SPECIAL AIR MISSION: POLIO

By Charles C. Smith, Jr. MD
 Clinical Professor of Medicine, University of Louisville School of Medicine
 Presented to the Innominate Society for the Study of Medical History
on Tuesday, February 11, 2003

This paper is respectfully dedicated to the memory of Dr. Roy Saxton Cornell, who gave his life for his fellow man

When Elisha reached the house, there was the boy lying dead on the couch. He went in, shut the door on the two of them and prayed to the Lord. Then he got on the bed and lay upon the body, mouth to mouth, eyes to eyes, hands to hands. As he stretched himself out upon him, the boy’s body grew warm.  Elisha turned away and walked back and forth in the room and then got on the bed and stretched out on him once more. The boy sneezed seven times and opened his eyes. 2 Kings 4: 32-35

This seems to be a period to recall polio in the recent medical literature from my review of
it, perhaps because of the appearance of the “post-polio” syndrome and maybe because
those of us who lived it are passing from the scene and are rushing to print. Even a recent
movie features a polio victim, Frida, the Mexican artist. While serving as a flight surgeon
in the United States Air Force 1956-58 I participated in a number of missions to move
polio patients in iron lungs both in the “zone of interior” and from overseas. This is a story
about those missions and the path to a watershed in medicine in my time provided by it.
But basically tonight’s story involves breathing.

Rosemary and I went on a nostalgia trip to San Antonio last May. We visited all our old
“haunts” and my old base, now the home of the School of Aerospace Medicine, Brooks
AFB, Texas. I had written them in January 2002 sending a copy of my orders and a
newspaper clipping about one of my missions. A colonel from the school called and we
were granted access to the archives at the school and visited the museum where one of
our old iron lungs is on display.

Poliomyelitis was a major player in the lives of those of us in my age group. The threat was
a constant in the lives of our mothers especially. You couldn’t go swimming or to the movies during late summer in the 1930s, 1940s and early 1950s because of it. You played with a friend one day and in the next 48 hours they might be dead. My 6-year-old first cousin was one of those who died. It was best known then by its other name, infantile paralysis. For example, I took one of the new first-year med students to the movies as his second year host at the Kentucky Theater in fall, 1952 and 2 days later he was in an iron lung at Louisville General Hospital.

This disease probably has existed for thousands of years. Egyptian steles (1580-1350 BC) showed withered legs.[1] Epidemics were common in this country in the first half of the 20^th century starting with the New York epidemic in 1916. In New York City alone that year there were 8,900 cases and 2,400 deaths. Across 26 states there were 27,000 cases and 6,000 deaths. This disease was not related to filth and poverty, striking all strata of society. There was also the suggestion that children in wealthier families who had less exposure to other children and poor hygiene were more susceptible since they had no opportunity to acquire antibodies through subclinical infection.[2] This was also the explanation for so many very young children contracting the disease, thus the name, infantile paralysis.

A Louisvillian, Simon Flexner, and Hideyo Noguchi at the Rockefeller Institute thought they had seen the microbe causing it early on in 1916.[3] Of course, John Enders won the Nobel Prize for his discovery of the actual virus in 1948. Perhaps fortuitously it struck a political heir who was to become a powerful president. Franklin Delano Roosevelt, contracted the disease on Campobello Island in 1921. Probably this led to the great support given to The National Foundation for Infantile Paralysis run by Basil O’Connor, his law partner, and the race to a vaccine funded by the NFIP. It made a shrine out of Warm Springs in Georgia where the president established the “little White House” because he felt the warm spring waters had helped him recover. Here he would frolic with other younger polio patients and was known as “Uncle Rosie”. It’s worth a visit to it sometime.  Certainly it led to the March of Dimes on our streets and the President’s birthday balls over the entire country on President Roosevelt’s birthday as fund-raisers.[4]

The disease affected the gray matter, thus the name poliomyelitis from 2 Greek words meaning “gray” and “marrow” (of the spinal cord), and the results were devastating especially if at the brainstem level.[5] As a result there could be loss of respiratory capability as well as swallowing function with disastrous results. The need for artificial means of ventilation was great.

As you know in my new role as librarian I am reviewing our archives to catalog them. In an October, 1927 paper to the Innominate Society on “The History of Respiration”, Dr. Murray Kinsman notes that Robert Boyle showed in 1660 that air was essential to life. He placed a small animal in a closed vessel and evacuated the air by placing a candle and noted the death of the animal and the extinguishing of the candle. Dr. Kinsman then noted that Robert Hooke, probably the greatest scientist of all time and Boyle’s student, demonstrated that if the thorax of a dog were opened; life could be prolonged by artificial respiration, again in the 1600s.[6]

Our story next turns to Consolidated Gas Co., New York City, in 1925, looking for a method to breathe for workers overcome by gas or electrocution, not at all related to polio. They turned to Dr. Cecil K. Drinker, Professor of Physiology at Harvard School of Public Health noted for his studies on pulmonary edema. He, in turn, consulted his brother Philip Drinker, a chemical engineer, who was working on a solution to the problem of artificial respiration. A $5000 grant was made to the school with $2000 for construction of a respirator. A 1929 article in JAMA showed the result.[7] By the way, the electric company of Consolidated, through the Edison Institute, also funded work by Dr. William Kouwenhoven at Johns Hopkins in 1928 on electric defibrillation of the heart to counteract arrhythmias brought on by electrocution. He was an electrical engineer. More about this later.

Drinker had surmounted the problem. The patient’s head stuck out the end of the tank. There was a sponge rubber seal to make it airtight. And the air was exhausted from the tank sufficient to produce negative pressure causing the chest to expand and thus produce breathing.  Dr. Cecil Drinker felt that if the seal were tight enough to work it would impede cerebral circulation. However Phil Drinker consulted Cluett and Peabody, makers of Arrow shirt collars and the Knox Hat Company for sizing of the neck and head and the rubber industry for help on the sponge rubber to surmount this problem. A garage mechanic’s “creeper” allowed the subject to slide into the tank. Later boat portholes were added through which to work with the patient.

It worked, and the Warren E. Collins Company in Braintree, Mass. built the respirators.  A few months later in October 1928 an 8-year-old girl with polio developed progressive weakening of respiration and the new machine was brought into her room so she could see it and get used to the noise for a few hours. Early the next morning, when comatose from hypoxia she was placed in the machine. The staff was afraid to turn on the power. Phil Drinker came and started the pump, and in less than a minute saw the child regain consciousness. She then asked for ice cream. Phil Drinker said he stood there and cried, as did everybody in the room.

The doctors at the Children’s Hospital were initially bothered by a moral question; once they had succeeded in saving a polio life by means of a machine, would the patient be obliged to stay on the machine forever? Therefore you might not ought to put patients in an iron lung. Soon it was evident that most patients regained breathing ability and could come out of the lung. So an instrument developed by industry became a savior for patients with polio.

Originally a vacuum cleaner motor was used to exhaust the air but later switched to a bellows to automatically close and open to alternate the pressure in the tank (more about this later). Each unit cost $2000 but they were produced slowly. At this point John Haven Emerson steps into the picture, either grandson of Ralph Waldo Emerson or son of Emerson’s great-nephew, according to which author you believe. I believe the latter. Although still young, Jack was well known for his exceptional talent as an equipment designer. Another stated problem with the Drinker respirator was the inability to vary the rate, although Drinker’s original article states that the rate could be varied. So Emerson developed a respirator selling for less than $1000 and solved the breathing-rate changes?[8]

An epilogue on Phil Drinker’s paper: He clearly stated the inadequacies of the Sylvester prone pressure method of artificial respiration most of our age group learned in Boy Scouts or Red Cross. Even so, it took another 20-25 years to supplant the Sylvester method with a better one.

Soon iron lungs were being positioned around the country and the world to meet the needs of polio patients. Dr. Drinker had shown it would work and Jack Emerson’s machines added to the success of the lung! The nation and world had settled into a recurrent pattern of polio care through the 1954 epidemic, the last before the release of the Salk vaccine in 1955.

I worked on the wards of the Louisville General Hospital before my senior year in medical school in the last epidemic here in 1954 and we had some 18 iron lungs in action at one time. After that the incidence of polio declined markedly due to the successive vaccines of Drs. Salk and Sabin. Dr. Sabin’s oral vaccine “polished off” the disease as a threat in the early 1960s. This was in large part due to the NFIP.

The United States Air Force had become involved in the movement of polio patients through the Military Air Transport Service (MATS) (now Air Mobility Command). Commercial services for moving such patients left much to be desired. In 1952 the School of Aviation Medicine at Randolph Field, Texas set up a research project to evaluate available commercial respirators. Emphasis was placed on (1) Construction, ease of operation, and applicability, (2) Cycling characteristics, pressure and respiratory flow patterns, (3) ventilatory and respiratory gas transport efficiency, and (4) subjective reactions.

The results concluded that the most dependable and reliable respirator was one encasing the entire body. Since there were no acceptable commercial light-weight full-body respirator units available a new   one with light-weight power unit and valving mechanism which would operate a full body shell was developed. The features included:

1.       Operate continuously for an indefinite period.

2.       Supply adequate ventilation and flow rates to comply with individual’s demand, size, sex and build.

3.       The respiratory curves should be such as to simulate a normal physiological pattern, or be adjustable to supply any desired pattern. The extra-thoracic pressure differential should have a range from –30 cm. Of water to +15 cm. The duration of inspiration should approximate 35% of the cycle and expiration 65%. . The frequency of the cycle should be adjustable to a range which will provide an adequate minute volume at an acceptable tidal volume.

4.      The machine should provide either positive or negative pressure as deemed needed by the operator.

5.       Safety features:

      (a) A device to indicate power failure.

(b) A device to indicate the degree of ventilation.

(c) A method of emergency manual operation.

(d) Safety measures against crashes and turbulence.

6.       It should operate through a temperature range of –10 C. to +50 C. and at altitudes from sea level to 15,000 feet.

7.       The equipment should be light-weight, durable and easily moved without 
 impairing performance.

8.       It must be operable on either 24 volt DC or 110 volt AC[9]

The machine the Air force developed called the SAM lung worked and in January 1955 the School of Aviation Medicine reported on 50 patients moved in1952-54[10]. There were no fatalities. Earlier air evacuation efforts had mortality, I suspect, because the patients did not have tracheotomies and it was essential to be able to suction the airway regularly and irrigate with saline since the air aloft was dry on board. These patients also could not effectively cough in the iron lung. Regular cleaning of the inner liner of the tracheotomy tube was also a high priority. I suspect the tracheotomy was the real savior in the care of polio patients with breathing involvement in toto. These principles were especially important on overseas flights where flying time alone was 30 hours Germany to Seattle, Washington and 37 hours total Tokyo to Chicago. Earlier literature seemed to indicate a reluctance to perform tracheotomy.

The respirator developed ran by means of a power unit containing a high-speed impeller driven by a vacuum cleaner motor (Sears) running at 18000 RPM on 110-volt AC current. Another similar power unit ran on 24-volt DC current. This could operate on a storage battery, 24-volt aircraft current and by a rectifier on 110 volt AC. The power units could be easily removed and replaced. Extra units were always available on board. The cycling rate could be varied from 5 to 30 cycles per minute depending on direction of flow of air in the compartments in the impeller box. The pressure pattern during each cycle could be varied dependent on the cam shape on the unit. Once the cam stuck on one of the units in mid-Pacific as I brought 2 Marines home from Okinawa with bulbar polio and a squirt of nupercainal ointment took care of it. The pressure pattern chosen had a rapid build-up of negative tank pressure followed by a sudden drop in pressure permitting the elastic recoil of the lungs to promote expiration passively, followed by a short rest period. This was as opposed to the conventional bellows that produced a sine wave pressure pattern in the larger respirators. A Bennett respiratory meter was used to measure ventilation. There was no ability to measure O-2 tension other than in a research lab.

The respirator would be able to ventilate patients up to an altitude of 18,000 feet. There was a bellows on the bottom of the tank, which could be operated by a detachable hand lever and would provide intratank pressures from +35 to –35 cms. of water in case of loss of power. On a flight over the Pacific the Navy aircraft commander asked me about ditching contingencies and I told him we’d just load the lungs on a life raft and pump them!  The weight of the entire shell respirator and battery was 255 lbs, and it would fit anywhere a litter would go!

  By 1953 no civilian air transportation service was any longer willing to undertake the expense of providing movement of polio patients and at the same time there was a move to transfer patients quickly to a center for care where trained personnel and equipment were available. The number of requests during this time to the Continental Division of MATS had reached 50+ per year.

By 1956 new cases of polio had ceased in the United States but the Salk vaccine had not reached overseas. The first few moves I made were moving civilian patients from community hospitals to medical centers and once from Tuscaloosa, AL back home to Minneapolis when a patient decompensated on a family trip to Florida. This took us from small town Texas to Jefferson Davis in Houston, University of Oklahoma Hospital in Oklahoma City to Creighton University hospital in Omaha, Hot Springs, SD to Fitzsimmons Army in Denver, Fitzsimmons to Bronx VAH, and once a Guillan’-Barre from Albuquerque to Fitzsimmons. Later we moved a sailor from the University of Utah to Oakland Naval Hospital. Salt Lake City when I picked up the sailor.

The first flight overseas was to Benghazi, Libya to get a missionary surgeon, Dr. Roy Saxton Cornell, who was in a British Army hospital. He had gone to Libya to establish a missionary hospital and contracted polio with respiratory arrest. The British had a tank division there because President Nasser of Egypt had seized the Suez Canal. We moved him by way of the USAF Wiesbaden Hospital for an overnight rest to King County Hospital in Seattle, the major teaching hospital of the University of Washington. This was an example of the Air Force’s ability to perform a priceless service for an American citizen. Here is an excerpt from the letter written by Dr. William Wagner of the Baghdad Hospital in Benghazi after the move through the General Conference of the Seventh-Day Adventist Church:

“It would be hard to describe to you the overwhelming feeling of gratitude that came to us as we witnessed the evacuation team of the American Air Force arrive here and immediately commence their preparation of Dr. Cornell for his long journey home. The serious problems we had anticipated were solved quickly by this experienced team with their excellent equipment”.

               “America always goes after her own”.

I had the good fortune to talk to Dr. Cornell’s son, Kendal, an attorney in California, this past week. Dr. Cornell survived 21 years but he forever required the use of a chest respirator during the day and a rocking bed at night. He was an avid reader and lived to see most of his grand children born. Before polio he not only established the American hospital at Benghazi but also was a licensed pilot and accomplished mountain climber as well as husband and father of 3 children.[11] Thus I dedicate this paper to him.

As mentioned in 1958 we went to Okinawa to get 2 men from the 1^st Marine Division who had contracted polio on maneuvers in the Philippines. We are fortunate to have their doctor here tonight!

All this was great and the success of the SAM lung was gratifying and for me personally it was a very satisfying experience. But the watershed event was back in the Libyan Desert in 1957. After landing and having tea with the doctors and “sisters” we went to see Dr. Cornell and instead of an iron lung existence he was lying in bed with a machine by his bed from which a tubing ran to a tracheotomy! It was my first view of a ventilator. I remember the name-Radcliffe ventilator from Oxford. The patient was receiving wonderful bedside care and was very content. He had a large #10 cuffed tracheotomy tube in place. He was not real happy when we showed him our little cage. Suffice it to say, I gave him my best bedside charm (as much as a future internist could give a surgeon) and we made the move to Seattle. Dr. Eugene Conner has kindly supplied me with a picture of the Radcliffe ventilator and an accompanying write-up.[12] Kendal Cornell told me this was the first time the ventilator had been used by the British.

The Danes had pointed out the success of positive pressure breathing in the epidemic of 1952 in Copenhagen. Faced with 2722 polio patients between July and December 1952 with 70 patients requiring artificial ventilation at any one time and with only one Emerson tank respirator and six chest respirators, the Danes turned to Dr. B. Ibsen in anesthesiology. He instituted tracheotomy with insertion of a large rubber cuff-tube in the trachea and bag ventilation. Two hundred medical students were employed daily to manually perform the bag ventilation.[13] Mortality rates were markedly lowered.

 The British had developed the Radcliffe ventilator by 1953 in response to this report from Denmark. I was not to see another ventilator until Dr. Conner got the Mǿrch at Louisville General Hospital in 1959. Dr. Mǿrch in Denmark had developed it in response to the polio epidemic and the results with positive ventilation during the 1952 epidemic. At the General Hospital the ventilators were used mostly for “flail chest” due to injury. Louisville hospitals later got the first generation ventilators in the mid-1960s. My brother was at the NIH 1962-64 and recalls they got a Bird ventilator during that time though his Bellevue-trained colleagues still wanted to still use iron lungs.

In the period of medicine we have just covered there was no CPR. When you died, you died. As a resident I did open chest cardiac massage occasionally on selected patients on the wards, but we largely operated in the dark since monitoring was to come along later as a result of the space program. Closed chest cardiac resuscitation started as I finished my residency in 1961. Bill Milnor, co-author of the original article with Kouwenhoven from Johns Hopkins outlining closed chest massage and defibrillation was in Louisville visiting the late Chuck McGaff when I was Chief resident in 1961 and told us of their work. [14] There was also no monitoring of blood gasses available during that same era. And the ICU-CCU was to come along later in the 1960s. Real sick folks went to the recovery room in the OR for care by the anesthesiologists.

The Mörch ventilator was also used for medicine overdoses and tetanus in my patients as a resident. I used the iron lung on one COPD and one case of myasthenia gravis.

But with the development of better systems of positive pressure ventilation a whole new vista of care opened and a new specialty, pulmonary and intensive care medicine. The anesthesiologist had carried the burden of ventilation to that point. Our friend Jack Emerson discovered volume-preset ventilators in the late 1950s, which could be used in the assist or control mode of respiratory rate determination. The advent of modern electrodes for blood gasses and safe arterial puncture in the mid to late 1960s then led to the concept of an organized system in a new setting, the intensive care unit. This led to a new specialty, pulmonary medicine. When the Petty group in 1967 reported 12 patients with a new name, ARDS, who responded to positive end-expiratory pressure we entered a new era in medicine- the PEEP era.[15]

 Judah Skolnick could not be here tonight. He represents the transition to a new kind of pulmonary medicine from the medical chest physician who read x-rays and gave pneumothoraxes. Dr. Skolnick served a summer research scholarship with Dr. Conner when Gene was chairman of Anesthesiology at the University of Louisville. During that summer Dr. Conner influenced him to enter the new field of pulmonary medicine. It was really a patient with tetanus on the Mörch that did it. Up until that point anesthesiology had been responsible for the advance into artificial positive pressure ventilation. For instance, my mentor on my first Air Force polio move was Dr. (Col.) Arthur Tarrow, chief of anesthesiology at Wilford Hall Hospital, Lackland Air Force Base. Engstrom had introduced the first new method of positive pressure artificial ventilation into anesthesia in the early 1950s. His work also suggested improved survival in polio patients. By the way, Petty used an Engstrom ventilator to start PEEP.

With this new tool one could oxygenate the fallen patient whether it be from cardiac arrest, exacerbation of COPD, or smoke inhalation etc. And we were off and running into a brave new world of prolongation of life, sometimes good but maybe not always and polio was no longer the archenemy.

So a gas and electric company initiated a chain of events that led to a discovery of ways to breathe for a human when he could not breathe for himself. They also sparked defibrillation. A dread disease, polio, propelled this artificial breathing into widespread use. Better ways were then found to do this. Dr. Kinsman’s talk in the second year of our society was right on the mark and contemporary with Dr. Drinker’s efforts that led to this new era in medicine promised by Robert Hooke 300 years before.

Thanks to the sacrifice of Dr. Roy Cornell and his many fellow patients, in a sense, we have our present system of artificial ventilation.