The Rise and Fall of Modern Medicine

by James Le Fanu

  The history of psychiatry in the post-war years exemplifies, in a very dramatic form, how the growth of the possibilities of treating illness could occur in the absence of any substantial understanding of the nature of the problem being treated, or indeed why the treatment worked.* Human intelligence – such as Henri Laborit’s acute perception of the euphoric quietude induced by promethazine – played a role. So of course does ‘science’, in particular neurochemistry and pharmacology. Nonetheless we are dealing with the triumph of empiricism, where everything else is a mystery. Why should a compound that blocks histamine in the tissues of the body also interfere with an entirely different chemical – dopamine – in the brain in a way that alleviates symptoms of schizophrenia? What is schizophrenia? What is its cause? The map of mental illness, like that of Africa before the arrival of the Victorian explorers, remains a blank.

  *An account of the many other important therapeutic innovations in the treatment of psychiatric illness can be found in Appendix II.

  5

  1952: THE COPENHAGEN POLIO

  EPIDEMIC AND THE BIRTH OF

  INTENSIVE CARE

  There are many reasons why people may end up on an intensivecare unit, most frequently following major operations, but also after head injury, septicaemia or respiratory failure from paralysis of the chest muscles. At any one time a patient can be hitched up to a dozen or more pieces of equipment: heart monitor, machines to measure the concentration of gases in the blood and the blood pressure, a pacemaker, a dialysis machine. It all looks, and is, so impressive that it can be difficult to appreciate that central to all this technological wizardry is just one piece of equipment, the ventilator blowing oxygen into the lungs. Oxygen alone ensures the heart carries on beating, ‘buying time’ for tissues to heal and the complications of impaired body function to be attended to. The indispensable role of oxygen in human physiology has been known for the best part of 200 years, but the appreciation of its central role in the survival of the critically ill starts abruptly with the Copenhagen polio epidemic of 1952.

  Anyone wandering on to Ward 19 of Copenhagen’s Blegdams Hospital in the autumn of 1952 would have been confronted by an extraordinary sight. In each of the seventy beds arranged in two straight lines lay a child paralysed with polio with a hollow plastic tube inserted into the trachea through a cut in the neck – a tracheostomy – to which was attached another long piece of tubing, at the end of which was a rubber bag. Next to each bed sat a young medical student who, every few seconds, would squeeze the bag, blowing oxygen through the tubing into the child’s lungs and then letting go, repeating this action for six hours at a stretch. Four times a day the shift changed and another group of students would arrive on the ward to take over, a routine that continued day in, day out for more than six months. Many quit after a few weeks, suffering from emotional and physical exhaustion, yet according to Ann Isberg, one of the children, ‘it was not a sad time’, rather ‘like [during the] war there was a spirit of resistance – everybody was doing their best’. By the time the polio epidemic was over, 1,500 medical students had ‘done their best’, squeezing the bag for more than 165,000 hours, as a result of which the mortality rate among the polio victims had fallen from over 90 per cent to 25 per cent. There is really nothing remarkable about this type of treatment – other than its scale. The technique of ventilation by ‘bagging’ through a tube had been common practice in operating theatres for many years. Nonetheless, it required a major shift in thinking, precipitated by the catastrophic polio epidemic in Copenhagen in 1952, for ‘assisted ventilation’ to become the central feature of the care of the seriously ill.1

  The polio virus is ingested in contaminated food or water and absorbed through the gut wall, from where it spreads to paralyse the nerves in the spinal cord that control muscular movement. Most cases arose in the summer, hence its description as ‘the summer plague’. Periodically it flared up to cause a major epidemic whose fearful impact is not difficult to imagine. One day a child was happy and healthy, the next day he was in bed with a temperature and the day after he would wake up unable to move a limb. With luck the paralysis progressed no further and the child was left with a weak, flaccid and useless limb, but when the virus travelled up the spinal cord to involve the nerves controlling the muscles of respiration, the consequences were dreadful.

  With the onset of respiratory difficulty, it seems almost as if the children are suddenly awakened to the struggle before them. Little children seem to age in a few hours. One sees the heedless, careless, sleepy child become all at once wide-awake, highly strung . . . The whole mind and body appeared to be concentrated on respiration. Respiration becomes an active voluntary process, every breath represents hard work. The child gives the impression that he has a fight on his hands. Instinctively he husbands his strength, refuses food and speaks, when speech is necessary, quietly with few words . . . He is nervous, fearful, and dreads being left alone, the mouth becomes sealed with frothy saliva which the child is unable to swallow, so collects between his lips and waits for the nurse to wipe it away. He likes to have his lips wet with cold water, but rarely attempts to take a drink in his mouth for he knows he cannot swallow it. There is a little bluish tingeing of the lips and tongue but much more distinctive is the pallor, which is sometimes striking. Sweating is profuse, then his respiration gets weak, the mind becomes dull, and with the occasional return of a lucid interval, he gradually drifts into unconsciousness. An hour or more later respiration ceases.2

  In 1931 the Harvard physician Philip Drinker came up with a solution of sorts – the ‘iron lung’ that permitted some polio victims to be kept alive long enough for their nerves to recover and the power of the respiratory muscles to be restored. Within the iron lung a series of valves created a negative pressure that pulled the chest wall outwards, forcing air into the lungs. The pressure in the iron lung then promptly returned to normal and the natural elasticity of the lungs forced air out again.3 There was, however, one group of polio patients for whom not even the iron lung could offer the hope of salvation. In these the virus travelled even further up the spinal cord to involve not just the muscles of respiration but also the muscles at the back of the throat involving swallowing. Their lungs had no protection against the secretions from the mouth; they literally drowned in their own saliva.

  In September 1951 the University of Copenhagen hosted the Second International Poliomyelitis Conference. The atmosphere was one of well-justified optimism, as it was attended by both men involved in the development of the soon-to-be-released polio vaccine, Jonas Salk and Albert Sabin. Nonetheless the presence of so many doctors and scientists involved in the treatment of polio meant that almost inevitably some would have been ‘silent’ carriers of the polio virus, so they were almost certainly the source of the catastrophic epidemic that engulfed Copenhagen the following year.4

  When the epidemic began, Blegdams Hospital was poorly prepared, possessing only one iron-lung-type ventilator and six smaller ones that fitted over the chest. Over the previous decade about ten patients a year had been admitted with polio sufficiently severe to require ventilatory treatment (seventy-six in all), but of these only fifteen had survived – a mortality rate of 80 per cent. But this time the hospital was literally overwhelmed. By the middle of August it was admitting new polio cases at the rate of fifty a day. ‘We were soon faced with the intolerable dilemma of having to choose which patients to treat with the few respirators at hand and whom not to treat,’ recalled Dr H. C. A. Lassen, the hospital’s chief physician. Clearly the acquisition of more respirators was not the solution, as even those lucky enough to be treated on the few that were available still died. As Lassen observed, ‘We were forced to seek new ways of ventilating our patients, the need for improvisation became imperative.’ Dr Mogens Bjorneboe, another physician at the hospital, suggested they seek the advice of an anaesthetist, Dr Bjorn Ibsen, but Lassen was sceptical, reflecting a prejudice very prevalent at the time that anaesthetists were not r
eally ‘proper doctors’ but technicians whose competence did not stretch beyond the operating theatre.5

  There were, however, no other suggestions forthcoming, so Ibsen was duly summoned. He was indeed a competent technician but also a profoundly thoughtful man, as the revolutionary solution he proposed required him first to challenge the fundamental tenets of contemporary medical understanding of the precise cause of death in polio.

  The final stage of the illness was signalled by a rise in blood pressure, fever and clammy skin, following which death came quite suddenly. This sequence of events had always been attributed to the disease process itself, in which it was believed that the virus had attacked the brain centres involving control of temperature and circulation. Ibsen, after observing patients on the ward, talking to the doctors and visiting the autopsy room, realised this explanation was incorrect. He was struck by the fact that even the children treated with the iron lung ventilator still had such a high mortality rate. These children, he suggested, were dying not from the polio virus’s effect on the brain but from inadequate ventilation, and their terminal symptoms – the rise in blood pressure, fever and clammy skin – were caused by insufficient oxygenation of the brain. His solution was extreme. The iron lung respirators should be dispensed with, and to ensure adequate ventilation all the polio patients should have a tracheostomy, after which they should be ventilated by hand, the only certain way of getting sufficient oxygen into their lungs. This requires some clarification. The iron lung simulated the normal action of the lungs by creating a negative pressure, which expanded the lungs and in doing so drew air down into them. Ibsen’s technique, by contrast, involved placing a tube down into the airways through an incision in the trachea, through which it was possible not only to aspirate the secretions that might be blocking the airways but also to blow oxygen into the lungs. The essence of Ibsen’s solution, then, was to replace one relatively ineffective method of ventilation with a much more effective one.

  It was undoubtedly a curious situation, with Ibsen, an anaesthetist who had no personal experience of treating polio, telling Lassen, the chief physician of the hospital to which all polio cases from Copenhagen and eastern Denmark were admitted, that his understanding of the final stages of the disease was mistaken. Lassen was unconvinced, but he gave Ibsen the benefit of the doubt. There followed one of the most dramatic and, in its consequences, profoundly influential moments in the history of medicine. Lassen picked a twelve-year-old girl, Vicki, ‘who was in a very bad condition with paralysis of all four limbs. She was gasping for breath. Her temperature was a hundred and two degrees Fahrenheit. She was cyanotic [blue] and sweating.’ Ibsen asked the ENT surgeon to perform a tracheostomy, through which he introduced a cuffed tube attached to a ventilator bag. Initially he found it very difficult to inflate her lungs, as the airways were in spasm. Within minutes she was dying. Discreetly the hospital physicians who had gathered to observe the new treatment realised they had duties elsewhere and started to drift away. The girl too was, not surprisingly, becoming very agitated, so Ibsen gave her a slug of the barbiturate Pentothal, at which point her own weak respiratory efforts ceased. And as she stopped breathing, her bronchi relaxed, and Ibsen was finally able to ventilate her. ‘When the other physicians returned . . . the girl’s skin colour had returned to normal. Both body temperature and blood pressure were restored to normal too. This twelve-year-old girl was the first patient during the epidemic who survived as a result of this medical intervention.’

  And now Ibsen was able to confound the sceptics. Were his theory correct, then when Vicki was transferred back to the iron lung respirator, the insufficient ventilation it offered should result in an accumulation of carbon dioxide in the blood that would cause her temperature and blood pressure to rise – and that is precisely what happened. Then, as Ibsen intermittently squeezed his ventilator bag, her condition improved again.

  Lassen now energetically applied himself to the implementation of this new therapy, involving the mass recruitment of medical students already described. It is only a matter of elementary mechanics to devise a machine that can do the work of human hands, so by the following year ventilating patients for long periods of time became a practical proposition. The consequences were momentous.6

  As the news of these remarkable events spread, many doctors travelled to Copenhagen to see for themselves. One was a neurologist from Oxford’s Radcliffe Infirmary, Dr Ritchie Russell, whose monograph on polio was the standard text on treatment of the illness.7 Impressed by what he saw, he returned to England to rewrite his textbook and start treating patients with the new method. The first was a sixteen-year-old schoolgirl, Janet Deeley. She did not have polio but rather an acute inflammation of the nerves – known as Guillain-Barré syndrome – of such severity that every muscle in her body was paralysed except for those that controlled her eye movements. There were mutterings from his colleagues that it was unethical to try to keep someone alive whose senses and reason were intact but trapped within an immobile body, but at Dr Russell’s insistence an ENT surgeon performed a tracheostomy and she was linked up to a ventilator. In this way she was kept alive for six weeks until the inflammation in the nerves had subsided and the power began to return to her muscles. She later qualified as a nurse and for a while worked on the unit where she had been treated before marrying a farmer and having four children. Her recovery, as one of the physicians involved in looking after her, Dr A. Crampton-Smith, later observed, was a crucial moment, making it certain ‘that no patient could die of respiratory failure at the Radcliffe Infirmary without being ventilated. If she had died it might have set the whole business back many years, but she got better and that was the end of the argument . . . there could never be any question again of withholding artificial ventilation.’8

  It is necessary here to take a few steps back to properly appreciate the science behind Ibsen’s solution, which in turn requires trying to imagine the situation with which he was confronted. We know now that his solution was correct at two levels – first, the immediate cause of death in children with polio could be prevented by adequate ventilation; second, adequate ventilation, if continued for long enough, would ‘buy time’ for the power of the respiratory muscles to recover. Back in 1952 neither supposition was at all obvious. So here was Ibsen summoned for his advice, walking the wards full of dying children struggling for breath, seeing the curtains drawn around the bed of yet another child who had just succumbed despite having been treated with the ‘iron lung’. How did he grasp instinctively that the fundamental problem was one of inadequate ventilation of the lungs? How did he appreciate that, were this corrected and these children kept alive for long enough, the power of their respiratory muscles would eventually recover? Ibsen did not have a blinding flash of insight, but perceived a directly analogous situation to the circumstances of these dying children: every day in the operating theatre anaesthetists induced the same situation by deliberately paralysing the patients’ respiratory muscles with the drug curare and then maintaining their respiration artificially.

  Curare is a poison that blocks the neuromuscular junction, the site where the electrical impulses from the nerve release a chemical to stimulate movement of the muscle, and had been used for hundreds of years by South American tribes for hunting, being placed on the tip of the arrows that were then fired through a blowpipe. It was first used to facilitate surgery by Howard Griffith and Enid Johnson from Montreal in 1942 seeking to overcome the main impediment to surgical procedures, especially on the abdomen – the tendency of the muscles of the abdominal wall to go into spasm – which, as can be imagined, makes access to the contents of the abdominal cavity much more difficult. Griffith and Johnson found that within one minute of the administration of curare, the abdominal muscles became ‘as soft as dough’, allowing the surgeon to operate ‘without any difficulty’.9

  But the real potential of curare was not appreciated until 1946, when a Liverpool anaesthetist, T. Cecil Gray, reported on its use in ov
er 1,000 cases in which it was not only helpful in relaxing the muscles of the abdomen during an operation but also, when given in a higher dosage than before, such that the respiratory muscles were paralysed, permitted much lower doses of anaesthetic to be given. His argument was as follows: the standard anaesthetic practice at that time, hard as it may be to believe, was to induce anaesthesia with a heavy dose of barbiturate drugs or gas resulting in a state of ‘deep anaesthesia’, but the patient continued to breathe spontaneously, ventilating his lungs with the help of an oxygen mask, as if he were asleep. Cecil Gray perceived that if the muscles were completely paralysed with curare, the state of deep anaesthesia would be unnecessary and it would be possible to get away with a much lower dose of anaesthetic, which was highly desirable for many reasons. The problem was obviously that this would interfere with the patient’s own ability to breathe. His brilliant insight was to appreciate that this could be allowed to happen with the anaesthetist ‘taking over’ and artificially ventilating the patient. Towards the end of the operation the effects of the curare would either be wearing off or could be reversed by another drug and the patient would then start breathing on his own.10

  Within this historical perspective, Ibsen’s suggestion to Lassen that his children with polio should have a tracheostomy and be artificially ventilated is more readily understandable. From his experience in the operating theatre Ibsen knew all about the consequences of inadequate ventilation, and the necessity to ensure adequate amounts of oxygen reached the lungs in patients whose respiratory muscles were paralysed by curare. All that was needed was to bring that experience to bear in the situation of children whose respiratory muscles were paralysed for a different reason, by the polio virus. The essence of his solution then was simply the transfer of knowledge and expertise from one discipline – anaesthetics – to another.