Polio Wars (2 page)

This book also focuses on the limber, healthy child patient featured on the 1945 container. Here is a dramatic, if sentimentalized, depiction of the results of a special kind of clinical care, yet the container does not show any doctor, hospital bed, syringe, or other symbol of medical science. For the American public the most powerful omission may have been the familiar picture of a polio patient: the crying child in a hospital bed with arms or legs in plaster casts; the fearful child waiting for an orthopedic operation; or the “recovered” child discharged with crutches or braces, all images typical in March of Dimes campaigns. On this “Sock Polio” container, health has been achieved in another way, through compassion and care based on a distinctive understanding of the body shared by Kenny and her staff but not by other professionals.

In an era when nurses were seen as the recipients of medical science rather than its designers, Kenny knew that her claims to a new understanding of polio were controversial before their content was even known. At first she presented herself as a supplicant to scientists, seeking their assistance to explain the meaning of the new symptoms she had identified and the reasons her methods worked. Her 1941 textbook had the temperate title
Treatment of Infantile Paralysis in the Acute Stage
. But as the Institute prospered and Kenny was feted as a savior, she began to argue that her work embodied a new concept of polio drawn from a close reading of the body. Polio, she said, was not solely a neurological
disease but also a disease of muscles and “peripheral structures.” By the time Kenny published her 1943 textbook
The Kenny Concept of Infantile Paralysis
she had begun to argue that it was impossible to teach anyone to treat the symptoms she had identified if they did not understand her concept of the disease. Indeed, she frequently added, the prognosis for a patient treated without this new knowledge would always be far poorer than for a patient treated by professionals who fully understood the Kenny concept of polio.

Kenny knew to speak of “improvement” rather than “cure,” but she often did exaggerate her results. As early as the 1930s she learned the power of the press and the importance of a good story. She was accused by her critics of being a publicity hound, of practicing mistaken and perhaps even harmful methods, and of making unrealistic promises to disabled patients and their families. At times she boasted of her distance from the medical establishment; at other times she made much of her medical allies. She found strong public support when she attacked the elitism of the medical profession in both Australia and North America, but she also sought out and relied on the financial and social assistance from the elite in business and society. She said she chose to follow only “orthodox” physicians, but her clinical practice and its values drew on alternative attitudes toward medical science, toward the disabled, and toward chronic care. Her patients as well as the nurses and physical therapists she trained to become Kenny technicians were central to the functioning of her work. Her students saw her life as one of struggle and sacrifice, a story that was central to the image she projected and one they frequently retold as a way to keep their own spirits up as they battled for clinical autonomy and professional respect from skeptical peers and medical supervisors.

Her critics denigrated her work by drawing on their understanding of medical history, technical innovation, and gender relations. Yet many professionals were frustrated that neither the techniques of modern medical science nor an appeal to medical history enabled them to attack Kenny effectively. Indeed Kenny's experiences illuminate a side of American medical politics in which claims of nonpartisanship by philanthropies failed and where political and social allegiances defined who was on a hospital's medical staff, where a patient was cared for, and which patient was seen as suitable for orthopedic surgery and which for home care. In this world, as polio patients ruefully learned, wheelchairs were expensive, ramps nonexistent, and schools and workplaces inaccessible. The lived experience of polio paralysis meant social discrimination as well as physical disability.

The process of therapeutic change has a disturbingly messy history, as medical historian Erwin Ackerknecht pointed out long ago.
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At the dawn of the twentieth century, despite emerging laboratory-trained experts preaching rationality and caution, Americans continued to seek out therapeutic panaceas: in the 1920s goat glands for enhanced male virility and in the 1930s sulfa drugs to cure all kinds of infections and vitamins to treat and prevent newly identified “deficiency” diseases. But how could professionals decide what worked and when to change their practice? And how did they know who to trust? Drugs and surgical techniques were concrete, discrete interventions that appeared to have clear effects on the body and could be tested against a placebo in a medical trial. But other clinical methods were more amorphous, resisting any simple test.

Moreover, the popular and professional understanding of scientific innovation was profoundly gendered. The slow, careful procedures of physical therapy were mostly carried out by women; innovation in science through animal experiments or the study of human tissues and body fluids was something so dramatic and transformative that
it was the province of male professionals. A clinical trial was also a gendered project, since it involved “masculine” strength for clinicians to withhold a therapy despite their humane feelings for individual patients. Although there was much discussion about the importance of such trials to assess Kenny's methods, no clinical trial of her work was ever undertaken. Her methods were widely accepted, reflecting popular and professional enthusiasm rather than rational, measured assessment. And once her methods were taken up, as Kenny had hoped, no one wanted to use the old methods.

Polio is a common, contagious viral infection that has been endemic around the world for many centuries. The earliest records of a disease resembling polio were found in ancient Egypt. Until the late nineteenth century the virus rarely caused paralytic symptoms as most infants were protected from infection by maternal antibodies and young children usually experienced only mild symptoms that were often mistaken for a gastrointestinal attack or influenza. As levels of sanitation improved, children were protected from infection until they were older and more vulnerable. Children exposed to the virus after the age of 2 or 3 years were more likely to develop paralysis as the virus traveled from the intestines to the central nervous system. In the late 1890s polio outbreaks appeared first in Scandinavia and then in other industrialized Western countries including the United States. In 1909 the virus was identified as a “filterable agent,” smaller than a bacterium, but it could not be seen through a microscope until the electron microscope was developed in the late 1930s. Patients without clear paralytic symptoms were often given spinal taps, mainly to establish that the patient did not have meningitis or another similar disease.
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Today, despite the existence of effective vaccines, polio remains both endemic and epidemic in countries with inadequate sanitation, nutrition, and medical resources. Today there is a consensus that the polio virus is spread by contaminated fecal matter, but until the early 1950s there were many theories about how the disease spread and just how contagious it was.

Working with children paralyzed during polio outbreaks in the 1910s, Boston surgeons Robert Lovett and Arthur Legg and physical therapists Wilhemine Wright and Janet Merrill developed therapies based on the concept of rest and the enforced straightening of limbs. The improper use of muscles, they argued, would cause deformities and therefore patients, especially children whose movements could not easily be controlled, had to be strictly confined to positions that would keep their bodies straight. Often this involved casts and splints, followed by braces and corsets. As polio was considered infectious new patients were confined for 3 to 6 weeks in an infectious disease hospital or a general hospital's isolation ward. In polio's early or acute stage no massage or exercises were used for expert opinion held, in the words of nurse Jesse Stevenson, that “deformities develop even more quickly when the muscles are sensitive.”
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During the next “convalescent” stage, which could range from several months to 2 years, patients stayed in general wards or crippled children's homes, usually restrained in casts and splints. After weeks or months, patients were sent home and given exercises and perhaps also heat or electrical therapies, sometimes under the direction of a physical therapist. As there were few of these professionals outside of specialized rehabilitation institutions, however,
more often exercises were explained to the patient's mother when the patient was discharged. The patient was told to continue to wear the braces and use the crutches and to return for a follow-up examination, which usually involved testing individual muscles for strength and range of motion. When underused muscles withered and limbs grew unevenly, and after physicians determined that no further recovery of muscle strength could be expected, they prescribed orthopedic surgery such as muscle transplantation.
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“Probably no other one disease requires so many different types of operations for its satisfactory treatment,” reflected one orthopedist in the 1920s.
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On rare occasions critics warned that immobilization, while important, could lead to “vasomotor and trophic disturbances in the affected extremities” as well as “circulatory interference.”
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Only much later did polio experts admit that many orthopedic surgeons got “terrible results.” In 1955, an orthopedist recalled with horror 24 patients in the 1930s who were placed in casts and splints, some for as long as 2 years, while he and other specialists waited “for their muscles to recover.”
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Muscle testing, codified by Lovett and Legg, was the major technology used by physical therapists to show patients and other professionals improvement in muscle strength and power, and to assess the necessity for orthopedic surgery. It was based on 2 techniques: muscle positioning and muscle movement. In muscle positioning the body parts not being tested had to be held as firm and stable as possible as the therapist applied pressure (or “resistance”) to the muscle or muscle group in order to estimate its strength based on the amount of pressure applied and the amount of strength required to hold the test position. The therapist had to understand the intricate workings of muscles and muscle groups to be able to detect any substitution movements used by the patient (consciously or unconsciously) to compensate for muscle weakness. To assess a muscle's range of motion and flexibility, a part was moved through a specified arc of motion and in a specified direction. These tests were used to seek a pattern of muscle weakness, for the degree of functional strength was believed to bear a definite relationship to the extent and degree of pathology, including the site of the nerve lesion. Such tests required a detailed understanding of anatomy and muscle function to be able to achieve an accurate grading of muscle strength and motion.
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Their accuracy depended on the skill and judgment of each individual physical therapist. Indeed, testing could also be used to assess the efficacy of therapies; thus, Lovett used the muscle test to indicate the danger of excessive “massage and therapeutic exercise.”
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Further, while muscle testing demanded that the therapist understand intricate muscle anatomy and physiology, it did not assume any such knowledge for the patient. Indeed these tests tended to point out muscle weakness and inability, rather than strength and functionality.

In the early 1920s a few orthopedic surgeons developed other treatments. Los Angeles orthopedist Charles Lowman turned a former fish pond on the grounds of the Orthopedic Hospital-School into a modern therapeutic pool, shortened the long watchful waiting period typical for early polio cases, and began to allow patients into the pool using muscle reeducation under water as early as a week after the quarantine period. These techniques Lowman believed helped to keep “the channels of communication open between the central nervous system and the muscle.”
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The experience of Franklin Roosevelt in the 1920s inspired a surge of optimism around hydrotherapy. Roosevelt, a wealthy lawyer who had been nominated for the vice presidency by the Democratic Party, was paralyzed by polio in 1921 at the age of 39 years. In his search for therapies that would enable him to walk
again he traveled to Warm Springs, then a run-down resort in rural Georgia, to try out its heated mineral springs. He was sufficiently impressed by this treatment to purchase the resort and develop it into a polio rehabilitation center. By 1928 when he was elected governor of New York he was known as the man who had battled and conquered his paralysis, a story that, although not really true, was even more crucial during his successful campaign for the presidency in 1932.
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During the 1930s polio care took a conservative turn. Physicians learned not to expect much improvement in their patients' muscles and were suspicious of those who claimed success.
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Orthopedic surgeons George Bennett and Robert Johnson and physical therapists Henry and Florence Kendall at the Baltimore Children's Hospital-School were disheartened to see that some of their patients recovered “to normal with little or no treatment” while others remained “hopelessly crippled even though given the best care.” “No one is justified in making an early prognosis,” they concluded, for “it is impossible to determine the outcome.”
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The Kendalls were also convinced that patients were harmed by “frequent, improper handling, and over-treatment.” Concerned about muscles that lost their natural reflexes through overstretching they relied on frames, casts, splints, and very mild exercises, rejected underwater exercises, and suggested that some patients might benefit from “complete rest in the bed for several years.”
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By the early 1940s, muscle exercises were still part of polio care, but there was a consensus that underwater exercises had been overemphasized. Even at Warm Springs, according to its chief surgeon, only a quarter of his patients exercised in the center's thermal pools.
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