Sister Elizabeth Kenny and Polio in America: Doyenne or Demagogue in Her Role in Rehabilitation Medicine?
2017; Wiley; Volume: 10; Issue: 2 Linguagem: Inglês
10.1016/j.pmrj.2017.11.012
ISSN1934-1563
Autores Tópico(s)History of Medical Practice
ResumoIn 2017, it is difficult to understand the fear that permeated American culture about poliomyelitis in the late 1930s and through the 1940s. Polio epidemics seemed to randomly attack every late summer or fall during that era, striking down infants and young children irrespective of socioeconomic status, leaving some with severe paralysis or even causing death. There was no known vector, no cure, no method of prevention. This fear was fueled by media and the intense fundraising efforts of the National Foundation for Infantile Paralysis (NFIP), the foundation formed through the support of Franklin Delano Roosevelt and better known as the March of Dimes 1. It was and is the most successful disease-specific foundation in our nation's history 2, 3. NFIP campaigns captured millions of dollars by raising the dread specter of polio, eventually funding the Salk and Sabin vaccine research that led to the obliteration of polio in America. But for those who contracted polio, there was no effective treatment. Sister Elizabeth Kenny, an Australian nurse, arrived in America in 1940. She had already received great acclaim as well as disdain for her then-radical methods of treating acute polio. She was brash, controversial, and outspoken about the existing methods of polio treatment. She aggressively challenged the mostly male medical profession. Her treatment methods, however, were very consistent with the concepts of physical medicine and rehabilitation (PM&R), and consequently her efforts found support from the early developers of the field. Her fortuitous arrival in Minnesota, a state whose citizens were acutely aware of polio because of repeated epidemics there, promoted the development and respect for this nascent medical specialty, PM&R. Without the ongoing polio epidemics, Kenny's intense media coverage, and her symbiotic relationship with some of PM&R's early pioneers, our field would have had a slower start. Elizabeth Kenny was born to Michael and Mary Kenny in 1880, in Warialda, Australia, a remote bush country village 375 miles from Sydney in the northwest corner of New South Wales, the region of the nation with the greatest population density. Elizabeth was the third of four children in the Kenny household. She was an independent child from an early age, a tomboy who loved to roam the bush on foot and on horseback. Educated in a one-room schoolhouse, her formal schooling seems to have ended in her teens, but she was bright, an avid reader, with no interest in the traditional lives of bush ranch women. Kenny developed an early interest in medicine and nursing after she fractured her forearm in a horseback accident. She was treated by a local physician, Dr Aeneas John McDonnell, with whom she developed a mentorship that served her for years 1, 2. In later years, her descriptions of her training varied, and although she wrote that she was a graduate nurse, no record of formal nursing training has ever been found 2. Instead she seems to have worked under the tutorship of a number of nurses and physicians, all of whom seemed to respect her dedication and work ethic. Kenny became a “bush nurse,” traveling the local area and treating the ill, making referrals when appropriate to the local hospital, but accepting only barter for her services. Her skills and reputation as a nurse healer grew. Traveling on horseback through the bush country, she served as a mid-wife and treated work injuries and sick adults and children. In 1911, Kenny encountered her first case of infantile paralysis, and soon there were others: 6 of the 20 children in her region were infected during this first of Australia's many epidemics 2. There were no known treatments for this disease, so she applied what she had previously seen in the treatment of limb injuries—warm poultices, gentle movements, tender support, and hope 1. It was reported that all 6 recovered without paralysis 2. McDonnell had become a senior member of the regional health care community during this time, and he shared with her all that was known about poliomyelitis from the regional medical library. However, he also advised her that she had treated these children with methods precisely counter to the then-prevailing medical standards, despite the fact that they had recovered far better than others treated by those conventional methods 2. Australia entered World War I on August 4, 1914, along with England. Kenny, restless to gain new experiences, prevailed on McDonnell to write testimonials supporting her experience and skill. Carrying these, she traveled to England to participate in the medical support of the troops. She was appointed an army nurse in 1915, despite her lack of formal credentials. She was sent to France, where shortly thereafter she was wounded with shrapnel from a shell explosion, sustaining injuries to her left leg that would plague her throughout her life. She returned to the front, serving with distinction. Kenny was promoted to the nursing equivalent of first lieutenant, which in the Australian military gave her the formal title of Sister, a title that she proudly carried for the rest of her life. After the war, she returned to Australia to serve again as a rural nurse practitioner. In 1926, she adopted an 8-and-a-half-year-old girl from a broken home and named her Mary, in honor of Kenny's mother. Kenny never married, but Mary would accompany her and assist her in her work and at home throughout most of her life, and especially as they entered a new phase 2. By 1931, poliomyelitis was recognized as a worldwide threat. The rigidly held medical belief in that period was that the disease affected only a population of the anterior horn cells, killing or severely damaging these cells. All musculoskeletal sequelae were caused by strong normal muscles pulling on weaker ones 1, 2. As a consequence, physicians encased the limbs in splints and plaster, in positions intended to protect against this unopposed muscle pull. Such restraints were maintained for periods of weeks to many months. This practice lacked a solid foundation of scientific research but continued to be the prevailing methodology. Rest and joint restriction were the primary methods of treatment. Concepts of movement and exercise did not exist in the general management of polio at that time. In fact, they were felt to be deleterious 1. The field of physical therapy was in its infancy, and at that time in Australia, the term to describe the field was massage therapy 2. Sister Elizabeth Kenny examining a polio patient, 1942. Kenny had significant experience treating meningitis from her wartime experience in troopships, which often had epidemic losses due to this disease, and she had seen the value of exercise, moist heat, and movement 1, 2. She also believed that a person's willpower played a major role in recovery from disease. She developed her clinical methods through practical experience, combined with a willingness to counter contemporary medical beliefs. She had begun to formulate conceptual theories as to why her methods worked, and these too did not often conform to conventional medical beliefs. Despite her unconventional concepts and methods, she would not treat patients without a physician's concurrence and oversight 1, 2. Her techniques included the use of warm and cold compresses, saltwater immersion (although she later abandoned that treatment), and gentle progressive exercise of specific muscles, concentrating on allowing no muscle substitution or fatiguing of weakened muscles 1, 2. Physicians who worked with her were impressed by her results and even more by her tenacity and patience. In 1933, a group of physicians recommended to the Queensland Health Administration that she be allowed to demonstrate her techniques at Brisbane General Hospital 1, 2. The demonstration in Brisbane failed miserably. Her morning presentation to the children's massage staff came across as unprofessional. She was perceived as a bush nurse with no formal medical training. Kenny was trying to demonstrate muscle stimulation using manual tapping and vibration over the tendon, a technique unknown at that time 1, 2. The afternoon session before the medical staff went no better. She evaluated a young boy who had been diagnosed with acute polio 2 years previously. He had very visible tonic muscular rigidity in his cervical paraspinal muscles, and Kenny called this phenomenon “muscular spasm.” The audience reacted with jeering and laughter—dead muscles could not possibly be in spasm! This was precisely the clinical condition that she had been successfully treating with moist heat, yet the audience walked out on her 2. However, community supporters and the physicians who had worked closely with her began a strategic process of applying political pressure to create a Queensland Health Ministry governmental clinic under her supervision. The government sent Dr Raphael Cilento, the Queensland director-general of health, to review her sanatorium. He was impressed and recommended establishment of a governmental clinic, overseen by Kenny, for both patient treatment and staff training 1. In early 1934, a clinic was opened in the Queen's Hotel in Townsville, Queensland. Within a month of opening, she had 17 patients, a population from places throughout Eastern Australia that grew to more than 60 within months 1. The clinic was a huge success but was not without obstacles, including the development of professional jealousies. Headstrong throughout her life, Kenny even antagonized her earlier physician advocate, Raphael Cilento, who had become a powerful force in regional health care administration. The Queensland branch of the Massage Association (the physiotherapists' organization) petitioned the government to halt her practices, seeking to have only its members designated as polio therapists 1. However, the growth of the Townsville clinic population demanded expansion, and a second branch clinic was opened in Brisbane in mid-1934 with Kenny in charge, and over the first year, 400 patients benefited 2. Medical concerns remained over her frequent exaggerated claims of treatment outcomes, and her occasional use of the term “cure.” In late 1935, a Royal Commission consisting of a group of 8 physicians including McDonnell was appointed to review the results of “the Elizabeth Kenny method of treating infantile paralysis…and to compare the results of the Kenny method with orthodox treatment.” Despite concerns, she was given responsibility for a new Sydney clinic and shortly thereafter another in Toowoomba, Queensland. By late 1936, the clinics had more than 600 patients, including some from China and London, with 600 more on waiting lists 2. The medical director was her friend Dr Jean Rountree, with whom she worked closely and successfully 2. In April 1937, while the physician review was ongoing, Kenny was invited to London to establish a clinic there, and she traveled with 2 of her therapists. The English medical establishment was unwelcoming, but Sir Frederick Menzies, the Chief Medical Officer of the London County Medical Office of Health, gave her his blessing and allowed her to develop the Kenny Unit at Queen Mary's Hospital for Children, an 840-bed long-stay children's hospital in Carshalton, United Kingdom 1. Initially aghast by her removal of casts and braces from patients, the English therapists saw clinical successes that erased their skepticism. Physician support remained absent, however, even while the program grew. A British Medical Commission reviewed the results of her methods and their report was cool, with the conclusion that many elements of her methods were “harmless but of unproved value” 4. Kenny returned to Melbourne, and in January 1938, the Australian Royal Queensland Commission released their findings. It was devastating. In 130 pages, the Commission reported that her clinical projections were almost never fully achieved, and that “some patients became deformed who might not have become so under orthodox treatment.” The document stated that “immobilization was essential in polio care” and underreported the adverse results of orthodox treatment as conventionally practiced throughout Australia 1. The report recommended that the money spent on her programs could have been better spent expanding orthopedic departments and vocational training. The authors concluded that a minimal improvement in self-care abilities was of scant consequence and was therefore a waste of public money 2. In response to public pressure and the media, Kenny attracted the support of Billy Hughes, a wealthy philanthropist and the federal minister of health 2. He facilitated the establishment of a clinic she led at Royal North Shore Hospital in Sydney. Outcomes there resulted in expansion into a Newcastle Hospital clinic. Even more important, the Brisbane clinic moved into the highly respected Brisbane General Hospital, despite medical staff disagreements over her protocols 1, 2. She had some ardent and powerful proponents, including Dr Aubrey Pye, the physician director of the Brisbane Hospital complex, but her highly vocal opponents dismissed her results as only natural recovery 1. An increasingly confident Kenny shocked hospital physicians when she removed a child from an iron lung and treated him with thoracic hot packs. The child survived, regaining independent respiratory function 1. Five leading medical academicians and hospital medical director physicians made a public declaration, stating that her methods demonstrated that rigid immobilization was unnecessary, moist heat was beneficial, joint movement was protective, and, when carefully administered, muscle re-education was therapeutic, and the effects could continue for 1-2 years. Even that failed to convince the doubters 2. But while Kenny's methods produced results, her medical explanations for their basis relied on concepts that were foreign and even bizarre to many other practitioners. She believed, for example, that prolonged immobilization led to diminished neural impulses, with interference of “the normal function of the subconscious mind,” decreasing circulation, increasing joint stiffness, and creating an “alienation of the affected part” 1. Kenny published her first book, based on work done between 1931 and 1934, in 1937 2. It received dismal reviews in the British Medical Journal 2. Her methods had evolved radically since that publication. In 1941, shortly after her arrival in the United States, she published a monograph, Treatment of Poliomyelitis in the Acute Stage 5. It featured early versions of her methods and also did not find favor. As Australia entered World War II, Kenny saw war news displace positive commentary on her polio methods, but she did notice an article in JAMA by physiatrist Kristian Hansson lamenting the lack of effective polio treatments 6. She began to believe that America might provide a more receptive area for her work. Alan Lee, a supportive Brisbane surgeon had just returned from America, where he spoke with physicians at the Mayo Clinic and gained awareness of the NFIP as a potential supporter for Kenny's work 1. Other staunch Brisbane physician advocates, including Pye, concurred that Sister Kenny needed a more fertile field than Australia to gain the acceptance her methods deserved, and they orchestrated a trip abroad for Kenny to meet polio experts in the United States. They cajoled William Forgan Smith, Queensland's premier, to give her £300 for shipboard passage to America. Kenny departed with daughter Mary in March 29, 1940 1. America in 1940 was not yet in the War, but the nation was obsessed with the fear of polio. Poliomyelitis awareness in America had escalated dramatically, in part because of Franklin D. Roosevelt's diagnosis in 1926. His election to the Presidency in 1932 created increased momentum for the fight against polio, despite the White House's efforts to hide the depiction of his residual disabilities 7, 8. Roosevelt and his former law partner, Basil O'Connor, worked to create the NFIP in 1938, and this led to the March of Dimes campaign, the greatest money-making philanthropic effort in our nation's history 1, 2. O'Connor became its director 7. Polio season was a time of panic for all parents, the fear somewhat justified because one third of all pediatric disablement was due to polio during this era 2. The then-orthodox treatment of prolonged encasement in plaster was almost as bad as the disease. It typically ended with a few hours of physical therapy late in the disease. Even Kristian Hansson, professor of physical medicine at Cornell University, argued for setting 6 months as the beginning of physical rehabilitation 9. In a 1936 article in JAMA, Arthur Legg of Harvard University recommended beginning ambulation only after 9 or 10 months in cases of moderate lower extremity weakness 10. Roosevelt himself was unable to stir medical support for active, acute rehabilitation 8. Landing in San Francisco April 16, 1940, Kenny and daughter Mary traveled by train to New York City with a plan to meet with O'Connor, the head of the NFIP. O'Connor was out of town, and Kenny met instead with Peter Cusack, executive secretary of the NFIP 1. While there, she was given a Public Health Service Bulletin on polio by Florence and Henry Kendall, which advised lengthy splinting, rest, joint protection, and absolute avoidance of fatigue, stating the official position on polio treatment 11. Cusack relayed to her that the NFIP conducted no research or treatment itself, instead funding institutions that did, and he referred her to the American Medical Association (AMA) headquarters in Chicago 1. Discouraged by her New York experience, she was ready to return home, but she traveled to Chicago to meet with the AMA's Council on Physical Therapy. The AMA officials were unimpressed with her unusual explanation of treatment methods. Kenny had come to believe that the primary pathology in polio was muscle spasm, accompanied by incoordination and the concept of “mental alienation,” a concept that flew in the face of conventional medical wisdom. She was dispatched to meet with Dr John Coulter, head of the physical therapy department at Northwestern University, but his therapists also were skeptical of her explanations 1. Only her daughter's cajoling kept her from heading home without visiting the Mayo Clinic. She departed for Rochester, Minnesota, to meet with staff, her letters of introduction from physicians in Australia in hand 1, 2, 12. At Mayo, Sister Kenny first met with Melvin Henderson, chair of the department of orthopedics, and the person who the Australian surgeon Alan Lee had met the previous year. Henderson was intrigued and referred her to Dr Frank Krusen, the pre-eminent physician in the new specialty of physical medicine. Krusen listened to her arguments, face-to-face and in lectures over 2 days. Krusen, still considering her physiologic explanations and treatment programs with deep skepticism, referred her to colleagues at the University of Minnesota at Minneapolis, because that city had a far larger population of polio patients 1, 13. At the University of Minnesota, she met Dr Wallace Cole, orthopedics department chair, and physiatrist Dr Miland Knapp, who at age 35 was chief of physical therapy, giving him a copy of her earlier monograph, Treatment of Poliomyelitis in the Acute Stage, which featured early versions of her methods 1, 5, 13. Although her work had undergone evolutionary changes since its initial publication, she was able to explain these treatment modifications to his satisfaction. After demonstrating her techniques and with summer arriving, Cole and Knapp requested Kenny stay in Minneapolis to treat the anticipated patients. In addition, with their support, the NFIP awarded the University of Minnesota a grant to study the Kenny techniques 1, 2. However, NFIP funding provided for inpatient care but only a meager food and housing subsidy for Kenny, and this began to raise more tensions between her and the NFIP. Kenny's relationship with NFIP Director O'Connor had never been a comfortable and collegial one. Kenny was a brash and outspoken woman from Australia, and O'Connor an Eastern-bred male power broker. Nevertheless, Kenny began her work at Minneapolis General Hospital (now Hennepin County Medical Center), in a ward where she was given a free hand to implement her protocols. In August of 1940, the epidemic began in full swing, and Kenny worked tirelessly from 5:30 AM until midnight to treat the growing population of polio patients. By year's end, she and her daughter had treated 26 acute and subacute polio patients 13. Her therapeutic results sufficiently impressed Knapp and Cole to write a JAMA article suggesting that her “method may well be the basis of the future treatment of infantile paralysis” 13. John Pohl, a Minneapolis-based orthopedist, Harvard-trained under Robert Lovett, FDR's New York physician, and trained to use strict immobilization techniques, was a skeptic. However, he had grown tired of hearing the cries of children encased in plaster. Pohl allowed Kenny to oversee one of his patients, a college-aged youth with severe polio sequelae and who was still using a wheelchair for mobility after being diagnosed a year earlier. The patient was admitted, and with the medical staff in disbelief, Kenny removed his braces and corset. By year's end, he was ambulatory using forearm crutches. He returned to the University and subsequently graduated with a law degree 2. Pohl became an evangelist, bringing others on board, and he and Kenny began collaborating on a book shortly after her arrival in Minneapolis in 1941. The book, The Kenny Concept of Infantile Paralysis and Its Treatment, was published in 1943 14. The book was reviewed in a disdainful, unsigned British Medical Journal article to which Kenny responded vigorously 15, 16. After these developments, Pohl, Cole, and Knapp recommended that Kenny be allowed to participate in a study of her methods at Minneapolis General Hospital. The March of Dimes provided a subsistence salary as well as research funding 1, 2. She supervised others but also learned from her own work, modifying care as she deemed necessary. She taught her young patients to name their muscles accurately. During a grand rounds presentation of the case of a young girl, the resident asked the patient to contract her buttocks. The young girl looked at him and said, “Do you mean my gluteus maximus?” 2. Mayo's Henderson wrote NFIP's O'Connor that “she has something worthwhile to teach us” 2. In 1941, Cole and Knapp wrote in JAMA that the Kenny results were without adverse effects such as contractures and scoliosis, and that the patients had less disability than expected, were more comfortable and cheerful than typical, and that her results clearly showed that no harm had resulted from her “abandonment of immobilization” 13. By 1941, the national media had begun to lavish praise on Kenny's work, raising further concerns among medical professionals as well as with O'Connor and the NFIP. A subcommittee was formed within the NFIP's Committee on Research, with Cole and Knapp leading, and Krusen and Irvin McQuarrie, famed pediatrician at the University of Minnesota, participating. All had been initial skeptics 2. The report produced later that year substantially validated the merits of the Kenny methods, and the committee published an editorial in JAMA stating that, “in the early stages of polio, the length of time which pain, tenderness and spasm are present is greatly reduced, and contractures caused by muscle shortening…are prevented by the Kenny method” 17. The report was widely publicized in the national media. Kenny's fame grew, as did acceptance of her methods. Harvard orthopedist Frank Ober, then President of the American Orthopedic Association, turned from hardcore skeptic to supporter, writing in JAMA that, “Many surgeons believe in prolonged rest and immobilization. Prolonged fixation in one position causes stiffness in muscles and joints, and delays recovery. Sister Kenny has demonstrated that …when her ideas are applied, splinting is not necessary. Sister Kenny's treatment is superb nursing and common sense” 18. Mayo physiatrist Earl Elkins wrote in the Archives of Physical Therapy that, “All of these facts make it urgent that the Kenny treatment be used” in subsequent epidemics 19. Even Krusen had been won over, writing that, “she should be given full credit for having developed a new and extremely interesting concept of the symptoms of early poliomyelitis and the proper management of these symptoms” 20. Dr Robert Bennett, Medical Director of Warm Springs and FDR's physician, wrote Krusen after spending time with Kenny, Knapp, and Pohl in Minneapolis that, “All of a sudden I understood what Kenny in her very mixed-up way was trying to put across. It was almost like getting religion—I felt like a purified convert” 2. Bennett wrote in the Archives of Physical Therapy that, “The Kenny method is a logical, intelligent attempt to treat this new syndrome, and prevent its crippling sequelae.” He went on to state that “In the acute stage of the disease, it should be obvious that we must accept the Kenny method in whole or in part…” 21. Kenny had encouraged Minneapolis to create a polio-specialty hospital, which was opened within a remodeled children's hospital in December 1942, and was dedicated as the 65-bed Elizabeth Kenny Institute, with Pohl as medical supervisor and Knapp directing university courses there. Kenny was given the title of “honorary director” 2. Reader's Digest scholarships funded 2-year trainees in the Kenny methods. The city fathers proudly supported the Institute, having seen Minneapolis achieve international fame for its medical advances in the management of polio 2. The early treatment of polio in the United States truly was a story of failure. Because the symptomatic manifestations of polio involved extremities, and because there were no medications that affected the disease course, orthopedics became the medical specialty overseeing most polio patients 1. Rest and rigid fixation for 12-24 months was a common practice, whereas others perhaps more enlightened used Hubbard tanks and warm water pools 6, 22. Henry and Florence Kendall in their 1939 Public Health Bulletin stressed immobilization as the essential treatment in the acute stage (which they felt extended from 3 to 6 weeks), based on their belief that any movement of a weak or paralyzed muscle risked overstretch with consequent delay in recovery or even permanent paralysis 11. They advised the use of splints or plaster to avoid placing weakened or paralyzed muscles under strain or stretch. They stated that “young children may easily be left without treatment for a month” after the acute stage, “a total of about 2 months since onset.” But because of paralysis and contractures, many patients subsequently underwent orthopedic surgical procedures including tendon transfers and contracture releases. A 1941 study published in the Journal of Bone and Joint Surgery by J. R. McCarroll and C. H. Crego described a study of 160 patients with 325 affected extremities to analyze the effects of 6 combinations of immobilization and physical therapy in treatment outcomes 23. The paper described 6 groups of polio survivors: Group 1 with initial plaster immobilization for a prolonged duration of 1-3 months followed by no physiotherapy, Group 2 with 1-3 months immobilization followed by 3-6 months of daily 20-minute therapy sessions, Group 3 with 4-18 months immobilization followed by no physiotherapy, Group 4 with 3-12 months immobilization followed by continued immobilization plus undescribed physiotherapy, and Group 5 with delayed immobilization (6 months post-onset) without physiotherapy. Group 6 represented individuals from remote communities receiving no treatment whatsoever lacking the services of orthopedists or physiotherapists. These latter patients typically were in bed only during the acute phase of illness and were encouraged to walk and exercise as soon as they were able to venture from bed. The authors concluded that there was no form of therapy in the first 5 groups that offered significant benefits and somewhat apologetically stated that the highest percentage of satisfactory brace-free outcomes occurred in the sixth group of patients, who had had no treatment whatsoever. Despite the authors awareness of Kenny methods, the study did not include any patients treated in using these or similar methods. Kenny had come to believe that the traditional belief that polio sequelae were caused by simply a flaccid paralysis was incorrect. She referred to the initial symptom in acute polio as muscular spasm, which created a sustained tonic contraction of muscles, resulting in inability to move the extremity. This was described by nurses working with Kenny as “fibrillary twitching, fasciculations, and hyper irritability of the muscle to stretching.” The second major symptom she described was incoordination, due in part to muscle substitution and in part due to disruption of normal motor unit organizational processes. The third major symptom she referred to as mental alienation, which was the inability of a muscle to produce voluntary purposeful movement despite the presence of intact neuromuscular structures 1, 2. Krusen, in a lengthy article describing her concepts, called this a “physiologic block which must be distinguished from the organic interruption resulting from the destruction of anterior horn cells by the disease” 20. Kenny's first described concept, muscular spasm, flew in the face of traditional American medical beliefs that polio never actually affected muscle function directly but rather caused the failure of anterior horn cells. Even though spasms, usually accompanied by pain, had been noted by earlier clinicians working with polio, thi
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