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Historical Perspective

1. Rehabilitation Medicine (1897-1914)
   1. The Advent of R. Tait McKenzie
   2. McKenzie at the University of Pennsylvania
   3. Rehabilitation Medicine Before World War I
   4. The Orthopedic Surgeons Sponsor Physiotherapists

REHABILITATION MEDICINE (1897-1914)

The first signs of rehabilitation medicine at the University of Pennsylvania are contained in a report of the Children's Orthopedic Department to the Board of Managers of the University of Pennsylvania Hospital in 1894. The report calls attention to the need for an "orthopedic gymnasium" in a proposed new surgical building. When the new facility, the Agnew Building, was opened in 1897, it did indeed contain a room under the children's orthopedic ward for "the development of muscular power with apparatus for both mechanical and hot air massage, gymnastics and Swedish movement." The gymnasium was supervised by Miss A.S. Kite under the direction of the hospital's orthopedic surgeon, deForest Willard, M.D. By 1898, Kite was able to report that approximately 2,000 patients, with problems ranging from flat feet to infantile paralysis, had been registered in the Orthopedic Gymnasium for Children. The number of patients treated in the Orthopedic Gymnasium increased steadily thereafter, from 3,700 in 1899 to 6,738 in 1900 to 8,851 in 1903.¹

From 1904 through 1906, the reports to the Board of Managers were submitted under the heading "Orthopedic Ward," i.e., the children's designation was dropped. These reports were submitted by George M. Piersol, M.D., resident in orthopedic surgery under Willard, and marked the beginning of George Morris Piersol's long association with physical medicine and rehabilitation at the University Hospital. In his 1906 report, Piersol lists 7,475 visits to the Orthopedic Ward.²

The Advent of R. Tait McKenzie

The development of rehabilitation medicine at the University of Pennsylvania was sparked by the arrival of Robert Tait McKenzie, M.D. in 1905. McKenzie came to Philadelphia to direct the University's new Department of Physical Education. McKenzie's appointment was intended to improve the health of the undergraduate college students and was part of a larger initiative which included the construction of an indoor gymnasium (Weightman Hall) and an outdoor athletic field and stadium (Franklin Field).

McKenzie was an extraordinary individual. After receiving his medical degree, he remained at McGill University in Montreal, Canada, for about 15 years, first as a demonstrator in anatomy and subsequently as Director of Physical Training and Instructor in Gymnastics, all the while conducting a private practice in orthopedic surgery.³

Following presentation of his paper on facial muscles under stress to the American Society of Anatomists in 1899, McKenzie was approached by George A. Piersol, Professor and Chairman of Anatomy at the University of Pennsylvania, with an offer to become his assistant. McKenzie turned the offer down, feeling that his interests were better reflected in the newly formed Society of College Gymnasium Directors and in his activities as Medical Director of Physical Training at McGill University. McKenzie thus chose physical education over anatomy.

McKenzie at the University of Pennsylvania

When McKenzie was offered the directorship of the new Department of Physical Education at the University of Pennsylvania, the structure of the University was unlike that of any other university either in the United States or Europe. It was essentially a corporation loosely organized into departments rather than schools. Each department had its own faculty; the provost was a member and president of each faculty. McKenzie insisted on "a full professorship on the medical faculty, payment of a reasonable but not large salary directly by the University and not through or by the athletic association, responsibility to the university alone and not a committee or association" and time to continue his medical practice.⁴

Despite McKenzie's insistence on a position on the medical faculty as a condition for accepting his appointment, he initially appears in the University catalogs as a Professor of Physical Therapy in the Department of Physical Education. Second year medical students could, however, take a physical therapy course with McKenzie in the University's Department of Physical Education and Physical Therapy even though no such course was formally part of the medical curriculum.

In 1906, McKenzie gave his first lectures to third and fourth year medical students. In five lectures that dealt with the application of exercise to medicine, he reviewed the role of exercise in treating faults of posture and flat feet, lateral curvature of the spine, diseases of the nervous system, diseases of nutrition, and diseases of the heart and circulatory system. Soon after arriving at the University of Pennsylvania, McKenzie decided that there was a need for a scientific textbook on exercise. He believed that too many modalities were being left in the hands of masseurs. The medical profession regarded the use of electricity with suspicion. The use of radiant light and heat had just begun to attract attention and hydrotherapy was still confined to spas and Turkish baths. No attempt had been made to give a comprehensive view of the whole specialty of physical medicine with particular attention to the possibilities, and especially the limitations, of these methods which were apparently new but were, in reality, old and fundamental methods of medical treatment.⁵ McKenzie's treatise "Exercise in Education and Medicine" was published by W.B. Saunders in 1909. In his preface, McKenzie wrote:

Exercise and massage have been used as remedial agencies since the days of Aesculapius, but definite instruction in their use has seldom been given to medical students. Perhaps a certain laziness inherent in both patient and physician tempts to the administration of a pill or draught to purge the system of what should be used in normal muscular activity, but there is a wide dearth of knowledge among the profession of the scope and application of exercise in pathologic conditions and the necessity of care in the choice and accuracy of the dosage will be emphasized throughout the second part of the book.⁶

In Part II, entitled "Exercise in Medicine," McKenzie describes the use of exercise in treating physical defects, such as flat feet and scoliosis, and also diseases of the circulation and nervous system, obesity, and locomotor ataxia. He states that the purpose of exercise in pathologic conditions should be to change anatomic structure and to stimulate physiologic function. The relation between form and function was the foundation of McKenzie's medicine as well as his art.

By 1910, the Department of Physical Education was offering a course of lectures to third and fourth year medical students which dealt with the use of exercise for defects of posture and development, for diseases of nutrition, the circulation and the nervous system. In 1911-1912, a course dealing with exercise and massage in disease was offered by the Department of Physical Education for second year medical students. The class met twice per week for 12 weeks and the course was also listed in the School of Medicine catalog with the additional information that fourth year medical students are given supplementary lectures on the therapeutic use of temperature, light, and electricity.

Rehabilitation Medicine Before World War I

Prior to World War I, physicians who used physical modalities or advocated simple treatment with fresh air, water, exercise and dietary modification were considered quacks by others in the medical profession. Across the United States, as at the University of Pennsylvania, the orthopedic surgeons were often the first to recognize the need for new approaches in the treatment of disabling conditions, from fractures and dislocations to arthritis and paralysis. The first Professor of Physical Therapy at the University of Pennsylvania, R. Tait McKenzie, had a private practice in orthopedic surgery throughout his career.

In 1912, the medical staff at the Hospital of the University of Pennsylvania was reorganized. McKenzie is described briefly as a "physical therapist," a title that was later adopted by non-physician health professionals. That year, Josef B. Nylin, M.D., a Swedish physician, was also named "Assistant Physician" for a new facility, the Laboratory of Physical Therapy. The following year, Physical Therapy appeared for the first time as a hospital department. Nylin's Laboratory of Physical Therapy accumulated 3,587 cases and the Orthopedic Gymnasium recorded 5,108 treatments. The diseases were categorized as circulatory, digestive, nervous or bone and joint.⁷

The Orthopedic Surgeons Sponsor Physiotherapists

The late 19th and early 20th centuries saw the establishment of special facilities in hospitals to administer massage, exercise and hydrotherapy, always under the direction of an orthopedic surgeon. As has previously been discussed, the University of Pennsylvania Hospital opened its facility, the "Orthopedic Gymnasium," in 1897. At the Massachusetts General Hospital, a "Medicomechanical" department was established in 1904 with technicians performing the needed therapy under the guidance of Joel Goldthwait, M.D., Chief of Orthopedic Surgery. In 1911, the Mayo Clinic authorized a Section in Orthopedic Surgery and recognized that as the work of the Section increased, "physiotherapists" (allied health professionals) would be needed. Formal training in physiotherapy was not available to allied health professionals until the Mayo Clinic organized a program in 1918.⁸