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Chapter V

Contents

CHAPTER V

Dietitians, Physical Therapists, and Occupational Therapists

Dietitians, physical therapists, and occupational therapists became part of the Army's medical program during World War I. As civilian employees, they served not only in the United States, but also with the American Expeditionary Forces in France and with the army of occupation in Germany.1 Because they were not expected to enter hostile fire zones, they continued to perform their duties as civilians in the years between World Wars I and II. As such, they were entitled neither to military pay and privileges nor to military training. Military status was not authorized until the first year of World War II had demonstrated that civilian employees of the Army serving overseas were subject to the same risks as military personnel, with virtually no protection under international law. In December 1942, Congress approved military status with relative rank for physical therapists and dietitians but excluded occupational therapists. It was not until June 1944 that dietitians and physical therapists achieved full commissioned status. Occupational therapists continued to serve as civilians throughout the war.

Wartime training programs in dietetics, physical therapy, and occupational therapy were designed to accomplish two major objectives: to provide military orientation of civilian-trained, and to increase the number of, qualified graduates available for Army service. Physical and occupational therapists also conducted training programs for enlisted technicians. Although they engaged in training programs at different times and in various ways, their solutions to the problems of training were similar.

BASIC MILITARY ORIENTATION FOR NEWLY APPOINTED PERSONNEL

Dietitians

In the early years of World War II, dietitians were expected to perform their duties after a brief period of on-the-job military orientation. From October 1940 until late 1941, all dietitians were sent to Walter Reed General Hospital, Washington, D.C., for military orientation. Upon completion of approximately 6 months' duty at the hospital, they were transferred to other Army hospitals to organize dietetic departments. Special training in administrative procedures peculiar to

    1Unless otherwise indicated, this chapter is based on Army Medical Specialist Corps. Washington: U.S. Government Printing Office, 1968.


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military service was approved by the Surgeon General's Office on 15 February 1941. This training was initiated at fixed Army hospitals from 2 to 4 weeks before dietitians were to be transferred to newly constructed installations.2

In April 1942, The Surgeon General authorized establishment of training pools for civilian dietitians with no experience in the Medical Department who were designated for duty outside the continental United States.3 In addition, overseas volunteers from the American National Red Cross, upon request, were assigned to these pools for training. Instruction included lectures on organization of Army hospitals, Army regulations, organization of the mess department, relationship of dietitians with other personnel in the mess department and departments of the hospitals, personnel records, hospital fund reports, and procurement of food. Dietitians were given on-the-job experience in each section of the hospital mess so they would be familiar with all phases of management: procuring, preparing, and serving food, and planning special diets. Assignment to these pools was discontinued in December 1942 when military status was authorized.

Dietitians assigned to affiliated units scheduled for overseas service went on active duty with their units at specified Army posts. They worked with the post hospital dietitian to become familiar with procedures and methods and participated in maneuvers to learn to work and live under field conditions. These maneuvers made the dietitians conscious of ways to improve or improvise equipment and to substitute various foods to relieve ration shortages. A special 60-hour course, "Cooking of Dehydrated Foods," was made available to dietitians selected for overseas service. The production of dehydrated foods, packaging and storing, reconstituting, menu planning, and actual preparation of meals were studied. Special training was given in the preparation of dehydrated food under field conditions as well as in maintenance and operation of cooking equipment and sanitation in field messes. These dietitians lived on dehydrated foods or combination of dehydrated foods and fresh rations for part of the course.

In October 1943, the Army Nurse Corps established basic training centers throughout the country for new nurses going overseas. It was not until 1944, however, that dietitians entering the Army or those assigned to overseas hospital units were sent to the training course for nurses. To accommodate dietitians, the nurses' training course eliminated 23 hours of nursing subjects and substituted 23 hours of dietetic subjects.4 In 1945, 53 hours of instruction were deleted from the nurses' training course and other material was substituted for the basic training of dietitians.5 This program provided 17 hours of lectures and demonstrations conducted by dietitians and 36 hours of on-the-job understudy in a hospital mess.

Physical Therapists

The training programs for physical therapists developed in a pattern similiar to those for dietitians. Many physical therapists joining affiliated units at the beginning

    2Unless otherwise indicated, sections on Army dietitians are based on Manchester, Katharine E.: History of the Army Dietitian. [Official record.]
    3Circular Letter No. 34, Office of The Surgeon General, U.S. Army, 16 Apr. 1942.
    4Army Service Forces Circular No. 163, 27 Dec. 1943.
    5War Department Mobilization Training Program No. 8-7,16 June 1945.


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of the war had no previous Army experience. Training plans called for a period of observation and orientation that included on-the-job training, instruction in customs of the service, organization of the Medical Department, procurement of supplies, and the organization and administration of physical therapy clinics in Army hospitals. Orientation courses were to be established in 1942 at several hospitals,6 but available evidence indicates that only Walter Reed General Hospital activated a program. Without supervision from the Surgeon General's Office, command responsibility was confused and the program was poorly executed.

In 1943, after military status was achieved, newly appointed physical therapists, who had not been trained in one of the Army physical therapy courses, were included in courses for newly appointed nurses and dietitians. Hours scheduled for the professional orientation of nurses and dietitians were replaced by special instruction for physical therapists. Special topics included the organization and administration of Army physical therapy clinics, their relationship to other hospital activities, and the treatment of patients not normally seen in civilian hospitals. Particular attention was given to the treatment of amputees and patients with injuries of the central and peripheral nervous systems; muscle, sensory, and electrodiagnostic tests; measurements of joint range of motion; bandaging adaptions of exercise apparatus; and the utilization of floor space. Following V-J Day, all of these basic military training courses were terminated.

Occupational Therapists

Because occupational therapists did not have military status during World War II they could not be integrated into the basic military training programs established for nurses, dietitians, and physical therapists.

In October 1943, 2-week indoctrination courses were established for newly appointed occupational therapists at Lovell General Hospital, Ayer, Mass., Lawson General Hospital, Atlanta, Ga., and Letterman General Hospital, San Francisco, Calif.7 Of the 96 hours of instruction, 36 were devoted to on-the-job experience with orthopedic and psychiatric patients, in convalescent shops, and on wards under the direct supervision of experienced occupational therapists. The remaining hours were devoted to lectures, conferences, demonstrations, and tours. The schedule avoided solid blocks of time on any given subject. Students had access to the medical library and sat in on roundtable discussions with members of the occupational therapy staff. Orientation courses were discontinued in July 1944.8 By this time, a majority of chief occupational therapists had attended the course and could indoctrinate the new personnel on their staffs.

PROFESSIONAL TRAINING PROGRAMS

In contrast to the relatively simple matter of arranging short military orientation courses, a far greater problem confronted the Medical Department: that of

    6See footnote 3, p. 152.
    7Letter, The Adjutant General to Commanding Generals, First to Ninth Service Commands, 7 Oct. 1943, subject: Orientation Course for Occupational Therapists, inclosure thereto.
    8Army Service Forces Circular No. 229, 22 July 1944.


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providing the additional numbers of qualified occupational therapists, physical therapists, and dietitians needed to staff Army hospitals. Neither the outbreak of war in Europe nor the expansion resulting from the Selective Service Act brought these specialists into military service in adequate numbers because most of them were women and were not subject to compulsory military service. In any event, the total number of qualified dietitians, physical therapists, and occupational therapists in the United States was not sufficient to meet both civilian and military requirements if the Army was to fulfill its patient care responsibilities. Emergency training programs for all three specialist groups were required.

ACCELERATION AND EMERGENCY TRAINING PLANS

Dietitians

The need for training student dietitians in Army hospitals was recognized shortly after World War I. In 1922, a course was established at Walter Reed General Hospital for such a purpose. Throughout the interwar period, enough qualified dietitians graduated from the course to supply all Army hospitals authorized to employ them. The training program at Walter Reed General Hospital provided theoretical instruction as well as on-the-job experience, and graduates were qualified for duty in Army hospitals. In addition, students were given an opportunity for staff experience by service in positions of responsibility. By August 1942, 211 dietitians had graduated from the course at Walter Reed General Hospital. A single course satisfied the needs of the peacetime Army but, to meet wartime requirement, the program had to be accelerated and expanded to include other hospitals. In civilian hospitals, the number of training courses increased from 38 to 60. Even this was not enough, and other plans had to be developed to meet the increased demand for dietitians.

On 17 July 1942, a meeting was held between representatives of the Surgeon General's Office, the American Dietetic Association, and the Civil Service Commission. Two plans were recommended. Plan A provided that the program conducted in Army hospitals would be divided into two sections, the student dietitian course and the apprentice dietitian course. Plan B provided for the establishment of a 6-month student dietitian program in approved civilian hospitals from which the students would be transferred to an Army hospital for the 6-month Army hospital apprentice course. A combination of these plans was finally adopted. Minimum educational qualifications were the same as those previously established for the student dietitian program. The first class, 16 students appointed under Plan A, reported to Walter Reed General Hospital on 24 August 1942.

Six-month Army hospital student course.-The 6-month curriculum established for student dietitians at Walter Reed General Hospital was used as a guide for setting up three additional Army hospital student dietitian training courses, all approved by the American Dietetic Association. In May 1943, Fitzsimons General Hospital, Denver, Colo., started a course under the direction of Capt. Mildred G. Allbritton, AMSC. The course at Brooke General Hospital,


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Fort Sam Houston, Tex., started in July 1943, under the direction of Capt. Nell Wickliffe, AMSC. The last student dietitian course was established at Lawson General Hospital, in September 1943, under the direction of Capt. Hilda M. Lovett, AMSC.

The abbreviated, 6-month course was designed to furnish thorough training in the diet in health and disease and in the organization and administration of a dietetic department in an Army hospital. Over 200 hours of lectures were given in diet therapy and administration. Dietetics for medical and surgical patients was taught by Medical Corps officers and heads of dietary departments. On-the-job training in therapeutics totaled 11 weeks and included writing special diets, diet instruction to ward and clinic patients, supervision of ward kitchens, and participation in ward rounds. A minimum of 2 weeks each was spent in the surgical cardiac, urological, and pediatric wards, gastrointestinal and diabetic sections, and in the infant formula room. Fourteen weeks were spent in administrative on-the-job training. A comprehensive program afforded experience in all areas of administration: menu planning; purchasing; ordering, preparing, and serving food; inventory and portion control; cost accounting; and personnel management.

Six-month civilian hospital student course.-In September 1942, Miss Nelda Ross, President of the American Dietetic Association, sent a letter to the director of each of the 60 approved civilian training courses for dietitians in an attempt to determine which civilian hospitals had facilities to cooperate with the Army. In her letter, Miss Ross made it clear that students who successfully completed this program would meet the 1-year requirement for membership in the American Dietetic Association. Response to her inquiry indicated that the plan was generally acceptable to hospitals in which at least 10 students were enrolled. At a few hospitals, problems with staff and facilities made it impossible to participate. Some chief dietitians were afraid that the release of students after 6 months would further disorganize dietary departments, already plagued with excessive wartime turnover of employees. Other chief dietitians, who had already rearranged their training plan to provide for enrollment of student dietitians twice a year, believed that it would be difficult to add still another program to their training schedule.

Under the program finally adopted, training in civilian hospitals included 6 weeks in special diet kitchen and ward service; 2 weeks of private patient service; 4 weeks of pediatrics, including formula preparation; 4 to 6 weeks in outpatient clinics; 6 to 8 weeks of administration, including purchasing, ordering, accounting, and menu planning; as well as some work with personnel and preferably experience in a cafeteria or dining room. Lectures in diet therapy and infant feeding and experience in teaching dietetics to student nurses were required.

Six-month Army hospital apprentice course.-Because of differences in the civilian and military basic courses, the 6-month apprentice course in Army hospitals had to be tailored to provide apprentices with the experience required to qualify them for membership in the American Dietetic Association. Every effort was made to establish appropriate programs at the 32 hospitals to which students could be assigned for apprentice training (fig. 15).


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FIGURE 15.-Student dietitian discussing recipe with head cook.

Throughout 1943, the apprentice training course followed a program of instruction outlined by The Surgeon General. A subsequent program, published by The Surgeon General on 1 May 1944, provided a more detailed guide for instructors. These courses were adapted locally to meet the individual needs of apprentice dietitians at each hospital.

The 26-week apprentice program emphasized practical experience by including 16 weeks in administration of food service sections, 8 weeks in therapeutic phases of food service activities, and 2 weeks of lectures. To meet American Dietetic Association requirements for staff experience during dietetic internship, assignment in a supervisory capacity was scheduled during the last month of apprentice training.

Qualified experience apprentice entrance plan.-A final dimension was added to the program when courses were adjusted to permit home economists with bachelor of science degrees in foods and nutrition, or majors in institutional man-


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agement that contained specified courses, to substitute work experience for the first 6 months of hospital training. Early in 1943, an increasing interest in the Army's training program was expressed by home economists who possessed every qualification for certification except internship or hospital work experience. When it was determined that the number of home economists with food service experience interested in becoming dietitians was large enough to make a special program practical, The Surgeon General won approval of the American Dietetic Association for a plan to substitute such experience for the Army or civilian hospital student course, and admit experienced home economists directly into the 6-month apprentice program. Between September 1943 and September 1945, 128 home economists received direct appointments to apprenticeship.

Several enlisted members of the Women's Army Corps with backgrounds in home economics also expressed an interest in the dietitian course. On 6 March 1945, the Surgeon General's Office authorized the establishment of the first training course for enlisted members of the Women's Army Corps at McCloskey General Hospital, Temple, Tex.9 Ten apprentices were authorized in each class, but only five applied. Upon completion of the course, they were commissioned as Medical Department dietitians. The course, which began on 15 June 1945 and was discontinued on 1 January 1946, was the only dietitian course for enlisted women given during World War II.

After V-J Day, a study was made to determine postwar requirements. Authority was subsequently granted to proceed with the training of students on duty as of 1 October 1945, and to commission them upon completion of the course. Appointments for individuals who had not yet begun training were canceled. By October 1946, all training courses for dietitians were terminated, except the one at Brooke General Hospital.

Physical Therapists

In 1941, a Central Physical Therapy Board was established in the Surgeon General's Office10 to work with the Subcommittee on Physical Therapy, National Research Council, and the Federal Security Agency on problems associated with the expansion of the physical therapy program in Army hospitals. Among the problems presented to this board was the subsidization of civilian physical therapy training courses. A survey made by the American Medical Association's Council on Medical Education and Hospitals, early in 1942, revealed that civilian physical therapy training courses requiring tuition were experiencing difficulty in maintaining full enrollment. The Subcommittee on Physical Therapy recommended that the War Department subsidize these courses. Because of the planned expansion of the Army physical therapy training program, it was The Surgeon General's opinion that the subsidy of civilian training courses could not be justified.11 The Subcommittee on

    9War Department Circular No. 71, 6 Mar. 1945.
    10Office Order No. 348, Office of The Surgeon General, U.S. Army, 21 Nov. 1941.
    11Memorandum, Col. John A. Rogers, MC, Office of The Surgeon General, for Chief of Staff, G-3, attention: Colonel West, 10 June 1942.


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Physical Therapy was similarly unable to persuade the Selective Service to defer male physical therapists until completion of their training.

Expansion of the Army physical therapy training program was accomplished by the establishment of courses directed to three groups: Civilian students who would take all of their training in Army hospitals; enlisted members of the Women's Army Corps who would take all of their training in Army hospitals or take the apprenticeship phase of their training in Army hospitals after completing courses in selected civilian institutions; civilian students who would take the apprenticeship phase of their training in Army hospitals following the completion of courses in a civilian institution.

Civilian students.-Early in 1941, The Surgeon General proposed the establishment of an emergency training course. This course, consisting of 6 months of formal instruction followed by 6 months of applicatory training, was to replace the regular 9-month course conducted at Walter Reed General Hospital. The proposal was approved by the Council on Medical Education and Hospitals, which also approved a plan to allow civilian institutions to conduct 6 months of theoretical instruction, followed by 6 months of supervised apprenticeship in selected Army hospitals.

On 1 July 1941, the first Army emergency course was initiated at Walter Reed General Hospital. Every 3 months, a class of 10 students was authorized. The 26-week program included intensive study in anatomy, physiology, pathology, kinesiology, therapeutic procedures, and their application to military medicine. Emphasis was placed on the treatment of patients with combat injuries. Additional courses were established in October 1942 at the Fort Sam Houston Station Hospital; Army and Navy General Hospital, Hot Springs, Ark.; O'Reilly General Hospital, Springfield, Mo.; and Fitzsimons General Hospital. All were conducted on the same plan as the course at Walter Reed General Hospital.

Following this expansion, the number of civilians in Army physical therapy training courses increased, but the authorized capacities of these courses could not be maintained because college graduates with a physical education background were being offered increasingly attractive positions by industry and by the other military services. A series of meetings held in 1944, in San Francisco, Calif., Los Angeles, Calif., Chicago, Ill., Boston, Mass., and New York, N.Y., featuring talks and War Department films, resulted in renewed interest in the Army physical therapy training programs. In January 1944, there were only enough eligible civilian applicants to fill one class of trainees, but the increasing number of certified applicants in the succeeding months justified further expansion of the program. Additional courses for civilian students were established at Bushnell General Hospital, Brigham City, Utah, on 10 July 1944, and at Ashford General Hospital, White Sulphur Springs, W. Va., on 10 August 1944.

Civilian students enrolled after August 1944 were required to meet the physical standards for commissioned officers. This policy was recommended by the Physical Standards Division, Surgeon General's Office, to reduce the number of students who could not meet the physical requirements for commissioning.

Military students.-In July and August 1943, the director of physical thera-


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pists initiated conferences between the Training Division and the Women's Army Corps to discuss the possibility of making Army physical therapy courses available to enlisted women. Such a program would not only assist in meeting the procurement requirements for physical therapists, but it would also offer these women an opportunity for professional and military advancement. The program was approved in August 1943,12 and Stanford University, Palo Alto, Calif., the University of Wisconsin, Madison, Wis., and the D. T. Watson School of Physiotherapy, Leetsdale, Pa., were selected to conduct the program. These courses began in October 1943 and continued until October 1944 when the expansion of courses in Army general hospitals enabled the Army to discontinue training at civilian institutions. While training was conducted at civilian institutions, the War Department paid tuition, room, and board, and provided textbooks and other teaching aids. An officer in the Women's Army Corps, assigned with each group of students, was responsible for military administrative procedures. Army physical therapy training was available to enlisted women who were under 44 years of age, who had no dependents under 14 years of age, and who had an Army General Classification Test score of 110 or over.

In December 1943, the Secretary of War authorized direct recruitment of women qualified for the Women's Army Corps for the purpose of attending physical therapy training courses, with the assurance of a commission as a physical therapist upon completion of the course.13 Women recruited for this specific program comprised more than half of the total military enrollment in these courses.

In June 1944, the maximum age for enrollment was reduced from 44 to 37 years. This change resulted from a study which revealed that trainees in the upper age group often experienced difficulty in adjusting to intensive academic study and to living and working in close association with groups of younger women. A similar change was made in the age requirement for applicants for these courses from within the ranks of the Women's Army Corps.

The establishment of two all-Negro station hospitals in the United States and the activation of three such hospitals for overseas duty raised the question of supplying physical therapists for these hospitals. A physical therapy training course for Negro students was established at the Fort Huachuca Station Hospital, Ariz., on 1 October 1943 (fig. 16). When the requirement for Negro physical therapists was met by commissioning trainees in October 1944, the training of both military and civilian Negro students at Fort Huachuca was terminated.

The enrollment for five courses conducted in Army general hospitals was changed from civilian trainees to military trainees in January and February 1944. Two additional courses for military trainees were established at Lawson General Hospital and at Percy Jones General Hospital, Battle Creek, Mich. An additional number of students were enrolled after July 1944 when concurrent classes at quarterly intervals were authorized. This plan was put into effect in all general

    12War Department Memorandum No. W635-18-43, 22 Aug. 1943.
    13Letter, The Adjutant General to Commanding General, First Service Command, Army Service Forces, 14 Dec. 1943, subject: Recruitment of Physical Therapy Aides.


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FIGURE 16.-Enlisted student physical therapist adjusting infrared lamp in preparation for treatment of patient's left shoulder, Fort Huachuca Station Hospital, Ariz.

hospitals conducting courses except Percy Jones, where housing facilities were inadequate.

All assignment to physical therapy training courses was terminated in October 1945.14 The 325 physical therapy students then enrolled were allowed to complete their training.

Apprentice training program.-The program of apprentice training for graduates of the 6-month civilian emergency physical therapy courses developed slowly. Because civilian apprentices were assigned through the service commands

    14Memorandum, Maj. Emma E. Vogel, WMSC, Director of Physical Therapists, Office of The Surgeon General, for Col. Floyd L. Wergeland, MC, Director, Training Division, 9 Oct. 1945, subject: Termination of Physical Therapy Training.


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FIGURE 17.-Apprentice physical therapists in training, Fletcher General Hospital, Cambridge, Ohio. (Top) Civilian apprentice receives instruction in massaging scar tissue. (Bottom) Enlisted apprentice learns to apply shortwave diathermy apparatus. (Courtesy of National Library of Medicine.)


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with the program, they were too often assigned on the basis of personnel requirements, with little consideration given to their need for continued instruction and supervised practice. Management of this program improved when centralized control was vested in the Surgeon General's Office late in 1942.15

Subsequently, The Surgeon General directed that training would consist primarily of supervised clinical practice in the treatment of patients, both in the physical therapy clinic and in hospital wards (fig. 17). Emphasis was placed on the treatment of combat injuries, such as peripheral nerve, brain, spinal cord, chest and vascular injuries, and amputations. The program included attendance at conferences, participation in ward rounds, and at least 1 hour daily of roundtable discussion of treatment programs and current medical literature. Apprentices were also trained in the administration of physical therapy clinic, the preparation of records and reports, and the procedures for requisitioning supplies. For the on-the-job phase of training, enlisted apprentice physical therapists were assigned to 20 general hospitals and civilian apprentices were assigned to 31 other general hospitals.

After V-J Day, the directors of the civilian emergency physical therapy courses were advised that the 6-month applicatory training in selected Army hospitals would be terminated. Since the Army apprentice program for civilian students was terminated, arrangements were made for students enrolled in the 6-month emergency civilian course to have their apprenticeship experience elsewhere. On 10 October 1945, The Surgeon General wrote to the directors of civilian courses expressing his recognition of the valuable contribution these schools had made to the war effort.16 Although a large number of emergency courses were conducted in civilian institutions, enrollment in these courses was far below expectations except in the two schools where training was tuition free.

Experience in this program clearly demonstrated that in order to train apprentice physical therapists in the treatment of patients with combat injuries, clinical experience should be afforded in general hospitals where patients could be observed in large numbers. Station and regional hospitals proved inadequate for this training, and after 1943, there was a decrease in use of station and regional hospitals and greater utilization of general hospitals. It was demonstrated also that the efficiency of the apprenticeship program depended not only on the clinical experience available but also on the supervision exercised by the chief physical therapist and by the Physical Therapy Branch, Surgeon General's Office.

Occupational Therapists

At the outbreak of World War II, eight qualified occupational therapists and four occupational therapy assistants were on duty in five Army hospitals. By V-J Day, 899 occupational therapists and apprentices were working in 76 hospitals in the continental United States.

    15Memorandum, The Adjutant General for Commanding Generals, All Service Commands, 24 Oct. 1942, subject: Dietetic and Physical Therapy Personnel in Army Hospitals.
    16Letter, Col. Floyd L. Wergeland, MC, Director, Training Division, Office of The Surgeon General, to Dr. Frank H. Krusen, Mayo Clinic, Rochester, Minn., 10 Oct. 1945.


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Recruitment problems.-The Surgeon General's decision to appoint occupational therapists as civilian employees without commissions and to limit the establishment of occupational therapy clinics to Army hospitals in the Zone of Interior proved a serious handicap to recruiting and training.17 These decisions made it clear that occupational therapy was considered more valuable for convalescent patients evacuated to the Zone of Interior than for patients with acute injuries and illnesses hospitalized in the Communications Zone.

Lack of recognition and lack of status, however, were the least of the Medical Department's recruiting problems. Far more serious was the close approximation of the Army's estimated need and the total number of registered occupational therapists. By early 1944, so many new Army hospitals had been built or planned for priority construction that the target for personnel was set at 1,000.18 Yet, there were scarcely 1,300 graduates in the professional registry. Since the Army could not hope to recruit over 75 percent of the total civilian supply of occupational therapists, the best solution seemed to be the establishment of an emergency training program.

Design and purpose of War Emergency Course.-The War Emergency Course was outlined by the Occupational Therapy Branch of the Surgeon General's Office, in collaboration with the War Manpower Commission and the Committee on Education of the American Occupational Therapy Association. The latter body reviewed course plans at a special meeting on 21 March 1944 and found that they satisfied minimum standards established by the American Medical Association. Civilian schools had, for several years, qualified college graduates in an 18-month course. Prerequisites for these courses included a college degree with a specified number of hours in biology, psychology, and sociology. With this background, schools were able to telescope the required professional curriculum into 9 months of academic work and 9 months of supervised clinical experience.

In an effort to further shorten professional education, the Army singled out skills and techniques as the most time-consuming part of the curriculum and added these to the prerequisites for the War Emergency Course. The qualifications of applicants thus became a bachelor's degree, with a course in basic psychology, and a major in arts and crafts, industrial art, home economics, or fine or applied arts.19 All were required to possess at least three manual skills and were required to be citizens of the United States and between the ages of 21 and 35 years. The course plan provided a 4-month academic curriculum of medical subjects and occupational therapy, followed by 8 months of apprenticeship in Army general hospitals. By raising admission standards, the academic phase of the emergency course was shortened by 5 months, and the clinical phase was reduced by 1 month. Together, these accounted for a 6-month, or 33 1/3 percent, reduction in course length.

The Surgeon General's request to establish an emergency course to train 600

    17(1) Letter, Everett S. Elwood, President, American Occupational Therapy Association, to Maj. Gen. James C. Magee, The Surgeon General, 20 Mar. 1940. (2) Letter, Maj. Gen. James C. Magee, The Surgeon General, to Everett S. Elwood, President, American Occupational Therapy Association, 1 Apr. 1940.
    18Willard, Helen S., and Spackman, Clare S. (editors): Principles of Occupational Therapy, 1st edition. Philadelphia: J. B. Lippincott Co., 1947.
    19Memorandum, The Surgeon General for Commanding General, Army Service Forces, 26 Apr. 1944, subject: Occupational Therapists.


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civilians yearly was approved by the Army Service Forces in May 1944.20 The circular authorizing this course and specifying the civilian schools to participate appeared a month later.21 By the terms of contracts negotiated with civilian schools participating in this Government subsidized program, The Surgeon General retained authority to prescribe curriculum, teaching methods, classroom materials, and class schedules. Representatives of his office could inspect school facilities and courses at any time and require periodic progress reports on each student. Schools were required to remove any student from the course who failed to maintain a satisfactory standing or who The Surgeon General, for any reason, desired withdrawn.

The War Emergency Course was accelerated from 18 to 12 months by the requirement of additional prerequisites. Each applicant accepted for training was required to have at least three manual skills, but the average possessed was even greater because most of the candidates either had majored in art or home economics or had supplementary experience in teaching creative and manual skills. The general level of education allowed many courses to be eliminated from the academic phase of the traditional curriculum. Over 90 percent of the students had bachelor's degrees, and over 3 percent had master's degrees. The average educational level of nondegree students was 3.8 years beyond high school.

In contrast to the limited number of crafts was the time devoted to the sciences, clinical conditions, and the theory of occupational therapy. Schools taught only two of the major arts and crafts, which they selected to conform with their facilities and the skills of their staff. The list of crafts drawn up by the Army was headed by woodworking and printing, and most schools selected these subjects. Several schools offered weaving or radio and electrical repair in lieu of printing. Science and occupational therapy accounted for two-thirds of the total curriculum. Conspicuously absent from the wartime curriculum were psychology-a prerequisite-and pediatrics. Weekly schedules included 24 hours of classes and 12 hours for visits, field trips, collateral reading, and study. Upon completion of the academic phase of training, The Surgeon General assigned trainees to selected general hospitals for 8 months of clinical affiliation.

The clinical program was designed to provide orientation to the Army and an opportunity to apply the principles, processes, and techniques studied during the 4-month academic phase. Modifications of the standard program were permitted to adapt it to local facilities. Forty Army general hospitals were designated to conduct the clinical phase. A detailed program of instruction for the period of clinical affiliation was published by The Surgeon General in October 1944. Eighty-seven hours were devoted to craft activities to perfect or supplement skills learned in the academic phase. Additional practice and exploration of craft techniques were provided by work experience periods. In this way, time removed from the academic phase was made up in the clinical phase.

In August 1944, the clinical portion of the War Emergency Course was opened to students who had completed the equivalent of the academic portion of regular

    20Memorandum, William H. Kushnick, Director of Civilian Personnel and Training, Civilian Personnel Division, Office of The Secretary of War, for Office of The Surgeon General, thru Army Service Forces, Headquarters, Industrial Personnel Division, 9 May 1944, subject: Approval of Contract for Training of Occupational Therapists.
    21Army Service Forces Circular No. 189, 22 June 1944.


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FIGURE 18.-Classes for occupational therapy apprentices, Battey General Hospital, Rome, Ga. (Top) Anatomy. (Bottom) Kinesiology.


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civilian training courses.22 Students who had satisfactorily completed some part of the apprentice period in accredited civilian hospitals became acceptable for completion of this period in selected Army hospitals. By extending subsidized training to students in regular civilian courses, approximately 150 additional apprentices were enrolled and employed in Army hospitals as graduate occupational therapists (fig. 18).

APPOINTMENTS, CLASSIFICATIONS, AND SALARIES OF TRAINEES

In February 1939, all civilian positions in Army hospitals, including student dietitians at Walter Reed General Hospital, were brought into the Civil Service.23 The Surgeon General's Office was authorized to give classified status to the 10 student dietitians who entered training on 1 September 1939 and who were appointed without civil service examinations. However, students remained ungraded for another 5 years. After deductions for quarters, subsistence, and retirement, take-home pay from a salary of $420 was approximately $45 per annum.

In 1941, when the emergency training program in physical therapy was initiated, physical therapy students were also classified in ungraded civil service positions, received the same salaries as student dietitians, and were subject to the same deductions. At this time, the Civil Service Commission authorized the additional training position of apprentice physical therapist and provided for reallocations from the position of student to that of apprentice and ultimately to that of graduate without approval of examination by the Commission. The positions of apprentice physical therapist and apprentice dietitian were subprofessional and were designated SP-3. The salary for these positions was $1,440, less $180 for quarters and subsistence.

By 1944, when the emergency course in occupational therapy was initiated, classification and salary for Medical Department trainees had improved even further. Ungraded students (dietitians, physical therapists, or occupational therapists) were changed to SP-3, at $1,440 per annum, and the position of apprentice in each of these categories was upgraded from SP-3 to SP-4, at $1,620 per annum. Both salaries were enhanced by 20-percent overtime pay for schedules in excess of 40 hours per week. However, both were still subject to a deduction of 5 percent for retirement and $180 for quarters and subsistence. Civilian students and apprentices were required to furnish their own uniforms, textbooks, and incidentals. Uniforms authorized for wear were the same as those for graduates.

TRAINING PERFORMANCE REPORTS

During the clinical phase of training, performance reports were required for all apprentices. Reports on apprentice dietitians were completed 1 month before the end of the training period and forwarded to the Surgeon General's Office. A record

    22Army Service Forces Circular No. 263, 15 Aug. 1944.
    23Executive Order 7916, 24 June 1938.


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of final physical examination, a photograph, and an application for appointment accompanied the report. Final performance reports for physical therapy apprentices were completed after the training period by the clinical supervisors and forwarded to The Surgeon General. These reports provided information about the trainee's proficiency, the amount of clinical practice completed, personality traits, and adaptability for commissioned military service and were retained as a part of the trainee's permanent record. Reports on occupational therapy apprentices were completed by the hospitals at periodic intervals during the 34-week program and submitted to The Surgeon General. One copy was sent to the schools in which apprentices received their academic instruction and from which they would be certified eligible for registration on completion of the course. The Surgeon General was authorized to separate an apprentice from a course at any time for failure to maintain satisfactory clinical performance, for inability to adjust to hospital service, or for other cause.

MAINTENANCE OF EDUCATIONAL AND PROFESSIONAL STANDARDS

Emergency training programs in dietetics, physical therapy, and occupational therapy developed as a result of cooperation between the Medical Department and officials or committees of professional organizations. Courses met the minimum educational requirements of the American Dietetic Association and, for physical and occupational therapists, the Council on Medical Education and Hospitals of the American Medical Association. Throughout the war, The Surgeon General maintained these educational standards. Each group, however, had its own problems.

In the fall of 1944, the Civil Service Commission questioned the need for the strict educational requirements for student dietitians. The question arose because of the Commission's interpretation of a provision in the Veterans' Preference Act of 1944 which eliminated minimum educational requirements as a qualification for other than scientific, technical, or professional positions. The Civil Service Commission's interpretation came as a surprise to the Surgeon General's Office. In a letter of protest, Maj. Gen. George F. Lull, Deputy Surgeon General, stated:24

The dietitian in the Medical Department of the Army is a commissioned officer. She assists the medical officer by filling his diet prescriptions. It is, therefore, most important that the best qualified individuals be obtained for training. It is highly improbable that this type of personnel could be secured if the educational requirements are discontinued.

A favorable reply was received from the Commission:25

In certifying persons for the position of student dietitian, apprentice dietitian, student physiotherapy aide and apprentice physiotherapy aide, only those eligibles will be certified who meet the requirements prescribed by the War Department as necessary for commissioned officers.

    24Memorandum, Maj. Gen. George F. Lull, Deputy Surgeon General, to U.S. Civil Service Commission, 12 Sept. 1944, subject: Educational Requirements for Dietitians.
    25Letter, M. L. A. Mayer, Executive Director, Civil Service Commission, to Maj. Gen. George F. Lull, Deputy Surgeon General, 24 Oct. 1944.


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Occupational therapists had problems with both educational and physical standards. Although the majority of applicants for the War Emergency Course were qualified, a small percentage was found unacceptable because of poor academic records, physical conditions, or personality disorders. The Surgeon General's struggle to maintain professional standards was complicated by Civil Service Commission policies giving preference to veterans, the disabled, wives, and widows, which required the acceptance of several candidates neither physically nor educationally qualified for training. Another problem was created by extremely liberal substitution of experience for education. Occasionally, The Surgeon General contested decisions and won his argument against unqualified certifications. Too often, they had to be accepted and disqualified later for failing to meet physical or academic standards.

The prerequisite of a college degree in physical education for civilian students taking the physical therapy course was established by the Medical Department as the entrance requirement before 1941. In May 1944, the Medical Department requested authority to change the educational requirement to include a major field in biology. This revision was not published until October, but it was informally approved in the selection of students enrolled after August 1944.

Military applicants for the physical therapy course were required to have completed not less than 2 years in an approved college with satisfactory courses in biology and other sciences. The term "satisfactory course in biology and other sciences" was interpreted as a minimum of 15 semester hours selected from anatomy, bacteriology, biology, chemistry, hygiene, kinesiology, physics, physiology, psychology, and zoology. This departure from the established standards roused fears that the Army would jeopardize professional standards. While the Army did depart from its previously established prerequisites, it still conformed to the minimum standards established by the American Medical Association.

In October 1944, the minimum requirement in science hours was increased from 15 to 26 semester hours, with 6 hours as the minimum in biology. The remaining hours were selected from courses in anatomy, bacteriology, chemistry, entomology, hygiene, kinesiology, parasitology, physics, physiology, psychology (maximum 3 semester hours), zoology, or other courses in biology or natural science. This change was necessary because many 2-year college students with only 15 hours in the sciences were not academically prepared to cope with the Army's intensive training program. The number of students with a 2-year college background constituted only 9 percent of the total number of enlisted students enrolled from October 1943 to November 1945. The average number of college years for the overall total of these students during this period was 3.7 years.

The training period (student and apprentice phases) for civilian physical therapy students was 12 months, while training period for enlisted students was 9 months. The shorter training period for military students was justified by their previous military orientation and the number of patients available for therapy in Army general hospitals. During 1944, enlisted apprentice physical therapists were given training far in excess of the 400 clinical hours required by the American Medical Association.


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SCHOOLS AND HOSPITALS CONDUCTING TRAINING COURSES FOR THE ARMY

Emergency training programs to increase the number of dietitians, physical therapists, and occupational therapists were established at educational institutions and at civilian and military hospitals. Fifteen civilian hospitals conducted the student phase for dietitians, 33 Army hospitals conducted the apprentice phase, and 4 Army hospitals conducted both phases. The first emergency course began in August 1942. Civilian institutions completed their Army courses in 1945, and all Army accelerated programs, except one, came to a close in March 1946.

The 6-month academic phase of emergency physical therapy training was conducted in 38 courses at 15 civilian institutions. In addition, 10 Army hospitals conducted 33 emergency academic courses for civilian students and 28 for enlisted students. The first emergency course was started in July 1941, but the courses in civilian schools did not start until 1942. Emergency physical therapy training programs were discontinued soon after V-J Day. However, Army hospitals conducting the academic phase continued classes until 10 February 1946 and hospitals accepted these students for on-the-job training for another 6 months.

Twenty-one emergency courses for occupational therapists were given at eight civilian schools, while the clinical phase of this program was conducted at 40 Army hospitals. School courses started in July 1944 and ended in November 1945. The clinical phase of training extended 8 months beyond the war. The last 51 apprentices, scheduled to graduate in July 1946, were transferred to Veterans' Administration hospitals for pay and training.

RESULTS OF EMERGENCY TRAINING PROGRAMS

Without emergency training programs, the Army could not have recruited enough qualified medical specialists to meet wartime requirements. Both dietitians and physical therapists numbered approximately 1,600 at the peak of their strengths. Only 21 percent of the Medical Department dietitians were trained through Army programs, but Army training qualified approximately 55 percent of the physical therapists. Occupational therapists, the smallest group numerically, trained 78 percent of their peak strength of approximately 900 through emergency courses. In each instance, the professional group concerned thought that the apprentice phase of training in military hospitals was valuable in familiarizing students with Army procedures. Experience in treatment of war injuries was especially valuable for physical and occupational therapists. Emergency training courses for dietitians, physical therapists, and occupational therapists expanded educational programs for the whole profession. The demand in all three of these health fields during the war resulted in the number of civilian schools offering dietetic internships increasing from 38 to 60; in physical therapy, from 15 to 36; and in occupational therapy, from five to 21.

Both during and after the war, the fear was expressed that a lowering of


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standards was inherent in the Army's accelerated physical therapy training program. In 1945, Dr. Frances A. Hellebrandt, Medical Director, Baruch Center of Physical Medicine, Medical College of Virginia, Richmond, Va., made a careful analysis of the 6-month academic phase of the Medical Department physical therapy course. Doctor Hellebrandt, who had served as medical director of the physical therapy training course for enlisted members of the Women's Army Corps conducted at the University of Wisconsin from October 1943 to October 1944, concluded that:

     *   *   * Careful study of the scope and content of the WAC course suggests that in reality it surpasses anything previously attempted by the average apprentice type of approved hospital technician training school.

     *                               *                               *                               *                               *                               *                               *

     The Army has demonstrated that the essentials of subject matter in a variety of technical fields can be taught effectively by new methods which drastically shorten the learning period. *    *    *  We would be short sighted indeed if we failed to study the pedagogical experiments of the war *   *   * .26

TRAINING ENLISTED PHYSICAL THERAPY TECHNICIANS

The Medical Department had long recognized that trained enlisted assistants were necessary in the operation of a physical therapy clinic. Until late in the war, male enlisted assistants were trained on-the-job. Because of increasing patient loads and the loss of male technicians to combat units, The Surgeon General directed the service commands, in a telegram dated 28 February 1945, to estimate their requirements for enlisted women trained as physical therapy technicians. On the basis of this information, a formal training program was established. Applicants for these courses were required to have completed 2 months of training at the Medical Department Enlisted Technicians School. Those selected were carefully screened by the staff of the school, the medical director of physical therapy, and the chief physical therapist, Brooke General Hospital.

The program of instruction consisted of a 4-week course (192 hours) in selected physical therapy procedures and a general orientation in this field of therapeutics. To prepare enlisted women for hospital assignment as rapidly as possible, courses were established in 13 general hospitals. Graduates were eligible for the classification of enlisted physical therapy technician.27 The last class enrolled on 9 July 1945. Four hundred and thirteen enlisted women were trained in this program.28

COURSE FOR OCCUPATIONAL THERAPY ASSISTANTS

If graduate occupational therapists could have been recruited in larger numbers or if the War Emergency Course had begun earlier in the war, a course for occupa-

    26Hellebrandt, F. A.: Analysis of the WAC Emergency Physical Therapy Training Program. Arch. Phys. Med. 26: 507, 514, August 1945.
    27War Department Technical Manual 12-427, 12 July 1944; Change 1, 12 Apr. 1945.
    28Memorandum, Maj. Emma E. Vogel, WMSC, Director of Physical Therapists, to Col. Harold C. Lueth, Military Personnel Division, Office of The Surgeon General, 6 Aug. 1945.


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tional therapy assistants would have been unnecessary. However, in June 1944, only 180 occupational therapists were on duty in Army general hospitals,29 and more than a year would elapse before graduates of the War Emergency Course could be qualified for staff appointments. On 2 October 1944, the director of the Reconditioning Consultants Division, Surgeon General's Office, reported to The Surgeon General that a program for training enlisted women as occupational therapy assistants had been submitted to Army Service Forces.30 The 1-month course was approved by the Army Service Forces on 16 November 1944.31

In January 1945, recruiting for this course ended, and, during the remaining 10 months of its operation, students were drawn exclusively from the Women's Army Corps. Halloran General Hospital, Staten Island, N.Y., was selected and Capt. Josephine E. Springer, WAC, chief occupational therapist at Tilton General Hospital, Fort Dix, N.J., was transferred to Halloran General Hospital and placed in charge of the program. The Surgeon General's Office approved candidates, allotted quotas to the service commands, and returned trainees to service commands for assignment to hospitals. Applicants for training were required to have completed basic military training and to have either a civilian background of teaching experience and some knowledge of a handicraft or an expert ability in some handicraft plus a high school education and an aptitude for teaching.

On 9 December 1944, 14 students reported for the first class. By April 1945, 141 students had attended the course. That same month, the course was discontinued because the training requirements for occupational therapy assistants had been met. The following month, a request for reestablishment of the course had to be submitted because enlisted assistants were needed for the expanding convalescent hospital program. Army Service Forces approved The Surgeon General's request.32 The promptness of Army Service Forces in approving the Medical Department's request enabled classes to run consecutively until 27 October 1945, when the 11th class graduated and the occupational therapy assistants training course for enlisted members of the Women's Army Corps was discontinued. Of the 295 students enrolled in this course, 278 satisfactorily completed requirements and were subsequently assigned to selected Army hospitals where they assumed much of the burden of diversional activity programs.

    29Memorandum, Maj. Henry B. Gwynn, MC, for The Surgeon General, 17 June 1944, subject: Semimonthly Report of the Reconditioning Division for the Period 1-17 June 1944.
    30Memorandum, Col. Augustus Thorndike, MC, for The Surgeon General, 2 Oct. 1944, subject: Semimonthly Report of the Reconditioning Consultants Division for the Period 16-30 September 1944.
    31Memorandum, Brig. Gen. R. W. Bliss, Chief, Operations Service, Office of The Surgeon General, for Commanding General, Army Service Forces, 4 Nov. 1944, subject: Orientation Training for Occupational Therapy Assistants (WAC), with 1st indorsement thereto, 16 Nov. 1944.
    32(1)Letter, Brig. Gen. R. W, Bliss, Chief, Operations Service, Office of The Surgeon General, to Commanding General, Army Service Forces, attention: Director of Military Training, 13 Apr. 1945, subject: Orientation Training for Occupational Therapy Assistants (WAC), with 1st indorsement thereto, 23 Apr. 1945. (2) Letter, Brig Gen. R. W. Bliss, Chief, Operations Service, Office of The Surgeon General, to Commanding General, Army Service Forces, attention: Director of Military Training, 28 May 1945, subject: Orientation Training for Occupational Therapy Assistants (WAC). (3) Transmittal Sheet, Col. S. M. Prouty, GSC, Executive, Office of the Director of Military Training, Army Service Forces, to The Surgeon General, 7 June 1945, subject: Orientation Training for Occupational Therapy Assistants (WAC), with inclosure 1 thereto, 28 May 1945.

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