Polio Wars (37 page)

The 1943 textbook did not function as Kenny and Pohl had hoped. Kenny technicians and other therapists and nurses used the red book more as a technical manual than as a scientific work. For many physicians it confused rather than clarified. “I find the book on the ‘Concept' and the other literature very easily understandable,” a sympathetic surgeon told Pohl, “but am sorry to say & see too many doctors of better training than I have had who still seem completely befuddled. They should come and see the work or it should be taken to them, one or the other.”
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Clinical results still remained the most impressive evidence Kenny and her technicians could provide. Nor had the textbook resolved divisions among physicians as Stimson discovered when he gave a talk on Kenny at the New York Post-Graduate Medical School and Hospital in early 1944. His host later apologized for the criticisms of one physician who “got a little out of hand and was so very emphatic.”
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When physical medicine specialists and orthopedists debated the value of Kenny's work it was part of a broader struggle over not only the supervision of polio care but the field of rehabilitation. Orthopedic surgeons were usually the senior and wealthier colleagues, but both groups considered themselves experts in the treatment of disabling conditions.

With the growing public interest in paralyzed children, polio had come to play a major role in defining the practice of physical medicine.
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Capitalizing on the newsworthy nature of Kenny's work the American Congress of Physical Therapy had awarded Kenny their annual Gold Key award in 1942 to honor the person who has made the greatest contribution to the field of physical therapy during the past year. The previous recipient had been Franklin Roosevelt for “his unremitting labors for the prevention and cure of poliomyelitis.”
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Kenny's award, her supporters pointed out, was “the first time in the history of the organization that a woman had been the recipient of the honor.”
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While it was difficult to assess a recent therapeutic contribution “on account of lack of perspective and the influence of personality that colors their contributions,” the president of the Congress told Kenny, the group had nonetheless recognized “your devoted labors [which] have been outstanding in nature and have resulted in raising the discipline of physical therapy to a higher standard.”
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As doctors specializing in physical medicine struggled to improve their profession's status Kenny's work was both frustrating and exhilarating. They were the first physicians to come to Minneapolis to take Kenny's courses, and most of them were directors of physical therapy programs at their home institutions.
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In November 1942 an entire issue of their specialty journal the
Archives of Physical Therapy
was devoted to the Kenny method, and comments on the topic appeared in almost every issue during the 1940s.
²⁵²

Robert Bennett's acceptance of Kenny's work especially impressed his peers. Although his Warm Springs staff dealt mainly with chronic patients, he had adopted Kenny's methods and integrated them in his new school of physical therapy. When Kenny complained about a placard at the 1942 AMA exhibit announcing the Kenny method was being taught at Warm Springs, Bennett supposedly retorted that as it was “the method of choice”
he intended to teach it whether she liked it or not.
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In various journal articles he argued that her work did not contradict proven pathology, for her theory of a “physiologic blockage” might be part of “the central nervous system's reaction to virus invasion.” In any case, the work was proving itself clinically sound and “our research men, our physiologists and pathologists must, and eventually will, give us the basis for these newer clinical manifestations.”
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He pointed to a distinct change in her ideas and practices now that she was working at the University of Minnesota. The fact that her work was “much more logical and scientific” than “just five years ago as evidenced by her book published in 1937” was, he felt, the result of the able support of the faculty of the University of Minnesota, especially the guidance of Miland Knapp.
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FIGURE 3.3
An advertisement for Pohl and Kenny's 1943 textbook promoting a “completely new theory” of polio. [Advertisement]
Archives of Physical Therapy
(April 1943) 24: back page.

Kenny's work remained a source of tension between physical medicine specialists and orthopedists. William Stratton Clark, who directed the physical medicine department of a hospital in Dayton, Ohio, came to Minneapolis and was impressed by lectures from Pohl and Knapp, which combined “the coordination of the Kenny concept with
known physiological and pathological principles and hypotheses.” But back in Ohio he encountered resistance from his peers, finding it “difficult for a man in my specialty to convince our local orthopedic surgeons.” Clark began to try to arrange for these surgeons to go to Minneapolis, for he felt that second- or third-hand knowledge would not convince them. “There is no doubt,” he told Pohl, that “the Kenny concept, when passed through human minds, becomes opinionated and distorted, much as do certain bacteria in being passed through a series of laboratory animals.”
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Paul Carson, the director of the Wichita Children's Clinic, found that his own enthusiasm alienated rather than convinced other physicians. Even after he and his Kenny-trained physical therapist “had some very thrilling results,” many of his colleagues continued to express considerable opposition and “I heard the other day that one Doctor said my middle name was ‘Kenney [sic].' ”
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Part of the problem was the issue of respect. The term
physical therapy
was generally used to refer to the work of both technicians and doctors, and orthopedists tended to consider themselves more medically qualified than physical medicine specialists. At the end of 1943 the AMA's Council on Physical Therapy renamed itself the Council on Physical Medicine. Likewise, the American Congress of Physical Therapy became the American Congress of Physical Medicine. These changes, reformers hoped, would place the specialty of physical medicine on a par with other established specialties.
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More important than name changes were 2 major philanthropic sources of support: the NFIP, which funded physical medicine specialty training, and Bernard Baruch, the millionaire-industrialist who gave over a million dollars to establish specialized research and training centers in physical medicine.
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The power of money was clear to some Kenny opponents. One Harvard physician suggested that many orthopedic surgeons were “falling in with the popularity of the [Kenny] method, not so much because of the genuine belief in it, but because of the possibility of getting grants.”
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Whatever the physiological explanation for spasm, it was generally accepted as a clinical sign that required attention. Physicians began to look for ameliorative techniques less complicated and labor intensive than Kenny's methods. The drug Prostigmine (or neostigmine), first synthesized in 1931 and used to treat neuromuscular disorders like myasthenia gravis, seemed promising.
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Prostigmine was first tested on patients with polio in Kenny's new hometown. Knapp began testing the drug with the help of Herman Kabat, a young neurophysiologist, in early 1942. Knapp and Kabat found that Prostigmine was a distinct help in decreasing spasm and pain and restoring “muscle coordination.” According to science writer Paul de Kruif who had stayed away from the Kenny story but wrote about Kabat, Kabat gave his first injection of Prostigmine to a “badly spasmed woman” who, even after intensive Kenny treatment, was still unable to sit as “her back was stiffened and knifed through with pain.” This patient improved as did a boy whose case of boils had meant he was not able to have hot packs; soon after the injection, he could turn over easily in bed and then do push-ups.
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Kabat published his work in
Science
and the
Journal of Experimental Medicine
and with Knapp in
JAMA
and in the
Journal of Pediatrics
.
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In October 1943 the NFIP gave the University of Minnesota a large grant
that included this research, but after problems working with Maurice Visscher, the head of the physiology department, Kabat left Minnesota and took a poorly paid position in the U.S. Public Health Service in Washington, D.C.
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Kabat then began to treat a variety of disabled patients with “spastic” muscles, and found that Prostigmine was astonishingly successful. One stroke victim “within 24 hours after the first injection” was able to “put a cigarette in his mouth with his right hand.” His work with multiple sclerosis patients, publicized by de Kruif in the
Reader's Digest
, caught the attention of California industrialist Henry Kaiser who asked him to treat his son and later founded the Kabat-Kaiser Institute (later part of Kaiser-Permanente).
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Even though de Kruif presented Kabat as dismissive of many of Kenny's ideas, Kabat himself promoted his “neuromuscular reeducation” techniques for multiple sclerosis, polio, and cerebral palsy that “like the Kenny treatment … [help] patients recover nerve-muscle control.”
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Another drug was even more intriguing: curare, a muscle relaxant used as an anesthetic and to treat spastic muscles in tetanus convulsions and cerebral palsy.
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In 1945 New Jersey orthopedist Nicholas Ransohoff added curare injections to his clinical treatment of polio to ease spasm. After a brief note in
JAMA
he offered a long paper on curare at the AMA's 1946 annual meeting, which, according to
Colliers
, “convinced some doctors it may be as important, or more important, than the famous Sister Kenny technique.”
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Despite warnings by anesthesiologists that curare could cause respiratory paralysis and death and that it was “a dangerous weapon in the hands of the inexperienced and untrained,” physicians were eager to try it.
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Ransohoff's technique promised to alter the routine of hot pack care, enabling patients to leave bed more quickly and thus, he claimed, taking a heavy burden off the nursing staff of a hospital.
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In Pittsburgh Jessie Wright tried curare on her patients at the D. T. Watson Home and agreed that “we need to get away from packs. I think they have been very much overdone.”
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Kenny was not convinced that any drug could work as well as her system of hot packs and muscle exercises. When she examined one of Knapp's patients whose spasm was supposed to have been corrected by Prostigmine, she found “spasm very evident.” “I would not consider Prostigmine a reliable drug,” she began telling medical audiences. “It may be a suitable adjunct but of itself it has not proved satisfactory.”
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Fishbein's growing hostility to Kenny and her claims was reflected in a series of studies published in
JAMA
during 1943 on polio's physiology. The critics Fishbein published replayed the old story that much of Kenny's method was not good, and what was good was not new. The Kenny concept was inadequate as a physiological explanation, Harvard physical medicine specialist Arthur Watkins and Mary Brazier, a neurophysiologist at the Massachusetts General Hospital, argued, and in any case “muscle shortening” through spasm had been recognized for many years.
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In “The Significance of Muscle Spasm” Plato Schwartz and Harry Bouman agreed, adding that her theory of the disease, based “solely on clinical observation,” could hardly be as reliable as a “logical premise” that had been “slowly developed from the work of many men in various countries.”
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Even more definitive was a study by Columbia neurologist Joseph Moldaver whose testing of muscles suggested that spasm did not exist, and that paralysis was the result
of nerve destruction. Moldaver had attended one of Kenny's courses in Minneapolis in 1943 and, while she was away, had tested her patients, finding that a number of their muscles scored zero. Extremely annoyed to find out a visiting researcher had overridden her strict rules against muscle testing, Kenny had reminded her staff about the worthlessness of such tests before spasm had been relieved.
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But Moldaver presented his work to the New York Academy of Medicine in May 1943, and it was reported in the
New York Times
and
Time
and published in
JAMA
. His analysis of electrodiagnostic tests of 49 patients was widely interpreted as contradicting Kenny's theory that untreated muscle spasm could lead to neuromuscular degeneration. Moldaver did not believe that spasm explained polio paralysis at all. Spasm, he argued, was a complex phenomenon involving the meninges covering the nerve roots of the spinal cord, and incoordination was the result not of the diminution of nerve impulses but “the inability of partially or totally degenerated muscles to respond to otherwise normal nerve impulses.” This study, according to
Science News Letter
, reaffirmed “the century-old view of infantile paralysis as a disease of nerve destruction or damage.” Thus, as orthopedists had long argued, polio had to be treated not by active exercises but with rest to avoid further nerve damage.
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So potent were Moldaver's conclusions that even researchers who found some evidence of muscle changes resisted Kenny's explanations. In the
American Journal of Clinical Pathology
, for example, when researchers discovered “degeneration of nerve and muscle,” which, they acknowledged, could be “considered to show ‘spasm,' ” they instead described these changes as secondary to injured nerve cells of the spinal cord.
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