Polio Wars (36 page)

In his introduction Pohl had the difficult task of both confronting and convincing his wary peers. He began with an attack on orthodox polio therapy pointing out that immobilizing techniques that allowed weakened muscles to rest had made sense, based on the orthodox concept of polio, and yet, as he and other orthopedists knew well, “deformities too frequently occurred.” The Kenny concept explained why immobilization was so often unsuccessful. Orthodox therapy had ignored the possibility that “loss of control of muscle could be due to disorganization and disruption of the nerve cell connections.” As a result, Pohl declared, “orthodoxy has erred both in the recognition as well as in the interpretation of the physical findings in the disease.” Indeed the new concept introduced by Kenny was “so radically opposed to the old as to almost warrant considering the entity as a new disease.” He speculated briefly on the physiological and pathological etiology of these new symptoms, concluding that the polio virus probably “affects muscle as well as nerve tissue.”
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In frustratingly repetitive prose Kenny and Pohl's main text explained how to identify and treat spasm, alienation, and incoordination. Unlike the kinds of spasm seen in “other disorders of the neuromuscular or skeletal system of the body,” polio spasm did not completely relax under general anesthesia and could be relieved by moist heat “treating the specific area of involvement,” suggesting that a “local process is taking place in the muscle.” The exact mechanism of the process of alienation was not clear, but it was possibly the result of “disturbance of the physiological continuity of the motor tracts between the conscious voluntary brain and the muscle.” Incoordination was the result of “a disorganization of the regulating motor centers of the nervous system” that disrupted the “natural rhythmic and cooperative action of associated muscles.”
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Here, the body's neurological functioning had become disordered like the middle of a war or a badly organized hospital. Kenny's method could restore physiological order by bringing body memory to the conscious mind.

Crucial to the healing process was the Kenny technician, skilled in reading the body and in special techniques to help patients regain proper body awareness. So insightful were these techniques that the “contractile function [that]… occurs first in the subconscious level of the mind” could be observed by a technician “long before the patient's mind is conscious of the returning ability to perform voluntary action.”
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The text provided contradictory comments about who should care for patients. Because polio care
required “extraordinary attention to detail, alertness for the interpretation of unfavorable conditions, and ingenuity in the application of methods to relieve distress” it demanded a higher degree of nursing skill, and therefore patients should be sent to a properly equipped hospital or clinic so that therapy could begin at the earlier possible moment. But because early treatment consisted not of highly technical procedures but simple nursing and the “solicitous care of sick muscles,” any person could tell “by visual examination the part of the body where muscle spasm is present” and could use domestic equipment such as a common laundry wringer, woolen blankets, and hot water.
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Thus Kenny technicians were crucial for effective muscle alignment and regaining muscle awareness but sympathetic parents could make their own hot packs and deal with the initial pain and sensitivity.

Pohl's bold claim that “deformities do not occur” made sense only if readers accepted Kenny's new definition of “deformity” as a patient without muscle strength or supple movement.
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This definition was reinforced by 100 illustrations, including a series of 15 photographs showing Kenny overseeing a boy's exercises that demonstrated the “complete restoration of normal function to the neuromuscular system of the body.” More explicitly, the caption below one photograph of a young woman using a Kenny (short) crutch noted that she “has complete paralysis of left lower extremity, and partial of right lower extremity … yet she walks well without braces. Note the absence of deformities.” Surgery was mentioned briefly but as a therapy of last resort that would “aid in the rehabilitation of selected cases.”
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Fully functioning bodies were the ideal; assistive devices were signs of therapeutic failure.

A year before this text was published Knapp had protested to other polio specialists that he wanted to get rid of the idea that Kenny's methods consisted solely “of hot packs and passive motion” instead of “an attempt to treat the disease systemically.”
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Now in his concluding commentary Knapp argued that he and other Minneapolis physicians were convinced that Kenny had introduced a “new concept” that was “correct.” He retreated slightly to argue that new therapies did not need to have a scientific rationale from the outset, for “clinical results are, after all, the final proof of the value of any treatment method.” Still as “the medical mind requires explanations and theories” and sought to interpret results in terms of pathology and physiology, researchers should now investigate “the scientific basis for the Kenny concept” in order to improve this treatment “to its highest possible level.” Some of her ideas might initially look “unphysiological” but “deeper and more detailed thought shows them to be consistent with the best of muscle physiology.” In any case few studies had correlated the relationship between damaged anterior horn cells and affected muscles; in fact, he knew of “no extensive studies of pathologic changes within the muscle itself during the acute stage of the disease.” Kenny's methods were based on a “radical” interpretation of polio's symptoms, which he believed was her “greatest contribution.” As for her new interpretation of polio it was possible, Knapp admitted, that “inflammatory or toxic changes might be present in the muscle itself.” In any case, Kenny had jolted physicians “out of our complacent groove of thought [and] … some worthwhile advance is bound to result from both her revolutionary ideas and the frantic efforts of her opponents to refute them.”
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O'Connor sent copies of the new textbook to 2 leading scientists: neuroanatomist Howard Howe at Johns Hopkins and physiologist Walter Bradford Cannon at Harvard. Both men, neither of them clinicians, found Kenny's methods “well worked out, effective,
and in many instances very ingenious,” and they assured O'Connor that they were “well disposed toward the Kenny method.”
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But their assessments of the textbook differed. Howe disliked the book's “authoritarian style” and its mixing of facts “with contradictions and undocumented theorizing.” He felt it showed “a very superficial knowledge of neuroanatomy and physiology.” Pohl (whom Howe regarded as the senior author) regarded alienation and incoordination “as proved because he merely states them as truth,” yet in reality these symptoms were “so contrary to well substantiated observations that considerable objective evidence is required.” Howe drew a stark difference between pathological evidence and clinical evidence. He did not believe there was direct action of the virus on the muscle, which he called “a concept for which at the moment there is not the slightest evidence.” Recent NFIP grants, he noted, were awarded to a number of projects dealing with the problems of nerve and muscle and he regretted that “that the interpretation of Miss Kenny's results” was not left to those who were “well qualified to do it.” Still, he doubted that his opinion would convince “the prejudiced and uninformed,” for making such scientific distinctions was “like trying to explain the difference between a steam engine and a gasoline motor to a Hottentot.”
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Cannon, who had just retired from his position as the chair of Harvard's physiology department and was battling Bell's palsy and other ailments, was more open to the physiological challenges Kenny's concept posed.
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He could see why it was difficult for Kenny to have the medical world understand her ideas for, in his view, her terms were poorly chosen. Alienation reminded him of “specialists in mental disease [who] are known as alienists!” As for “mental awareness” that was “the only kind there is” and a better term would be “
directed
awareness.” Her use of “the subconscious mind” was “reprehensible, despite fairly common usage,” and a term like “subconscious centers” would be better. From a physiological point of view Cannon was willing to consider that the polio virus might directly affect the muscle and that “testing affected muscles for the virus would be worthwhile.” Spasm, he felt, “in all probability results from irritation of motor cells in the spinal cord.” The phenomenon of alienation of a normal muscle “is, so far as I am aware, quite novel [and]… deserves careful investigation.” In taking seriously both Kenny's concept and the evidence she used, Cannon was horrified by what it implied about past polio therapy, which he felt was one of “the grimmest mistakes in all medical history.”
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Howe's and Cannon's comments did not provide NFIP officials with the clarity to weigh in on either side of the controversy. But the silence was filled by other voices. Illustrated by electromyographic images, studies by physiology researchers provided hints of a complicated picture of nerves and muscles that invigorated nurses and physical therapists already imbued with “Kenny enthusiasm.” Although orthopedists continued to argue that patients' clinical improvements were the result of better nursing or some poorly understood pathological process, the evidence of recovered patients suggested that, whether Kenny was able to explain it or not, there was some connection with the virus and the paralyzed muscles. The press called her successes “Kenny miracles.” Although she argued that any of her technicians could achieve the same results, she nonetheless enjoyed occasions when surrounded by doctors, nurses, parents, hospital trustees, and reporters she could demonstrate the efficacy of her work. In New York City, for example, as 50 other patients waited to be examined, she told one boy to “put your brain in your foot. Think of nothing except your foot and how it works.” When the muscle jumped there was “an audible gasp from the circle of spectators.” “I have given that muscle its
sense,” Kenny told her audience. “If it had been actually paralyzed, of course I could not have done what I did.”
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We have but one weapon against the ravages of polio,
Colliers
declared: “the method of treatment devised by Sister Elizabeth Kenny, the Australian nurse.” The magazine briefly mentioned orthopedic surgeons who could transplant muscle and tendon sections “from good muscles to bad ones.” But more powerful was the description of a warehouse owned by the NFIP that was full of splints, for during the previous year only one physician had requested “this cruel apparatus.” “If the disease does strike,” the article concluded ominously, “pray that someone in your town has had the foresight to have a local physiotherapist trained in Kenny methods.”
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More cautious was the War Department whose 1943 Circular Letter No. 175 on the management of polio recommended the use of hot packs, passive movements, and other “conventional methods which have received general acceptance and are in general use” applied by physical therapists under the “careful direction of medical officers.”
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In a fiery editorial titled “Fact and Fancy in Poliomyelitis” the
British Medical Journal
surveyed the current debate on polio therapy inspired by Kenny and Pohl's textbook. Protesting that those interested in the many problems around polio have not been unreceptive to fresh ideas, the editor pointed out that “in the realm of treatment … it is always most difficult to secure the dispassionate assessment of results that is so essential to rational therapy.” Kenny's methods might be useful but the assessment of their value had been “adversely complicated by the intrusion of theoretical fantasies that can only prejudice the issue.” In an effort to dampen down popular enthusiasm the editor argued that “it would have been better had Sister Kenny and her supporters been content to subject her methods to adequate and prolonged trial, and to have let them stand or fall by their merits.” Still, physicians must scrutinize the textbook's ideas “by the proper standard applicable to all medical theories” for Pohl, an experienced orthopedist, “sponsors the concept.” Without commenting further on the book's physiological and pathological speculations the editor did agree that the “problem of pain and tenderness in the affected muscles … calls for some explanation.”
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When physical medicine specialists reviewed the 1943 textbook they tried to demonstrate both skepticism and authority. Richard Kovacs wrote a vaguely laudatory review, arguing that “everyone agrees that Miss Kenny deserves great credit for her original ideas.” He pointed out that her ideas had “only evolved gradually” for her 1937 text had said nothing about muscle spasm or hot packs, and he praised the new textbook for its omission of “the large amount of controversy and argumentation which marred Miss Kenny's earlier writings.”
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Moist heat was not new but had been advocated by Lovett, according to an unsigned review in the
New England Journal of Medicine
, but nonetheless the book was fundamental for an understanding of Kenny's polio treatment “and should be in the hands of everyone concerned with the care of patients with this disease.”
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In the
Physiotherapy Review
orthopedist John Coulter called the book an “up-to-date discussion of the technics now being advocated by Sister Elizabeth Kenny,” quoted Ober's praise of the method's superb nursing, and declared that “this book should be read and studied by every physical therapist treating infantile paralysis.”
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Mary MacDonald, the book's reviewer in the
American Journal of Nursing
, agreed with Coulter, adding that many nurses had hoped that the book would “settle all argumentative discussions regarding the Kenny concept and the Kenny method of treatment” and the book “has fulfilled all expectations.”
MacDonald was pleased to see Kenny and Pohl state that “no disease demands a higher degree of nursing skill.” Overall it provided “a definite, well-organized and authentic description” of Kenny's work and should be in the library of every nursing school.
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