CHAPTER V
Dietitians, Physical Therapists, and OccupationalTherapists
Dietitians, physical therapists, and occupational therapists becamepart 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 ExpeditionaryForces in France and with the army of occupation in Germany.1Because they were not expected to enter hostile fire zones, they continuedto perform their duties as civilians in the years between World Wars Iand II. As such, they were entitled neither to military pay and privilegesnor to military training. Military status was not authorized until thefirst year of World War II had demonstrated that civilian employees ofthe 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 therapistsand dietitians but excluded occupational therapists. It was not until June1944 that dietitians and physical therapists achieved full commissionedstatus. Occupational therapists continued to serve as civilians throughoutthe war.
Wartime training programs in dietetics, physical therapy, and occupationaltherapy were designed to accomplish two major objectives: to provide militaryorientation of civilian-trained, and to increase the number of, qualifiedgraduates available for Army service. Physical and occupational therapistsalso conducted training programs for enlisted technicians. Although theyengaged in training programs at different times and in various ways, theirsolutions 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 performtheir duties after a brief period of on-the-job military orientation. FromOctober 1940 until late 1941, all dietitians were sent to Walter Reed GeneralHospital, Washington, D.C., for military orientation. Upon completion ofapproximately 6 months' duty at the hospital, they were transferred toother Army hospitals to organize dietetic departments. Special trainingin administrative procedures peculiar to
1Unless otherwise indicated, this chapter isbased on Army Medical Specialist Corps. Washington: U.S. Government PrintingOffice, 1968.
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military service was approved by the Surgeon General's Office on 15February 1941. This training was initiated at fixed Army hospitals from2 to 4 weeks before dietitians were to be transferred to newly constructedinstallations.2
In April 1942, The Surgeon General authorized establishment of trainingpools for civilian dietitians with no experience in the Medical Departmentwho were designated for duty outside the continental United States.3In addition, overseas volunteers from the American National Red Cross,upon request, were assigned to these pools for training. Instruction includedlectures on organization of Army hospitals, Army regulations, organizationof the mess department, relationship of dietitians with other personnelin the mess department and departments of the hospitals, personnel records,hospital fund reports, and procurement of food. Dietitians were given on-the-jobexperience in each section of the hospital mess so they would be familiarwith all phases of management: procuring, preparing, and serving food,and planning special diets. Assignment to these pools was discontinuedin December 1942 when military status was authorized.
Dietitians assigned to affiliated units scheduled for overseas servicewent on active duty with their units at specified Army posts. They workedwith the post hospital dietitian to become familiar with procedures andmethods and participated in maneuvers to learn to work and live under fieldconditions. These maneuvers made the dietitians conscious of ways to improveor improvise equipment and to substitute various foods to relieve rationshortages. A special 60-hour course, "Cooking of Dehydrated Foods,"was made available to dietitians selected for overseas service. The productionof dehydrated foods, packaging and storing, reconstituting, menu planning,and actual preparation of meals were studied. Special training was givenin the preparation of dehydrated food under field conditions as well asin maintenance and operation of cooking equipment and sanitation in fieldmesses. These dietitians lived on dehydrated foods or combination of dehydratedfoods and fresh rations for part of the course.
In October 1943, the Army Nurse Corps established basic training centersthroughout the country for new nurses going overseas. It was not until1944, however, that dietitians entering the Army or those assigned to overseashospital units were sent to the training course for nurses. To accommodatedietitians, the nurses' training course eliminated 23 hours of nursingsubjects and substituted 23 hours of dietetic subjects.4 In1945, 53 hours of instruction were deleted from the nurses' training courseand other material was substituted for the basic training of dietitians.5This program provided 17 hours of lectures and demonstrations conductedby dietitians and 36 hours of on-the-job understudy in a hospital mess.
Physical Therapists
The training programs for physical therapists developed in a patternsimiliar to those for dietitians. Many physical therapists joining affiliatedunits at the beginning
2Unless otherwise indicated, sections on Armydietitians 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 June1945.
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of the war had no previous Army experience. Training plans called fora 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 physicaltherapy clinics in Army hospitals. Orientation courses were to be establishedin 1942 at several hospitals,6 but available evidence indicatesthat only Walter Reed General Hospital activated a program. Without supervisionfrom the Surgeon General's Office, command responsibility was confusedand the program was poorly executed.
In 1943, after military status was achieved, newly appointed physicaltherapists, who had not been trained in one of the Army physical therapycourses, were included in courses for newly appointed nurses and dietitians.Hours scheduled for the professional orientation of nurses and dietitianswere replaced by special instruction for physical therapists. Special topicsincluded the organization and administration of Army physical therapy clinics,their relationship to other hospital activities, and the treatment of patientsnot normally seen in civilian hospitals. Particular attention was givento the treatment of amputees and patients with injuries of the centraland peripheral nervous systems; muscle, sensory, and electrodiagnostictests; measurements of joint range of motion; bandaging adaptions of exerciseapparatus; and the utilization of floor space. Following V-J Day, all ofthese basic military training courses were terminated.
Occupational Therapists
Because occupational therapists did not have military status duringWorld War II they could not be integrated into the basic military trainingprograms established for nurses, dietitians, and physical therapists.
In October 1943, 2-week indoctrination courses were established fornewly 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 weredevoted to on-the-job experience with orthopedic and psychiatric patients,in convalescent shops, and on wards under the direct supervision of experiencedoccupational therapists. The remaining hours were devoted to lectures,conferences, demonstrations, and tours. The schedule avoided solid blocksof time on any given subject. Students had access to the medical libraryand sat in on roundtable discussions with members of the occupational therapystaff. Orientation courses were discontinued in July 1944.8By this time, a majority of chief occupational therapists had attendedthe course and could indoctrinate the new personnel on their staffs.
PROFESSIONAL TRAINING PROGRAMS
In contrast to the relatively simple matter of arranging short militaryorientation courses, a far greater problem confronted the Medical Department:that of
6See footnote 3, p. 152.
7Letter, The Adjutant General to Commanding Generals, Firstto Ninth Service Commands, 7 Oct. 1943, subject: Orientation Course forOccupational 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. Neitherthe outbreak of war in Europe nor the expansion resulting from the SelectiveService Act brought these specialists into military service in adequatenumbers because most of them were women and were not subject to compulsorymilitary service. In any event, the total number of qualified dietitians,physical therapists, and occupational therapists in the United States wasnot sufficient to meet both civilian and military requirements if the Armywas to fulfill its patient care responsibilities. Emergency training programsfor all three specialist groups were required.
ACCELERATION AND EMERGENCY TRAINING PLANS
Dietitians
The need for training student dietitians in Army hospitals was recognizedshortly after World War I. In 1922, a course was established at WalterReed General Hospital for such a purpose. Throughout the interwar period,enough qualified dietitians graduated from the course to supply all Armyhospitals authorized to employ them. The training program at Walter ReedGeneral Hospital provided theoretical instruction as well as on-the-jobexperience, and graduates were qualified for duty in Army hospitals. Inaddition, students were given an opportunity for staff experience by servicein positions of responsibility. By August 1942, 211 dietitians had graduatedfrom the course at Walter Reed General Hospital. A single course satisfiedthe needs of the peacetime Army but, to meet wartime requirement, the programhad to be accelerated and expanded to include other hospitals. In civilianhospitals, the number of training courses increased from 38 to 60. Eventhis was not enough, and other plans had to be developed to meet the increaseddemand for dietitians.
On 17 July 1942, a meeting was held between representatives of the SurgeonGeneral's Office, the American Dietetic Association, and the Civil ServiceCommission. Two plans were recommended. Plan A provided that the programconducted in Army hospitals would be divided into two sections, the studentdietitian course and the apprentice dietitian course. Plan B provided forthe establishment of a 6-month student dietitian program in approved civilianhospitals from which the students would be transferred to an Army hospitalfor the 6-month Army hospital apprentice course. A combination of theseplans was finally adopted. Minimum educational qualifications were thesame as those previously established for the student dietitian program.The first class, 16 students appointed under Plan A, reported to WalterReed General Hospital on 24 August 1942.
Six-month Army hospital student course.-The 6-month curriculumestablished for student dietitians at Walter Reed General Hospital wasused as a guide for setting up three additional Army hospital student dietitiantraining courses, all approved by the American Dietetic Association. InMay 1943, Fitzsimons General Hospital, Denver, Colo., started a courseunder the direction of Capt. Mildred G. Allbritton, AMSC. The course atBrooke General Hospital,
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Fort Sam Houston, Tex., started in July 1943, under the direction ofCapt. Nell Wickliffe, AMSC. The last student dietitian course was establishedat 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 trainingin the diet in health and disease and in the organization and administrationof a dietetic department in an Army hospital. Over 200 hours of lectureswere given in diet therapy and administration. Dietetics for medical andsurgical patients was taught by Medical Corps officers and heads of dietarydepartments. On-the-job training in therapeutics totaled 11 weeks and includedwriting special diets, diet instruction to ward and clinic patients, supervisionof ward kitchens, and participation in ward rounds. A minimum of 2 weekseach 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 comprehensiveprogram afforded experience in all areas of administration: menu planning;purchasing; ordering, preparing, and serving food; inventory and portioncontrol; cost accounting; and personnel management.
Six-month civilian hospital student course.-In September 1942,Miss Nelda Ross, President of the American Dietetic Association, sent aletter to the director of each of the 60 approved civilian training coursesfor dietitians in an attempt to determine which civilian hospitals hadfacilities to cooperate with the Army. In her letter, Miss Ross made itclear that students who successfully completed this program would meetthe 1-year requirement for membership in the American Dietetic Association.Response to her inquiry indicated that the plan was generally acceptableto hospitals in which at least 10 students were enrolled. At a few hospitals,problems with staff and facilities made it impossible to participate. Somechief dietitians were afraid that the release of students after 6 monthswould further disorganize dietary departments, already plagued with excessivewartime turnover of employees. Other chief dietitians, who had alreadyrearranged their training plan to provide for enrollment of student dietitianstwice a year, believed that it would be difficult to add still anotherprogram to their training schedule.
Under the program finally adopted, training in civilian hospitals included6 weeks in special diet kitchen and ward service; 2 weeks of private patientservice; 4 weeks of pediatrics, including formula preparation; 4 to 6 weeksin outpatient clinics; 6 to 8 weeks of administration, including purchasing,ordering, accounting, and menu planning; as well as some work with personneland preferably experience in a cafeteria or dining room. Lectures in diettherapy and infant feeding and experience in teaching dietetics to studentnurses were required.
Six-month Army hospital apprentice course.-Because of differencesin the civilian and military basic courses, the 6-month apprentice coursein Army hospitals had to be tailored to provide apprentices with the experiencerequired to qualify them for membership in the American Dietetic Association.Every effort was made to establish appropriate programs at the 32 hospitalsto which students could be assigned for apprentice training (fig. 15).
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FIGURE 15.-Student dietitiandiscussing recipe with head cook.
Throughout 1943, the apprentice training course followed a program ofinstruction outlined by The Surgeon General. A subsequent program, publishedby The Surgeon General on 1 May 1944, provided a more detailed guide forinstructors. These courses were adapted locally to meet the individualneeds of apprentice dietitians at each hospital.
The 26-week apprentice program emphasized practical experience by including16 weeks in administration of food service sections, 8 weeks in therapeuticphases of food service activities, and 2 weeks of lectures. To meet AmericanDietetic Association requirements for staff experience during dieteticinternship, assignment in a supervisory capacity was scheduled during thelast month of apprentice training.
Qualified experience apprentice entrance plan.-A final dimensionwas added to the program when courses were adjusted to permit home economistswith bachelor of science degrees in foods and nutrition, or majors in institutionalman-
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agement that contained specified courses, to substitute work experiencefor the first 6 months of hospital training. Early in 1943, an increasinginterest in the Army's training program was expressed by home economistswho possessed every qualification for certification except internship orhospital work experience. When it was determined that the number of homeeconomists with food service experience interested in becoming dietitianswas large enough to make a special program practical, The Surgeon Generalwon approval of the American Dietetic Association for a plan to substitutesuch experience for the Army or civilian hospital student course, and admitexperienced home economists directly into the 6-month apprentice program.Between September 1943 and September 1945, 128 home economists receiveddirect appointments to apprenticeship.
Several enlisted members of the Women's Army Corps with backgroundsin home economics also expressed an interest in the dietitian course. On6 March 1945, the Surgeon General's Office authorized the establishmentof the first training course for enlisted members of the Women's Army Corpsat McCloskey General Hospital, Temple, Tex.9 Ten apprenticeswere authorized in each class, but only five applied. Upon completion ofthe course, they were commissioned as Medical Department dietitians. Thecourse, which began on 15 June 1945 and was discontinued on 1 January 1946,was the only dietitian course for enlisted women given during World WarII.
After V-J Day, a study was made to determine postwar requirements. Authoritywas subsequently granted to proceed with the training of students on dutyas 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, exceptthe one at Brooke General Hospital.
Physical Therapists
In 1941, a Central Physical Therapy Board was established in the SurgeonGeneral's Office10 to work with the Subcommittee on PhysicalTherapy, National Research Council, and the Federal Security Agency onproblems associated with the expansion of the physical therapy programin Army hospitals. Among the problems presented to this board was the subsidizationof civilian physical therapy training courses. A survey made by the AmericanMedical Association's Council on Medical Education and Hospitals, earlyin 1942, revealed that civilian physical therapy training courses requiringtuition were experiencing difficulty in maintaining full enrollment. TheSubcommittee on Physical Therapy recommended that the War Department subsidizethese courses. Because of the planned expansion of the Army physical therapytraining program, it was The Surgeon General's opinion that the subsidyof civilian training courses could not be justified.11 The Subcommitteeon
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 SurgeonGeneral, 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 Serviceto defer male physical therapists until completion of their training.
Expansion of the Army physical therapy training program was accomplishedby the establishment of courses directed to three groups: Civilian studentswho would take all of their training in Army hospitals; enlisted membersof the Women's Army Corps who would take all of their training in Armyhospitals or take the apprenticeship phase of their training in Army hospitalsafter completing courses in selected civilian institutions; civilian studentswho would take the apprenticeship phase of their training in Army hospitalsfollowing the completion of courses in a civilian institution.
Civilian students.-Early in 1941, The Surgeon General proposedthe establishment of an emergency training course. This course, consistingof 6 months of formal instruction followed by 6 months of applicatory training,was to replace the regular 9-month course conducted at Walter Reed GeneralHospital. The proposal was approved by the Council on Medical Educationand Hospitals, which also approved a plan to allow civilian institutionsto conduct 6 months of theoretical instruction, followed by 6 months ofsupervised apprenticeship in selected Army hospitals.
On 1 July 1941, the first Army emergency course was initiated at WalterReed 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 militarymedicine. Emphasis was placed on the treatment of patients with combatinjuries. Additional courses were established in October 1942 at the FortSam Houston Station Hospital; Army and Navy General Hospital, Hot Springs,Ark.; O'Reilly General Hospital, Springfield, Mo.; and Fitzsimons GeneralHospital. All were conducted on the same plan as the course at Walter ReedGeneral Hospital.
Following this expansion, the number of civilians in Army physical therapytraining courses increased, but the authorized capacities of these coursescould not be maintained because college graduates with a physical educationbackground were being offered increasingly attractive positions by industryand 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, resultedin renewed interest in the Army physical therapy training programs. InJanuary 1944, there were only enough eligible civilian applicants to fillone class of trainees, but the increasing number of certified applicantsin the succeeding months justified further expansion of the program. Additionalcourses for civilian students were established at Bushnell General Hospital,Brigham City, Utah, on 10 July 1944, and at Ashford General Hospital, WhiteSulphur Springs, W. Va., on 10 August 1944.
Civilian students enrolled after August 1944 were required to meet thephysical standards for commissioned officers. This policy was recommendedby the Physical Standards Division, Surgeon General's Office, to reducethe number of students who could not meet the physical requirements forcommissioning.
Military students.-In July and August 1943, the director of physicalthera-
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pists initiated conferences between the Training Division and the Women'sArmy Corps to discuss the possibility of making Army physical therapy coursesavailable to enlisted women. Such a program would not only assist in meetingthe procurement requirements for physical therapists, but it would alsooffer 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 theD. T. Watson School of Physiotherapy, Leetsdale, Pa., were selected toconduct the program. These courses began in October 1943 and continueduntil October 1944 when the expansion of courses in Army general hospitalsenabled the Army to discontinue training at civilian institutions. Whiletraining was conducted at civilian institutions, the War Department paidtuition, 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 therapytraining 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 GeneralClassification Test score of 110 or over.
In December 1943, the Secretary of War authorized direct recruitmentof women qualified for the Women's Army Corps for the purpose of attendingphysical therapy training courses, with the assurance of a commission asa physical therapist upon completion of the course.13 Womenrecruited for this specific program comprised more than half of the totalmilitary enrollment in these courses.
In June 1944, the maximum age for enrollment was reduced from 44 to37 years. This change resulted from a study which revealed that traineesin the upper age group often experienced difficulty in adjusting to intensiveacademic study and to living and working in close association with groupsof younger women. A similar change was made in the age requirement forapplicants for these courses from within the ranks of the Women's ArmyCorps.
The establishment of two all-Negro station hospitals in the United Statesand the activation of three such hospitals for overseas duty raised thequestion of supplying physical therapists for these hospitals. A physicaltherapy training course for Negro students was established at the FortHuachuca Station Hospital, Ariz., on 1 October 1943 (fig. 16). When therequirement for Negro physical therapists was met by commissioning traineesin October 1944, the training of both military and civilian Negro studentsat Fort Huachuca was terminated.
The enrollment for five courses conducted in Army general hospitalswas changed from civilian trainees to military trainees in January andFebruary 1944. Two additional courses for military trainees were establishedat Lawson General Hospital and at Percy Jones General Hospital, BattleCreek, Mich. An additional number of students were enrolled after July1944 when concurrent classes at quarterly intervals were authorized. Thisplan was put into effect in all general
12War Department Memorandum No. W635-18-43,22 Aug. 1943.
13Letter, The Adjutant General to Commanding General, FirstService Command, Army Service Forces, 14 Dec. 1943, subject: Recruitmentof Physical Therapy Aides.
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FIGURE 16.-Enlisted studentphysical therapist adjusting infrared lamp in preparation for treatmentof patient's left shoulder, Fort Huachuca Station Hospital, Ariz.
hospitals conducting courses except Percy Jones, where housing facilitieswere inadequate.
All assignment to physical therapy training courses was terminated inOctober 1945.14 The 325 physical therapy students then enrolledwere allowed to complete their training.
Apprentice training program.-The program of apprentice trainingfor graduates of the 6-month civilian emergency physical therapy coursesdeveloped slowly. Because civilian apprentices were assigned through theservice commands
14Memorandum, Maj. Emma E. Vogel, WMSC, Directorof Physical Therapists, Office of The Surgeon General, for Col. Floyd L.Wergeland, MC, Director, Training Division, 9 Oct. 1945, subject: Terminationof Physical Therapy Training.
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FIGURE 17.-Apprenticephysical therapists in training, Fletcher General Hospital, Cambridge,Ohio. (Top) Civilian apprentice receives instruction in massaging scartissue. (Bottom) Enlisted apprentice learns to apply shortwave diathermyapparatus. (Courtesy of National Library of Medicine.)
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with the program, they were too often assigned on the basis of personnelrequirements, with little consideration given to their need for continuedinstruction and supervised practice. Management of this program improvedwhen centralized control was vested in the Surgeon General's Office latein 1942.15
Subsequently, The Surgeon General directed that training would consistprimarily of supervised clinical practice in the treatment of patients,both in the physical therapy clinic and in hospital wards (fig. 17). Emphasiswas placed on the treatment of combat injuries, such as peripheral nerve,brain, spinal cord, chest and vascular injuries, and amputations. The programincluded attendance at conferences, participation in ward rounds, and atleast 1 hour daily of roundtable discussion of treatment programs and currentmedical literature. Apprentices were also trained in the administrationof physical therapy clinic, the preparation of records and reports, andthe procedures for requisitioning supplies. For the on-the-job phase oftraining, enlisted apprentice physical therapists were assigned to 20 generalhospitals and civilian apprentices were assigned to 31 other general hospitals.
After V-J Day, the directors of the civilian emergency physical therapycourses were advised that the 6-month applicatory training in selectedArmy hospitals would be terminated. Since the Army apprentice program forcivilian students was terminated, arrangements were made for students enrolledin the 6-month emergency civilian course to have their apprenticeship experienceelsewhere. On 10 October 1945, The Surgeon General wrote to the directorsof civilian courses expressing his recognition of the valuable contributionthese schools had made to the war effort.16 Although a largenumber of emergency courses were conducted in civilian institutions, enrollmentin these courses was far below expectations except in the two schools wheretraining was tuition free.
Experience in this program clearly demonstrated that in order to trainapprentice physical therapists in the treatment of patients with combatinjuries, clinical experience should be afforded in general hospitals wherepatients could be observed in large numbers. Station and regional hospitalsproved inadequate for this training, and after 1943, there was a decreasein use of station and regional hospitals and greater utilization of generalhospitals. It was demonstrated also that the efficiency of the apprenticeshipprogram depended not only on the clinical experience available but alsoon the supervision exercised by the chief physical therapist and by thePhysical Therapy Branch, Surgeon General's Office.
Occupational Therapists
At the outbreak of World War II, eight qualified occupational therapistsand four occupational therapy assistants were on duty in five Army hospitals.By V-J Day, 899 occupational therapists and apprentices were working in76 hospitals in the continental United States.
15Memorandum, The Adjutant General for CommandingGenerals, All Service Commands, 24 Oct. 1942, subject: Dietetic and PhysicalTherapy 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 appointoccupational therapists as civilian employees without commissions and tolimit the establishment of occupational therapy clinics to Army hospitalsin the Zone of Interior proved a serious handicap to recruiting and training.17These decisions made it clear that occupational therapy was consideredmore valuable for convalescent patients evacuated to the Zone of Interiorthan for patients with acute injuries and illnesses hospitalized in theCommunications Zone.
Lack of recognition and lack of status, however, were the least of theMedical Department's recruiting problems. Far more serious was the closeapproximation of the Army's estimated need and the total number of registeredoccupational therapists. By early 1944, so many new Army hospitals hadbeen built or planned for priority construction that the target for personnelwas set at 1,000.18 Yet, there were scarcely 1,300 graduatesin the professional registry. Since the Army could not hope to recruitover 75 percent of the total civilian supply of occupational therapists,the best solution seemed to be the establishment of an emergency trainingprogram.
Design and purpose of War Emergency Course.-The War EmergencyCourse was outlined by the Occupational Therapy Branch of the Surgeon General'sOffice, in collaboration with the War Manpower Commission and the Committeeon Education of the American Occupational Therapy Association. The latterbody reviewed course plans at a special meeting on 21 March 1944 and foundthat they satisfied minimum standards established by the American MedicalAssociation. Civilian schools had, for several years, qualified collegegraduates in an 18-month course. Prerequisites for these courses includeda college degree with a specified number of hours in biology, psychology,and sociology. With this background, schools were able to telescope therequired professional curriculum into 9 months of academic work and 9 monthsof supervised clinical experience.
In an effort to further shorten professional education, the Army singledout skills and techniques as the most time-consuming part of the curriculumand added these to the prerequisites for the War Emergency Course. Thequalifications of applicants thus became a bachelor's degree, with a coursein basic psychology, and a major in arts and crafts, industrial art, homeeconomics, or fine or applied arts.19 All were required to possessat least three manual skills and were required to be citizens of the UnitedStates and between the ages of 21 and 35 years. The course plan provideda 4-month academic curriculum of medical subjects and occupational therapy,followed by 8 months of apprenticeship in Army general hospitals. By raisingadmission standards, the academic phase of the emergency course was shortenedby 5 months, and the clinical phase was reduced by 1 month. Together, theseaccounted for a 6-month, or 33 1/3 percent, reduction in course length.
The Surgeon General's request to establish an emergency course to train600
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 OccupationalTherapy Association, 1 Apr. 1940.
18Willard, Helen S., and Spackman, Clare S. (editors): Principlesof Occupational Therapy, 1st edition. Philadelphia: J. B. Lippincott Co.,1947.
19Memorandum, The Surgeon General for Commanding General, ArmyService Forces, 26 Apr. 1944, subject: Occupational Therapists.
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civilians yearly was approved by the Army Service Forces in May 1944.20The circular authorizing this course and specifying the civilian schoolsto participate appeared a month later.21 By the terms of contractsnegotiated with civilian schools participating in this Government subsidizedprogram, The Surgeon General retained authority to prescribe curriculum,teaching methods, classroom materials, and class schedules. Representativesof his office could inspect school facilities and courses at any time andrequire periodic progress reports on each student. Schools were requiredto remove any student from the course who failed to maintain a satisfactorystanding or who The Surgeon General, for any reason, desired withdrawn.
The War Emergency Course was accelerated from 18 to 12 months by therequirement of additional prerequisites. Each applicant accepted for trainingwas required to have at least three manual skills, but the average possessedwas even greater because most of the candidates either had majored in artor home economics or had supplementary experience in teaching creativeand manual skills. The general level of education allowed many coursesto be eliminated from the academic phase of the traditional curriculum.Over 90 percent of the students had bachelor's degrees, and over 3 percenthad master's degrees. The average educational level of nondegree studentswas 3.8 years beyond high school.
In contrast to the limited number of crafts was the time devoted tothe sciences, clinical conditions, and the theory of occupational therapy.Schools taught only two of the major arts and crafts, which they selectedto conform with their facilities and the skills of their staff. The listof crafts drawn up by the Army was headed by woodworking and printing,and most schools selected these subjects. Several schools offered weavingor radio and electrical repair in lieu of printing. Science and occupationaltherapy accounted for two-thirds of the total curriculum. Conspicuouslyabsent 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 academicphase of training, The Surgeon General assigned trainees to selected generalhospitals for 8 months of clinical affiliation.
The clinical program was designed to provide orientation to the Armyand an opportunity to apply the principles, processes, and techniques studiedduring the 4-month academic phase. Modifications of the standard programwere permitted to adapt it to local facilities. Forty Army general hospitalswere designated to conduct the clinical phase. A detailed program of instructionfor the period of clinical affiliation was published by The Surgeon Generalin October 1944. Eighty-seven hours were devoted to craft activities toperfect or supplement skills learned in the academic phase. Additionalpractice and exploration of craft techniques were provided by work experienceperiods. In this way, time removed from the academic phase was made upin the clinical phase.
In August 1944, the clinical portion of the War Emergency Course wasopened to students who had completed the equivalent of the academic portionof regular
20Memorandum, William H. Kushnick, Directorof Civilian Personnel and Training, Civilian Personnel Division, Officeof The Secretary of War, for Office of The Surgeon General, thru Army ServiceForces, 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 foroccupational therapy apprentices, Battey General Hospital, Rome, Ga. (Top)Anatomy. (Bottom) Kinesiology.
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civilian training courses.22 Students who had satisfactorilycompleted some part of the apprentice period in accredited civilian hospitalsbecame 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 inArmy hospitals as graduate occupational therapists (fig. 18).
APPOINTMENTS, CLASSIFICATIONS, AND SALARIES OF TRAINEES
In February 1939, all civilian positions in Army hospitals, includingstudent dietitians at Walter Reed General Hospital, were brought into theCivil Service.23 The Surgeon General's Office was authorizedto give classified status to the 10 student dietitians who entered trainingon 1 September 1939 and who were appointed without civil service examinations.However, students remained ungraded for another 5 years. After deductionsfor quarters, subsistence, and retirement, take-home pay from a salaryof $420 was approximately $45 per annum.
In 1941, when the emergency training program in physical therapy wasinitiated, physical therapy students were also classified in ungraded civilservice positions, received the same salaries as student dietitians, andwere subject to the same deductions. At this time, the Civil Service Commissionauthorized the additional training position of apprentice physical therapistand provided for reallocations from the position of student to that ofapprentice and ultimately to that of graduate without approval of examinationby the Commission. The positions of apprentice physical therapist and apprenticedietitian were subprofessional and were designated SP-3. The salary forthese 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 improvedeven further. Ungraded students (dietitians, physical therapists, or occupationaltherapists) were changed to SP-3, at $1,440 per annum, and the positionof 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 overtimepay for schedules in excess of 40 hours per week. However, both were stillsubject to a deduction of 5 percent for retirement and $180 for quartersand subsistence. Civilian students and apprentices were required to furnishtheir own uniforms, textbooks, and incidentals. Uniforms authorized forwear were the same as those for graduates.
TRAINING PERFORMANCE REPORTS
During the clinical phase of training, performance reports were requiredfor all apprentices. Reports on apprentice dietitians were completed 1month before the end of the training period and forwarded to the SurgeonGeneral's Office. A record
22Army Service Forces Circular No. 263, 15Aug. 1944.
23Executive Order 7916, 24 June 1938.
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of final physical examination, a photograph, and an application forappointment accompanied the report. Final performance reports for physicaltherapy apprentices were completed after the training period by the clinicalsupervisors and forwarded to The Surgeon General. These reports providedinformation about the trainee's proficiency, the amount of clinical practicecompleted, personality traits, and adaptability for commissioned militaryservice and were retained as a part of the trainee's permanent record.Reports on occupational therapy apprentices were completed by the hospitalsat periodic intervals during the 34-week program and submitted to The SurgeonGeneral. One copy was sent to the schools in which apprentices receivedtheir academic instruction and from which they would be certified eligiblefor registration on completion of the course. The Surgeon General was authorizedto separate an apprentice from a course at any time for failure to maintainsatisfactory clinical performance, for inability to adjust to hospitalservice, or for other cause.
MAINTENANCE OF EDUCATIONAL AND PROFESSIONAL STANDARDS
Emergency training programs in dietetics, physical therapy, and occupationaltherapy developed as a result of cooperation between the Medical Departmentand officials or committees of professional organizations. Courses metthe minimum educational requirements of the American Dietetic Associationand, for physical and occupational therapists, the Council on Medical Educationand 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 needfor the strict educational requirements for student dietitians. The questionarose because of the Commission's interpretation of a provision in theVeterans' Preference Act of 1944 which eliminated minimum educational requirementsas a qualification for other than scientific, technical, or professionalpositions. The Civil Service Commission's interpretation came as a surpriseto the Surgeon General's Office. In a letter of protest, Maj. Gen. GeorgeF. Lull, Deputy Surgeon General, stated:24
The dietitian in the Medical Department of the Army isa commissioned officer. She assists the medical officer by filling hisdiet prescriptions. It is, therefore, most important that the best qualifiedindividuals be obtained for training. It is highly improbable that thistype of personnel could be secured if the educational requirements arediscontinued.
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 physiotherapyaide, only those eligibles will be certified who meet the requirementsprescribed by the War Department as necessary for commissioned officers.
24Memorandum, Maj. Gen. George F. Lull, DeputySurgeon General, to U.S. Civil Service Commission, 12 Sept. 1944, subject:Educational Requirements for Dietitians.
25Letter, M. L. A. Mayer, Executive Director, Civil ServiceCommission, to Maj. Gen. George F. Lull, Deputy Surgeon General, 24 Oct.1944.
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Occupational therapists had problems with both educational and physicalstandards. Although the majority of applicants for the War Emergency Coursewere qualified, a small percentage was found unacceptable because of pooracademic records, physical conditions, or personality disorders. The SurgeonGeneral's struggle to maintain professional standards was complicated byCivil Service Commission policies giving preference to veterans, the disabled,wives, and widows, which required the acceptance of several candidatesneither physically nor educationally qualified for training. Another problemwas created by extremely liberal substitution of experience for education.Occasionally, The Surgeon General contested decisions and won his argumentagainst unqualified certifications. Too often, they had to be acceptedand disqualified later for failing to meet physical or academic standards.
The prerequisite of a college degree in physical education for civilianstudents taking the physical therapy course was established by the MedicalDepartment as the entrance requirement before 1941. In May 1944, the MedicalDepartment requested authority to change the educational requirement toinclude a major field in biology. This revision was not published untilOctober, but it was informally approved in the selection of students enrolledafter August 1944.
Military applicants for the physical therapy course were required tohave completed not less than 2 years in an approved college with satisfactorycourses in biology and other sciences. The term "satisfactory coursein biology and other sciences" was interpreted as a minimum of 15semester hours selected from anatomy, bacteriology, biology, chemistry,hygiene, kinesiology, physics, physiology, psychology, and zoology. Thisdeparture from the established standards roused fears that the Army wouldjeopardize professional standards. While the Army did depart from its previouslyestablished prerequisites, it still conformed to the minimum standardsestablished by the American Medical Association.
In October 1944, the minimum requirement in science hours was increasedfrom 15 to 26 semester hours, with 6 hours as the minimum in biology. Theremaining 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 naturalscience. This change was necessary because many 2-year college studentswith only 15 hours in the sciences were not academically prepared to copewith the Army's intensive training program. The number of students witha 2-year college background constituted only 9 percent of the total numberof enlisted students enrolled from October 1943 to November 1945. The averagenumber of college years for the overall total of these students duringthis period was 3.7 years.
The training period (student and apprentice phases) for civilian physicaltherapy students was 12 months, while training period for enlisted studentswas 9 months. The shorter training period for military students was justifiedby their previous military orientation and the number of patients availablefor therapy in Army general hospitals. During 1944, enlisted apprenticephysical therapists were given training far in excess of the 400 clinicalhours required by the American Medical Association.
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SCHOOLS AND HOSPITALS CONDUCTING TRAINING COURSES FOR THEARMY
Emergency training programs to increase the number of dietitians, physicaltherapists, and occupational therapists were established at educationalinstitutions and at civilian and military hospitals. Fifteen civilian hospitalsconducted the student phase for dietitians, 33 Army hospitals conductedthe apprentice phase, and 4 Army hospitals conducted both phases. The firstemergency course began in August 1942. Civilian institutions completedtheir 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 wasconducted in 38 courses at 15 civilian institutions. In addition, 10 Armyhospitals conducted 33 emergency academic courses for civilian studentsand 28 for enlisted students. The first emergency course was started inJuly 1941, but the courses in civilian schools did not start until 1942.Emergency physical therapy training programs were discontinued soon afterV-J Day. However, Army hospitals conducting the academic phase continuedclasses until 10 February 1946 and hospitals accepted these students foron-the-job training for another 6 months.
Twenty-one emergency courses for occupational therapists were givenat eight civilian schools, while the clinical phase of this program wasconducted at 40 Army hospitals. School courses started in July 1944 andended in November 1945. The clinical phase of training extended 8 monthsbeyond the war. The last 51 apprentices, scheduled to graduate in July1946, were transferred to Veterans' Administration hospitals for pay andtraining.
RESULTS OF EMERGENCY TRAINING PROGRAMS
Without emergency training programs, the Army could not have recruitedenough qualified medical specialists to meet wartime requirements. Bothdietitians and physical therapists numbered approximately 1,600 at thepeak of their strengths. Only 21 percent of the Medical Department dietitianswere trained through Army programs, but Army training qualified approximately55 percent of the physical therapists. Occupational therapists, the smallestgroup numerically, trained 78 percent of their peak strength of approximately900 through emergency courses. In each instance, the professional groupconcerned thought that the apprentice phase of training in military hospitalswas valuable in familiarizing students with Army procedures. Experiencein treatment of war injuries was especially valuable for physical and occupationaltherapists. Emergency training courses for dietitians, physical therapists,and occupational therapists expanded educational programs for the wholeprofession. The demand in all three of these health fields during the warresulted in the number of civilian schools offering dietetic internshipsincreasing from 38 to 60; in physical therapy, from 15 to 36; and in occupationaltherapy, from five to 21.
Both during and after the war, the fear was expressed that a loweringof
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standards was inherent in the Army's accelerated physical therapy trainingprogram. In 1945, Dr. Frances A. Hellebrandt, Medical Director, BaruchCenter of Physical Medicine, Medical College of Virginia, Richmond, Va.,made a careful analysis of the 6-month academic phase of the Medical Departmentphysical therapy course. Doctor Hellebrandt, who had served as medicaldirector of the physical therapy training course for enlisted members ofthe Women's Army Corps conducted at the University of Wisconsin from October1943 to October 1944, concluded that:
* * * Carefulstudy of the scope and content of the WAC course suggests that in realityit surpasses anything previously attempted by the average apprentice typeof approved hospital technician training school.
* * * * * * *
The Army has demonstratedthat the essentials of subject matter in a variety of technical fieldscan be taught effectively by new methods which drastically shorten thelearning period. * * * We wouldbe short sighted indeed if we failed to study the pedagogical experimentsof the war * * * .26
TRAINING ENLISTED PHYSICAL THERAPY TECHNICIANS
The Medical Department had long recognized that trained enlisted assistantswere necessary in the operation of a physical therapy clinic. Until latein the war, male enlisted assistants were trained on-the-job. Because ofincreasing patient loads and the loss of male technicians to combat units,The Surgeon General directed the service commands, in a telegram dated28 February 1945, to estimate their requirements for enlisted women trainedas physical therapy technicians. On the basis of this information, a formaltraining program was established. Applicants for these courses were requiredto have completed 2 months of training at the Medical Department EnlistedTechnicians School. Those selected were carefully screened by the staffof the school, the medical director of physical therapy, and the chiefphysical 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 thisfield of therapeutics. To prepare enlisted women for hospital assignmentas rapidly as possible, courses were established in 13 general hospitals.Graduates were eligible for the classification of enlisted physical therapytechnician.27 The last class enrolled on 9 July 1945. Four hundredand thirteen enlisted women were trained in this program.28
COURSE FOR OCCUPATIONAL THERAPY ASSISTANTS
If graduate occupational therapists could have been recruited in largernumbers or if the War Emergency Course had begun earlier in the war, acourse for occupa-
26Hellebrandt, F. A.: Analysis of the WAC EmergencyPhysical Therapy Training Program. Arch. Phys. Med. 26: 507, 514, August1945.
27War Department Technical Manual 12-427, 12 July 1944; Change1, 12 Apr. 1945.
28Memorandum, Maj. Emma E. Vogel, WMSC, Director of PhysicalTherapists, to Col. Harold C. Lueth, Military Personnel Division, Officeof The Surgeon General, 6 Aug. 1945.
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tional therapy assistants would have been unnecessary. However, in June1944, only 180 occupational therapists were on duty in Army general hospitals,29and more than a year would elapse before graduates of the War EmergencyCourse could be qualified for staff appointments. On 2 October 1944, thedirector of the Reconditioning Consultants Division, Surgeon General'sOffice, reported to The Surgeon General that a program for training enlistedwomen as occupational therapy assistants had been submitted to Army ServiceForces.30 The 1-month course was approved by the Army ServiceForces on 16 November 1944.31
In January 1945, recruiting for this course ended, and, during the remaining10 months of its operation, students were drawn exclusively from the Women'sArmy Corps. Halloran General Hospital, Staten Island, N.Y., was selectedand Capt. Josephine E. Springer, WAC, chief occupational therapist at TiltonGeneral Hospital, Fort Dix, N.J., was transferred to Halloran General Hospitaland placed in charge of the program. The Surgeon General's Office approvedcandidates, allotted quotas to the service commands, and returned traineesto service commands for assignment to hospitals. Applicants for trainingwere required to have completed basic military training and to have eithera civilian background of teaching experience and some knowledge of a handicraftor an expert ability in some handicraft plus a high school education andan aptitude for teaching.
On 9 December 1944, 14 students reported for the first class. By April1945, 141 students had attended the course. That same month, the coursewas discontinued because the training requirements for occupational therapyassistants had been met. The following month, a request for reestablishmentof the course had to be submitted because enlisted assistants were neededfor the expanding convalescent hospital program. Army Service Forces approvedThe Surgeon General's request.32 The promptness of Army ServiceForces in approving the Medical Department's request enabled classes torun consecutively until 27 October 1945, when the 11th class graduatedand the occupational therapy assistants training course for enlisted membersof the Women's Army Corps was discontinued. Of the 295 students enrolledin this course, 278 satisfactorily completed requirements and were subsequentlyassigned to selected Army hospitals where they assumed much of the burdenof diversional activity programs.
29Memorandum, Maj. Henry B. Gwynn, MC, forThe Surgeon General, 17 June 1944, subject: Semimonthly Report of the ReconditioningDivision 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 ConsultantsDivision 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: OrientationTraining for Occupational Therapy Assistants (WAC), with 1st indorsementthereto, 23 Apr. 1945. (2) Letter, Brig Gen. R. W. Bliss, Chief, OperationsService, Office of The Surgeon General, to Commanding General, Army ServiceForces, attention: Director of Military Training, 28 May 1945, subject:Orientation Training for Occupational Therapy Assistants (WAC). (3) TransmittalSheet, Col. S. M. Prouty, GSC, Executive, Office of the Director of MilitaryTraining, Army Service Forces, to The Surgeon General, 7 June 1945, subject:Orientation Training for Occupational Therapy Assistants (WAC), with inclosure1 thereto, 28 May 1945.
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