The Physiological Challenges of the 1952 Copenhagen Poliomyelitis Epidemic and a Renaissance in Clinical Respiratory Physiology

Abstract

The 1952 Copenhagen poliomyelitis epidemic provided extraordinary challenges in applied physiology. Over 300 patients developed respiratory paralysis within a few weeks, and the ventilator facilities at the infectious disease hospital were completely overwhelmed. The heroic solution was to call upon 200 medical students to provide round-the-clock manual ventilation using a rubber bag attached to a tracheostomy tube. Some patients were ventilated in this way for several weeks. A second challenge was to understand the gas exchange and acid-base status of these patients. At the onset of the epidemic, the only measurement routinely available in the hospital was the carbon dioxide concentration in the blood, and the high values were initially misinterpreted as a mysterious “alkalosis.” However, pH measurements were quickly instituted, the PCO₂ was shown to be high, and modern clinical respiratory acid-base physiology was born. Taking a broader view, the problems highlighted by the epidemic underscored the gap between recent advances made by physiologists and their application to the clinical environment. However, the 1950s ushered in a renaissance in clinical respiratory physiology. In 1950 the coverage of respiratory physiology in textbooks was often woefully inadequate, but the decade saw major advances in topics such as mechanics and gas exchange. An important development was the translation of the new knowledge from departments of physiology to the clinical setting. In many respects, this period was therefore the beginning of modern clinical respiratory physiology.

Appendices

Appendix

Logistics of the long-term manual ventilation. One of the most remarkable features of the epidemic was the way medical students and others were organized to provide round-the-clock, long-term manual ventilation. Information about this is given in three contemporary articles in the Danish medical journal Ugeskrift for Laeger by Thomsen [31], Bjorneboe [6], and Hansen [17]. Thomsen was one of the medical student “ventilators,” Bjorneboe was on the medical staff of the Blegdam Hospital, and Hansen was mayor of Copenhagen. Later Wackers [34] interviewed a number of the people involved.

The emotional demands on the patient and student were enormous [31]. A young patient would be admitted struggling to breathe, a tracheostomy was performed, and he (or she) would meet the 18–19 year-old students who were to keep him alive by squeezing the bag for an indefinite period. Bonding between the patient and student was strong, especially for young children. Four or five students were allocated to each patient because of the 24 h coverage, but the same students always ventilated the same patient. In the case of young children, the student read to them and played games. If a new student was added to the team for some reason, the patient initially reacted strongly. Communication between the patient and student was difficult because of the tracheostomy tube, but students learned to lip read, and some patients gave information by moving their eyes.

Very early in the epidemic, when it was clear that large numbers of students would be required, the medical student council was involved, and they accepted the responsibility for rostering the students, arranging for them to be excused from otherwise obligatory courses, and negotiating payment for their services. The students worked 6–8 h shifts, which was both emotionally and physically demanding. During an 8 h shift, there was a 10 min “smoke” break each hour, and a half-hour meal break in the middle, but otherwise the student was continually compressing the bag.

There were many technical problems connected with the manual ventilation [6]. The students first had instruction on the general principles from an anesthesiologist and then 3 or 4 h of practical instruction with the equipment. Equipment problems included unexpected emptying of the oxygen tank, kinking of the tube from the tank, and damage to the ventilating bag. The CO₂ absorber had to be changed periodically, and the tracheostomy tube could slip down and occlude a main bronchus. Periodic suctioning of the airways was necessary in some patients.

Observation of the patient was very important, and another student in the team or nurse would monitor the pulse rate and blood pressure from time to time. There was continual surveillance by doctors and nurses walking up and down the wards to give help where needed. Many students found the emotional and physical demands too much and gave up. Also there was a concern about developing polio, although this apparently never happened to any of the students. As the epidemic wore on, the second year students who had done most of the ventilating were partly replaced by first-year students, who, in the European system, would have come straight from high school and might be only 18 year old.

The economic impact of the epidemic was vast. Very quickly, the Blegdam hospital ran out of beds and three other hospitals were recruited. Large numbers of extra doctors, including anesthesiologists, nurses, and hospital staff were required as well as the medical students. The cost of the epidemic up to April 1953 was estimated to be 5–6 million Danish Kroner [17], that is about 30 million US$ at today’s exchange rate.

Postscript

When this manuscript was being prepared, I wrote to several of the student “ventilators” but received no replies. However, after the paper was accepted for publication, I received a most interesting letter from Dr. Uffe Kirk who was 25 years old in 1952 at the time of the epidemic. He had just finished medical school and was asked to play a major role in organizing the medical student ventilators. Here are some extracts from his account.

“The difference between ordinary patients requiring ventilation and polio patients was characteristic: They were conscious! The students invented ways to communicate with their patients. Some patients holding a small stick in their mouths communicated by pointing at letters on a poster, laboriously spelling what they wanted to say. This went fairly well because the student learned to half-guess what the patient would say after only a few letters. The student would then say out loud what he or she thought the patient meant, and the patient would then wink in one way if the student had guessed right and in another way if not. If the student was in no way near the correct answer, the patient could point at the word “Idiot” written on the poster. This way the student always received a message from the patient if the ventilation required correcting. It was almost a safer way to correct ventilation than laboratory tests, blood pressure, and other medical controls.

The intimate relation made the students very concerned about the well being of their patients. They were exhilarated at every positive sign but were also very sad when things went downhill. And it did for many patients. Even though the students knew that death was a very real option, they were mentally strained when their patients died.

At worst, the patients died during the night. The light in the wards was dimmed in order not to disturb the patients in their sleep. But the faint light and the fact that the students were not able to tell anything from the ventilation made it impossible for the students to know that their patient had died. It was therefore a shock for the student when morning came and he/she realized that the patient had been dead for a while….

Not so long ago professor Bjørn Ibsen was lauded at a conference here in Denmark. He sat on a chair in the front row when a woman of ~ 65 year quietly went up to him, kissed him on the cheek and said ‘Thank you for my life!’

In 1952 she was the twelve-year old girl whom Bjørn Ibsen was permitted to try and save by means of tracheostomy and a tube through which he wanted to ventilate in replacement of her [paralysed] respiration. He succeeded and the woman was proof of that, and was the direct cause of 1500 medical and dental students ventilating polio patients for 165,000 h at the Blegdam Hospital in 1952 thereby saving ~ 100 people who would have been lost without this effort….”

The complete letter has been placed in an archive in the Mandeville Special Collections Library at the University of California, San Diego.