Poliomyelitis: A Brief History
John Paul (1971), from whose detailed history much of the information in this document was drawn, suggests that since polio is the only common disease which results in the sudden paralysis of a previously healthy child, its history should be relatively easy to trace. He concludes, however, that this is not the case. Though there are many descriptions of lame and crippled children in the Bible and other early writings, the descriptions are typically too brief to be undeniably identified as polio-related.
Still, there is a general consensus that cases of polio, if not sporadic epidemics, pre-date recorded history. As evidence of the early existence of poliomyelitis, Paul (1971) and other writers offer an Egyptian stele (stone carving) dating between 1580 and 1350 B.C. that shows a young man with an atrophied leg, which looks like a limb deformity that might have been caused by polio.
It was not until the late 1700's, however, that the existence of polio was described with any degree of certainty. After numerous 18th century outbreaks, a British physician named Michael Underwood provided the first clinical description, referring to polio as "debility of the lower extremities" (Paul, 1971, p. 23).
Little was written about polio in the early part of the 19th century until the appearance of Jacob Heine's work. A German physician, Heine published a 78 page monograph in 1840 which not only described the clinical features of the disease, but also noted that its symptoms suggested the involvement of the spinal cord. Yet, the limited medical knowledge of the time and the sub-microscopic nature of the polio virus kept Heine and others from understanding the contagious nature of the disease. Even with the relatively large outbreaks of polio that occurred in Europe during the second half of the 19th century, physicians speculated causes such as teething, stomach upset, and trauma (Paul, 1971).
The first major polio epidemic reported in the United States occurred in Vermont during the summer of 1894. It consisted of 132 total cases, including some adults. Again, causation was attributed to such factors as "overheating, chilling, trauma, fatigue, and such illnesses as typhoid fever, whooping cough, and pneumonia" (Paul, 1971, p. 85).
Not until 1908 was the actual polio virus identified by two Austrian physicians, Karl Landsteiner and E. Popper. Following their discovery, polio became a reportable disease entity, and the state of Massachusetts began counting polio cases in 1909 (Bradshaw, 1989).
It was during that same year that American physician Simon Flexner successfully induced polio infection in monkeys. This allowed for increased research opportunities as well as unwarranted optimism concerning a "polio cure." However, this optimism quickly subsided, and by 1913 the complexities of prevention and treatment had become apparent (Paul, 1971).
The year 1916 saw a large outbreak of polio in the United States. Though the total number of affected individuals is unknown, over 9000 cases were reported in New York city alone. Attempts at controlling the disease largely involved the use of isolation and quarantine. Though these measures proved ineffective, quarantines during polio outbreaks were continued for many decades.
The 1920's saw the development and first use of the infamous "iron lung," a metal coffin-like contraption that aided respiration, but imprisoned those polio patients who needed it, in some cases for life. However, most polio-related research during this decade centered on the "therapeutic use of convalescent serum" to treat acute polio patients (Paul, 1971). This "serum" was made from the blood of monkeys and humans who had recently recovered from polio and was administered by injection. Based on the results of several small, poorly designed research studies, as well as the fact that a similar approach had apparently been successful in treating meningitis, some physicians were convinced that this "treatment" could prevent paralysis. Even serum from "hyperimmunized" horses was tried. Hopes for the effectiveness of convalescent serums ran high until the early 1930's when results of several relatively well conducted field trials yielded discouraging results. As Paul (1971, p. 198) noted, "The demise of serum therapy after so many years of crude trials on which claims of its value had been made by so many physicians, a number of whom were acknowledged authorities and occupied high places in the medical hierarchy, must have been a bitter pill to swallow - if such a metaphor is appropriate."
So, after about two decades of hope, this form of treatment was abandoned. Like so many other "polio treatments," the only positive thing that could be said for serum's use was that at least it wasn't harmful.
With medical research during this decade being essentially a bust, probably the most important polio-related event of the 1920's had nothing to do with medical advances. Rather, it was the fact that Franklin Delano Roosevelt was struck with the disease in 1921. Not a typical polio patient by any means, FDR was 39 years of age at the time and had been his party's vice presidential candidate in 1920.
His misfortune proved to be a stroke of luck, not only for polio victims, but for those with other disabilities as well. FDR's crippling illness was to have a major impact on public perceptions of individuals with handicaps, which tended to be very negative. As Longmore (1987, p. 359) stated, individuals with physical handicaps were typically, "kept at home, out of sight, in back bedrooms by families who felt a mixture of embarrassment and shame about their presence." Even those in the medical profession tended to look on "cripples" with disdain. "Declared an influential orthopedic text in 1911: a failure in the moral training of a cripple means the evolution of an individual detestable in character, a menace and a burden to the community, who is only apt to graduate into the mendicant and criminal classes" (Longmore, 1987, p. 359). Whether this view was due to a belief that "cripples" were somehow being punished by God for their sins is difficult to surmise, but because of these attitudes it is not surprising that children with physical disabilities were likely to be barred from attending public schools. Though these negative attitudes and tendencies toward devaluation were well ingrained, a careful strategy of public imagemaking of FDR as being heroically triumphant in spite of his physical limitations contributed to a limited form of acceptance for those with handicaps, at least as long as they didn't complain and continued their "cheerful striving toward normalization" (Longmore, 1987, p. 361). Still, the country would certainly not accept a "cripple" as its president. Therefore, as Hugh Gregory Gallagher (1994) has so well documented, FDR had no choice but to conceal the extent of his disability from the public. The fact that only two out of the many thousands of photos of FDR show him in his wheelchair illustrates the extent of this "magnificent deception."
At least as important as FDR's impact on attitudes towards and treatment of those with handicaps was the effect of his prestige and his family's wealth on advances in the treatment and prevention of polio. Much of the story of his impact on the battle against the disease is tied to Warm Springs, Georgia, where in October, 1924 Roosevelt checked into a cottage on the grounds of the dilapidated Meriwether Inn because of reports that the waters there could somehow "cure" paralysis. According to Hugh Gregory Gallagher (1994), shortly after FDR's arrival, the Atlanta Journal published an article titled "Franklin D. Roosevelt Will Swim to Health." The article not only described the therapeutic effect of Warm Springs, but also stated that Roosevelt had received a warm welcome there. It was syndicated and appeared in many newspapers across the country. "Not surprisingly, there was a quick response from polios who had seen the article. Letters came pouring in addressed to Roosevelt at Warm Springs. Some desperate polios simply packed their bags and set off for warm springs without so much as invitation, permission, or warning. They had come drawn by Roosevelt's example, and he took an immediate and genuine interest in them" (Gallagher, 1994, p. 39). Thus began Warm Springs' role as a therapeutic center and haven for polio survivors. FDR bought the resort eighteen months after first arriving there, committing more than two-thirds of his personal fortune to the purchase (Gallagher, 1994). He soon renovated and expanded it, and Warm Springs became his second home.
In 1926, the Warm Springs Foundation was formed. It was eventually to become the National Foundation for Infantile Paralysis. Under the direction of FDR's law partner, D. Basil O'Connor, this non-profit foundation became national in scope. It not only led the way in galvanizing public interest in polio, but also played a crucial role in raising millions of dollars for the treatment of polio patients and polio-related research.
The Warm Springs Foundation was started just in time as the decade of the 1930's saw an increase in the frequency and magnitude of polio outbreaks in the United States. Most notable among the epidemics was one that occurred in Los Angeles during the summer of 1934. Nearly 2500 polio cases were treated from May through November of that year at Los Angeles County General Hospital alone. The city was panic-stricken with the appearance of "50 new cases a day" (Paul, 1971, p. 221).
However, the 1930's were also years of medical advances and much hope. It was during this decade the discovery was made that there were at least two separate strains of polio virus. (It was later determined that there were three strains.) Even more noteworthy, though, were the attempts by two physicians to develop a polio vaccine. These efforts culminated in 1935 with field trials for vaccines developed by Maurice Brodie and John Kollmer. Using what John Paul (1971, p. 259) referred to as "kitchen chemistry," the two hurried their "vaccines" into readiness, each fearing the other would succeed first. Brodie concocted his from an emulsion of the ground-up spinal cords of infected monkeys. He attempted to deactivate the virus by exposing it to formalin (a formaldehyde mixture). This formalin-inactivated concoction was first tried with twenty monkeys, then with 3000 children. Though it is unclear exactly what occurred, "something went wrong and Brodie's vaccine was never used again" (Paul, 1971, p.256).
Kollmer's attempt at developing a vaccine was based on a slightly different premise. His idea was to use live, but slightly weakened (attenuated) virus, again taken from the spinal cords of infected monkeys. The virus was attenuated by mixing it with various chemicals and refrigerating it for fourteen days. Paul (1971, p. 258) called the result a "veritable witches brew." Again, after trying his "vaccine" on a few monkeys, himself, his children, and twenty-two others, Kollmer was optimistic enough to distribute thousands of doses to physicians across the country. Unfortunately, the vaccine was not only ineffective, but was blamed for causing many cases of polio, some of which were fatal. In his remarks at a meeting of the Southern Branch of the American Public Health Association held in 1935, Kollmer is reported to have said, "Gentlemen, this is one time I wish the floor would open up and swallow me." (Paul, 1971, p. 260).
In spite of his failed attempts at vaccine development, Kollmer apparently managed to pick up the pieces and go on to a successful, if not distinguished, research career. This was not the case for Brodie. Unable to find an important research position, he died shortly after accepting a minor position in Michigan. "It is alleged that he took his own life" (Paul, 1971, p. 261). Thus, tragically, he did not live to see Salk's successful development of a polio vaccine based on his concept of using formalin inactivated virus. Even more tragically for the hundreds of thousands who contracted polio in the 1940's and 50's, the 1935 fiasco made the scientific community so gun shy that polio vaccine trials on human subjects were not attempted again for nearly twenty years.
As most of the developed world became embroiled in the Second World War, the first half of the decade of the 1940's saw few new polio-related developments. One important exception to this was the arrival in the United States of Sister Elizabeth Kenny and her then unorthodox approach to polio treatment.
Not a nun, Elizabeth Kenny was a former Australian army nurse. The title "Sister" was a reference to her military rank as chief nurse, and had no religious connection. In her work with Australian polio patients, Sister Kenny had developed a treatment procedure that involved massage, exercises, and wrapping affected limbs with hot, moist compresses to reduce muscle spasms and the resultant pain. She also stressed the importance of psychotherapy in treatment, insisting children had to be "willed to move paralyzed limbs" (Willis, 1979, p. 32). This approach was totally contrary to the accepted medical treatment of the time which typically involved long-term splinting and casting to immobilize the limbs, combined with prolonged bed rest. Unfortunately for the many who received it, this standard practice did more harm than good, causing only atrophy and inflexibility in already weakened limbs.
After her approach had become the accepted form of treatment in Australia, the 53 year old Kenny came to the United States to promote her ideas. In his monograph for the Hennepin County Historical Society, Don Albertson (1978) writes that she arrived first in California where she was virtually ignored by the medical community. After getting a similarly cool reception in New York from D. Basil O'Connor, then chairman of the National Foundation for Infantile Paralysis, Kenny decided to return to Australia. However, because she had letters of introduction to physicians in Chicago and at the Mayo Clinic in Rochester, Minnesota, she decided to stop in those two cities before leaving for home.
Fortunately, she found the people in the midwest at least friendlier, if not necessarily enthusiastic about her ideas. Albertson (1978, p. 2) quotes Kenny as remarking, "The whole city of Rochester, in fact, seemed to exude friendliness." She also found some physicians in Rochester who were at least willing to listen to her and gave the first presentation in the United States regarding her procedures to members of the Mayo Clinic staff. Though impressed with her ideas, there were no acute polio patients being treated at Mayo at that time. Therefore, Kenny was referred to Doctors Wallace Cole and Miland Knapp in Minneapolis, where there were many acute cases.
Cole and Knapp arranged for her to work with some of their more severe cases, including Robert Gurney, who was interviewed for this book (Polio's Legacy: An Oral History). Since she achieved some success with these patients, other physicians soon invited her to work with their patients. Albertson (1978, p. 5) reports, "Each week saw more cases showing benefits of her techniques, and soon it became necessary to find facilities to handle the cases that were brought to her."
Before long she had an entire ward at Minneapolis General Hospital (now Hennepin General) set up for her work, and a year later additional space was provided at the University of Minnesota Hospital. Shortly thereafter, the first Sister Kenny Institute opened on December 17, 1942. The Sister Elizabeth Kenny Foundation was formed in 1943 to support both her work with polio patients and to further the teaching of her methods.
Her methods remained controversial, and a report of a special American Medical Association committee first published in 1944 was very critical of the Kenny approach (Committee, 1969). The National Foundation never embraced her ideas and finally gave them only a grudging endorsement, acknowledging that the "treatment had some basis in fact" (Paul, p. 342). Nevertheless, by the mid-1940's, the Kenny method had become pretty much the standard treatment for polio patients in the United States. Though there does not appear to be scientific research to substantiate any long-term benefits of the method, it was certainly preferable to the traditional approach of immobilization.
Elizabeth Kenny died in 1952, but her followers continued her work. In fact, the Sister Kenny Institute is still in existence and continues to provide services to persons with disabilities. Though polio is no longer its primary mission, the Institute offers evaluation and treatment to those experiencing polio's late effects and is a leader in research and dissemination of information on these conditions.
Other than Sister Kenny's impact on the treatment of those with paralytic polio, the early 1940's saw little other progress in either prevention or treatment. Most of the best medical researchers were either in the military or working on military-related projects. Therefore, their civilian research interests were put on the back burner. However, some, including Jonas Salk, would later apply the knowledge they gained from research conducted for the military to their work on polio.
Other polio-related information gained during World War II was learned the hard way. Experiences of allied military troops further confirmed adult susceptibility to polio. This was particularly the case when they were stationed in locations with primitive sanitation systems. U.S. and British personnel in Africa, the Middle East, and the Philippines were hit particularly hard. With the occurrence of large epidemics of polio in the U.S. immediately after the war (an average of more than 20,000 cases a year during the period 1945-49), it was speculated by some that service personnel may have "brought the virus home with them" (Smith, 1990, p. 86).
The combination of large scale post-war polio epidemics and the discharge of medical researchers from their military obligations resulted in renewed interest in polio research. Most of this research now centered on vaccine development. Though Jonas Salk would eventually develop the first effective vaccine, he was a newcomer to the field of polio research. In fact, in her book detailing the story of the vaccine's development, Jane Smith (1990) states that Salk actually became involved in polio research only as a means of obtaining funding for his new laboratory in Pittsburgh.
This laboratory, funded by the Sarah Mellon Scientific Foundation as an attempt to put Pittsburgh on the medical map, opened shop in 1947. As one of its first projects, Salk's facility was one of four laboratories awarded research grants for the polio virus typing project, which began in 1948. Though it was long suspected that there were three separate antigenic types of polio virus, this would need to be definitely known so that a vaccine could provide protection against all viral strains. This project was seen by Salk as "a dull but dependable investment that would provide a regular dividend of money for his lab..." (Smith, 1990, p. 117). Though Salk had not previously been involved in polio research, his participation in the Armed Forces Epidemiological Board, which worked on the development of influenza vaccines during the war, provided him with invaluable experience for both virus typing and, eventually, polio vaccine development (Paul, 1971, p. 415).
Smith (1990) suggests that Salk's newness to the study of the polio virus may actually have benefited him. Since he had no involvement in an ongoing polio research program, he started out fresh, without any preconceived notions. Perhaps this is why he was the only polio researcher to use the newly developed tissue culture method of cultivating and working with the polio virus that had recently been developed by John Enders and others at Harvard University. Other researchers, including Albert Sabin, who would later develop the oral polio vaccine, continued to do their work with monkeys infected with the polio virus, a more difficult and time-consuming process.
Salk's work on the influenza virus during the war gave him another advantage over others studying the polio virus. In his attempts at developing an influenza vaccine, he had worked with "killed virus." Therefore, it was only natural for him to use this same approach to developing a polio vaccine. Sabin and the others who were already involved in polio vaccine development were using live, attenuated (weakened) virus, again a more difficult task.
Resurrecting the idea of using formalin inactivated (killed) virus tried by Brodie in his failed work of the 1930's, by 1950 Salk and his cohorts were already leading the way in developing a polio vaccine. According to a Time Magazine article which appeared in 1953 ("Vaccine"), Salk added mineral water to his formaldehyde treated virus as a means of holding the virus in the body long enough to enhance the formation of antibodies, just as mineral oils were added to hold penicillin in the system.
By 1952, early versions of his vaccine had already proven successful with small samples of patients at the Watson Home for Crippled Children and the Polk State School, a Pennsylvania facility for individuals with mental retardation (Paul, 1971; Smith, 1990). Salk reported the results of these promising, albeit small-scale, studies to the National Foundation's Committee on Polio Vaccination in January, 1953. Perhaps because the country had just experienced the worst polio epidemic in history (about 58,000 cases in 1952), the committee went against the urgings of Sabin and others and decided to back Salk's work. Massive national field trials, the magnitude of which were never seen before or since, were organized a year later to test the vaccine's effectiveness.
According to Mierer (1972), nearly two million children participated in the 1954 field trials at a cost of about five million dollars. (One can only guess what the cost would be today!) Mierer states that these large numbers were necessary because of the "relatively low incidence of the disease and its great variability from place to place and time to time..." (pp. 5 and 6).
There was some disagreement in the scientific community regarding exactly how the field trials should be conducted. One plan which was backed by the National Foundation proposed to offer vaccination to second-graders at participating schools and compare them to non-vaccinated first and third-graders in the same schools (an "observed control approach"). This plan was criticized by some scientists, however, because the physicians eventually charged with making the polio diagnosis would know whether or not a child had been vaccinated. Thus, their judgment could be biased. Additionally, since only children whose parents had volunteered their participation would be vaccinated, some differences, particularly in socio-economic status, were likely to exist between the vaccinated and unvaccinated groups.
To overcome these objections, it was proposed that children be randomly assigned to vaccinated or non-vaccinated groups, with those not vaccinated receiving an injection of a saline (salt) solution colored to look exactly like the Salk vaccine. Not the children, their parents, nor even their physicians would know whether a child had been given the real vaccine or the placebo, saline solution. This "placebo control approach," as Mierer (1972) calls it, overcame the arguments of potentially biased results. However, there were objections on ethical grounds as some wondered about the appropriateness of giving children a "fake" vaccine for a feared and potentially deadly disease.
In the end, both approaches were used, and the decision regarding in which study to participate was left to individual departments of health. Eventually, about 750,000 children participated in the placebo control study, and slightly over one million in the observed control experiment. Though the placebo control study was judged more conclusive, results of the two studies were similar. The vaccine was not totally effective in preventing polio, but those vaccinated were less than one-half as likely to contract polio as the non-vaccinated control group. Additionally, in those cases where a vaccinated child was diagnosed with polio, the disease was more likely to be judged as non-paralytic (Mierer, 1972).
News of the successful vaccine trials was released at a formal press conference held in Ann Arbor, Michigan (the site where the research data from the field trials had been gathered and analyzed) on April 12, 1955. It was broadcast on both radio and television. Though some in the scientific community criticized the manner in which the announcement was made as sensationalized, the results were greeted with public euphoria. "Flushed by the first report that the vaccine had worked, exuberant citizens rushed to ring church bells and fire sirens, shouted, clapped, sang and made every kind of joyous noise they could. City councils and state legislatures postponed their regular business to draft resolutions congratulating Salk for his wonderful achievement" (Smith, 1990, p. 319).
Following the public announcement, a nationwide vaccination program was quickly undertaken. Though several pharmaceutical companies were contracted to produce the vaccine, Jones (1993) reports that during the first year (1955) only enough could be manufactured to vaccinate about one-third of the roughly 18 million children and adolescents under the age of twenty. However, by 1957, ample supplies were already available to vaccinate everyone. Surprisingly, not all chose to have their children vaccinated, and so Smith (1990) reports that a large scale advertising campaign was initiated, including the public vaccination of Elvis Presley. In spite of this measure, by 1960 only about 71% of those under the age of 20 were fully vaccinated with another 15% partially vaccinated (Jones, 1993).
In any operation of this magnitude, of course, not everything will go exactly as planned, and the polio vaccination program was no exception. Unfortunately, some of those vaccinated actually developed polio, apparently from the vaccine. It was later learned that some of the lots of vaccine manufactured by Cutter Laboratories of California contained live polio virus. Fortunately, this was the only such incident (Paul, 1971).
Though apparently no study was ever conducted to examine the long-term effectiveness of the Salk vaccine, the statistics dramatically illustrate at least its short term success. From pre-vaccine highs of about 58,000 cases in 1952 and 35,000 cases in 1953, the rate dropped to about 5600 cases in 1957, the first year after the vaccine was widely available (Jones, 1993).
By 1962, the Salk vaccine was replaced by the Sabin oral vaccine. The effectiveness of this new vaccine had been demonstrated in field trials conducted in 1958 and 1959. Using live, attenuated (weakened) virus, the oral vaccine was not only superior in terms of ease of administration, but also provided longer lasting immunization (Nathanson, 1982).
With the Salk and later the Sabin vaccines providing a one-two punch, polio was down and out for the count, at least in the United States. In 1964, only 121 cases were reported nationally. Currently, there are typically fewer than ten new cases per year, but none originates from native, "wild" polio virus. Rather, these cases are either vaccine related or "imported." (Nathanson, 1982).
There were still about 100,000 cases of polio worldwide in 1993 (Keegan, 1994), primarily in Asia and Africa, but large-scale immunization efforts in China (WHO, 2013) and India (CDC, 1996) beginning in the nid-1990s have greatly reduced that number. The Global Polio Eradication Initiative had set a goal to completely eradicate polio worldwide by the year 2000, but wars, natural disasters, and poverty in Asian and African nations have prevented this goal from being completely achieved. Therefore, there are still sporadic polio outbreaks in the 21st Century.
Though polio has largely been eradicated in the developed world, its legacy remains. In 1977, the National Health Interview Survey reported that there were 254,000 persons living in the United States who had been paralyzed by polio (Frick and Bruno, 1986), and the total number of polio survivors in this country may still exceed 600,000. The number world-wide is probably more than ten million, many of whom must be experiencing polio's late effects.
The above polio history is a revised version of
Chapter 1 of my book, Polio's
Legacy: An Oral History (Sass, 1996). This page was posted by Edmund Sass, Ed. D. and was
last updated March 16, 2014. You may e-mail him at email@example.com
See the references for this page.
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