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Some prehistory of New Zealand intensive care medicine.

At the end of March 1961 the Auckland Hospital Board, New Zealand, received "The Annual Report 1960 of the Respiratory Unit--Auckland Hospital" (1). Figure 1 shows this title from what is now a historical treasure in the history of Australasian intensive care medicine. It represents a defining point, since, by its account of that unit's organisation and workload, it provides evidence that a genuine intensive care unit had been functioning there for at least a year. Within its text was reference to a preceding formalised Central Respiratory Unit, operating since December 1957 and also located in the hospital's infectious diseases block. The full 1960 report is reproduced in the book Intensive Care in New Zealand. A History of the New Zealand Region of ANZICS (2), a copy of which was sent to all members of the Australian and New Zealand Intensive Care Society in 2002. Some selected events from prior to the signal year of 1960 are, in my view, precursors to New Zealand's intensive care medicine.

Many intensivists will think of the 1950s in terms of the evolution of intermittent positive pressure ventilation for acute respiratory failure, which Auckland Hospital's Central Respiratory Unit exemplified. But of relevance to this article is the time before intermittent positive pressure ventilation and intensive care medicine all started, which had been with Albert Bower and V Ray Bennett in a relatively modest way at Los Angeles, 1949 to 1950 (3), but particularly by Bjorn Ibsen and colleagues at Copenhagen, 1952 to 1953 (4). Also relevant are non-respiratory critical disorders of the time. So in its latter part, this paper will concentrate on some medical-type interventions in New Zealand, before Auckland's stand-alone intensive care unit, the country's first, was established there.

SOURCES OF INFORMATION

Some medical accounts of the time prior to established European settlement in New Zealand come from early books and journals, and a sampling of titles is listed as an Appendix.

Following European settlement, and prior to the first New Zealand Medical Journal (NZMedJ) in 1893 (and the Australasian Medical Gazette preceding it, initially from 1880), the documentary sources include local newspapers, reports and papers in medical journals, also centennial and other anniversary histories of hospitals and townships.

[FIGURE 1 OMITTED]

Two valuable local resources are:

1. Colonial newspapers, Papers Past, see: papers-past.natlib.govt.nz

2. The New Zealand Electronic Text Centre (Victoria university, Wellington), see: nzetc.org.

Fortunately, some books printed earlier in the 19th century, not readily found now, have been digitised (in 'full view') for searching at books.google.co.nz, e.g. John Savage's of 1807 (5) or JK Ernst Dieffenbach's of 1843 (6).

Among medical journals, the Lancet is available online back to its first issue in 1823. Although the catalogue of PubMed online does not currently go back further than 1949, the printed Index Medicus dates back to 1879. There is also a small number of pre-1949 citations included in PubMedCentral, searchable via PubMed.

Dr LD Gluckman's (New Zealand) Medical Histories

I would draw attention to the writings and two books on New Zealand medical history (Figure 2) by Dr Laurie Gluckman (the 1964 founder of the Auckland Medical History Society, Figure 3). For this account I have drawn on them repeatedly.

Tangiwai, published 1976 (7), discusses medical times in New Zealand before 1860, while more recently, in the posthumous 2002 Touching on Deaths (8) (to be considered further) Gluckman details 384 Auckland inquests, 1841 to 1864, for causes of death among settlers. (Today's trauma intensivists would see many opportunities present then for their field of practice). There were 53 paediatric but only four Maori inquests. The book also informs us about some of Auckland's own medical history and its medical practitioners of that time.

MAORI OF PRE-EUROPEAN NEW ZEALAND

Multiple early documents and books by Europeans emphasise the general health and fine physical condition of the Maori population, e.g. J Savage, 1807 (5(p. 90)). Yet for the Maori, pre-European time was essentially one of survival of the fittest ("all the unfit were speedily eliminated", for which David MacMillan (9(p. 26)) acknowledged Captain James Cook). Commonly, unnatural deaths came from drowning (discussed further below), accidental trauma or war trauma (and for some of those captured during battle, as a preliminary to being eaten [Footnote 1]). Forty years could be old age, few were beyond fifty.

The Reverend Wm Colenso's assessment of Maori from about 1835 was "while bad physicians, they were tolerably good surgeons,- especially in reducing dislocations and reducing broken bones" (13(p. 25)); George Bennett confirmed the latter, 1831 (14(p. 435)). However, especially on considering the kind of dressings Maori used for treatment of wounds and umbilical cord stumps, it seems hard to accept one historian's claim that there was "no tetanus" (7(p. 102)). Gluckman stated "the pre-European Maori did not differentiate sickness and death" (7(p. 51)). They believed sickness was due, 1) remotely, either to violation of tapu (holy or prohibited) or witchcraft, and 2) immediately, to evil spirits invading the person (10(I, p. 219)). So their (priestly) tohunga would attend. But Europeans generally considered the Maori attitude towards illness to be unsympathetic (7(p. 70)). George Bennett, visiting New Zealand (and Polynesian islands), 1829 to 1830, observed "Natives appear to have no compassion one for the other" (14(p. 628)). Further, the sick, (even if a princess (6(p. 25))) were shifted to outside the whare (house), either to "a separate hut erected on purpose" (13(p. 628)) or in the open air, lest their dying inside should contaminate it (7(p. 47)). This came to affect practices in Auckland's new (1847) hospital, as Lady Martin remembered: "We were obliged to have a little hut put up for him to die in: so strong is the native feeling against occupying a house in which anyone has died that the hospital would have been deserted" (11(p. 77)). Gluckman lists (8(p. 20)) the principal causes of death in Maori before European settlements (and especially 1840) as drowning, injury, war injuries, tattooing sequelae, stingray ('reputed'), dysentery and other alimentary disorders (including those from putrescent food); plus Makutu, a term used for death of supernatural origin (somewhat like that "later known of as The Rapidly Fatal Melancholia of the South Sea Islander" (7(p. 143))).

[FIGURE 2 OMITTED]

The arrival of Europeans was followed by infectious diseases such as syphilis and gonorrhoea (and other sexually transmitted diseases), tuberculosis, measles, rubella, mumps, smallpox, chickenpox, influenza (7(p. 231)), whooping cough (8(p. 21)) and measles and scarlet fever (10(I, p. 219)). Colenso wrote in 1865 (13) of a rewharewha (influenza) epidemic some 45 to 50 years earlier which "destroyed nearly 3-5ths of the people of the more Southern parts of the Northern island". Some Europeans also brought alcoholism with its attendant evils (7(p. 109)). Earlier in 1807, J Savage had noted (5(p. 17)) the Maori had "a great aversion from [to] spirits and I do not find that they have any mode of intoxication". (Footnote 2.)

[FIGURE 3 OMITTED]

Although midwife Mrs Henry Williams described her 1827 attempt to revive a Maori from suicidal hanging (7(p. 49)), there was little written about Maori suicide before 1840 (7(p. 230)), when John Ward could inform colonists of "occasional suicide by females under the influence of jealousy" (15(p. 65)) and that "it is usual for the head-wife to commit suicide after her husband's death" (15(p. 63)). By 1843 JK Ernst Dieffenbach elaborated the reasons he could confirm Maori suicide as "not uncommon" (6(p. 111-112)). (Compare: by the 1960s time of early intensive care medicine in New Zealand, intensivists were frequently confronted with attempted suicides in the population at large, but by then the common method for such attempts was by barbiturate self-overdosing, as exemplified at Auckland's intensive care unit (17). One harbinger of these lies in the first case reported in New Zealand of oxalic acid self-poisoning [probably], 1840, which Gluckman refers to (7(p. 71)), from Major Thomas Bunbury's perhaps rare Reminiscences of a Veteran Vol. 3, 1861.)

DROWNING IN NEW ZEALAND

In reporting on causes of death and diseases affecting the native population before European settlement, Gluckman (8(p. 20)) had listed drownings first among the killers of Maori. (But see the asterisked note in Table 1.) Thos Garland's mid-20th century Department of health (New Zealand) booklet (18) declared Maori had their own practice for resuscitation from near-drowning and asserted that it "occasionally still [was] the practice of Maori to use it on the apparently drowned" (Figure 4). In Tangiwai Gluckman also referred to this, dating it around 1835 and quoted Sir Peter Buck (7(p. 54,154)): "A drowned person would be suspended by the heels over a smoking fire". One wonders (as also did Gluckman) at the authenticity of such a statement, but by 1840, Wellington surgeon George Monteith was advising that head-down posture for the apparently drowned "tends only to the speedy loss of any chance of re-animation" (19).

Contrasted with this "drainage" method was the practice of applying expired-air ventilation for resuscitation after drowning, probably first described for these waters during that time in 1837 by Felix Maynard (12(p. 102-103)) (Figure 5), surgeon on the whaling ship Asia. On arriving from Van Dieman's Land at New Zealand's "true fishing [whaling] grounds, S. latitude 44.50[degrees]", he resuscitated a drowned apprentice-sailor who was "cold and blue and inanimate". Maynard "forced [his] own breath into the bronchial tubes of the drowned man" through a tube made from "3 or 4 quills" of an albatross wing and after "efforts lasting a quarter of an hour" the victim recovered.

G Monteith's 1840 advocacy for resuscitating the drowned also included mouth-to-mouth expired-air ventilation, by "breathing in at the mouth or nostrils of the patient, so as to inflate the lungs, and afterwards the air expelled by pressure made with the hand upon the chest" (19).

LK Gluckman's 1841 to 1864 review of 384 Auckland inquests revealed 130 fatal drownings (8(p.104)), of which he numbered 111 in the sea, 18 in wells, one in a pit; while one drowning was suicidal. (Thus did he mean that all other 129 drownings were nonsuicidal? And since Gluckman stated that only "22 of the deaths [by drowning] were considered accidental" (8(p. 100)), did he regard 107 drownings being other than accidental?) He noted that alcohol--which was unknown to the Maori before James Cook's arrival (7(p. 122))--was involved in 20 drownings (8(p. 100)).

[FIGURE 4 OMITTED]

By 1865 a New Zealand newspaper (20) was publishing the recommendations of the (British) Royal National Life Boat Institution, which, after soliciting the best advice available in Britain, had advocated the following sound principles for treating the drowned: "The points to be aimed at are--

first and immediately, the restoration of breathing; and

secondly, after breathing is restored, the promotion of warmth and circulation".

However this was accompanied by a poorer method, since it supported use of the then new (1856) Marshall hall-type artificial breathing movements, employing repetitive cycles, approximately 15/min, of tipping the body from a prone position on the ground to fully onto one side, then backwards to prone before alternating to the other side. (The newspaper article also detailed "Appearances which generally accompany Death"--i.e. from drowning).

And incidentally, concerning interventions, Dr Edward Shortland reported that partial-drowning was an actual Maori treatment for tutu berry poisoning. "The natives' remedy is to plunge the patient in the sea or a river, keeping his head below water till he is nearly drowned, and then to roll his body on the shore till sickness is produced sufficient to eject the contents of the stomach. This practice, although rough, is rational and the best they could have adopted under their circumstances" (21(p. 190-193)).

Although the high incidence of river drownings did reduce with the laying of more and more roads and bridges, New Zealand's continuing high-fatality drowning rate associated with swimming, river crossing, and boating or canoeing, continued to be "the national death" (9(p. 167)).

AUCKLAND CORONIAL ENQUIRIES, 1841 TO 1864

Between 1841 to 1864 autopsies were conducted, for five coroners by 39 surgeons and two other doctors (8(p. 111)). Table 1 presents Gluckman's listing of the causes of death. We need to remember that whatever conclusions and diagnoses were arrived at then could be made only in terms of the knowledge and understanding of the times. In instances where the cause of death was not being elucidated, intervention was frequently attributed to the hand of God. The prominence of drowning has already been mentioned.

[FIGURE 5 OMITTED]

Significantly, alcohol was involved in 91 or 24.7% of 369 inquests where 56 were intoxicated, while at least 67 were males, with "the DTs" (delirium tremens) likely in 10 drowned (8(p. 100)).

Regarding deaths at "Our Hospital" (Auckland's, 1842 to 1856) Lady Barker asserted "It must not be supposed that all our patients died. On the contrary, the larger number got well" (11(p. 82)).

Contrast however, an 1847 Wellington newspaper's trauma report (Papers Past (22)) providing an account of the less fortunate Rachel Branks from Johnsonville, still breastfeeding her youngest of three, who had both legs fractured, one compound, by the tree her husband was felling on 14 September 1847. She had to wait overnight for "the colonial surgeon", Dr John Patrick Fitzgerald, to come from Wellington to reset the fractures--effected only with difficulty. (By this date, although ether was known to have anaesthetic properties, unfortunately it was still 12 days before its first administration took place in New Zealand, and that twice on the same day: in a Wellington prison and then on Wellington Hospital's second patient admitted.) She was then transported over a cart-track to Wellington Hospital on the very day it was opening, becoming its first patient, only for her to die from tetanus a fortnight later (Figure 6).

[FIGURE 6 OMITTED]

NEW ZEALAND MEDICINE REACHES THE LANCET, 1850

In 1829 surgeon Geo Bennett had "the first [paper] on disease as it affected New Zealand to be recorded in a medical journal" (7(p. 49)), one concerning rheumatic disease (14(p. 435-436)). But it was Auckland's scarlet fever epidemic of 1848 that provided New Zealand's first penetration of The Lancet (23) (none is found before 1850), when reported by the renowned Dr Arthur Thomson (10), surgeon (Figure 7). Of 146 victims admitted to Auckland Hospital, 18 died, indicating severity of the streptococcal infection. Regarding sequelae, it was stated "Only 11 had dropsy" (possibly post-streptococcal acute glomerulonephritis?).

From days long before clinical trials of treatment for sepsis, the following exemplifies what could then be prescribed for a girl aged four years: her "treatment consisted in an emetic and purgative; afterwards small doses of calomel; diaphoretic mixture; hot bath; cold to the head, etc. Two ounces of blood were taken from the jugular vein, during the convulsions, without benefit". Convulsions and coma terminated fatally on the fourth day. (Footnote 3.)

[FIGURE 7 OMITTED]

More in The Lancet

After Henry Slade's report of "Remarkable saves from [war] bullet wounds" (25) (four cases of dangerous wounds of head and chest, followed by recovery, of course without oxygen or transfusions, let alone intravenous fluids), New Zealand did not have much Lancet presence in the second half of the 19th century, except for a few minor reports, e.g. urethral stricture in 1875.

But from 1890 The Lancet featured "our own [i.e. New Zealand] correspondent", (I am unaware of how or whether New Zealand was being reported in the British Medical Journal at that time), while in 1898 a Lancet paper (26) detailed six major operations, all successfully treated, at Christchurch Hospital: two were abdominal, three gynaecological, but another included trephining for a hydatid brain abscess which had become complicated. See Footnote 4 regarding interventions developing in Australia.

LARYNGEAL INTUBATION IN DIPHTHERIA, 1889

A Canterbury doctor, Walter Hacon (29), reported in the NZMedJ (30) that to resuscitate a five-year-old "strong child" in respiratory arrest--attributable to chloroform being administered for a tracheotomy to relieve diphtheritic obstruction--he intubated him with a catheter (Footnote 5). The child was then able to have the tracheotomy performed, but died 14 hours later, presumably from the disease. On the basis of this experience, hacon then recommended intubation as useful: "I believe there is a good future for intubation" (in diphtheria), since it enabled a tracheotomy to be avoided. He also maintained that he found the intubation easy to perform on a patient in extremis. However, he did not refer to (was unaware of?) intubations for laryngeal diphtheria in the USA, 1885 (Joseph O'Dwyer, New York (32-33)) and from 1890, if not before, in Australia, when the Australasian Medical Gazette reported a Dr Hales as having intubated 100 Australian diphtheria patients by September 1890, with 38 surviving34. (Although laryngeal intubation then became controversial, intubation with O'Dwyer tubes at Melbourne's Fairfield hospital continued ongoing into the 1920s, with a total by then of 1175 intubated, among 3746 laryngeal diphtheria patients and 16.3% dying--vs 58.7% deaths among 92 such patients managed by tracheotomy (35).)

TETANUS REPORTED AROUND 1900 IN NEW ZEALAND

In 1897 a Dr A Marsack (36) treated two boys with tetanus (here now, was a real intensive care medicine illness), thereby completing his two year series of 11 cases, which had an overall death total of seven (five died within 48 hours), although these last two patients being reported survived. Antitoxin dosing was heavy (multiple "1 gramme" doses), while sedation was per sleep doses of chloral, repeated pro re nata. The accounts for these two survivors were quite detailed and although the spasms were "not the severest type", they were dangerous.

In 1901 Dr Hatherley (37) at Wanganui Hospital reported two further tetanus cases, now employing a wider range of sedation: morphine, potassium bromide and ethanol.

1. A four-year-old boy, with trismus, opisthotonus and spasms received anti-tetanic serum; chloral 5 gr, potassium bromide 5 gr, three hourly; morphia; brandy. After 15 days he was improving.

2. A three-year-old boy, with spasms affecting swallowing and breathing, received anti-tetanic serum, chloral 10 gr, potassium bromide 10 gr four hourly, then less often. After 11 days he was improving.

Hatherley observed that anti-tetanic serum injections had a "marked controlling influence" and advised that the gravity of symptoms should govern the frequency of these injections.

MOUTH-TO-MOUTH RESCUE BREATHING

In 1904 the NZMedJ documented JF McLean (38) maintaining oxygenation for a neonate by mouth-to-mouth resuscitation, which he kept up throughout 11 hours(!) of unresponsiveness, in which only mouth-to-mouth "could keep the child's blood oxygenated". ("Sylvester's [sic] method" had been "given a trial but was of little use, so we settled down to mouth-to-mouth insufflation".) Although a "rosy" child developed, "it" never breathed again. McLean then recommended mouth-to-mouth for "apparently asphyxiated infants".

This mouth-to-mouth mode of treatment received supportive advocacy in discussion of McLean's paper: "Dr Moore [of Wellington] agreed that the mouth-to-mouth method was the very best that could be adopted. he had practised it now for some time, and he believed it would succeed in cases where any other method would fail."

McLean also described seven hours, then abandonment, of "artificial respiration", (its type was unspecified, so was it also "Sylvester's"?) for a patient (of what age?) who had become apnoeic during anaesthesia for an operation treating mastoid disease which developed a brain abscess. Although that measure produced a good colour and circulation throughout, there never was spontaneous breathing. Autopsy showed the abscess had burst into the fourth ventricle.

INSUFFLATION POSITIVE PRESSURE VENTILATION, 1914

Around this time positive pressure ventilation with intratracheal insufflation anaesthesia (i.e. as per Chas Elsberg's adoption of the animal method of Samuel Meltzer and son-in-law John Auer for a patient's thoracic surgery (39)) made it possible to prevent the great pneumothorax problem of intra-thoracic surgery. The Hon. Dr Nash (40) of Sydney, NSW, presented Dr Piero Fiaschi's "simple and portable" apparatus to New Zealand at the 1914 Australasian Medical Congress in Auckland, in a paper on insufflation anaesthesia (with pressure insufflation and pulmonary elasticity expiration, with intermissions 3-6/min. Dr McDonald of Lidcombe, NSW, described to the meeting 11 intratracheal anaesthetics for surgical operations, one intra-thoracic). The paper contained the valuable message, "An intra-tracheal insufflator should be an item of equipment in every hospital, not alone for anaesthesia, but as an artificial respirator".

TRACHEOTOMY FOR LARYNGEAL DIPHTHERIA, 1918

From Wellington hospital, Dr D Fitzgerald (41) advocated tracheotomy alone, as an intervention for obstructive laryngeal diphtheria, with the stoma maintained open (without a tracheotomy tube) by big-bite stay-sutures and a metal frame, all we have in explanation of which is the paper's diagram (Figure 8). his paper claimed "All our [domestic] cases done under conditions similar to those obtaining in a hospital"(!), whereas a reader might expect the sites reversed. No case data are supplied. Fitzgerald applied "Large doses of antitoxin", i.e. >25,000 units, and had the airway toileted with moistened stiff quills for mucus and with forceps to pick out membrane. If relief was inadequate then he employed a steam tent.

[FIGURE 8 OMITTED]

TREATMENTS OF CARDIAC ARREST, 1918 AND 1945

Again in 1918, after claiming some successes in "several cases of heart massage during the last year or two", surgeon Carrick Robertson (42) attended three further patients for whom he compressed the heart from below the diaphragm to restart it by direct cardiac massage.

1. A man who arrested while Robertson was operating for appendicitis "did well" after direct cardiac massage delivered through a second abdominal incision, and a short arrest-to-massage time (artificial respiration was not mentioned).

2. Also, Robertson was called to a sailor of 34 years, with a thumb abscess, who had arrested during anaesthesia,--and was "dead for three minutes, probably five"--and provided "artificial respiration" and direct cardiac massage (per a rectus muscle incision and squeezing the heart through a softened diaphragm). After initial recovery to a state of cerebral irritability, by the third day he was normal though amnesic.

3. But a girl of nine having a tonsillectomy, "arrested [detected so, per stethoscope] some time before" she became apnoeic also, had direct cardiac massage through the diaphragm, but unsuccessfully. Following her autopsy, failure was attributed to status lymphaticus, a condition now time-expired. Direct cardiac massage was advised to be applied only "after failure to restore animation with the usual restoratives".

Nearly 30 years later in 1945, during extraction of multiple septic teeth after a total dosage of 1.2 g of thiopentone administered to the patient over 35 minutes, the loss of detectable pulse with apnoea (hence the patient was "lifeless" for 10 minutes) led Stephen Barclay (43) to incise up through the diaphragm for direct cardiac massage. Agents included [O.sub.2]/C[O.sub.2], coramine, picrotoxin, "intraventricular" adrenaline and later, neosynephrine to boost blood pressure. After return of spontaneous circulation, Barclay inserted an endotracheal tube and for the next hour supplied artificial respiration by intermittent negative pressure ventilation from a Both respirator, until spontaneous ventilation returned. However it was all too late to prevent the anoxic cerebral outcome now so well recognised post-resuscitation. The patient died after four and a half days. Barclay appended to his account the arrest of a bronchitic male of 53 treated with artificial respiration and cardiac massage for more than one hour, coramine and adrenaline, all of which failed.

The author described good resuscitation principles, emphasising that synchronous artificial respiration and cardiac massage are needed promptly, accepting intubation as vital and that arrest time to natural return of spontaneous circulation or to adequate resuscitation was critical. (Footnote 6.)

MODERN WORLD WAR II TREATMENTS OF ShOCK FOR CIVILIAN PRACTICE

At an Auckland Postgraduate Conference, April 1943, Captain LA Erskine (US army) (46) defined trauma principles to New Zealand medicine. Thus, "The replenishment of the blood volume is the paramount objective" whether that was via crystalloids, colloidals, plasma, (whole-)blood (directly) or amino-acids. While the use of vasospastics (adrenaline, noradrenaline) was "distinctly questionable", morphine, "putting the patient at rest" and mild warmth were advantageous.

After the war, in 1946 JM (Jock) Staveley (47) summarised his wartime transfusion experience for civilian use by stating "the greatest help comes from the actual supply of blood rather than in anything new relating for indications for transfusion or in the administration of blood". Even though blood for field-use had been pre-typed, but had no cross-matching and was Group O only, it was to be as fresh as possible, while the necessity for clean apparatus was considered essential. (A rechecking of the blood-typing at three months showed around 8% error.)

THIOPENTONE FOR ECLAMPTIC CONVULSIONS, 1946

Again in 1946, PD Short (48) presented two successful recoveries from convulsions, after administering thiopentone sodium infusions. A 26-year-old multiparous woman developed six convulsions postpartum, then a further one while being admitted to Nelson Hospital in deep coma with hypertension (155/100 mmhg). A thiopentone sodium drip stopped an eighth fit after one minute, but the thiopentone sodium needed re-starting after two further fits. This established control of fitting and after about 12 hours the woman was awake and rational.

A fitting, pregnant (27 weeks), hypertensive (220/11 mmhg), multiparous woman in coma had no further fits following treatment by a thiopentone sodium drip, was conscious after about 17 hours, then was delivered of a dead foetus.

Neither patient required as much as a total of 0.5 g thiopentone, both breathed spontaneously.

ADVANCES IN TREATMENT OF TETANUS: THIOPENTONE ANAESTHESIA AND CURARISATION, 1945 AND 1950

In 1945 Dr SC Hawes (49) ensured three days of "almost surgical" anaesthesia by a thiopentone sodium drip (1 g per 0.5 l of 0.9% NaCl) for an 11-year-old boy with great pain from tetanus spasms. Thiopentone sodium was given initially pro re nata to control spasms, but "he had to be kept nearly continuously at an almost surgical level of anaesthesia for the first three days". A total of 20 g (including wastage) by the sixth day had the tetanus manageable enough to transfer him onto rectal tribromoethanol (Avertin[R]) but also done for fear of hepatic damage. he was not intubated, but the essentials of sedation and quiet were appreciated and ensured. Anti-tetanic serum 100,000 units was given for the first eight days, with recovery following from the 10th day. Hawes recommended "A quiet room and an intelligent nurse" and that "Sedative therapy is the keystone of treatment".

In 1950, after a decade of 11 other unpublished New Zealand cases of tetanus with two recoveries, and another series treated by basal sedation with 50% surviving, DW Beaven (50) and his Christchurch team supplied a six-year-old boy with anaesthetic doses of tribromoethanol with 350 mg tubocurarine (d-TC) over [greater than or equal to] 12 days, to control his tetanus spasms and severe opisthotonus. The d-TC given was around 30 mg daily, with a 350 mg total. On the third day he had needed artificial respiration (of a type unspecified) and prostigmine reversal of d-TC for either "an overdose or cumulative effect of curare". No airway tubes were mentioned, postural drainage was emphasised and nursing interventions were kept minimal or timed to sedation peaks. On the 12th day medication was changed to chloral and paraldehyde by gastric tube, with recovery following the last spasm on the 21st day.

NEUROLOGICAL VENTILATORY FAILURE, ESPECIALLY IN POLIOMYELITIS

Intensive care medicine advances during the 1950s in New Zealand are covered in the book Intensive Care in New Zealand (2).

Since "The greatest threat to the health of New Zealanders in the years 1940 to 1949 was neither syphilis nor tuberculosis but poliomyelitis" (51), this account finishes with a few words about artificial respiration for polio, most of which is also in Intensive Care in New Zealand.

* 1928-onwards, it is not clear if there were any Drinker respirators in New Zealand.

* 1938, November, Wellington hospital's new Both "iron lung" first used for polio (51(p. 84)).

* 1939, Lord Nuffield donated 15 Both respirators to New Zealand.

* 1947-onwards, Boths were used in polio epidemics at Auckland Hospital.

* 1947, the Sister Kenny treatment employed at Waikato Hospital (52(p. 72)) (was the hospital's Nuffield-Both respirator used? (52(p. 60))).

* 1953, Timaru hospital had a long power lead temporarily run to a Both at the railway line for its polio patient to see Queen Elizabeth II's train pass through the town (2(p. 105)).

* 1954, Taranaki hospital's Ian Auld et al made their own (PPV) Radcliffe pump from plans sent from Oxford, UK (2(p. 104)).

* 1955, JE Caughey's polio report advised respiratory centres with ventilators (intermittent negative pressure ventilation, intermittent positive pressure ventilation) (53).

* 1950s, "Iron lungs" and cuirasses were used at Dunedin for epidemics (and presumably also at Christchurch).

* 1950s, at Auckland hospital's infectious diseases unit (ex-Dr WR Lang, personal communication):

--Boths were also used for polyneuropathy,

--Dr Ruthven Lang supplied hand-intermittent positive pressure ventilation per Oxford bellows,

--efforts were made to control tetanus spasms with thiopentone-sodium injections.

* 1961, polio epidemic at Auckland's Infectious Diseases/Central Respiratory unit: 16 tracheotomies/ intermittent positive pressure ventilation, one death. (54)

CONCLUSION

This outline shows that although the foundation of intensive care medicine is generally accepted as originating in the early-1950s at Copenhagen, in the preceding century up to that decade there were occasional activities which had some elements of what we recognise today as intensive care medicine interventions. We should acknowledge and venerate such pioneers who were often working under immense difficulties.

ADDENDUM

Comments on findings at Auckland inquests, 1841-1864 (from Laurie Gluckman's Touching on Deaths (8))

Dr Gluckman explains many of the concepts of disease as they were understood in those times and the meaning of terms used then (e.g. serous apoplexy), but now curious to us. Drowning was the commonest cause determined among inquests on 374 deaths. "Visitation of God" (sometimes "Act of God") was applied for non-specifiable natural causes--often when death was "in a natural way". Intemperance, either long-standing or acute, is mentioned remarkably often.

The explanations accepted for placing many in the apoplexy group (sudden collapse with loss of sensation and power) would be disputed today, as various causes of stroke etc., are buried under the blanket term "apoplexy". Lunacy was sometimes designated to avoid the stigma of suicide. The types of cardiac and pulmonary causes appear well considered at the autopsies. Thirteen of the sudden deaths seem likely to have been from a (then) unrecognised acute coronary syndrome. Haematemeses caused three deaths.

Alcohol was considered significant in 91 inquests (almost one quarter, of whom eight involved delirium tremens) with 56 intoxicated at death and 22 of such deaths considered accidental. In 11, alcohol was considered the direct cause of death (I suspect 18 actually, from the accounts). There was prior alcoholic history in 36. (See Table 1 re a count of 100 vs 91.)

Personally, I found it difficult to achieve identical counts repetitively: some of my countings were marginally different from Gluckman's (while other people's tallies could be different again), but nor would I consider my own counts error-free, of course.

Thus for drownings I made a total of possibly 143 (vs Gluckman's 130, with 21 of these paediatric [P]), from: 82 in sea/harbour, 26 on shores, 17 in wells (16P), 10 in river/creek/ditch (2P), two in a pond (1P), two in a swamp hole, two in pits (1P) and two in a bucket (1P).

Trauma deaths were not listed by Dr L Gluckman as a group but totalled at least 85 by their various causes, including: fires/burns (11) (not LG's nine), run over (7) (4P), falls from height (9) (2P), falls from a horse (5), other falls (9), overlain (2) (2P), crushed (8), smothered/suffocated (7) and tree falling (6) (1P) etc. One road crash was from horse vs cart. Gunshot wounds claimed 10 (6 suicidal), sunstroke (4); exposure (2). Choking caused an asphyxial death in four.

Convulsions caused at least nine (3P) deaths. Poisonings from that era (7) (4P), could also interest intensivists: two by self (one with corrosive sublimate 30 gr, one with prussic acid), five accidentally: two (2P) with tutu (tupaki berry), one with arsenic, one (1P) with laudanum, one (1P) with strychnine. Infection and sepsis was recognised uncommonly as the cause of death (two from dysentery, one from cholera-type and one from gallbladder rupture).

Footnote 1

Some recent writing in New Zealand on the subject of cannibalism in those times has raised controversy. In 1859 Arthur Thompson discussed it at length (10(II, p. 141-150)) (as his predecessors often had), writing that any practice, "despite a strong liking for it", was "never" for a food source (Savage, 1807, did acknowledge it in "dire necessity" (5(p. 35))) but primarily "from motives of revenge and hatred, to cast disgrace on the persons eaten, and to strike terror" (10(II, p. 147)). Mary Ann, Lady Martin called it "this deadly insult to the vanquished" (11(p. 58)), Felix Maynard inflicting an "outrage" (12(p. 36)). Dieffenbach saw the eating of enemy being employed as a means to assimilate the strength and courage of the vanquished (6(p. 128)) or, as Maynard saw it, also acquiring their soul (12(p. 236)).

Footnote 2

More recently we are informed (16) that around 1840 to 1872 "historical information indicates that the Maori response to the introduction of alcohol was in fact diverse and for much of the nineteenth century alcohol was non-problematic for many Maori [with] significant variation in the response of Maori to the introduction of alcohol in different parts of New Zealand during the period following European contact".

Footnote 3

Interestingly, Thomson concluded his article (deriving from 1848) with "A higher state of health existed among the [7003 European] inhabitants in the town and districts around Auckland than is to be found in almost any town or country in Europe". Gluckman's attributing the statement (7(p. 122)) that New Zealand "was the safest of all foreign stations for the serviceman" to p. 47 of Wm Swainson's 1853 account24 would appear, as far as I could find, to be an interpretation rather than the direct quotation he indicates it to be. In evidence, Gluckman also gave Thomson's supportive figures (8(p. 32)); and noted "The Maori envied the settler his good health" (7(p. 123)), while they expected every European to be skilled with a knowledge of medicine.

We can note that The New Zealand Company ensured its settlements had doctors as in other settlements. Government policy was that both naval and army medics would make their expertise available to sick settlers (7(p. 102)). (All navy ships had a surgeon, as had some whalers and other ships.) But it does amaze me to read of the number of times in the days of the earlier settlers when the arrival of a ship with a surgeon happened so conveniently, just when one was needed, such as for an amputation.

Footnote 4 (27)

As a diversion, it can be noted that in Australia some interventions going on at this time, 1888 to 1910 (as identified by the Australian and New Zealand College of Anaesthetists historian Gwen Wilson), included: artificial respiration (as per the methods of hall, Silvester, howard or Schafer), oxygen therapy, e.g. for diabetic coma (LW Bickle, 1892, cited by Wilson (27(p. 249))), progress in intravenous therapy, with saline or Ringer's solutions, especially for obstetrical haemorrhage (27(p. 285)), electrical stimulation for cardiac arrest, also rhythmic cardiac compression through opened chest or abdomen. (Direct) blood transfusion was becoming better known, but progress was quite limited, and it was given only in dire emergency, especially post-partum (27(p. 284)). While from Timaru (New Zealand), hV Drew (28) reported equipment for that procedure in a letter to the Australasian Medical Gazette of 1885 (27(p. 162)).

Footnote 5

hacon wrote of his intubation as "Malcolm's Operation", a term explored by Dr Basil Hutchinson F.A.N.Z.C.A., at his presentation to the Dunedin 1980 Anaesthetic Conference. After characteristically thorough investigation, Hutchinson pondered: "Who is Malcolm? I can find no Malcolm writing about intubation at this time [1889]. Did hacon mean Macewan? Perhaps his longhand was not clear and the typesetter made Malcolm out of Macewan, our pioneer of 1880" (for Macewen's intubating action, it was actually of 1878, documented 1880, RVT). Such an explanation accords well with a typesetting problem from the 1870 era, which I (RVT) have battled with recently (31).

Footnote 6

Concerning the recognised status of cardiac resuscitation at this time, Barclay stated others had 50 successful rescues by cardiac massage up to the time of his own attempt, with the first from Starling and Lane in 1902. He drew attention to a successful resuscitator, Dr Hamilton Bailey with his 40 experiences--who stated in the British Medical Journal (44) that 13 of these hearts "restarted in earnest", but only four patients survived. Bailey supplied admirably precise and lucid principles for operating theatre team-discipline and treatment of arrest from anaesthetic agents, calling for cardiac massage to be started by 90 seconds after arrest. Later he repeated his simplified action plan (45) after "being in a position to record three consecutive recoveries from impending death under anaesthesia".
APPENDIX
Titles of some early journals and books with New Zealand
medical references; See other examples in the reference list:
5, 6, 7, 9-15, 21, 24.

1642 Tasman A et al, in McNab R. historical
 Records of New Zealand vol. 1: 1908; vol. 2:
 1914
1768 to 1771 Banks, Sir J. Endeavour Journal.
1769 Cook, Capt J. First Voyage Journal.
1773 Cook, Capt J. Second Voyage Journal.
1783 de Surville JFM, du Fresne M-JM. In Abbe
 Rochon's Nouveau Voyage a la Mer du Sud.
1817 Nicholas JL. Narrative of a Voyage to New
 Zealand in 1814-15 (with Reverend S Marsden).
1824 Cruise, Capt RA. Journal of a Ten Month
 Residence in New Zealand.
1825 to 1855 Williams W. William William's Journal
 (Typescript in Auckland Museum).
1827 Earle A. Narrative of a Nine Month's
 Residence in New Zealand.
1827 to 1867 Baker, Rev. CB. Journal and Letters
 (typescripts in Auckland Museum).
1830 to 1835 d'urville J-S-CD. Voyage de la Corvette
 L'Astrolobe.
1831 to 1868 Puckey WG. Letters and Journals (in Auckland
 Museum Library).
1834 to 1880 Skinner WH. Pioneer Medical Men of Taranaki.
1836 Marshall, Dr WB. A Personal Narrative of two
 Visits to New Zealand in hMS Alligator AD
 1834
1838 Polack JS. New Zealand, Being A Narrative of
 Travels and Adventure.
1840 Ward J. Information relative to New Zealand,
 2nd ed *.
1841 Bright, Dr J. handbook for Emigrants.
1842 Terry C. New Zealand, its advantages and
 prospects as a British Colony.
1861 Bunbury, Maj T. Reminiscences of a veteran.
 Vol 3.

* Available online from books.google.co.nz by entering title and
author. Accessed April 2009.


ACKNOWLEDGEMENTS

I am delighted to acknowledge my generous helpers for this paper:

* Dr Basil Hutchinson, F.A.N.Z.C.A., who most valuably directed me to the NZMedJ papers, and for his innovative interpretation of "Malcolm's Operation".

* Dr Laurie Gluckman, F.R.A.C.P., F.R.C.Psych. for his essential two books, and Mrs Ann Gluckman for her generosity in giving me the very hard to find Touching on Deaths, for which I am most grateful.

* Treve Dromgool and David Churchouse of MedPhoto, Auckland City Hospital, for their kind assistance and much expertise with imagery.

* Philson Library, university of Auckland, for speedily securing me a large number of references.

* Jenny Jolley, ANZCA librarian, Melbourne for her expertise in locating the difficult reference for George Bennett.

* Dr Tony Newson, F.A.N.Z.C.A., F.R.C.A., for expert advice on early New Zealand archives and especially re Rachel Branks.

Accepted for publication on April 29, 2009.

REFERENCES

(1.) Spence M. The Annual Report 1960 of the Respiratory Unit--Auckland Hospital. Presented to the Auckland Hospital Board, Auckland 1961 (Mar).

(2.) Trubuhovich RV, Judson JA. Intensive Care in New Zealand. A History of the New Zealand Region of ANZICS. The authors, Auckland 2001.

(3.) Bower AG, Bennett VR, Dillon JB, Axelrod B. Part I: Investigation on the care and treatment of poliomyelitis patients. Ann West Med Surg 1950; 4(10):561-582. Part II: Physiological studies of various treatment procedures and mechanical equipment. Ann West Med Surg 1950; 4(11):686716.

(4.) Ibsen B. The anaesthetist's viewpoint on treatment of respiratory complications in poliomyelitis during the epidemic in Copenhagen, 1952. Proc Roy Soc Med 1954; 47:72-74.

(5.) Savage J. Some account of New Zealand; particularly the Bay of Islands, and surrounding country; with a description of the religion and government, language, arts, manufactures, manners, and customs of the natives, &c. &c. J Murray, London 1807 *.

(6.) Dieffenbach E. Travels in New Zealand: with contributions to the geography, geology, botany, and natural history of that country. 2 Volumes. J Murray, London 1843 *. From www.archive.org/search.php?query=subject%3A%22Maori%20language% 22 Accessed April 2009.

(7.) Gluckman LK. Tangiwai: a medical history of 19th century New Zealand. Auckland 1976.

(8.) Gluckman LK. Touching on Deaths. Gluckman A, Wagg M, eds. doppelganger, Auckland 2000.

(9.) MacMillan D. By-ways of History and Medicine (with special reference to Canterbury, New Zealand). Christchurch 1946.

(10.) Thomson AS. The story of New Zealand: past and present--savage and civilized. Vols I and II. Vol II is online. J Murray, London 1859 (reprinted Capper Press, Christchurch 1974) *.

(11.) Martin, Lady MA. Our Maoris. Society for Promoting Christian Knowledge, London 1884 (facsimile reprint Wilson & Horton, Auckland).

(12.) Maynard F. [Les Baleiniers. Dumas A, pere, ed. 3 Vols, 1858]. The Whalers (translated Reed FW). Hillman-Curl Inc., New York 1937.

(13.) Colenso W. On the Maori races of New Zealand. Trans & Proc New Zealand Institute 1968; 1:5-76 (from an original text for the 1865 New Zealand Exhibition).

(14.) Bennett G. The practice of medicine, surgery, &c. among the New Zealanders and natives of some of the Polynesian islands. Lond Med Gaz 1831-1832; 9 new series: Part 1 (Dec 24):434-439, Part 2 (Jan 28):628-633.

(15.) Ward J. Information relative to New-Zealand, compiled for the use of colonists by John Ward, Esq, secretary to the New-Zealand Company, 2nd ed. John W Parker, London 1840; p. 63 *.

(16.) Mancall PC, Robertson P, Huriwai T. Maori and alcohol: a reconsidered history. Aust N Z J Psychiatry 2001; 34:129-134.

(17.) Campion DS, Spence M. Barbiturate intoxication occurring in Auckland. N Z Med J 1964; 63:206-210.

(18.) Garland TO. Artificial Respiration. With special emphasis on the holger Nielsen method. New Zealand Government, Wellington 1953.

(19.) Monteith GD. Letter to the Editor. New Zealand Gazette. NZ Gaz & Britannic Spectator 1840 Sep 9; p. 2 (cols. 3-4).

(20.) Lewis R (for the Committee, Royal National Life-Boat Institution,UK). Treatment of the apparently drowned. West Coast Times 1865 Aug 17; p. 3-4 (cols. 6, 6).

(21.) Shortland E. The Southern Districts of New Zealand: a journal, with passing notices of the customs of the aborigines. Longman, Brown, Green & Longmans, London 1851; p. 190-193 *.

(22.) "Accident" (Newspaper Trauma Report). NZ Spectator & Cook's Strait Guardian 1847 Sep 18; III (issue 223), p. 2 (for Death Notice, see Oct 2).

(23.) Thomson AS. History of the first epidemic scarlet fever which prevailed in Auckland, New Zealand, during the year 1848. Lancet 1850; (12 Jan) 55 (1376):48-49.

(24.) Swainson W. Auckland, the Capital of New Zealand, and the adjacent country. Smith, Elder & Co, London 1853 (facsimile reprint Wilson & Horton, Auckland) *.

(25.) Slade h. Notes on the late New Zealand War. Lancet 1868; (11 Jan) 91 (2315):44-45 and (18 Jan) 91 (2316):83-85.

(26.) Nedwill C. Five cases of abdominal surgery and a case of hydatid tumour of the brain. Lancet 1898; (28 May) 151 (3900):1464-1467.

(27.) Wilson G. One Grand Chain, 1846-1934, Vol 1. J Thirlwell-Jones, ed. Australian and New Zealand College of Anaesthetists, Melbourne, 1995.

(28.) Drew HV. Letter: A simple and novel method of transfusion. Australasian Med Gaz 1885; 4:155.

(29.) Hutchinson BR. New Zealand's earliest anaesthetists. In: Keneally J, Jones M, eds. Australasian Anaesthesia. Melbourne: Australian and New Zealand College of Anaesthetists 2000. p. 91-93.

(30.) Hacon W. Catheterisation of the larynx (Malcolm's operation). N Z Med J 1889; 3 (old series):45.

(31.) Trubuhovich RV. Early artificial ventilation: the mystery of "Truehead of Galveston"--was he Dr Charles William Trueheart? Crit Care Resusc 2008; 10:338.

(32.) O'Dwyer J. Intubation of the larynx. New York Med J 1885; 42:145-147.

(33.) Trubuhovich RV. 19th century pioneers of intensive therapy in North America. Part 2: Joseph O'Dwyer. Crit Care Resusc 2008; 10:154-168.

(34.) Annotation (Drs hales, Newmarch, Clubbe, Lennox Browne reported). Australasian Med Gaz 1889-1890; 9:325-327.

(35.) Scholes FV. Diphtheria, Measles, Scarlatina, 2nd ed. Ch V-VII, Laryngeal diphtheria.Wm Ramsay, Melbourne 1927; p. 104-149.

(36.) Marsack A. Two consecutive cases of tetanus treated with tetanus antitoxin and chloral hydrate; recovery. Lancet 1897; (17 Apr) 149 (3842):1088-1090.

(37.) hatherley. Two cases of tetanus treated by injections of antitetanus serum. N Z Med J 1902; 2 (new series):401-407.

(38.) McLean JF. The resuscitation of apparently asphyxiated infants. N Z Med J 1904; 3 (new series):292-295.

(39.) Elsberg CA. The value of continuous intratracheal insufflation of air (Meltzer) in thoracic surgery. Med Rec 1910; 77:493-495.

(40.) Nash. Thoracic surgery and intra-tracheal insufflation. N Z Med J 1914; 13:83-96.

(41.) Fitzgerald D. Tracheotomy in diphtheria. N Z Med J 1918; 17:171-175.

(42.) Robertson C. Cardiac massage. N Z Med J 1918; 17:142-143.

(43.) Barclay S. Resuscitation by cardiac massage. N Z Med J 1946; 45:446-452.

(44.) Bailey H. Cardiac massage for impending death under anaesthesia. BMJ 1941; (19 Jul) ii:84-85.

(45.) Bailey h. Cardiac massage (letter). BMJ 1946; (5 Jan) i:29.

(46.) Erskine LA. Modern advances in the treatment of shock. N Z Med J 1944; 43 (Suppl):5-9.

(47.) Staveley JM. Blood transfusion in the army. Its application to civil practice. N Z Med J 1946; 45:358-360.

(48.) Short DP. Control of eclamptic convulsions by pentothal drip; a report of two cases. N Z Med J 1948; 47:485-486.

(49.) Hawes SC. Pentothal sodium in the treatment of tetanus. N Z Med J 1945; 44:22-23.

(50.) Beaven DW, Dobson DJ. Curare in tetanus. N Z Med J 1950; 49:24-25.

(51.) Barber L, Towers R. Wellington hospital 1847-1976. Wellington hospital Board, Wellington, New Zealand 1976.

(52.) Wright-St Clair RE. From cottage to regional base hospital. Waikato hospital 1887-1987. Waikato hospital Board, hamilton, New Zealand 1987.

(53.) Caughey JE. Recent advances in poliomyelitis. N Z Med J 1955; 54:10-18.

(54.) Manning RR, Lang WR. Respiratory and bulbar cases of poliomyelitis. A report of their management in Auckland, 1961. N Z Med J 1962; 60:506-512.

This article is based on a talk delivered 14 October 2008 at the ASA/NZSA Combined Scientific Congress, Wellington, New Zealand.

R. V. TRUBUHOVICH * Auckland, New Zealand

* M.B., Ch.B., M.Sc.(Oxon), F.R.C.A., F.A.N.Z.C.A., F.J.F.I.C.M., Honorary Intensivist Specialist.
TABLE 1
Touching on Deaths: Coronial Findings at 384 Auckland Inquests,
1841 to 1864 (8)

(As interpreted/determined by Dr L Gluckman, but now
re-arranged here by frequency)

Types of causes of death Number

Drowning 130
Alcohol factor * (males, at least 67) 91
"Visitation of/from God" 54
Apoplexy and serous apoplexy 44
head injury 23
"Lunacy" 20
Cardiac conditions (13 per PM, 6 not) 19
Bleeding (12 males) 17
Murder 16
Pulmonary conditions (8 per PM, 5 per history) 13
Fire/burns deaths (also 9 further enquiries into fires, 11
without deaths)
Gunshot wounds (6 suicides, 1 murder, 1 accident) 8
Poisonings 7
All other verdicts (4 sunstroke, 2 congenital heart 16
disease, 2 obstetrical, 2 neonatal, 2 dysentery, 1
neurologic, 1 typhus, 1 cholera, 1 stillbirth)

384 is the number of inquests the book lists and describes.

369 is the significant/examinable number, once we exclude 15
(per 9 inquests only for fires that were non-fatal, 1 not logged and
5 indeterminable--4 of these for bodies too decomposed).

469 is the total of coronial findings Gluckman describes in his
text, p. 99-108, originally arranged alphabetically.

378 is the number after extracting all 91 "alcohol related"
conditions from 469. (Yet 100 is the number he gives by
groupings for "alcohol related" conditions *.) Even without any
deaths being ascribed directly and solely to alcohol, leaving 378
(not 369) of these 469 conditions as classified above, there has to
be some overlap.

The 53 paediatric inquests include 1 stillborn and 2 neonates
(1 neglected, 1 overlain).

* Gluckman, having written of 91 occasions when alcohol could
be "considered a factor"6, then on the same page lists, as below,
deaths when an alcohol factor applied, which total 100. So
obviously they could not all be the sole causes of death; but,
presumably, there needed to be some overlapping, probably with
such as the group of deaths which were "due to natural causes":
23 apoplexies, 22 accidents, 20 drownings, 8 lunacies, 8 suicides,
7 natural deaths, 5 falls from heights, 3 burns deaths, 2 gunshot
deaths, 1 manslaughter, 1 fall from a horse.

PM=post mortem.
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