JG Farrell and The Lung : An early description of intensive care delirium in literature

JG Farrell (1935–1979) was an author born in England with Irish heritage.

His novels included the 1973 Booker Prize winning The siege of Krishnapur, Troubles and The Singapore grip. These three very different works form his Empire trilogy.

As a young man during the poliomyelitis epidemic of the 1950s he contracted polio and required mechanical ventilation in an iron lung. This experience informed a more obscure, and now out of print novel, The Lung, which contains perhaps the first description of intensive care delirium and the post intensive care syndrome in literature.

We examine this experience in light of the unprecedented numbers of patients now sharing similar experiences in the context of the current SARS-CoV-2 pandemic, and highlight its insights into the early reality of intensive care medicine.

JG Farrell

James Gordon Farrell was born in Liverpool in 1935 to William Farrell, an accountant, and Prudence Farrell, a secretary. At eight years of age he was sent to Terra Nova, a boarding school in Cheshire. His academic work and sporting talent impressed and, after becoming Head Boy, he won a scholarship to Rossall, a Lancashire public school. ¹

The family moved to Ireland in 1947 to be nearer to Prudence’s parents. Farrell continued to travel back and forth to Rossall, enjoying life in South Dublin on his holidays and coming to regard himself as Irish. Around this time, he described a recurring dream of drowning, oddly prescient of the near suffocation he later experienced.

Farrell continued his studies at Brasenose College, Oxford, in 1956 and looked set to excel on and off the rugby field. He completed only six weeks, however, before fate intervened. After a rugby training session he fell ill and was diagnosed with polio. ²

Within days Farrell was transformed from a 21-year-old muscular and high-performing rugby player into a patient, struggling to breathe with profound weakness of shoulders and neck. The sole means of ventilatory support available to such patients at this time was through negative pressure ventilation—the iron lung. Positive pressure ventilation was still in a pioneering phase and intensive care units were an emerging concept.

Farrell spent four weeks mechanically ventilated at Slade Isolation Hospital in Oxford and a further three months rehabilitating and undergoing intensive physiotherapy at Wingfield Morris Hospital, Headington. ³ On being allowed home to Dublin he was 25 kg lighter than before and had persistent upper body and respiratory muscle weakness.

These experiences informed the writing of The Lung and left an indelible psychological mark on Farrell. Many friends suspected that he suffered from what we would today term post-traumatic stress disorder. He later wrote, ‘I only have to close my eyes to see it all again in such sharp detail … so desperately tiring to struggle all the time and see nothing in the future.’ ³

Illness and consequent suffering are prominent themes of Farrell’s later work—cholera in The siege of Krishnapur and leukaemia in Troubles. Characters are often disenchanted and struggle to connect with others. It is in The Lung, however, that Farrell attempts to confront his most traumatic experience.

Farrell’s physical weakness was permanent and his breathing became progressively more difficult as the years went on. Twenty years later he slept ‘propped high with pillows to ease his breathing’ and struggled with recurrent respiratory infections. ³ Although Farrell and ‘the lung’ fought off polio in his 20s it seems the disease may have been a factor in his eventual death. While rock fishing in Bantry Bay, Ireland, in 1979 he was swept into the sea and drowned. He was 44 years old.

The Lung

In The Lung, Farrell tells the story of Martin Sands, a sometime writer in his 40s. He falls ill while drinking at a wedding and is rushed to hospital, struggling to breathe. There he first hears of the suspicion of polio, which he is told ‘is a neurotropic virus’ and we are immersed in the perspective of a critically ill patient, struggling to process information while reality is distorted around us.

Delirium is a prominent feature from arrival in hospital. Imagined scenes ‘lost on that immense snowfield’ with Sally, his ex-wife, are interspersed with horrifying repeated realisations of his predicament. In one passage he notices a nurse watching him carefully and speculates ‘perhaps she’s gone nuts and thinks I’m a boiled egg or something’ before ‘the truth exploded like a firework and drenched the darkness with fear. She was counting the rate of his breathing’.

Like Farrell, Sands is ultimately entombed in an iron lung to support his breathing. Powerless to resist, he is stripped naked, the machine sealed around his neck and robbed of his dignity—‘feminine eyes impassively inspected his sex which lay there, he thought, rather like a cluster of sea urchins dead on the empty highways of his body’. His loss of privacy and bodily autonomy are intense and dehumanising.

After a moment of sudden relief—‘the exhilaration of filling one’s lungs’—the discomfort of the iron lung becomes evident. The lung is time cycled; ‘You’ll find you can only speak when the machine is breathing out for you … you must swallow as the machine breathes out for you, otherwise it gets sucked into your lungs’. Sands is depersonalised and feels ‘For the doctor … he was merely part of the machinery’. He describes the horror of a nasogastric tube insertion and, in desperation, lapses into another fantastical hallucination, himself—‘striped, dripping fanged … looking for a delicate virgin antelope’—before he experiences a bolus of gastric feeding and assumes ‘that he had swallowed a small fish’. With Sands we experience the uncomfortable procedures critical care practitioners take for granted from the viewpoint of a baffled patient.

Unlike Farrell, who was a 21-year-old student when he became ill, Sands is an older man, experienced with women and essentially a womaniser. Throughout his hospitalisation he is haunted by his relationship with his ex-wife, to whom he was unfaithful four weeks into their marriage. In a bizarre coincidence, Marigold, her daughter and his stepdaughter, is a nurse who later cares for him. Sexual fantasies of both women intermingle to become a feature of his hallucination.

Sands appears to improve somewhat from the acute phase of his illness and is moved to a multi-occupancy room. There he meets Exmore, an atheist former preacher; Higgins, a former successful cricketer; and Wilson, who punctures car tyres in the local village and later takes a fatal overdose of sleeping pills. These characters are a source of much of the humour in the second half of the novel.

Sands develops a fixation on his nurse and former stepdaughter, Marigold. He is successful in his sexual conquest but it is a hollow one. It seems his desire was driven to prove to himself that he is still a man, despite his weakness and dependence, and the experience leaves him only ashamed and guilty. ‘She’s just a child, he thought. What on earth am I doing?’

As he recovers, Sands develops a friendship with a young girl named Monica, with whom he shares walks in the hospital grounds. He is devastated when he learns that she has terminal leukaemia. ‘All her desires and dreams and personality conceived for nothing. Monica! It was impossible to think of her dying.’ It seems that his guilt over surviving his own illness is magnified by the knowledge that this sinless girl is slowly dying.

Sands ultimately leaves hospital. He says goodbye to the doomed Monica, who could be said to represent the loss of his youth, Higgins, his loss of physical prowess, Exmore, his faith, and leaves hospital with confused emotions. He imagines a future with Marigold—‘I married my ex-stepdaughter and we had 10 children and lived happily ever after’—and finds it ‘just terrible’. Is there any hope for a happy life? We are left wondering whether he can ever recover or whether the experience has in fact taught him anything.

Farrell himself had mixed feelings about the novel. He later wrote ‘there are passages written with maximum ability but the book is uneven’. ³ Perhaps a more direct treatment would have been more consistent. Biographer Lavinia Greacen believed that the character of Sands was an attempt by Farrell to distance himself from the experience. ² Sands and the other characters act as buffers between the author and his ordeal. Sands is middle-aged and jaded, unlike the 21-year-old Farrell, an academic and athletic star at Oxford who had the world at his feet. The other characters seem vehicles for the themes Farrell cannot confront directly; faith, loss of youth and the inability to connect with others. The novel itself is a victim of the trauma it depicts.

Polio and mechanical ventilation

Poliomyelitis is an infectious disease caused by the poliovirus. It can result in flaccid paralysis requiring mechanical respiratory support. Prior to widespread vaccination, which began in the 1950s, it occurred in epidemics causing large numbers of deaths and chronic disability in many survivors. Today polio is eradicated in much of the world and in 2022 wild cases were seen only in Afghanistan, Pakistan and Mozambique. ⁴

The iron lung is a type of negative pressure ventilator. The patient’s body is encased in a sealed container within which the pressure is varied using a mechanically driven diaphragm at one end. The first successful use on a human was by Philip Drinker and Louis A Shaw Jr, professors at Harvard in 1928. They used their ventilator to resuscitate an eight-year-old girl who was suffering from respiratory failure due to polio for 122 hours, before she eventually died. ⁵

Drinker and Shaw used a refinement of previous designs and, despite a failed attempt to preserve their intellectual property rights, many imitator devices were created worldwide. ⁶ Farrell was likely ventilated in a Both–Nuffield respirator—by the 1950s they outnumbered Drinker machines in the UK 23 to 1. ⁷ The Both–Nuffield respirator, developed by two South Australian brothers, Edward and Donald Both, and manufactured by British car magnate Lord Nuffield, could be built at a fraction of the cost of the Drinker machine. ⁸ The Boths produced their device in response to a request from the South Australian government during their polio epidemic of the late 1930s.

Another outbreak of the disease in Copenhagen, Denmark, in 1952 inspired the next major development in mechanical ventilation and the creation of the first intensive care unit. During the first three weeks of the epidemic 27 of 31 patients ventilated on negative pressure ventilators died. ⁹ The chief physician at Blegdamshospital, Copenhagen, Henry Cai Alexander Lassen, consulted with anaesthetist Bjorn Ibsen to develop a solution.

At the time, physicians focused on cyanosis to assess oxygenation with no effective method to assess ventilation. Ibsen correctly identified high blood levels of carbon dioxide seen in polio patients who died as a consequence of poor ventilation. ⁹ He proposed using hand ventilation through tracheostomies to deliver positive pressure ventilation to such patients. Together with clinical scientist Poul Astrup, he also pioneered the use of regular blood gas analysis to assess the adequacy of ventilation. Their methods halved the mortality rate of polio patients needing respiratory support. ¹⁰

Ibsen placed these patients in a set area of the hospital, recognising the benefit of specially trained staff and concentrated resources. Thus, he was not only a pioneer in ventilation but created the first intensive care unit (ICU), a concept which later spread throughout the world, reaching Australia in the late 1950s. ¹¹

In later years electrically driven ventilators (‘mechanical students’, referring to the medical students they replaced) took over from hand ventilation of these patients. In time, negative pressure ventilators disappeared from use.

The hidden burden on intensive care survivors

In 2020 the SARS-CoV-2 pandemic spread worldwide.

Unprecedented pressure on health systems and, in particular, ICUs ensued. Healthcare organisations and governments scrambled to acquire enough ventilators to accommodate the surge of SARS-CoV-2 sufferers who would need them. Patients with SARS-CoV-2 were found to require prolonged mechanical ventilator support and, in many cases, spent more than a week intubated when invasive ventilation was required.

Prior to the 21st century the ‘ICU syndrome’ was the term used to describe the psychiatric symptoms associated with critical illness. In 1966, a year after the publication of The Lung, F Patrick McKegney, ¹² a New York psychiatrist and pioneer in the field of liaison psychiatry, coined the term ‘intensive care syndrome’, referring to the ‘madness’ seen in perioperative and critical care settings. The term remained loosely defined and used to describe both acute, reversible and chronic, irreversible conditions. ¹³

In 2000, Brian McGuire, an Irish psychologist, and his co-authors ¹⁴ were among the first to argue that the acute component of the ‘syndrome’ would be more helpfully described as ‘ICU delirium’ and described the features of reduced level of consciousness, disturbed cognition with acute onset and a fluctuating course. In The Lung Farrell gives us one of the first descriptions in literature of these features, long before the term was first used medically.

In addition to the ICU delirium so vividly depicted in the novel, Farrell later became a victim of what we would now call post intensive care syndrome (PICS). The Society of Critical Care Medicine defined PICS in 2012 ¹⁵ as ‘new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalisation.’ Farrell’s PICS involved chronic upper limb weakness and breathing difficulty and he refers to low mood and recurring dreams of his illness in his letters. ³

Farrell’s PICS may have contributed to his death through either its physical or its mental health features. He drowned when overcome by waves while rock fishing. It seems likely that his upper limb and respiratory weakness would have predisposed him to drowning in the event of immersion, and local suspicion in Bantry at the time was that he had committed suicide. A coroner ultimately ruled his death an accident and attributed it to dangerous weather conditions. ²

In the context of the SARS-CoV-2 pandemic, unlike the obvious requirement for ventilators and ICU beds, the impact of PICS is difficult to measure and likely enormous. It remains to be seen whether we can expand treatment and rehabilitation services for survivors with the same alacrity we applied to the acquisition of machines with which to prolong their lives.

Conclusion

The Lung gives us a fascinating insight into the critical care experience from a first-person perspective. Farrell’s experience has similarities to that of a modern intensive care patient but is surely more frightening. The methods used—such as brief interruptions of ventilator support to assess return of lung function—show us how far and how quickly the discipline of ICU medicine has evolved.

Farrell illustrates not only the physical and psychological horrors of the illness and the treatments to which we subject patients but also the post critical care experience. The book shows us that the recovery is never complete and forces the physician reader into the place of the patient through its non-linear and bizarre narrative. The Lung is distressing and disjointed, a less than perfect novel, and a hypnotic depiction of the patient experience.

When JG Farrell drowned in Bantry Bay in 1979 it seemed that polio and his chronic physical weakness had finally caught up with him. An eyewitness account calls this into question—‘I looked at the man in the water and he was so calm, not reaching out to me, not calling for help’. ² Haunted by nightmares of drowning since childhood, tormented by near suffocation in the lung, Farrell met his airless death, it seems, without fear.

In the wake of the SARS-CoV-2 pandemic, with unprecedented numbers of people now recovering from the effects of ICU admission and mechanical ventilation, The Lung may be seen as a form of ‘writing as therapy’. As the pandemic comes under control and we reflect on the experience, there may be insights to gain from analysing the lessons of previous eras and this forgotten novel, despite its limitations, warrants rediscovery.

Figure 1.

James G Farrell (1935–1979). Photograph. Image reproduced with permission from Michael Leonard and Viv Lawrence.