THE STORY OF THE LIVING COFFIN

Written by Dr. Sai Lavanya Patnala, Intern, Apollo Medical College, Hyderabad

It was a humid, rainy July day in 1952 when a six-year-old Paul Alexander came in from playing outside the family home in a Dallas suburb feeling feverish. His head pounded and his neck ached. Just five days later he could no longer speak, swallow, cough or hold a pen. He had contracted deadly polio. He was rushed to hospital, where a dedicated ward for the disease was jammed full with other youngsters. Barely breathing, a paralyzed Paul was left on a gurney in a hallway. A doctor eventually performed an emergency tracheotomy to relieve the congestion in his lungs. When he woke three days later, his tiny body was encased in an iron machine that made rhythmic wheezing then sighing noises.

HOW IT ALL BEGAN?

While we all know Polio as a largely eradicated disease, it was a huge concern in the 19^th century when incidence of poliomyelitis (polio) began to rise to epidemic proportions across Europe and North America, reaching their peak in the United States in 1952, with 57,628 cases in one year.⁽¹⁾

Polio was not recognized as a public health problem in the United States until a localized outbreak occurred in Vermont in 1894. The first great summer epidemic in 1916 claimed 6,000 lives and left 27,000 others with residual paralysis. Widespread panic occurred in many cities, particularly in New York, and the tragic consequences were heightened by ignorance of the disease. The worst epidemic occurred in 1952, which left more than 57,000 people dead or paralyzed.⁽²⁾

In the days of epidemics, only a small percentage of infected persons developed clinical signs consisting of fever, headache, and stiffness of the neck and back, while fewer developed paralysis. In a second phase of the disease, infection might localize in the gray matter of the central nervous system, with some predilection for lower motor neurons in the anterior horn tissue of the spinal cord. Only supportive treatment was possible. Of patients afflicted with paralysis, at least 50% recovered completely, whereas somewhat fewer than 25% might suffer severe permanent disability. The most serious were the cases with bulbar involvement (of the medullary centers), but respiratory paralysis could also occur without bulbar involvement by lower motor neuron damage. Respiratory failure could be managed only with a mechanical respirator.⁽²⁾No satisfactory mechanical respirator existed before 1929, when Philip Drinker and Louis Shaw described an apparatus of their own design.⁽²⁾

WHAT IS THE IRON LUNG?

Popularly named the iron lung, the Drinker respirator is a cylindrical metal chamber large enough to accommodate the patient’s entire body without restriction, leaving the head outside the chamber under atmospheric pressure.  One end of the cylinder could be released and would slide out on casters together with the stretcher on which the patient’s body lay. Airtight closure of the chamber could be accomplished quickly by securing levers around the rim. A series of rubber collars of different sizes were fabricated to provide an essentially airtight seal at the patient’s neck.⁽²⁾ The respirator worked by pushing air into the lungs by method of artificial respiration called External Negative Pressure Ventilation (ENPV).⁽¹⁾ The large bellows used in later models raised and lowered pressure within the tank to assume the entire work of breathing. When they sucked air out of the box, air pressure in fell and the patient’s lungs automatically expanded, drawing fresh air into the diaphragm. When the bellows allowed air back into the box, the air pressure rose and the patient’s lungs deflated passively, pushing air out of them. This invention supported thousands of patients afflicted with respiratory paralysis during the polio era. It was later superseded by positive-pressure airway ventilators.⁽²⁾ Despite the advantages of positive ventilation systems, negative pressure ventilation is a truer approximation of normal physiological breathing and results in a more normal distribution of air in the lungs. It may also be preferable in certain rare conditions.⁽³⁾

Figure 1. Respirator diagram from Boston Children’s nursing procedures handbook, 1958-1959.

Rows of iron lungs filled hospital wards at the height of the polio outbreaks of the 1940s and 1950s, helping children, and some adults, with bulbar polio and bulbospinal polio. A polio patient with a paralyzed diaphragm would typically spend two weeks inside an iron lung while recovering.⁽³⁾

Most patients only used the iron lung for a few weeks or months depending on the severity of the polio attack, but those left with their chest muscles permanently paralysed by the disease faced a lifetime of confinement. ​​​​​​ Therapists used several techniques to help patients regain strength in their chest muscles. By slowly extending the time outside the cabinet the patient could gradually build up the muscles to the point where they could spend most of the day outside the iron lung, returning to it at night to give tired bodies time to rest.⁽¹⁾

Once an effective polio vaccine was developed in the 1950s, the incidents of polio infection fell dramatically and only a very few machines were needed in hospitals. But for patients dependent on them to breathe, the old iron lungs were gradually replaced with modern ventilators.⁽¹⁾

Figure 2. Respirator unit at the Haynes Memorial Hospital, Boston, August 1955⁽²⁾

POLIO PAUL AND HIS STORY

Figure 3. Paul Alexander, known as the iron lung man, who recently passed away (4)

On March 11, 2024, Paul Alexander of Dallas, United States, died at the age of 78. He had been confined to an iron lung for 72 years from the age of six and was the last man living in an iron lung.⁽³⁾

Alexander, who was also known online as ‘Iron Lung Man,’ spent the last seven decades of his life living in an iron lung after contracting polio when he was 6 years old in the 1950s and was paralyzed from the neck down, leaving him unable to breathe on his own. ⁽⁵⁾

Despite newer inventions, Alexander remained inside his original iron lung for since then. Speaking to The Guardian, he said he was already used to living in the iron lung and had even learned to breathe for short periods of time without it. He also never wanted to have a hole in his throat again.⁽⁶⁾

Being confined to a 600-pound iron lung did not restrict his zest for life. He obtained his law degree, passed the bar to become a lawyer and wrote a book, all while his entire body, except his head, was immobilized in the machine. Alexander was passionate about protecting children from polio and eradicating the now-rare disease.⁽⁵⁾

CONCLUSION

India, which had seen 200,000 annual cases of the virus a year in the 1990s was declared free from Polio in 2014. There has not been a new case of polio in the US since 1979, or in the UK since 1984, and by 2000, the World Health Organization declared all of the Americas and the western Pacific region polio-free. However, in the fall of 2022, an unvaccinated person in New York developed paralysis from a polio infection, emphasizing the need to target vaccination efforts to vulnerable communities.⁽⁷⁾

Achieving and sustaining eradication of Polio has been quite an achievement for the health care industry. It is thus, crucial to continue the effort to maintain the status of a polio-free world. 

REFERENCES

1. https://www.sciencemuseum.org.uk/objects-and-stories/medicine/iron-lung
2. Meyer J. A. (1990). A practical mechanical respirator, 1929: the “iron lung”. The Annals of thoracic surgery, 50(3), 490–493. https://doi.org/10.1016/0003-4975(90)90508-4
3. Wikipedia contributors. (2024, March 14). Iron lung. In Wikipedia, The Free Encyclopedia. Retrieved 16:32, March 14, 2024, from https://en.wikipedia.org/w/index.php?title=Iron_lung&oldid=1213657383
4. https://www.the-sun.com/news/10768130/iron-lung-paul-alexander/
5. https://globalnews.ca/news/10356211/paul-alexander-iron-lung-polio-death/#:~:text=Most%20patients%20spent%20a%20few,a%20lifetime%20in%20the%20machine.
6. https://www.dailymail.co.uk/news/article-12464879/Man-lived-iron-lung-70-years-explains-why.html
7. https://www.scientificamerican.com/article/first-u-s-polio-case-in-nearly-a-decade-highlights-the-importance-of-vaccination/