and on Aug. 27 the first patient was treated with the method which soon became our method of choice . . .’ This seems quite fair, but the true story is that Ibsen’s name was not mentioned in the primary version of the manuscript, and it was only after the editor of the Lancet insisted that Ibsen’s contribution was acknowledged (Astrup 1997). In his book – Management of Life-threatening Poliomyelitis1 – Lassen wrote in the introductory remarks ‘When in 1952 we were faced with the catastrophe we certainly were inadequately prepared to cope with the situation, and although we thought we knew something about the management of bulbar and respiratory poliomyelitis, it soon became clear that only very little of what we did know at the beginning of the epidemic was really worth knowing’. Lassen could have spared himself this uncharacteristic genuflection if he had not neglected the following pieces of evidence that were right in front of him. In the Danish weekly medical journal (Ugeskrift for Læger), Ellen M. Nielsen in 1946 published a paper on respirator (tank or cuirass) treatment of poliomyelitis patients.13 The results in bulbar-spinal polio patients were disheartening with a mortality rate close to 100%. Dr Nielsen did not suggest using IPPV, but she examined the respiratory function of the patients with the Douglas bag method. Low tidal volumes and extremely low respiratory quotients (RQs) were found. She concluded that the patients had respiratory insufficiency with carbon dioxide accumulation and acidosis, and that the acid-base disturbance might contribute to the death of the patients. The investigation was carried out in Lassen’s Department of Communicable Diseases at the Blegdam Hospital and published in a journal where Lassen was on the editorial board. Considering the hierarchical organization of the department, it is inconceivable that Lassen had not sanctioned the submission of the paper for publication. So he must have been familiar with the results. Furthermore, Lassen was well versed in respiratory physiology. In 1937, he had coauthored two papers published in the Journal of Clinical Investigation on respiratory physiology.14,15 Among other respiratory variables, RQ was determined. So the significance of Dr Nielsen’s findings 10 years later should, in my
505
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opinion, not have eluded Lassen. (Lassen’s coauthors were, by the way, Andre Cournand and Dickinson Woodruff Richards, Jr. Together with Werner Forssmann, they were awarded the 1956 Nobel Prize in Medicine.) There is at least one more good reason why Lassen should not have been ‘inadequately prepared to cope with the situation’ in 1952. In 1951, leading experts from around the world convened at the Second International Poliomyelitis Conference in Copenhagen.16 The honorary president of the conference was the Danish physicist and Nobel Laureate professor Niels Bohr, and the secretary general was professor H. C. A. Lassen. The conference lasted 5 days. There were no parallel sessions, and Lassen was the only participant from the Blegdam Hospital. In a lecture on the management of respiratory insufficiency, James L. Wilson (University Hospital, Ann Arbor, MI, USA) discussed the use of IPPV in selected cases.17 A more significant event, however, was a lecture given by Carl-Gunnar Engström from Stockholm – ‘The Importance of CO2 Retention by Respiratory Insufficiency Caused by Poliomyelitis’.18 Engström stated that the ‘frequently lethal course in such cases may be due to alterations caused by defective ventilation, primarily carbon dioxide blood retention and changes in pH’. And that the lethal course ‘can usually be regarded as a phenomena secondary to the serious alterations in the chemistry of the blood caused by underventilation’. Engström backed his contentions with case stories where negative pressure ventilators were shown to be insufficient and IPPV had to be resorted to. He, furthermore, demonstrated the first prototype of his positive pressure ventilator [produced by MIVAD, Stockholm, Sweden; Patent no. 1415541953 (1950)]. So the evidence was there, but Lassen failed to see the significance of it; once again, illustrating the timelessness of the Claude Bernard adage, it is what we do know that is a great hindrance to our learning that which we do not know.
the medical literature, his input has – unjustly – been regarded merely as the stepping stone, on which Bjørn Ibsen entered the scene. Without the effort of Bjørneboe, however, it is likely that it would have continued to be business as usual in Lassen’s Department of Communicable Diseases. Bjørneboe’s main clinical interest was in gastroenterology (hepatology). In 1957, he was appointed chief of the Department of Internal Medicine at the Bispebjerg Hospital in Copenhagen. From 1960, he was professor of internal medicine at the University of Copenhagen. He retired in 1980. In 1953, the first department of anesthesia in Denmark was established at Rigshospitalet, University Hospital of Copenhagen. Bjørn Ibsen had all the qualifications needed to become the first chief of the department. A serious competitor was Ole Secher (1918–1993), equally well qualified but also backed by influential professors at Rigshospitalet. Ibsen therefore sought support from Lassen – however in vain. Lassen refused to help because ‘battles are won by generals and not foot soldiers’ (Ibsen 2002). Lassen’s belittling of Ibsen’s contributions turned out to be fortuitous. When Rigshospitalet subsequently turned Ibsen down, he moved on to the Kommune Hospital (also in Copenhagen), where he established and inaugurated the first multidisciplinary intensive care unit in the world on 21 December 1953.19 Almost 150 years ago, Francis Darwin opined: ‘In science, credit goes to the man who convinces the world, not to the man to whom the idea first occurs’. The story of the Copenhagen poliomyelitis epidemic illustrates Darwin’s view perfectly. Lassen convinced the world. As a result, he became an honorary member of prestigious medical societies, he had departments for poliomyelitis patients named after him (Centre Henry Lassen at the Claude Bernard Hospital in Paris, 1955, Toulouse Hospital, 1958) and he was invited, as a world famous expert, to assist in five European polio epidemics between 1955 and 1959.
The aftermath
Post-script
Mogens Bjørneboe had only been employed in the Deptartment of Communicable Diseases from July 1951 when the epidemic broke out in July 1952. Therefore, he had no experience with polio patients when the epidemic escalated in August. With no preconceived views on the pathophysiology of the demise of the bulbar-spinal polio victims, he realized that the prevailing theory could be flawed. In
After having reviewed the merits and demerits of Bjørneboe, Ibsen and Lassen, I have come to realize that indeed they were not the true heroes of the story. The many hundreds of students, nurses and doctors who manually ventilated and cared for the patients displayed true courage of the first degree. When they volunteered, it was known that polio was contagious and that many patients had already suc-
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cumbed to it. The fact that only 1% of infected individuals would develop paralytic polio – and the rest just mild discomfort – was not recognized at the time. Furthermore, it was not known that nearly all of the nurses, students and doctors had been passively immunized during the previous 1934 and 1944 Copenhagen polio epidemics. That the caregivers were in fact not at risk of contracting poliomyelitis – and none did – certainly does not detract from their bravery. Conflict of interest: None
References 1. Lassen HCA ed. Management of life-threatening poliomyelitis. Edinburgh and London: E&S Livingstone, 1956. 2. Warwicker P. Breath of life. The story of the 1952 outbreak of poliomyelitis in Copenhagen. Copenhagen: Gyldendal, 2006. ISBN 87-02-04256-8. 3. Williams G. Paralysed with fear. The story of polio. London, UK: Palgrave Macmillan, 2013. ISBN 978-1-137-29975-8. 4. Wackers GL. Modern anaesthesiological principles for bulbar polio: manual IPPR in the 1952 polio-epidemic in Copenhagen. Acta Anaesthesiol Scand 1994; 38: 420–31. 5. Ibsen B. The anæsthetist’s viewpoint on the treatment of respiratory complications in poliomyelitis during the epidemic in Copenhagen, 1952. Proc Royal Soc Med 1954; 47: 72–4. 6. Bower AG, Bennett VR, Dillon JB, Axelrod B. Investigation on care and treatment of poliomyelitis patients. Ann Western Med Surg 1950; 4: 561–82. 7. Bower AG, Bennett VR, Dillon JB, Axelrod B. Investigation on care and treatment of poliomyelitis patients (Part II). Ann Western Med Surg 1950; 4: 686–716. 8. Lassen HCA. On the treatment of bulbar poliomyelitis – especially the emergent treatment of respiratory insufficiency. Ugeskrift Læger 1952; 114: 1415–7, (in Danish).
9. Lassen HCA. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen. Lancet 1953; 1: 37–41. 10. Lassen HCA. L’Epidemie de poliomyelite de 1952 a Copenhague. 349 cas avec insuffisance respiratore et paralysie de deglutition. Presse Medicale 1953; 61: 1667–70. 11. Lassen HCA. Poliomyelitis in Copenhagen, 1952. Glasgow Med J 1954; 35: 59–63. 12. Lassen HCA. Poliomyelitis in Copenhagen 1952. Dan Med Bull 1954; 1: 7–9. 13. Nielsen EM. On respirator treatment of respiratory paralysis in acute anterior poliomyelitis. Ugeskrift Læger 1946; 108: 1341–8, (in Danish). 14. Lassen HCA, Cournand A, Richards DW. Distribution of respiratory gases in a closed breathing circuit. I: normal subjects. J Clin Invest 1937; 16: 1–7. 15. Cournand A, Lassen HCA, Richards DW. Distribution of respiratory gases in a closed breathing circuit. II: pulmonary fibrosis and emphysema. J Clin Invest 1937; 16: 9–14. 16. The second international poliomyelitis conference Copenhagen 1951. Philadelphia, PA: J. B. Lippincott Co., 1952. 17. Wilson JL. Management of respiratory insufficiency. The second international poliomyelitis conference Copenhagen 1951. Philadelphia, PA: J. B. Lippincott Co, 1952: 215–20. 18. Engström C-G, Svanborg NA. The importance of CO2 retention by respiratory insufficiency caused by poliomyelitis. The second international poliomyelitis conference Copenhagen 1951. Philadelphia, PA: J. B. Lippincott Co, 1952: 431–6. 19. Berthelsen PG, Cronqvist M. The first intensive care unit in the world: Copenhagen 1953. Acta Anaesthesiol Scand 2003; 47: 1190–5.
Address: P.G. Berthelsen Private practice L.E. Bruuns Vej 40 Charlottenlund 2920 Denmark e-mail: [email protected]
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© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12311
Special Article
Manual positive pressure ventilation and the Copenhagen poliomyelitis epidemic 1952 An attempt at setting the record straight P. G. Berthelsen Private practice, Charlottenlund, Denmark
Accepted for publication 5 February 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
T
he story of the Copenhagen poliomyelitis epidemic in 1952–1953 has been told many times in books and journal articles.1–5 A short recapitulation is necessary, however, before I attempt to assess the
merits and demerits of the physicians involved in the treatment of polio patients during the severe Copenhagen epidemic. During the first 4 weeks of the epidemic, 27 of 31 patients with bulbar-spinal paralysis had died. With his back against the wall, the head of the Department of Communicable Diseases, professor Henry Cai Alexander Lassen, on the suggestion and urge of his senior registrar, Mogens Bjørneboe, reluctantly summoned a freelance anasthetist – Bjørn Ibsen. Ibsen had no experience with polio patients, but he recognized the clinical picture as one dominated by respiratory insufficiency with carbon dioxide retention – despite the use of negative pressure respirators. His advice was to tracheotomize the patients and use intermittent positive pressure ventilation (IPPV) afterwards. He demonstrated the feasibility of his method on a 12-yr-old girl in extremis on 27 August. Subsequently, he also demonstrated in the little girl, with carbon dioxide measurement (Brinkman’s carbovisor) and the Millikan oximeter that negative pressure respirators were of limited value in patients with bulbar-spinal respiratory insufficiency and that IPPV was what was needed.
Order of Merit Entertainment and manual positive pressure ventilation went hand in hand at the Blegdam Hospital.
At the top of the conventional list of physicians, involved in the saving of hundreds of lives during the devastating 1952–1953 poliomyelitis epidemic in
503 bs_bs_banner
P. G. Berthelsen
Denmark, one usually finds Henry Cai Alexander Lassen (professor, head of the Department of Communicable Diseases, the Blegdam Hospital, Denmark) and Bjørn Ibsen (freelance anesthetist). After having reviewed the medical literature, the personal, unpublished account from 1997 by Poul Astrup (chief of the laboratory, the Blegdam Hospital) and interviewed Ibsen in 2002, I present evidence for a new and more fair Order of Merit.
spasms. When the neuromuscular block occasionally became too pronounced (!), IPPV was used. The patient eventually died but Ibsen’s skills and methods had left a lasting impression. So when Bjørneboe came to realize the similarity between the curarized patient and polio victims, it was natural for him to think of Ibsen.
Mogens Bjørneboe (1910–2006)
Bjørn Ibsen is second on my list of merit. When consulted by Lassen, he almost instantly recognized, from his work in thoracic anesthesia, the clinical picture of inadequate carbon dioxide elimination. Furthermore, he also had a solution to the problem – positive pressure ventilation by hand with a simple to-and-fro system with a Waters’ canister for carbon dioxide absorption.5 And lastly, he was theoretically well prepared when he first met with Lassen at the Blegdam Hospital. For reasons I cannot imagine (unfortunately I never thought of asking him), Ibsen had requested reprints of two articles published by Bower in 1950 in a little known journal – the Annals of Western Medicine and Surgery – titled ‘Investigation on the Care and Treatment of Poliomyelitis Patients (I–II)’.6,7 Why he went to the trouble of writing to Bowers in Los Angeles (LA), without ever having been involved in treating patients with polio, is as I said beyond me, but it meant that he was well armed when he confronted Lassen, Bjørneboe, Astrup and Neukirch at the Blegdam Hospital in late August 1952. In the papers, Bower, Bennett, Dillon and Axelrod describe their experience with treatment of bulbar poliomyelitis using negative pressure tank respirators, positive pressure ventilation and the combination of the two modalities. They measured tidal volumes, vital capacities and blood gasses in 73 patients during the 1949 epidemic in LA. The patients were very ill with an average vital capacity of only 175 ml (0–900 ml) when not in the tanks. The LA experience demonstrated unequivocally that negative pressure ventilation was insufficient and resulted in carbon dioxide retention and acidosis. Only positive pressure or combined positive/ negative ventilation could secure sufficient tidal volumes. After the introduction of IPPV in LA, mortality fell from 79% in 1946 to 17% in 1949. Lassen and his colleagues were not aware of the papers. In the beginning, they viewed the findings of Bower with skepticism. They felt certain that the American patients were less sick and probably would not have been candidates for respirator treatment in
At the top of my list, I have Mogens Bjørneboe, MD – senior registrar in the Department of Communicable Diseases, the Blegdam Hospital in Copenhagen. To understand why I have ranked him as number one, it is necessary to recollect the hierarchical way the Department of Communicable Diseases (and most other medical and surgical departments as well) was run in the 1950s. The all-powerful chief of the department was professor H. C. A. Lassen. He was intelligent [‘actually damned intelligent’ (Ibsen 2002)] but also arrogant and self-reliant. His views were usually not challenged by junior doctors. Any disagreement with Lassen could easily wreck the future career of a dissident. Fortunately, it seems that Bjørneboe did not believe in respectful submission and that he was not unduly concerned over the possible consequences of a dissenting view. It was the common credo, in Lassen’s department, that polio victims died when the virus infection of the brain overwhelmed the patient. The clinical picture of cyanosis, hypertension, hyperthermia, respiratory distress and death [despite the use of negative pressure respirators (tank or cuirass)] was caused by the encephalitic state. In that situation, nothing more could be done.4 The reason I put Bjørneboe first on the list of merit is that he had the courage and acumen to challenge the prevailing view on the cause of death in patients with bulbarspinal polio. Furthermore, he had the audacity to suggest that an anesthetist (with no prior knowledge of polio) might be instrumental in saving patients who had hitherto died in great numbers during conventional therapy in a university Department of Communicable Diseases. When Bjørneboe suggested soliciting the help of Ibsen, it was not because they knew each other well. It was because he had once before seen Ibsen handle a patient with respiratory problems. In the summer of 1952 (while Lassen was away on summer holiday), Ibsen assisted Bjørneboe in treating a neonate with tetanus. Curare was used to alleviate
504
Bjørn Ibsen (1915–2007)
IPPV in bulbar poliomyelitis
Denmark. Fortunately, opinions changed after Ibsen’s one patient demonstration. At the time, expert opinion (Lassen’s) was enough so nobody requested a randomized controlled trial or further experiments. Positive pressure ventilation became the preferred method of handling respiratory problems in polio patients also in Copenhagen. And the mortality started to decrease from 87% before IPPV to 50% in the next 50 patients (27 August–7 September) and eventually to 26% at the end of 1952. Ibsen acted when called upon, but to top the Order of Merit, he should have volunteered his services. Copenhagen was not a big city and word got around. He must have known, also from the press, that the epidemic was unusually severe with many deaths. He had read the Bower papers, and therefore he knew the solution was IPPV and not ventilation with negative pressure devices such as tank or cuirass respirators. To oust Bjørneboe from the top of the Order of Merit list, Ibsen should have acted as boldly as Bjørneboe did when he confronted Lassen. It must however be realized that Ibsen was not the only one to commit this sin of omission. None of the world-renown and accomplished anesthetists, who were teaching at the World Health Organization (WHO) Anaesthesiology Centre Copenhagen, came forward with useful suggestions.
Henry Cai Alexander Lassen (1900–1974) H. C. A. Lassen is third and last in the Order of Merit. His all-important contribution was the way he organized the treatment of the many hundreds of patients with respiratory insufficiency. It was at his instigation that 1500 volunteers – doctors, trainees from the WHO Anaesthesiology Centre Copenhagen, and medical and dental students from the University of Copenhagen – were recruited to handventilate 333 polio victims with respiratory insufficiency, according to Ibsen’s scheme, for a total of 165,000 h.4 It is furthermore meritorious that Lassen (albeit without coauthors), already in 1952–1953, published extensively in English, French and Danish in many medical journals on the methods and results of the way polio patients were being managed at the Blegdam Hospital.1,8–12 This impacted the way polio patients were treated around the world, possibly saving thousands of lives. It is detracting, however, that Lassen found it quite difficult to acknowledge the essential contributions by Bjørneboe and Ibsen. In Lassen’s first paper on how to treat respiratory
insufficiency in October 1952 he writes ‘the situation has forced us to seek new ways – especially collaboration with anaesthetists’. In the more important Lancet publication 3 January 1953, Lassen states ‘At this point we consulted our anaesthetist colleague, Dr. B. Ibsen, and on Aug. 27 the first patient was treated with the method which soon became our method of choice . . .’ This seems quite fair, but the true story is that Ibsen’s name was not mentioned in the primary version of the manuscript, and it was only after the editor of the Lancet insisted that Ibsen’s contribution was acknowledged (Astrup 1997). In his book – Management of Life-threatening Poliomyelitis1 – Lassen wrote in the introductory remarks ‘When in 1952 we were faced with the catastrophe we certainly were inadequately prepared to cope with the situation, and although we thought we knew something about the management of bulbar and respiratory poliomyelitis, it soon became clear that only very little of what we did know at the beginning of the epidemic was really worth knowing’. Lassen could have spared himself this uncharacteristic genuflection if he had not neglected the following pieces of evidence that were right in front of him. In the Danish weekly medical journal (Ugeskrift for Læger), Ellen M. Nielsen in 1946 published a paper on respirator (tank or cuirass) treatment of poliomyelitis patients.13 The results in bulbar-spinal polio patients were disheartening with a mortality rate close to 100%. Dr Nielsen did not suggest using IPPV, but she examined the respiratory function of the patients with the Douglas bag method. Low tidal volumes and extremely low respiratory quotients (RQs) were found. She concluded that the patients had respiratory insufficiency with carbon dioxide accumulation and acidosis, and that the acid-base disturbance might contribute to the death of the patients. The investigation was carried out in Lassen’s Department of Communicable Diseases at the Blegdam Hospital and published in a journal where Lassen was on the editorial board. Considering the hierarchical organization of the department, it is inconceivable that Lassen had not sanctioned the submission of the paper for publication. So he must have been familiar with the results. Furthermore, Lassen was well versed in respiratory physiology. In 1937, he had coauthored two papers published in the Journal of Clinical Investigation on respiratory physiology.14,15 Among other respiratory variables, RQ was determined. So the significance of Dr Nielsen’s findings 10 years later should, in my
505
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opinion, not have eluded Lassen. (Lassen’s coauthors were, by the way, Andre Cournand and Dickinson Woodruff Richards, Jr. Together with Werner Forssmann, they were awarded the 1956 Nobel Prize in Medicine.) There is at least one more good reason why Lassen should not have been ‘inadequately prepared to cope with the situation’ in 1952. In 1951, leading experts from around the world convened at the Second International Poliomyelitis Conference in Copenhagen.16 The honorary president of the conference was the Danish physicist and Nobel Laureate professor Niels Bohr, and the secretary general was professor H. C. A. Lassen. The conference lasted 5 days. There were no parallel sessions, and Lassen was the only participant from the Blegdam Hospital. In a lecture on the management of respiratory insufficiency, James L. Wilson (University Hospital, Ann Arbor, MI, USA) discussed the use of IPPV in selected cases.17 A more significant event, however, was a lecture given by Carl-Gunnar Engström from Stockholm – ‘The Importance of CO2 Retention by Respiratory Insufficiency Caused by Poliomyelitis’.18 Engström stated that the ‘frequently lethal course in such cases may be due to alterations caused by defective ventilation, primarily carbon dioxide blood retention and changes in pH’. And that the lethal course ‘can usually be regarded as a phenomena secondary to the serious alterations in the chemistry of the blood caused by underventilation’. Engström backed his contentions with case stories where negative pressure ventilators were shown to be insufficient and IPPV had to be resorted to. He, furthermore, demonstrated the first prototype of his positive pressure ventilator [produced by MIVAD, Stockholm, Sweden; Patent no. 1415541953 (1950)]. So the evidence was there, but Lassen failed to see the significance of it; once again, illustrating the timelessness of the Claude Bernard adage, it is what we do know that is a great hindrance to our learning that which we do not know.
the medical literature, his input has – unjustly – been regarded merely as the stepping stone, on which Bjørn Ibsen entered the scene. Without the effort of Bjørneboe, however, it is likely that it would have continued to be business as usual in Lassen’s Department of Communicable Diseases. Bjørneboe’s main clinical interest was in gastroenterology (hepatology). In 1957, he was appointed chief of the Department of Internal Medicine at the Bispebjerg Hospital in Copenhagen. From 1960, he was professor of internal medicine at the University of Copenhagen. He retired in 1980. In 1953, the first department of anesthesia in Denmark was established at Rigshospitalet, University Hospital of Copenhagen. Bjørn Ibsen had all the qualifications needed to become the first chief of the department. A serious competitor was Ole Secher (1918–1993), equally well qualified but also backed by influential professors at Rigshospitalet. Ibsen therefore sought support from Lassen – however in vain. Lassen refused to help because ‘battles are won by generals and not foot soldiers’ (Ibsen 2002). Lassen’s belittling of Ibsen’s contributions turned out to be fortuitous. When Rigshospitalet subsequently turned Ibsen down, he moved on to the Kommune Hospital (also in Copenhagen), where he established and inaugurated the first multidisciplinary intensive care unit in the world on 21 December 1953.19 Almost 150 years ago, Francis Darwin opined: ‘In science, credit goes to the man who convinces the world, not to the man to whom the idea first occurs’. The story of the Copenhagen poliomyelitis epidemic illustrates Darwin’s view perfectly. Lassen convinced the world. As a result, he became an honorary member of prestigious medical societies, he had departments for poliomyelitis patients named after him (Centre Henry Lassen at the Claude Bernard Hospital in Paris, 1955, Toulouse Hospital, 1958) and he was invited, as a world famous expert, to assist in five European polio epidemics between 1955 and 1959.
The aftermath
Post-script
Mogens Bjørneboe had only been employed in the Deptartment of Communicable Diseases from July 1951 when the epidemic broke out in July 1952. Therefore, he had no experience with polio patients when the epidemic escalated in August. With no preconceived views on the pathophysiology of the demise of the bulbar-spinal polio victims, he realized that the prevailing theory could be flawed. In
After having reviewed the merits and demerits of Bjørneboe, Ibsen and Lassen, I have come to realize that indeed they were not the true heroes of the story. The many hundreds of students, nurses and doctors who manually ventilated and cared for the patients displayed true courage of the first degree. When they volunteered, it was known that polio was contagious and that many patients had already suc-
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IPPV in bulbar poliomyelitis
cumbed to it. The fact that only 1% of infected individuals would develop paralytic polio – and the rest just mild discomfort – was not recognized at the time. Furthermore, it was not known that nearly all of the nurses, students and doctors had been passively immunized during the previous 1934 and 1944 Copenhagen polio epidemics. That the caregivers were in fact not at risk of contracting poliomyelitis – and none did – certainly does not detract from their bravery. Conflict of interest: None
References 1. Lassen HCA ed. Management of life-threatening poliomyelitis. Edinburgh and London: E&S Livingstone, 1956. 2. Warwicker P. Breath of life. The story of the 1952 outbreak of poliomyelitis in Copenhagen. Copenhagen: Gyldendal, 2006. ISBN 87-02-04256-8. 3. Williams G. Paralysed with fear. The story of polio. London, UK: Palgrave Macmillan, 2013. ISBN 978-1-137-29975-8. 4. Wackers GL. Modern anaesthesiological principles for bulbar polio: manual IPPR in the 1952 polio-epidemic in Copenhagen. Acta Anaesthesiol Scand 1994; 38: 420–31. 5. Ibsen B. The anæsthetist’s viewpoint on the treatment of respiratory complications in poliomyelitis during the epidemic in Copenhagen, 1952. Proc Royal Soc Med 1954; 47: 72–4. 6. Bower AG, Bennett VR, Dillon JB, Axelrod B. Investigation on care and treatment of poliomyelitis patients. Ann Western Med Surg 1950; 4: 561–82. 7. Bower AG, Bennett VR, Dillon JB, Axelrod B. Investigation on care and treatment of poliomyelitis patients (Part II). Ann Western Med Surg 1950; 4: 686–716. 8. Lassen HCA. On the treatment of bulbar poliomyelitis – especially the emergent treatment of respiratory insufficiency. Ugeskrift Læger 1952; 114: 1415–7, (in Danish).
9. Lassen HCA. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen. Lancet 1953; 1: 37–41. 10. Lassen HCA. L’Epidemie de poliomyelite de 1952 a Copenhague. 349 cas avec insuffisance respiratore et paralysie de deglutition. Presse Medicale 1953; 61: 1667–70. 11. Lassen HCA. Poliomyelitis in Copenhagen, 1952. Glasgow Med J 1954; 35: 59–63. 12. Lassen HCA. Poliomyelitis in Copenhagen 1952. Dan Med Bull 1954; 1: 7–9. 13. Nielsen EM. On respirator treatment of respiratory paralysis in acute anterior poliomyelitis. Ugeskrift Læger 1946; 108: 1341–8, (in Danish). 14. Lassen HCA, Cournand A, Richards DW. Distribution of respiratory gases in a closed breathing circuit. I: normal subjects. J Clin Invest 1937; 16: 1–7. 15. Cournand A, Lassen HCA, Richards DW. Distribution of respiratory gases in a closed breathing circuit. II: pulmonary fibrosis and emphysema. J Clin Invest 1937; 16: 9–14. 16. The second international poliomyelitis conference Copenhagen 1951. Philadelphia, PA: J. B. Lippincott Co., 1952. 17. Wilson JL. Management of respiratory insufficiency. The second international poliomyelitis conference Copenhagen 1951. Philadelphia, PA: J. B. Lippincott Co, 1952: 215–20. 18. Engström C-G, Svanborg NA. The importance of CO2 retention by respiratory insufficiency caused by poliomyelitis. The second international poliomyelitis conference Copenhagen 1951. Philadelphia, PA: J. B. Lippincott Co, 1952: 431–6. 19. Berthelsen PG, Cronqvist M. The first intensive care unit in the world: Copenhagen 1953. Acta Anaesthesiol Scand 2003; 47: 1190–5.
Address: P.G. Berthelsen Private practice L.E. Bruuns Vej 40 Charlottenlund 2920 Denmark e-mail: [email protected]
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