Elementary, my dear Dr. Allen: the case of barium toxicity and Pa Ping.

OBJECTIVE: We aimed to review the English and Chinese literature on Pa Ping and to confirm by personal interview the story of how its pathogenesis was uncovered. BACKGROUND: In 1930, Dr. Alexander Stewart Allen noticed a pattern of illness arising in the region of Kiating, China. Area residents began presenting to local hospitals with nausea, vomiting, and diarrhea, and what emerged was a clinical picture of a gradual ascending paralysis that could result in death, termed Pa Ping. All 3 patients observed by Dr. Allen were male, had no family history of the disease, and had recently eaten before the onset of paralysis. Pa Ping developed in Dr. Allen himself, but he survived. METHODS: Medical literature was reviewed for primary sources. Interviews of living descendants and friends of the doctors in China and North America were conducted and information was corroborated by written records. RESULTS: Dr. Huang, with the National Central University College of Medicine, noticed a striking similarity between Pa Ping and familial periodic paralysis in 12 patients and reported 2 patients with Pa Ping treated with potassium citrate who experienced a reversal of the paralysis. Dr. K.T. Du analyzed meals of patients with Pa Ping seen by Dr. Zhe Tung and found barium in concentrations as high as 25.7%. This finding was confirmed by administering barium chloride to animals, which recapitulated the human syndrome. CONCLUSIONS: Although Dr. Huang had correctly noticed an underlying potassium depletion in patients with Pa Ping, the observations of Dr. Zhe Tung and Dr. K.T. Du ultimately established barium-induced hypokalemia as the underlying cause.

Notable Australian contributions to the management of ventilatory failure of acute poliomyelitis: with special reference to the Both respirator and Dr. John A. Forbes.

When Australia's 1937 epidemic of poliomyelitis created an urgent need for extra ventilating machines to compensate for respiratory paralysis, Edward Both, an innovative Adelaide biomedical engineer, invented a wooden-cabinet respirator capable of being made relatively quickly in sufficient quantity. His device, here called "the Both", alleviated the problem at Adelaide's Northfield Infectious Diseases Hospital and others, and in late 1938 was introduced into England when Both was visiting there. Appreciating its merits, Lord Nuffield financed assembly-line production at the Morris motor works in Cowley, Oxford. Then, through the Nuffield Department of Anaesthetics in Oxford's Radcliffe Infirmary, he had the Both distributed Commonwealth-wide, as a gift for treating ventilatory failure in polio - especially in children. For the 1937 epidemic in Victoria, and to the design of Melbourne University's Professor of Engineering, Aubrey Burstall, nearly 200 of another wooden-cabinet respirator were ultimately built. Some were installed at the Acute Respiratory Unit of the Infectious Diseases Hospital at Fairfield, then others "all over Australia". However, by the early 1950s, the Both had replaced Fairfield Hospital's "Burstall", which had functioned as Victoria's favoured respirator since 1937. Dr John Forbes at Fairfield became the foremost Australian clinician for expertise with the Both. Before the advent of intermittent positive pressure ventilation, the Both's usefulness had seen it tried for ventilatory failure in some non-polio conditions, but uptake of that application was limited. Nonetheless, Nuffield's philanthropy with the (Nuffield-)Both ultimately furthered progress along the 20th century pathway to intensive care medicine.

The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology.

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 Pco(2) 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.

On the physical death of Jesus Christ.

Jesus of Nazareth underwent Jewish and Roman trials, was flogged, and was sentenced to death by crucifixion. The scourging produced deep stripelike lacerations and appreciable blood loss, and it probably set the stage for hypovolemic shock, as evidenced by the fact that Jesus was too weakened to carry the crossbar (patibulum) to Golgotha. At the site of crucifixion, his wrists were nailed to the patibulum and, after the patibulum was lifted onto the upright post (stipes), his feet were nailed to the stipes. The major pathophysiologic effect of crucifixion was an interference with normal respirations. Accordingly, death resulted primarily from hypovolemic shock and exhaustion asphyxia. Jesus' death was ensured by the thrust of a soldier's spear into his side. Modern medical interpretation of the historical evidence indicates that Jesus was dead when taken down from the cross.