Polio Wars

by Rogers, Naomi

  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.”227 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.228 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.229 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.”230 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.”231 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.”232

  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.”233 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.”234

  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.235 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.”236

  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.”237

  We have but one weapon against the ravages of polio, Colliers declared: “the method of treatment devised by Sister Elizabeth Ke
nny, 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.”238 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.”239

  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.”240

  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.”241 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.”242

  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.”243 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.244

  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.”245 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.”246

  WHOSE PATIENT?

  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.247 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.”248 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.”249 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.”250

  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.251 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.253 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.”254 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.255

  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.”256 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].’ ”257

  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.258 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.259 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.”260