Howard Fischer
Uppsala, Sweden

In the 1950s, parents on both sides of the Atlantic dreaded the arrival of the annual polio epidemic. In the US, the number of polio cases peaked in the summer. In Scandinavia, the polio season was at its worst in September and October—the “autumn ghost.”

Studies done nearly a century earlier indicated that for most people, the infection was asymptomatic or produced only mild symptoms such as fever, headache, fatigue, vomiting, and diarrhea. A few patients developed paralysis. The virus attacked nerves in the spinal cord and brainstem. Limbs were paralyzed. More dangerous was the paralysis of the muscles of the thorax, making breathing difficult or impossible and sometimes leading to death. “Bulbar polio,” where the virus also involved the part of the brainstem that allowed for swallowing of saliva, sometimes accompanied respiratory paralysis, further worsening the victim’s breathing and eventual outcome.

Simon Flexner, MD, working on the mystery of the transmission of polio at the Rockefeller Institute in New York, made the unfortunate error of using the rhesus monkey (Macaca mulatta) as his experimental animal. The rhesus, unlike other monkeys, is highly resistant to polio infection. It can be infected with polio if infective material is injected directly into its brain, or placed into the nose as far as it will go. This mistake influenced subsequent research from about 1910 until 1940, when it was finally shown that other monkeys became infected when the virus was given orally. They then shed it in the stool. People could acquire polio from the ingestion of contaminated material.

In 1952, a severe polio epidemic hit Copenhagen, Denmark. There was no effective treatment. Some early vaccines produced in the US were at best ineffective, and one caused disease and was deadly. Trials using pooled and concentrated gamma globulin (antibodies) from the blood of recovered polio patients were inconclusive.

The only means of keeping patients with respiratory paralysis alive was by using the “iron lung.” This machine invented by Philip Drinker (1894–1972), an engineer and self-taught physiologist at Harvard University, was basically a box into which a patient was placed, with only the head outside the box. A pump was used to produce cyclic, intermittent negative pressure inside the box, which cause the lungs to expand despite the weakened respiratory muscles. When the pumped stopped during the “off” phase of each cycle, the chest contracted, and the lungs expelled their carbon dioxide-containing air. The machine had been designed to resuscitate gassed or electrocuted workers, but became the method of helping people with polio to survive. Its first clinical trial was in 1928; it kept a desperately ill eight-year-old girl alive for five days. She developed pneumonia, however, and died.

In Denmark, Dr. Bjørn Ibsen (1915–2007), a physician who devoted his research and clinical care to the problems of anesthesiology, was one of the first to compare a paralyzed patient with polio to the patients paralyzed and put under anesthesia for surgical operations. The Drinker iron lung was not effective for patients with bulbar polio and airways blocked by secretions. Even forcing air or oxygen under pressure into these obstructed bronchi did not help.

In 1952, a critically ill patient had a tracheostomy performed, an endotracheal tube was inserted, and the patient was “bagged” with oxygen. Mechanically squeezing the bag produced “positive pressure ventilation,” which forced air into the lungs. The tracheostomy also provided a way to suction out secretions.

Ibsen realized and proved with newly invented measuring technology that deaths from polio were caused by the retention of carbon dioxide in the blood. This produced a “respiratory acidosis.” Death was not due, as commonly believed, to overwhelming infection of the brain. Tracheostomy and bagging became the way to keep patients alive. Bagging required people squeezing the oxygen bag around-the-clock. Second-year medical students were enlisted for this tiring, hand-cramping but life-saving work. It became apparent that there were not enough second-year students to support the hundreds of polio patients in the Copenhagen infectious disease hospital, and all medical students were asked to help. The medical students were permitted to go back to their studies when dental students were recruited.

As a senior resident in pediatrics in the late 1970s, I was sent to a small community hospital to transport premature newborn twins in respiratory distress back to our children’s hospital. The community hospital had but one available ventilator in their neonatal nursery, so one baby was put on the ventilator and I intubated and bagged the other one until both were stable enough to move to our hospital. I continued bagging in the ambulance on the way back. It is not an exaggeration to say that just forty-five minutes or an hour of bagging produces a tired, cramping hand.

By 1953 mechanical ventilation had come into use, relieving the “student ventilators.” It became the standard of care as well in Sweden and at Oxford. In the US, the Drinker iron lung was still the main form of treatment until 1955.

As the polio epidemic calmed down in Copenhagen, ventilators were also used for people with crush injuries to the chest, and the cases of tetanus that occurred every year. As fewer patients with polio presented to the hospital, each time a patient needing a ventilator arrived, a group of nurses had to be trained in the care of a patient on a ventilator. It made sense, then, to set up a “tetanus room” staffed by the same nurses all of the time. With Ibsen’s guidance (and insistence), the Copenhagen Municipal Hospital started a “recovery room,” basically an ICU (intensive care unit) run by anesthetists, to which patients were directly admitted. The ICU was also a descendant of World War Two “shock rooms,” to which patients were quickly triaged. The postwar ICUs could treat respiratory failure with intubation and mechanical ventilation, cardiocirculatory failure with intravenous fluids and vasopressors, and renal failure with dialysis. The first ICU was established in Toronto in 1958, in South Korea in 1960, and in India in 1971.

In 1954, Jonas Salk’s killed polio virus vaccine was shown to be 80–90% effective in a trial with 1,800,000 children. A tragedy occurred when Salk vaccine produced by the Cutter Company “did not precisely follow Salk’s instructions for how to ensure that the virus was killed.” There was live polio virus in some of this vaccine, and ten people died and 164 were paralyzed. Vaccination acceptance rates slowed after the “Cutter incident” was publicized. Albert Sabin’s attenuated-virus oral polio vaccine was tested in 1959 in the USSR, since many children in the US had already gotten the Salk injectable vaccine. The oral vaccine had the additional advantage of producing immunity in the intestine, thus preventing an individual who had polio from passing the virus in the stool.

In Denmark, twenty-five patients remained ventilator-dependent after at least three years of support. Apartment houses were built in the 1950s to accommodate the needs of these individuals. Such was not the case in the US. In the 1970s, but more often closer to 1990–2000, a “post-polio syndrome” appeared in adults with recurrence of paralysis, especially in people who had paralytic polio before age six. Some speculated that this was due to a sort of “reactivation” of polio virus still present in the nervous system, the way that chickenpox virus could reactivate decades after the childhood infection to produce herpes zoster (“shingles”) lesions in adults. Perhaps 50% of individuals who had paralytic polio as children will suffer the post-polio syndrome.

This book is beautifully written, more of a “page-turner” detective story than a medical history. The medical literature cited is extensive. The personalities and ambitions of major participants in the polio and ICU stories are nicely and humanely described. The author, Hannah Wunsch, is an intensivist and anesthesiologist at Weill Cornell in New York City.

The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care
Hannah Wunsch
Vancouver: Greystone Books, 2023