The history of polio (poliomyelitis) infections extends into prehistory. Although major polio epidemics were unknown before the 20th century, the disease has caused paralysis and death for much of human history. Over millennia, polio survived quietly as an endemic pathogen until the 1900s when major epidemics began to occur in Europe;
soon after, widespread epidemics appeared in the United States. By
1910, frequent epidemics became regular events throughout the developed
world, primarily in cities during the summer months. At its peak in the
1940s and 1950s, polio would paralyze or kill over half a million people
worldwide every year.
The fear and the collective response to these epidemics would
give rise to extraordinary public reaction and mobilization; spurring
the development of new methods to prevent and treat the disease, and
revolutionizing medical philanthropy. Although the development of two polio vaccines has eliminated poliomyelitis in all but three countries (Afghanistan, Pakistan and Nigeria), the legacy of poliomyelitis remains, in the development of modern rehabilitation therapy, and in the rise of disability rights movements worldwide.
Early history
Ancient Egyptian paintings and carvings depict otherwise healthy people with withered limbs, and children walking with canes at a young age. It is theorized that the Roman Emperor Claudius was stricken as a child, and this caused him to walk with a limp for the rest of his life. Perhaps the earliest recorded case of poliomyelitis is that of Sir Walter Scott. In 1773 Scott was said to have developed "a severe teething fever which deprived him of the power of his right leg". At the time, polio was not known to medicine. A retrospective diagnosis of polio is considered to be strong due to the detailed account Scott later made, and the resultant lameness of his right leg had an important effect on his life and writing.
The symptoms of poliomyelitis have been described by many names.
In the early nineteenth century the disease was known variously as:
Dental Paralysis, Infantile Spinal Paralysis, Essential Paralysis of
Children, Regressive Paralysis, Myelitis of the Anterior Horns,
Tephromyelitis (from the Greek tephros, meaning "ash-gray") and Paralysis of the Morning. In 1789 the first clinical description of poliomyelitis was provided by the British physician Michael Underwood—he refers to polio as "a debility of the lower extremities". The first medical report on poliomyelitis was by Jakob Heine, in 1840; he called the disease Lähmungszustände der unteren Extremitäten ("Paralysis of the lower Extremities"). Karl Oskar Medin was the first to empirically study a poliomyelitis epidemic in 1890. This work, and the prior classification by Heine, led to the disease being known as Heine-Medin disease.
Epidemics
Major polio epidemics
were unknown before the 20th century; localized paralytic polio
epidemics began to appear in Europe and the United States around 1900. The first report of multiple polio cases was published in 1843 and described an 1841 outbreak in Louisiana. A fifty-year gap occurs before the next U.S. report—a cluster of 26 cases in Boston in 1893. The first recognized U.S. polio epidemic occurred the following year in Vermont with 132 total cases (18 deaths), including several cases in adults.
Numerous epidemics of varying magnitude began to appear throughout the
country; by 1907 approximately 2,500 cases of poliomyelitis were
reported in New York City.
Polio was a plague. One day you had a headache and an hour later you were paralyzed. How far the virus crept up your spine determined whether you could walk afterward or even breathe. Parents waited fearfully every summer to see if it would strike. One case turned up and then another. The count began to climb. The city closed the swimming pools and we all stayed home, cooped indoors, shunning other children. Summer seemed like winter then.
Richard Rhodes, A Hole in the World
On Saturday, June 17, 1916, an official announcement of the existence an epidemic polio infection was made in Brooklyn, New York.
That year, there were over 27,000 cases and more than 6,000 deaths due
to polio in the United States, with over 2,000 deaths in New York City
alone.
The names and addresses of individuals with confirmed polio cases were
published daily in the press, their houses were identified with
placards, and their families were quarantined. Dr. Hiram M. Hiller, Jr.
was one of the physicians in several cities who realized what they were
dealing with, but the nature of the disease remained largely a mystery.
The 1916 epidemic caused widespread panic and thousands fled the city
to nearby mountain resorts; movie theaters were closed, meetings were
canceled, public gatherings were almost nonexistent, and children were
warned not to drink from water fountains, and told to avoid amusement
parks, swimming pools, and beaches.
From 1916 onward, a polio epidemic appeared each summer in at least one
part of the country, with the most serious occurring in the 1940s and
1950s.
In the epidemic of 1949, 2,720 deaths from the disease occurred in the
United States and 42,173 cases were reported and Canada and the United
Kingdom were also affected.
Prior to the 20th century polio infections were rarely seen in
infants before 6 months of age and most cases occurred in children 6
months to 4 years of age.
Young children who contract polio generally suffer only mild symptoms,
but as a result they become permanently immune to the disease. In developed countries during the late 19th and early 20th centuries, improvements were being made in community sanitation, including improved sewage
disposal and clean water supplies. Better hygiene meant that infants
and young children had fewer opportunities to encounter and develop
immunity to polio. Exposure to poliovirus was therefore delayed until
late childhood or adult life, when it was more likely to take the
paralytic form.
In children, paralysis due to polio occurs in one in 1000 cases, while in adults, paralysis occurs in one in 75 cases.
By 1950, the peak age incidence of paralytic poliomyelitis in the
United States had shifted from infants to children aged 5 to 9 years;
about one-third of the cases were reported in persons over 15 years of
age. Accordingly, the rate of paralysis and death due to polio infection also increased during this time.
In the United States, the 1952 polio epidemic was the worst outbreak
in the nation's history, and is credited with heightening parents’ fears
of the disease and focusing public awareness on the need for a vaccine. Of the 57,628 cases reported that year 3,145 died and 21,269 were left with mild to disabling paralysis.
Historical treatments
In
the early 20th century—in the absence of proven treatments—a number of
odd and potentially dangerous polio treatments were suggested. In John Haven Emerson's A Monograph on the Epidemic of Poliomyelitis (Infantile Paralysis) in New York City in 1916 one suggested remedy reads:
“ | Give oxygen through the lower extremities, by positive electricity. Frequent baths using almond meal, or oxidising the water. Applications of poultices of Roman chamomile, slippery elm, arnica, mustard, cantharis, amygdalae dulcis oil, and of special merit, spikenard oil and Xanthoxolinum. Internally use caffeine, Fl. Kola, dry muriate of quinine, elixir of cinchone, radium water, chloride of gold, liquor calcis and wine of pepsin. | ” |
Following the 1916 epidemics and having experienced little success in
treating polio patients, researchers set out to find new and better
treatments for the disease. Between 1917 and the early 1950s several
therapies were explored in an effort to prevent deformities including hydrotherapy and electrotherapy.
In 1935 Claus Jungeblut reported that vitamin C treatment inactivates the polio virus in vitro, making it non-infectious when injected into monkeys.
In 1937, Jungeblut injected polio into the brains of monkeys, and found
that many more monkeys that also received vitamin C escaped paralysis
than controls - the results seemed to indicate that low doses were more
effective than high doses.
A subsequent study by Jungeblut demonstrated that polio infected
monkeys had lower vitamin C levels than others, and that the monkeys
that escaped paralysis had the highest vitamin C levels.
Jungeblut subsequently confirmed his findings in a larger study,
finding that natural vitamin C was more effective than synthetic vitamin
C, and as the disease progressed, larger and larger amounts of vitamin C
were needed for therapeutic effect.
In 1939, Albert Sabin reported that an experiment, employing the
technique of "forcefully expelling the total amount [of Polio] in the
direction of the olfactory mucosa, immediately drawing it back into the
pipette, and repeating the process 2 to 3 times",
was unable to confirm the results of Jungeblut, but found that "monkeys
on a scorbutic diet died of spontaneous acute infections, chiefly
pneumonia and enterocolitis, while their mates receiving an adequate
diet remained well."
Following this, Jungeblut found that "with an infection of maximum
severity, induced by flooding the nasal portal of entry with large
amounts of virus, vitamin C administration fails to exert any
demonstrable influence on the course of the disease, but with a less
forceful method of droplet instillation, the picture of the disease in
control animals becomes so variable that the results cannot be easily
interpreted; but the available data suggest that vitamin C treatment may
be a factor in converting abortive attacks into an altogether
non-paralytic infection." In 1979, R.J. Salo and D.O. Cliver inactivated Poliovirus type 1 by sodium bisulfite and ascorbic acid in an experiment.
In 1949-1953 Fred R. Klenner published his own clinical experience with vitamin C in the treatment of polio, however his work was not well received and no large clinical trials were ever performed.
Surgical treatments such as nerve grafting, tendon lengthening, tendon transfers, and limb lengthening and shortening were used extensively during this time.
Patients with residual paralysis were treated with braces and taught to
compensate for lost function with the help of calipers, crutches and
wheelchairs. The use of devices such as rigid braces and body casts, which tended to cause muscle atrophy due to the limited movement of the user, were also touted as effective treatments. Massage and passive motion exercises were also used to treat polio victims.
Most of these treatments proved to be of little therapeutic value,
however several effective supportive measures for the treatment of polio
did emerge during these decades including the iron lung, an anti-polio antibody serum, and a treatment regimen developed by Sister Elizabeth Kenny.
Iron lung
The first iron lung used in the treatment of polio victims was invented by Philip Drinker, Louis Agassiz Shaw, and James Wilson at Harvard, and tested October 12, 1928, at Children's Hospital, Boston. The original Drinker iron lung was powered by an electric motor attached to two vacuum cleaners,
and worked by changing the pressure inside the machine. When the
pressure is lowered, the chest cavity expands, trying to fill this
partial vacuum. When the pressure is raised the chest cavity contracts.
This expansion and contraction mimics the physiology of normal
breathing. The design of the iron lung was subsequently improved by
using a bellows attached directly to the machine, and John Haven Emerson modified the design to make production less expensive. The Emerson Iron Lung was produced until 1970. Other respiratory aids were used such as the Bragg-Paul Pulsator, and the "rocking bed" for patients with less critical breathing difficulties.
During the polio epidemics, the iron lung saved many thousands of
lives, but the machine was large, cumbersome and very expensive: in the 1930s, an iron lung cost about $1,500—about the same price as the average home.
The cost of running the machine was also prohibitive, as patients were
encased in the metal chambers for months, years and sometimes for life: even with an iron lung the fatality rate for patients with bulbar polio exceeded 90%.
These drawbacks led to the development of more modern
positive-pressure ventilators and the use of positive-pressure
ventilation by tracheostomy. Positive pressure ventilators reduced mortality in bulbar patients from 90% to 20%.
In the Copenhagen epidemic of 1952, large numbers of patients were
ventilated by hand ("bagged") by medical students and anyone else on
hand, because of the large number of bulbar polio patients and the small
number of ventilators available.
Passive immunotherapy
In 1950 William Hammon at the University of Pittsburgh isolated serum, containing antibodies against poliovirus, from the blood of polio survivors. The serum, Hammon believed, would prevent the spread of polio and to reduce the severity of disease in polio patients. Between September 1951 and July 1952 nearly 55,000 children were involved in a clinical trial of the anti-polio serum.
The results of the trial were promising; the serum was shown to be
about 80% effective in preventing the development of paralytic
poliomyelitis, and protection was shown to last for 5 weeks if given
under tightly controlled circumstances. The serum was also shown to reduce the severity of the disease in patients who developed polio.
The large-scale use of antibody serum to prevent and treat polio
had a number of drawbacks, however, including the observation that the
immunity provided by the serum did not last long, and the protection
offered by the antibody was incomplete, that re-injection was required
during each epidemic outbreak, and that the optimal time frame for
administration was unknown.
The antibody serum was widely administered, but obtaining the serum was
an expensive and time-consuming process, and the focus of the medical
community soon shifted to the development of a polio vaccine.
Kenny regimen
Early
management practices for paralyzed muscles emphasized the need to rest
the affected muscles and suggested that the application of splints would prevent tightening of muscle, tendons, ligaments,
or skin that would prevent normal movement. Many paralyzed polio
patients lay in plaster body casts for months at a time. This prolonged
casting often resulted in atrophy of both affected and unaffected muscles.
In 1940, Sister Elizabeth Kenny, an Australian bush nurse from Queensland,
arrived in North America and challenged this approach to treatment. In
treating polio cases in rural Australia between 1928 and 1940, Kenny had
developed a form of physical therapy
that—instead of immobilizing afflicted limbs—aimed to relieve pain and
spasms in polio patients through the use of hot, moist packs to relieve
muscle spasm and early activity and exercise to maximize the strength of
unaffected muscle fibers and promote the neuroplastic recruitment of remaining nerve cells that had not been killed by the virus. Sister Kenny later settled in Minnesota where she established the Sister Kenny Rehabilitation Institute,
beginning a world-wide crusade to advocate her system of treatment.
Slowly, Kenny's ideas won acceptance, and by the mid-20th century had
become the hallmark for the treatment of paralytic polio. In combination with antispasmodic medications to reduce muscular contractions, Kenny's therapy is still used in the treatment of paralytic poliomyelitis.
In 2009 as part of the Q150 celebrations, the Kenny regimen for polio treatment was announced as one of the Q150 Icons of Queensland for its role as an iconic "innovation and invention".
Vaccine development
In 1935 Maurice Brodie, a research assistant at New York University, attempted to produce a polio vaccine, procured from virus in ground up monkey spinal cords, and killed by formaldehyde.
Brodie first tested the vaccine on himself and several of his
assistants. He then gave the vaccine to three thousand children. Many
developed allergic reactions, but none of the children developed an
immunity to polio. During the late 1940s and early 1950s, a research group, headed by John Enders at the Boston Children's Hospital, successfully cultivated the poliovirus
in human tissue. This significant breakthrough ultimately allowed for
the development of the polio vaccines. Enders and his colleagues, Thomas H. Weller and Frederick C. Robbins, were recognized for their labors with the Nobel Prize in 1954.
Two vaccines are used throughout the world to combat polio. The first was developed by Jonas Salk, first tested in 1952, and announced to the world by Salk on April 12, 1955. The Salk vaccine, or inactivated poliovirus vaccine (IPV), consists of an injected dose of killed poliovirus.
In 1954, the vaccine was tested for its ability to prevent polio; the
field trials involving the Salk vaccine would grow to be the largest
medical experiment in history. Immediately following licensing, vaccination campaigns were launched, by 1957, following mass immunizations promoted by the March of Dimes the annual number of polio cases in the United States was reduced, from a peak of nearly 58,000 cases, to 5,600 cases.
Eight years after Salk's success, Albert Sabin developed an oral polio vaccine (OPV) using live but weakened (attenuated) virus. Human trials
of Sabin's vaccine began in 1957 and it was licensed in 1962.
Following the development of oral polio vaccine, a second wave of mass
immunizations led to a further decline in the number of cases: by 1961,
only 161 cases were recorded in the United States. The last cases of paralytic poliomyelitis caused by endemic transmission of poliovirus in the United States were in 1979, when an outbreak occurred among the Amish in several Midwestern states.
Legacy
Early in the twentieth century polio became the world's most feared disease.[citation needed] The disease hit without warning, tended to strike white, affluent individuals, required long quarantine
periods during which parents were separated from children: it was
impossible to tell who would get the disease and who would be spared. The consequences of the disease left polio victims marked for life, leaving behind vivid images of wheelchairs,
crutches, leg braces, breathing devices, and deformed limbs. However,
polio changed not only the lives of those who survived it, but also
affected profound cultural changes: the emergence of grassroots fund-raising campaigns that would revolutionize medical philanthropy,
the rise of rehabilitation therapy and, through campaigns for the
social and civil rights of the disabled, polio survivors helped to spur
the modern disability rights movement.
In addition, the occurrence of polio epidemics led to a number of
public health innovations. One of the most widespread was the
proliferation of "no spitting" ordinances in the United States and
elsewhere.
Philanthropy
In 1921 Franklin D. Roosevelt became totally and permanently paralyzed from the waist down. Although the paralysis (whether from poliomyelitis, as diagnosed at the time, or from Guillain–Barré syndrome)
had no cure at the time, Roosevelt, who had planned a life in politics,
refused to accept the limitations of his disease. He tried a wide
range of therapies, including hydrotherapy in Warm Springs, Georgia. In 1938 Roosevelt helped to found the National Foundation for Infantile Paralysis (now known as the March of Dimes), that raised money for the rehabilitation of victims of paralytic polio, and was instrumental in funding the development of polio vaccines.
The March of Dimes changed the way it approached fund-raising. Rather
than soliciting large contributions from a few wealthy individuals, the
March of Dimes sought small donations from millions of individuals. Its
hugely successful fund-raising campaigns collected hundreds of millions
of dollars—more than all of the U.S. charities at the time combined (with the exception of the Red Cross). By 1955 the March of Dimes had invested $25.5 million in research;
funding both Jonas Salk's and Albert Sabin's vaccine development; the
1954–55 field trial of vaccine, and supplies of free vaccine for
thousands of children.
In 1952, during the worst recorded epidemic, 3,145 people in the United States died from polio. That same year over 200,000 people (including 4,000 children) died of cancer and 20,000 (including 1,500 children) died of tuberculosis. According to David Oshinsky's book Polio: An American Story:
"There is evidence that the March of Dimes over-hyped polio, and
promoted an image of immediately curable polio victims, which was not
true. The March of Dimes refused to partner with other charity
organizations like the United Way."
Rehabilitation therapy
Prior to the polio scares of the twentieth century, most rehabilitation therapy
was focused on treating injured soldiers returning from war. The
crippling effects of polio led to heightened awareness and public
support of physical rehabilitation, and in response a number of
rehabilitation centers specifically aimed at treating polio patients
were opened, with the task of restoring and building the remaining
strength of polio victims and teaching new, compensatory skills to large
numbers of newly paralyzed individuals.
In 1926, Franklin Roosevelt, convinced of the benefits of hydrotherapy, bought a resort at Warm Springs, Georgia, where he founded the first modern rehabilitation center for treatment of polio patients which still operates as the Roosevelt Warm Springs Institute for Rehabilitation.
The cost of polio rehabilitation was often more than the average
family could afford, and more than 80% of the nation's polio patients
would receive funding through the March of Dimes. Some families also received support through philanthropic organizations such as the Ancient Arabic Order of the Nobles of the Mystic Shrine fraternity, which established a network of pediatric hospitals in 1919, the Shriners Hospitals for Children, to provide care free of charge for children with polio.
Disability rights movement
As
thousands of polio survivors with varying degrees of paralysis left the
rehabilitation hospitals and went home, to school and to work, many
were frustrated by a lack of accessibility and discrimination they experienced in their communities. In the early twentieth century the use of a wheelchair at home or out in public was a daunting prospect as no public transportation
system accommodated wheelchairs and most public buildings including
schools, were inaccessible to those with disabilities. Many children
left disabled by polio were forced to attend separate institutions for "crippled children" or had to be carried up and down stairs.
As people who had been paralyzed by polio matured, they began to
demand the right to participate in the mainstream of society. Polio
survivors were often in the forefront of the disability rights movement that emerged in the United States during the 1970s, and pushed legislation such as the Rehabilitation Act of 1973 which protected qualified individuals from discrimination based on their disability, and the Americans with Disabilities Act of 1990. Other political movements led by polio survivors include the Independent Living and Universal design movements of the 1960s and 1970s.
Polio survivors are one of the largest disabled groups in the world. The World Health Organization estimates that there are 10 to 20 million polio survivors worldwide.
In 1977, the National Health Interview Survey reported that there were
254,000 people living in the United States who had been paralyzed by
polio.
According to local polio support groups and doctors, some 40,000 polio
survivors with varying degrees of paralysis live in Germany, 30,000 in
Japan, 24,000 in France, 16,000 in Australia, 12,000 in Canada and
12,000 in the United Kingdom.