Polio Wars (3 page)

Tracing the relationship between polio's clinical symptoms and the pathology of the virus was difficult. Theories to explain the paralysis of muscles abounded, but the standard pathological concept reinforced a faith in immobilization. The polio virus was believed to create lesions in the brain and spinal cord, severing connections between muscles and nerves; a paralyzed limb, therefore, could be expected to regain only limited movement. As physicians saw polio as a neurological disease, they warned that any active movements could exacerbate these lesions and that muscle exercises should not be used until at least 8 weeks after a patient's fever had subsided, suggesting that the lesions had healed.
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Reflecting the profound stigma around physical disability and their own skepticism about recovery, physicians used splinting to keep the patient's body looking straight and “normal” rather than focusing on functionality.
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Although plaster splints and casts were often painful, clinicians considered them crucial in order to spare patients “the mental and physical pain of a hideous deformity,” as one orthopedic nurse noted.
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The most challenging part of polio therapy was the enforced period of rest through immobilization. To ensure that this therapeutic regime was followed hospitals had to rely on the efforts of trained graduate nurses. Indeed, argued one nursing textbook, “the entire success of the treatment depends upon the loyalty of the nurse in maintaining the position effected by splinting.”
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To dramatize how “a few seconds of nonsupport may do serious harm” orthopedic nurse Jessie Stevenson pointed out that “the nurse would be horrified at the thought of maintaining sterile technic in the operation room for
only part of the time
.” Even when muscle stimulation was allowed, she noted, it must be practiced “very gently” and by a professional who knew “the origin, insertion and action of all the important muscles.”
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Given the lack of such professionals, however, in practice immobilizing therapy frequently meant therapeutic neglect.

Elizabeth Kenny gained attention because her work dealt with a high profile disease and filled the therapeutic vacuum that surrounded it. Polio epidemics in the 1930s grew more serious and more frequent. Although the disease remained a relatively minor cause of morbidity and mortality, parents saw it as a major threat to their children's health. Polio left family doctors at a terrifying loss: epidemics could not be predicted or controlled; paralyzed patients sometimes recovered mobility, but often remained disabled in a world unfriendly to the disabled; and until the mid-1950s there was no vaccine to prevent it.

Kenny provocatively promised ambitious results. Her goal was fully recovered movement. She transformed standard polio therapies—especially splinting and surgery—into symbols of a failed and even harmful clinical program. Her therapies, especially her hot packs and muscle exercises, were based on distinctive ideas about polio as not solely a neurological disease but also one that affected muscles and skin. At first she talked about clinical signs (physical manifestations visible to the outside eye) that had been ignored and left untreated by polio experts, but gradually she came to see them as crucial symptoms (experiences of the patient) that provided evidence for a rethinking of polio's pathology and physiology.
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Her challenge to existing concepts of polio attracted patients and families as it embodied a different style of clinical practice: optimistic, energetic, patient-centered care.

In describing the experience of polio as she saw it Kenny relied on 3 crucial terms:
spasm
(a muscle in pain and contracting),
alienation
(a “physiologic block” that prevented “the proper transmission of a nerve impulse from the central nervous system to a contractible or nonparalyzed muscle”), and
incoordination
(the “loss of ability to use muscles in proper relationship to one another”).
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The language she used was strange to physicians' ears. The only term familiar to many orthopedic surgeons and physical therapists was spasm: a spastic muscle was well known in a variety of neuromuscular conditions, especially cerebral palsy.
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But Kenny's definition made polio's spasm unfamiliar, especially when she linked it to her system of treatment. Using a distinctive understanding of polio's clinical picture and her own techniques, her methods, she claimed, would help to restore normal function to a patient's muscles “to the fullest extent possible.”
²⁷

Immobilization, Kenny argued, had many dangers; most crucially, it prevented the treatment of the symptoms she had identified. It also interfered with the nutrition of skin, tissue, and muscles and diminished the volume of nerve impulses through the nervous system “along the afferent and efferent paths,” as well as interfering with “the normal function of the subconscious mind” and giving patients “an adverse psychological outlook.” Yet immobilization was “the paramount principle upon which the orthodox system is founded” and, according to the Kendalls, the main treatment for polio was “rest in a well-protected position.” The orthodox system was therefore based on principles that were the exact opposite of her system, especially in its view of how muscles were affected by the polio virus and how to ameliorate paralysis. In orthodox polio care affected muscles were not seen as spastic but flaccid, and were depicted as hanging loosely “like a hammock between their two points of attachment.” Paralysis was believed to be caused by healthy muscles stretching these weaker ones. But in Kenny's view, muscles in spasm were in fact the central cause of paralysis.
²⁸

According to Kenny, her methods treated properly identified symptoms correctly and therefore had far better clinical results. Spasm was the main reason that patients with polio experienced pain and paralysis. The
affected
muscles in polio were not those that could not move but their antagonists that were in a state of painful contraction or spasm that rendered the opposing muscles unable to move. Muscle spasm in polio could be distinguished from other kinds of shortened or contracted muscles for it did not relax under deep general anesthesia.
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To treat spasm she used what became known as hot packs or Kenny packs: soft, wool cloths immersed in boiling water, put through a wringer, and wrapped around the belly of the muscle in spasm, followed by protective coverings of oiled silk or rubber sheeting and then a dry cloth or towel. After around 15 minutes the hot packs cooled but they remained in place for about 2 hours on the principle that alternating heat and cooling would aid circulation and improve the “vitality” of the body's tissues.
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If spasm was not treated, she warned, muscles would become “toneless, flat, shortened and narrowed.”
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Alienation was the term Kenny used to explain other muscles that appeared to be paralyzed. These muscles were, she argued, alienated from the “conscious voluntary mind.” Unlike physicians' usually pessimistic prognosis, she argued that in most cases the “nerve pathways” were not destroyed but divorced from the voluntary “motor center.” On occasion, she conceded, there were some permanently paralyzed muscles, but alienated muscles could be identified by their ability to exhibit a slight amount of “tonus,” that is the tendon of the muscle would appear after the attendant had flexed the appropriate joint several times.
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Because of the pain associated with spasm and because the opposing alienated muscle was stretched beyond its normal resting place, patients lost awareness of this muscle, causing it to be “drop[ped] from the patient's consciousness and become alienated or divorced from voluntary action.” The attendant's job was to reestablish the “normal brain pathways” through careful passive muscle movements during which the body was kept in a normal alignment, and the patient was told to relax and think of nothing so as to conserve “nervous energy.”
³³
These movements were intended to stimulate both the muscle and the neural pathway. As it was crucial to keep the muscles “at their normal length between their points of origin and insertion,” she emphasized her attendants' detailed knowledge of muscle anatomy and physiology and the importance of giving the patient a fundamental knowledge of muscle function as well.
³⁴
To counter an alienated flexion of the forearm, for example, the attendant bent the patient's arm and placed the patient's elbow in the palm of her hand, supporting the patient's forearm with her hand. To help the patient gain “mental awareness,” the attendant asked the patient to visualize the point of attachment of the brachial muscle, then passively flexed the forearm, telling the patient not to make any physical effort. The attendant also watched the patient closely to see that no effort was made in any other muscle group. After the attendant had passively flexed the forearm 3 times and felt “that the brain path has been restored, the patient is required to put forth a physical effort at the end of the session.” This effort must be “concentrated, both mentally and physically, to the group from which a movement is expected to occur.”
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If left untreated alienated muscles could become paralyzed from disuse and lead to permanent paralysis and deformity.
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To explain the awkward ways that patients initially began to use their limbs and other body parts—which Kenny termed “spasmodic”—she developed the concept of incoordination. Polio, she argued, had disorganized the “normal physiological activity of the
nervous system.” This disruption of “the natural rhythmic and cooperative action of associated muscles” persisted after spasm had been released.
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The attendant needed a detailed understanding of “the harmonious action of the [muscle] groups working in sympathy” and how to apply “measures… to insure perfect harmony in all muscles.” The attendant also needed to be careful that the patient did not begin to use other muscles instead, for muscle substitution, Kenny warned, could make incoordination permanent.
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To reestablish connections “between the patient's mind and the more peripheral parts of his body” Kenny technicians held muscles using special “grips” or hand positions. Indeed, Kenny argued that a patient's mental effort to produce a muscular contraction could often be felt by an attendant's hand before the contraction actually occurred.
³⁹
The aim of this careful muscle reeducation was “to get the patient to picture everything in terms of normal function” and thereby counter the “disorganization” that had “occurred at the lesion which interferes with the co-ordination of movements.”
⁴⁰
While Kenny rejected standard hydrotherapy she did urge the use of warm baths and alternating cold sprays and warm douches as adjuncts to muscle reeducation to assist in the reestablishment of consciousness of the body's peripheral structures. These techniques would provide “afferent stimuli” that would keep the paralyzed body part in the patient's consciousness.
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Although Kenny rejected standard protective devices such as casts, frames, and splints she did protect her patients' muscles. Her patients would lay on a firm mattress supported by bed boards and a foot board so that their heels and toes were not on the mattress. When necessary she used a small rolled towel under or on either side of the knees; she never used anything that would seem like a splint that might “interfere with the proprioceptive reflexes” and with “the patient's feeling of normalcy.”
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Most of the therapies she used were drawn from the standard therapeutic repertoire for dealing with pain, sensitivity, and paralysis. Heat therapies were known to be helpful in “relieving and relaxing the sensitive extremities,” although physicians disagreed whether heated cloths and hot baths worked better than dry heat in lamps or diathermy (electrically induced heat).
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Before the 1940s some physicians used intermittent hot packs to increase circulation and maintain muscle nutrition but most agreed that the most important thing was to prevent deformity and relieve pain through the use of splints and casts.
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Patients in the early stages of polio were frequently misdiagnosed. Kenny believed that her trained clinical eye worked better than any other standard diagnostic tool. Indeed she suggested that the use of spinal taps was usually unnecessary and just added to a patient's pain. She firmly rejected standard muscle testing as likely to increase pain and produce inaccurate results, which would then lead to pessimistic prognoses. Testing muscles on patients in the acute stage of polio was particularly dangerous as it undermined the principles of her methods. Until spasm had been treated the patient was not allowed to attempt to use any muscles for “the only effective treatment … for the brain path” must be given “to counteract mental alienation.”
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Kenny alienated health professionals by her arrogant confidence in herself, her abrasive clinical teaching style, and her clear disdain for those who, as she characterized them in her 1943 autobiography, “have eyes but they see not.” She engaged in public debates with leading figures in American medicine and health philanthropy, including Morris Fishbein, general secretary of the American Medical Association (AMA), and Basil O'Connor, head of the NFIP. Despite her dismissive manner, however, Kenny recognized
the high status of physicians in American society and wanted to be taken seriously by them. And however unorthodox her ideas may have appeared, she was certainly never antiscience. She consistently tried to use the tools and vocabulary of modern experimental science to try to gain the respect of the medical establishment.