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Historical Perspective

3. Rehabilitation Medicine (1940-1987)
   1. The Military Prepares
   2. Howard A. Rusk
   3. The Poliomyelitis Epidemic
   4. Franklin Delano Roosevelt
   5. Rehabilitation Medicine Becomes a Specialty
   6. George M. Piersol
   7. The University of Pennsylvania Rehabilitation Commission
   8. The National Foundation for Infantile Paralysis
   9. The Piersol Rehabilitation Center
   10. Education in Rehabilitation Medicine at Penn
   11. The School of Auxiliary Medical Services
   12. William J. Erdman, II

REHABILITATION MEDICINE (1940-1987)

During the 1940s, several events and the personalities connected with them led to a world-wide interest in, and acceptance of, physical medicine and rehabilitation as a vital component of medical treatment.

The Military Prepares

As the United States prepared to enter World War II, the United States Army Medical Department laid plans for the "reconditioning" of wounded soldiers. These plans were summarized by the Division of Orthopedic Surgery as follows: A concept of rehabilitation is required that is entirely new. It treats the whole man and includes physical reconditioning and retraining, psychological adjustment and vocational guidance.²¹

The program offered at various convalescent hospitals was to include medical supervision, coordination of reconditioning efforts, teaching of crafts and military discipline. Despite the proclamation that "this is entirely new," many of the features of the proposed programs resembled closely those of the World War I efforts.

Three groups vied for the power and money involved in rehabilitating hundreds of thousands of returning soldiers: the Armed Forces, which was primarily concerned with returning soldiers to active duty; the Veteran's Administration, which had been created after World War I and was commited to the rehabilitation of disabled, discharged soldiers; and the Office of Vocational Rehabilitation, which had enjoyed a congressional mandate since the 1920s. Improvements in medical treatment brought about by sulfa drugs and penicillin, as well as advances in surgical techniques and transportation, decreased mortality but increased the number of disabled veterans far beyond all expectations.

Howard A. Rusk

In 1942, Howard A. Rusk, M.D., an alumnus of the University of Pennsylvania School of Medicine, began working with wounded soldiers at Jefferson Barracks in St. Louis, Missouri. He soon became Chief of the Army Air Forces Convalescent Training program. His work there led him to be called "The Father of Modern Rehabilitation Medicine." He showed that active rehabilitation promoted the return of soldiers to full duty and also prepared those unfit for further service to return to their communities as useful, functional individuals. During the post-war period, rehabilitation medicine reached its height in power and prestige. After World War II, Rusk created the Department of Physical Medicine and Rehabilitation of New York University and the Institute of Rehabilitation Medicine at Bellevue Medical Center. This Institute had its own personnel and beds and afforded comprehensive rehabilitation services in a private hospital setting. Through his writings in The New York Times, his contacts with many influential individuals, and his position as Director of the Institute of Rehabilitation Medicine at NYU Medical Center, Rusk increased public awareness of the need for rehabilitation as part of good medical practice.²²

The Poliomyelitis Epidemic

Epidemics of infantile paralysis afflicted children throughout the world during the 1930s and 1940s. Children who survived were often left severely paralyzed. Some spent the rest of their days in "iron lungs," the only apparatus then available to assist in breathing. During World War II, soldiers from all over the world developed the disease, which was then renamed "poliomyelitis." In 1940, an Australian nurse, Sister Kenny, articulated a revolutionary new treatment for polio victims. Prior to her efforts, treatment had consisted of absolute immobilization of affected limbs either through splinting or placement of the limb in a plaster cast. Sister Kenney argued that:"Immobilization prevents treatment of the disease; prolongs muscle spasms; prevents restoration of muscle action; and promotes stiffness which prevents the development of muscle power by re-education or re-awakening of nerve impulses."

She advocated warm, moist packs for muscle spasms and muscular manipulation to re-educate the muscles. Although orthopedists insisted that she did not know the mechanisms of the disease or muscle physiology, she did know paralyzed children. Her work represented a turning point in the after-care of paralyzed patients and pioneered the discipline of modern physical therapy.²³

Franklin Delano Roosevelt

The charismatic President Franklin Delano Roosevelt, played an important role in the development of rehabilitation medicine. As an adult victim of poliomyelitis, Roosevelt continually sought new treatment and worked at living a useful, active life. The Georgia Warm Springs Foundation, created by Roosevelt in 1927, led the country in rehabilitation and physical therapy for polio victims and became a symbol for the best in after-care. The Foundation was subsequently reorganized as the National Foundation for Infantile Paralysis and remains well-known for vigorous fund-raising efforts such as the annual March of Dimes.

Rehabilitation Medicine Becomes a Specialty

After World War II the practice of medicine became increasingly specialty-based. Not to be left behind, the American Board of Physical Medicine and Rehabilitation was formed and recognized as a specialty Board by the American Medical Association. The Board was composed of four members from the American Academy of Physical Medicine and Rehabilitation, four members from the American Medical Association, and three members from the Association of Academic Physiatrists. The Board certified the first specialist in Physical Medicine and Rehabilitation in 1947. Despite this "stamp of approval" by the American Medical Association, rehabilitation was never really accepted by mainstream medicine.

A basic course in Physical Medicine and Rehabilitation was offered in the Graduate School of Medicine of the University of Pennsylvania beginning in the 1943-1944 academic year. George M. Piersol, Director of the Center for Instruction and Research in Physical Medicine at the University Hospital, ran the course from 1944-1954.

George M. Piersol

George M. Piersol, M.D., a 1905 graduate of the University of Pennsylvania School of Medicine, had been chief resident in Orthopedic Surgery under Williard at the University Hospital where his early interest in physical medicine and rehabilitation began. He believed that if physical medicine was to achieve status in the medical profession, a "sound program of basic research in the field must be undertaken and opportunities for education in this field should be expanded and improved."²⁴

In 1947, when the first Department of Physical Medicine and Rehabilitation of the University of Pennsylvania School of Medicine was created, Piersol became the Department's first Professor and Chairman. Under Piersol, the place of Physical Medicine and Rehabilitation in the medical curriculum increased considerably. Piersol taught rehabilitation as a concept, not as a specialty. Nonetheless, he was a staunch advocate for the recognition of Physical Medicine and Rehabilitation as a specialty Board by the American Medical Association. In 1963, the Board recognized his contributions to Physical Medicine and Rehabilitation by designating him a diplomate.

In 1943, the wealthy and influential adviser to presidents of the United States, Bernard Baruch, created the "Baruch Committee on Physical Medicine." Piersol served on the Subcommittee on Clinical Research of this Committee. The Baruch Committee set out to improve the scientific basis of physical medicine and to gain recognition and respect for physical medicine in the medical profession. The Committee supported the establishment of major rehabilitation teaching and research centers in the United States. It also funded 57 fellowships during the 1940s. The efforts of the Baruch Committee bolstered academic physical medicine and rehabilitation. By 1945, the Archives of Physical Therapy had become the Archives of Physical Medicine and, in 1947, as noted above, the first physiatrist was Board certified.²⁵

Piersol's goals for the Department of Physical Medicine at the University of Pennsylvania predated the reports of the Baruch Committee. First, he set about reorganizing Departments of Physical Therapy at the University Hospital and the Graduate Hospital of the University of Pennsylvania in order to improve their visibility. Second, he sought to enlarge the educational activities of the Department by increasing instruction in physical medicine to undergraduate medical students. This added to the basic course in physical medicine which was already in existence at the Graduate School of Medicine with the aim of preparing physicians for teaching and research careers in the specialty. Finally, the Department was to institute and coordinate fundamental research in physical medicine.²⁶

Before 1952, only seven hours of instruction in physical medicine and rehabilitation were given to undergraduate medical students throughout the four years of medical school. The Hospital of the University of Pennsylvania had no facilities for long-term rehabilitation. Nor was there any organized teaching program that dealt with the concepts and techniques of rehabilitation.

The University of Pennsylvania Rehabilitation Commission

In 1952, the Vice President for Medical Affairs, Norman H. Topping, M.D., formed a Rehabilitation Commission at the University level. Members of the Commission represented all Departments in the University with an interest in rehabilitation. The Commission was responsible for formulating policies and for supervising teaching, service and research aspects in rehabilitation medicine at the University; the charge included both the undergraduate and graduate medical schools as well as the School of Auxiliary Medical Services. The Coordinator of the program and Secretary to the Rehabilitation Commission was William Dunbar, M.D., Assistant Professor of Physical Medicine and Rehabilitation. The original Commission was made up of members of the Departments of Neurosurgery, Psychiatry, Orthopedic Surgery, Neurology, Public Health and Preventive Medicine, Physical Medicine and Rehabilitation, Surgery and Internal Medicine. Subsequently, representatives from the Schools of Auxiliary Medical Services (later to become the School of Allied Medical Professions), Nursing and Dentistry, as well as the Departments of Sociology and Psychology, and the Social Service Department of the University Hospital, were added.²⁷

The National Foundation for Infantile Paralysis

In 1952, the National Foundation for Infantile Paralysis funded a number of pilot programs to improve the teaching of rehabilitation in medical schools in the United States. Recognizing that many post-poliomyelitis patients were not receiving adequate therapy, the Foundation believed that: "it is essential that the concept of rehabilitation and the basic techniques become part of the education of the medical student and the auxiliary personnel."²⁸ The newly formed Rehabilitation Commission at the University of Pennsylvania submitted a proposed plan for teaching rehabilitation in the University's medical school and was awarded a five-year grant.

The Piersol Rehabilitation Center

In 1954, using funds from the National Foundation for Infantile Paralysis, Piersol opened a rehabilitation center in the University Hospital and is listed as its Director. Since the University Rehabilitation Commission's grant proposal had included the establishment of a rehabilitation center, funds were readily available in support of Piersol's proposed center.

The Center opened in 1954, in a building which had been the maternity wing of the University of Pennsylvania Hospital. This Center was unique in that it was designed for inpatient care as well as a training and research unit. In 1959, the building was completely renovated with a gymnasium for physical therapy, occupational therapy and recreational therapy, a constant climate room for research in arthritis, and rooms for inpatients. When the renovated building opened in 1959, it was named the George Morris Piersol Building. Piersol had become Emeritus Professor of Physical Medicine and Rehabilitation in 1954. The team concept of rehabilitation medicine was put into practice in the new building. The team included physical therapists, occupational therapists, speech therapists, vocational counselors, social workers, and psychologists, under the leadership of a rehabilitation physician or "physiatrist." The services were offered to both outpatients and inpatients.

Education in Rehabilitation Medicine at Penn

In 1957, a concerted effort was made to integrate the principles of rehabilitation into the teaching programs of the various specialty departments in the School of Medicine. Second year students received a total of five hours of classroom instruction in the "survey of clinical medicine" and "preventive medicine and public health" courses. Third year students were offered a two and one-half hour course on the role of rehabilitation in chronic disease. In the fourth year, clinical conferences on topics in rehabilitation, such as paraplegia, hemiplegia and arthritis, were given weekly for a total of nine hours.

The teaching program in rehabilitation techniques was offered to undergraduate and graduate medical students, hospital interns and residents, graduate and student nurses, therapists and hospital personnel. The program was supported by grants from the National Foundation for Infantile Paralysis, the Office of Vocational Rehabilitation and the United States Public Health Service. The teaching was given by the Rehabilitation Center's staff from the School of Medicine, the Graduate School of Medicine, the School of Auxiliary Medical Services (later the School of Allied Health Professions) and the School of Nursing. A series of six five-day courses was also open to rehabilitation personnel from outside the University.²⁹

During the eight years of the teaching program, 14 courses in "Principles of Rehabilitation" were given to rehabilitation professional personnel, seven courses in "The Medical Aspects of Rehabilitation" were for the Pennsylvania Bureau of Rehabilitation counselors and three courses were given for graduate physicians. More than 800 persons were enrolled in these courses.

A program was also developed for hospital resident physicians in General Surgery, Internal Medicine, Urology, Neurology, Neurosurgery, and Orthopedic Surgery. As part of their residency training in the specialties, residents were required to attend rehabilitation evaluation conferences, attend seminars on special aspects of rehabilitation and provide consults for patients in the rehabilitation center.³⁰

The School of Auxiliary Medical Services

The School of Auxiliary Medical Services at the University of Pennsylvania was established in 1950 with the merger of the University Hospital's Division of Physical Therapy and the Philadelphia School of Occupational Therapy. Piersol, the Director of the Department of Physical Medicine at the Hospital became the Medical Director of Physical Therapy at the School.

The School offered a Bachelor of Science degree in Physical Therapy or Occupational Therapy. The Bachelor of Science degree required four years of study. An Associate degree, which took one year of study, was offered to those students who already had a Bachelor of Science degree with the appropriate science courses. The physical therapy courses and facilities were located at the Graduate Hospital of the University of Pennsylvania from 1950-1956. The program at Graduate Hospital had been accredited in physical therapy since 1931. Beginning in 1952, Bachelor of Science degrees were also available in medical technology and radiological technology.

In 1960, the School was renamed the School of Allied Medical Professions. By 1966-1967, only the postgraduate Associate degree was being granted. Physical Therapy, Occupational Therapy and the Orthotics/Prosthetics Sections were under the control of the Department of Physical Medicine, both administratively and financially. These divisions were always profitable and enabled the Department to operate in a fiscally responsible manner.

Interest in and support for physical medicine and rehabilitation had grown rapidly under Piersol's leadership. Throughout the 1950s, physiatrists increased their power and influence in the world of medicine. In an editorial written by Piersol in the 1952 issue of the Archives of Physical Medicine, he stated that "never in the field of physical medicine have educational possibilities been so excellent, professional opportunities so many and demand for qualified physiatrists so great." However, he was concerned that the medical profession in general showed little interest in this field and that young physicians did not choose to enter this specialty.³¹

William J. Erdman, II

In 1954, William J. Erdman II, M.D., succeeded Piersol as Chairman of Physical Medicine and Rehabilitation. He established a department supported by adequate funds with a thriving hospital facility. The department staff in 1955-1956 is listed as William J. Erdman, M.D., Associate Professor and Chairman; George M. Piersol, M.D., Emeritus Professor; Martin Schultz, M.D., and Herman O. Schwann, M.D., Associate Professors; Emery K. Stoner, M.D., Associate; Elinor Bindler and Emilie Maxwell, Assistant Instructors; and Thomas V. McKee, M.D., Assistant Instructor and Fellow. In 1956, Erdman became the 284th diplomate of the American Board of Physical Medicine and Rehabilitation.³²

Erdman also presented a course on Physical Medicine and Rehabilitation in the Graduate School of Medicine of the University of Pennsylvania. Erdman's course was the first systematic course offered to physicians in the United States. It was designed to offer clinical training that led to the practice of physical medicine and rehabilitation as a specialty. It was approved by the American Board of Physical Medicine and Rehabilitation for eight months of residency training. Besides facilities at the Graduate Hospital and the University of Pennsylvania Hospital, other hospitals in the area such as Bryn Mawr Hospital and Children's Hospital of Philadelphia were also used.

In 1964, at a ceremony celebrating the tenth anniversary of the opening of the Piersol Rehabilitation Center, Erdman, as Professor and Chairman of the Department of Physical Medicine and Rehabilitation and Director of the Piersol Center, reported that over 1,000 inpatients had been treated at the Piersol Center since its opening in 1954. He reported that the Center had treated paraplegia, hemiplegia, arthritis and neurologic disorders. The staff had increased to sixteen. Rehabilitation Medicine had become more visible in the medical curriculum with the addition of a 15-hour course in the fourth year devoted to practical rehabilitation.

In 1964, Erdman became President of the American Congress of Physical Medicine and Rehabilitation. This group, an outgrowth of the American Congress of Physical Therapy, was made up of more than 1,000 physicians who were interested in all types of rehabilitation, emotional and physical. The group was also responsible for publication of the Archives of Physical Medicine and Rehabilitation as well as administering the specialty board, the American Board of Physical Medicine and Rehabilitation. Erdman had established a reputation in the field as an expert in sports medicine while serving as team physician for the Philadelphia Ramblers ice hockey team and consultant to other Philadelphia professional teams. He also headed a team of American physicians who assisted in the rehabilitation of nearly 10,000 Moroccans paralyzed as a result of consuming adulterated olive oil.³²

Within the University of Pennsylvania Hospital the Physical Medicine and Rehabilitation group continued to grow. In 1971, Ms. Jennifer A. Bream, LPT, became Chief of Physical Therapy. Working closely with Erdman, she continued a program for chest therapy that she had begun in England. Together they developed an innovative program in horseback riding for the disabled. By the time she returned to England in 1980, Bream's Section of Physical Therapy was registering 5,000 patients per month.

However, Physical Medicine and Rehabilitation was still not an important part of the undergraduate medical school curriculum at the University of Pennsylvania School of Medicine or at other schools of medicine across the country. Medical schools continued to emphasize acute interventions over long-term rehabilitation. According to the Association of American Medical Colleges Directory for 1963-1964, 57 of the 88 American Medical Colleges had no listing for a rehabilitation department. The remaining 31 colleges listed organized departments of rehabilitation medicine, physical medicine and rehabilitation, or physical medicine.

A 1966 study sponsored by the Commission on Education for Physical Medicine and Rehabilitation, found little time allocated to the subject. The report indicated that the median number of clock hours in physical medicine and rehabilitation offered to undergraduate medical students was zero in the first year, one in the second year, eight in the third year, and seven in the fourth year. Even these numbers were a distortion since three or four large successful programs inflated the average number of hours.³³ At this time, the University of Pennsylvania Medical School had increased the number of hours of rehabilitation medicine in the four year curriculum to 25. Second year students took a four-hour course, "A Survey of Physical Medicine and Rehabilitation"; third year students were offered six hours of Rehabilitation as part of a clinical conferences course; fourth year students were given 15 hours of practical work in rehabilitation and demonstrations of rehabilitation techniques. The University Hospital Divisions of Physical Therapy, Occupational Therapy and Orthotics/Prosthetics continued to be partners with Physical Medicine in delivering rehabilitation services to hospital inpatients and outpatients.

By 1974-75, 52 percent of the 113 medical colleges reported organized departments of Rehabilitation Medicine that were not merely divisions of Departments of Surgery or Medicine. At this time the University of Pennsylvania Medical School had decreased the hours allotted to physical medicine and rehabilitation offering only one course to third year medical students for one hour per week for seven weeks, i.e., a total of seven hours.

The lack of time devoted in medical schools to physical medicine and rehabilitation, as well as the paucity of organized departments of physical medicine and rehabilitation, inevitably led to a shortage of academic physiatrists throughout the United States. Even institutions with dynamic leaders such as Erdman at the University of Pennsylvania or Rusk at New York University had to struggle to attract residents and fellows for their programs.

During the 1970s under Erdman, the Department of Physical Medicine and Rehabilitation increased to 31 members and increased its rehabilitation services at the University Hospital and in the community. Between 1968 and 1978, Erdman served as Medical Director of the Hospital of the University of Pennsylvania. In this role, he furthered the development of rehabilitation medicine at the institution and nationally.

In 1976, a grant from the Insurance Company of North American (now CIGNA) helped establish a Laboratory of Prosthetics and Orthotics as an integral part of the University Hospital. The first director of the new facility was Amin Hajj, M.D., formerly the director of an orthotics/prosthetics center in Lebanon. After the initial grant, this section became and remains self-supporting under the capable direction of its second director, Mr. David Showers, CPO.³⁴

In 1976, the Department of Physical Medicine and Rehabilitation became responsible for the Center for Information Resources. This Center had been a joint project of the IBM Corporation, the Office of Vocational Rehabilitation in Pennsylvania, and the University of Pennsylvania's Wharton School of Business and Commerce. The Center's mission was to enhance the lives of disabled persons through computer technology. The Center provided occupational training and subsequent employment in the data and information processing fields to persons with disabilities. The chief impact of the Center was in helping the disabled to become self-supporting. Besides financial support, the Department of Physical Medicine and Rehabilitation provided any medically-oriented services that the Center might request. Persons with quadriplegia, muscular dystrophy, poliomyelitis, juvenile arthritis, respiratory illness, brain injury, paraplegia, spina bifida and visual impairment were served by the Center. As of 1989, nearly 750 disabled persons had been employed by industry after training at the Center. In 1982, Dr. Erdman received an award from the United States Department of Education in recognition of his support in training the disabled in computer technology.³⁵

In the decade between 1974 and 1984, Rehabilitation Medicine suffered a period of decline. Despite an ever increasing awareness of the importance of rehabilitation in many medical specialties, particularly Neurology, Cardiology and Orthopedics, by 1984, only 64 percent of the 126 medical colleges had organized, separate departments of rehabilitation medicine. Nearly 14 percent of these colleges listed rehabilitation as a section/division in either Medicine, Surgery, Neurology or Orthopedics.

In 1979, after having served for 25 years as Chairman and Professor, Erdman requested that the Department of Physical Medicine and Rehabilitation undergo review and that the process of selecting a new chair for the Department be initiated. He promised to continue as Chairman until this effort was completed, anticipating that it could be completed within a year. This began a very unsettling period for the Department. As one of the first teaching departments in physical medicine and rehabilitation in the United States, approximately 10 percent of the physiatrists in the United States were graduates of the residency program given cooperatively by the University of Pennsylvania and the Hospital of the University of Pennsylvania. Among these were many academic department chairs and hospital chiefs of service.

The process of finding a new chairman proceeded very slowly. In 1987, after eight years of searching, none had been found and Erdman chose to resign, feeling that he could wait no longer to retire.