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Historical Perspective

2. Rehabilitation Medicine at the University of Pennsylvania (1914-1919)
   1. R. Tait McKenzie (Continued)
   2. Rehabilitation Medicine - World War I
   3. Growth of Physical Therapy as a Profession
   4. Physical Therapy Physicians Become "Physiatrists"
   5. Physical Therapy Department and Laboratory at the Hospital of the University of Pennsylvania (HUP)

REHABILITATION MEDICINE AT THE UNIVERSITY OF PENNSYLVANIA (1914-1919)

From 1914-1919, the course Physical Therapy at the University of Pennsylvania Medical School, was described as consisting of 18 lectures given by McKenzie, plus six hours of demonstrations in hydro- and thermotherapy given by Nylin. Nylin, a trained masseur, was a University of Pennsylvania graduate who served as McKenzie's assistant and succeeded him at the University Hospital when he retired.

From 1914-1918, the Physical Therapy Department of the Hospital of the University of Pennsylvania continued with the Orthopedic Gymnasium supervised by Miss Kite and the Laboratory of Physical Therapy directed by Nylin. These two facilities treated from 9,000 to 10,000 patients per year. From 1917-1919, for the first time, a report was not issued because of the influenza epidemic which raged throughout the City of Philadelphia.

R. Tait McKenzie (continued)

At McGill, McKenzie had demonstrated considerable talents as a painter and sculptor. It is as a sculptor that McKenzie attained everlasting fame.3 During these early years at the University of Pennsylvania, McKenzie continued to develop as a sculptor. His first work in the field of commemorative sculpture was completed in 1914. The work, entitled Youthful Franklin, still stands outside Weightman Hall on the campus of the University of Pennsylvania. This wonderfully conceived statue represents Benjamin Franklin beginning his youthful journey to the City of Philadelphia and the fame that would be his as one of the founding fathers in this country. McKenzie's understanding of human form and function is shown in this earliest work. His later magnificent athletic sculptures and reliefs would be put to use in his work with soldiers during and after World War I.

World War I had an enormous impact on rehabilitation medicine in general and at the University of Pennsylvania in particular. In 1915, McKenzie applied for a leave of absence from the University in order to join the British Royal Army Medical Corps as a surgeon. His reputation and writings preceded him and he was assigned to the Department of Physical Training under the Inspector of Gymnastics. McKenzie set about reorganizing and revitalizing the way in which the British Army dealt with solders disabled by combat as well as those deemed unfit to serve. His planned series of command "depots" where soldiers could be examined, diagnosed and treated was instituted. Treatment included massage, electricity, heat (wet and dry), and courses in physical exercise and training.

McKenzie returned to the University in 1916 but remained in the British Royal Army Medical Corps. He was briefly transferred by the British to his native Canada with duties similar to those he had in England. The energetic McKenzie subsequently wrote a short, 122-page book published in 1918, "Reclaiming the Maimed." In this book he describes his methods and equipment for the "gradual coaxing back toward normal" of those who had suffered in the war. He also felt "we must consider the whole field of physical therapy as applied to and affected by the Great War."⁹

"Reclaiming the Maimed" presents McKenzie's understanding of physical therapy and rehabilitation based on his experiences with disabled veterans in Britain and Canada. His chapters on electrotherapy, entitled "Medical Electricity," included accurate illustrations of the equipment used. They attempted to move electrotherapy out of the realm of quackery into that of science. McKenzie emphasized the importance of occupational therapy as a necessary part of the rehabilitation process, both for the physical and mental well-being of the disabled.¹⁰ This book stands as a review of the field of rehabilitation medicine as of 1918 .

After World War I, orthopedic surgeons who had been active in the United States Medical Service published a summary of their activities which included rehabilitation as well as surgical services. They also indicated their intent to go beyond surgery and include general health, education, and vocational rehabilitation.¹¹ Although they did not credit McKenzie directly, it is clear that his plans for making recruits physically fit and restoring the wounded to duty served as guidelines. Goldthwait, Chief of Orthopedics at Massachusetts General Hospital and Chairman of The War Reconstruction Committee of the American Orthopedic Association, spent months abroad studying the British system of treating the disabled, a system largely conceived by McKenzie.

As the United States prepared to join its European allies in the fighting of World War I, problems in organizing care for the expected number of the disabled soldiers became evident. Prior to the war, private and governmental support for the disabled had been growing gradually. The influx of young, acutely disabled soldiers drew attention to the medical and social problems created by physical disability.

Rehabilitation Medicine - World War I

The Medical Department of the United States Army, under the guidance of the Surgeon General, Merritte W. Ireland, M.D., had two divisions which were destined to be important to rehabilitation medicine: the Division of Orthopedic Surgery and the newly-created Division of Physical Reconstruction.9 The report on the Division of Orthopedic Surgery, given by its head, Elliott Brackett, M.D., a Harvard-trained orthopedic surgeon, called for the establishment of hospitals for the reconstruction of disabled soldiers. These hospitals could be "devoted to the medical care of all men who should be returned, also planned and equipped to reinstate the disabled soldier in the industrial world and allow him to become an independent wage earner."¹²

Under the physiotherapy section, the report stressed the need for massage and mechanical hydrotherapy and, more importantly, for a national training corps for personnel (therapists). It suggested that the personnel be drawn from schools of physical training and allied therapies. As a follow-up several schools were chosen: the Boston School for Physical Education; the New Haven Normal School in Connecticut; the Normal School for Physical Education in Battle Creek, Michigan; Posse Normal in Boston, Massachusetts; the Teacher's Physical Education Program at Oberlin College, Ohio; and the Physical Education Department of Leland Stanford Junior University in California. The report also suggested that standards be developed by the schools and that the trainees be designated "physical reconstruction aides." The work of these aides would subsequently be transferred to a new Division of Physical Reconstruction. Frank B. Granger, M.D., an early advocate of adding physical therapy techniques to general practice, was influential in planning the training program for the reconstruction aides.¹³

As Chief of the Division of Physical Reconstruction, Col. Frank C. Billings, M.D., established three special sections: one for education; one for physiotherapy including equipment, gymnasiums and other construction; and one for clinical work such as surgery, orthopedic surgery, head surgery and neuropsychiatry. The clinicians prescribed the types of occupational therapy and physical therapy to be carried out by the reconstruction aides. By 1919, 45 hospitals throughout the country had physiotherapy facilities and employed more than 700 reconstruction aides. Nearly 50,000 veterans, about half of the 125,000 disabled during World War I, are said to have been treated at these facilities.¹⁴

The rehabilitation of disabled veterans was the focus of a prolonged struggle for control between the Surgeon General and the Federal Board for Vocational Education. The Surgeon General established the Division of Physical Rehabilitation. The Federal Board for Vocational Education had been formed in 1917 to oversee the vocational rehabilitation of disabled veterans. The Board planned to place civilian vocational experts in hospitals to supervise testing, to evaluate prostheses and to prescribe occupational therapy. Physicians and vocational experts vied for authority in the field of and fought for special provisions to the Vocational Rehabilitation Act which was before the Congress in 1915. The Act legislated that each hospital under the Physical Reconstruction Division would have an agent of the Board for Vocational Education to serve the "compensable disabled." These provisions resulted in a sharp division between "medical" and "vocational" rehabilitation. According to the report, The Medical Department of the United States Army - World War I, the Federal Board for Vocational Education cooperated with the Physical Reconstruction Division's efforts but noted that there was a shortage of vocational/occupational instructors.¹⁵

McKenzie's book, "Reclaiming the Maimed," recognized the importance of vocational rehabilitation with an 11-page chapter entitled, Treatment by Occupation. In it he writes:

"Treatment by occupation differs from all other forms already described in that the remedy is given in increasing doses with the patient's improvement. It is the final page in his progress, to which all others lead up." ¹⁶

McKenzie further insists that the direction of treatment, with certain medical restrictions, be put in the hands of an officer trained in vocational guidance. After review by a Board, the patient, still under military discipline, should register and report to classes. A list of suggested courses includes school work, mechanical drawing, printing, woodworking, mechanics, electricity, motor car repair and farming. Affiliation with local technical schools and colleges was suggested.¹⁷

In 1920, a civilian Vocational Rehabilitation Law was passed which did not mention medical services. Physicians interested in rehabilitation changed their designation from physiotherapists to physical therapy physicians in order to separate themselves clearly from physiotherapists whom they considered to be "technicians" operating under the physician's direction.

Growth of Physical Therapy as a Profession

During the 1920s and 1930s, physical therapy physicians struggled to organize so that they could have a voice in the American Medical Association (AMA). In 1921, the AMA endorsed the efforts of the American Congress of Physical Therapy to educate physicians about the value of physical therapy in rehabilitating World War I veterans and to warn general practitioners of the dangers of "machine therapy." At this time there appeared:

"Mysterious, high priced electrical appliances in mahogany cabinets so that the term physical therapy was apt to call to mind, not heat, water, massage and exercises, the fundamentals of physical therapy, but rather the paraphernalia of the charlatan."¹⁸

Despite the conflicts for control, the work of the physical reconstruction aides during and after World War I led to the realization that physical therapy was an essential part of good patient care. The reconstruction aides, all female, functioned as physical therapy technicians and were charged with applying physiotherapy, hydrotherapy, electrotherapy, mechanotherapy and massage to disabled soldiers and veterans. In 1920, a small group of these aides formed the American Women's Therapeutic Association. The American Physiotherapy Association was incorporated in 1930 when it pledged to work with the American Medical Association to establish standards of education for physical therapists; to encourage the regulation of physical therapy practice by law; and to cooperate with, or under the direction of, the medical profession to provide a central registry for physical therapists.¹⁹ At this time the group agreed that all cases should be referred to physicians and that the referring physician would oversee the care of the patient.

Physical Therapist Physicians Become "Physiatrists"

In 1925, a group of physical therapy physicians founded the American College of Physical Therapy which became responsible for the publication of the Archives of Physical Therapy, X-ray and Radiology. In 1925, this group changed its name to the American Congress of Physical Therapy as it joined an AMA-sponsored group of the same name. By the mid-1930s, a group of prominent physical therapy physicians had established the American Registry of Physical Therapy Technicians. Registered physical therapists remained technicians under the supervision of physicians. By 1937, physical therapy physicians achieved recognition as a medical specialty. In an effort to distinguish themselves from the technicians who were called physical therapists and in order to gain respect within the medical profession, physical therapy physicians began to call themselves "physiatrists." Departments in medical schools were renamed "Departments of Physical Medicine." However, it would take a Second World War to make rehabilitation a full-fledged specialty.

Physical Therapy Department and Laboratory at the Hospital of the University of Pennsylvania (HUP)

In 1920, a physical therapy department was first listed in the curriculum at the University of Pennsylvania Medical School. Departmental faculty included McKenzie as Professor of Physical Therapy with William T. Johnson, M.D., as Instructor and Nylin as Associate. Bi-weekly lectures were given to second year students and were complemented by practical demonstrations in electrotherapy by Johnson and hydro- and thermotherapy by Nylin. The demonstrations were given in the Department of Physical Therapy at the University Hospital. This format was followed until McKenzie's retirement in 1931. That year, no Professor of Physical Therapy is listed, and Johnson and Nylin appear to have shared the teaching duties.

Occupational Therapy first appears in a 1919 report to the University Hospital Board of Managers from the Auxiliary Committee on Occupational Therapy stating that a trained occupational therapist had been hired. By 1920-1921, there were three trained occupational therapists on staff.

In 1923, McKenzie was listed as "physiotherapist" on the hospital staff. The physician-in-charge of the Physical Therapy Laboratory, Nylin, had two assistants, Miss Bilgrain and Mr. Frazer. In the mid-1920s, the Department of the University Hospital was reported as the "Physio-Therapy Department" and Nylin was designated as Chief of the Clinic, with two assistants. During this time, the department's equipment was constantly being upgraded. The new equipment included massage machines and electrotherapy apparatus. Thirteen to fourteen thousand patients were served by the clinic per year.

When the Maloney Clinic Building opened in 1929, the Physical Therapy Department of the Hospital was assigned offices on the fifth floor. The new facilities provided for such treatments as diathermy, suction pressure and hydrotherapy; the treatments were available to both private and ward inpatients as well as to outpatients. The adjoining fifth floor of the Gibson Building contained a large, well-equipped gymnasium.²⁰

While the medical specialty of physical therapy, i.e., "physiatry," continued to flourish at the University Hospital, its place in the Undergraduate Medical School curriculum gradually declined. During the 1937-1940 academic years, while Nylin was listed as Director, the course in physical therapy was given to third year medical students for only one hour per week for five weeks.