Efforts to assist people with disabilities changed over time, and by the turn of the twentieth century, disability was being redefined in America. Around 1890, some of the first institutions perhaps best referred to as "Hospital Schools", as well as the first vocational programs for the training of "cripples" emerged, along with the approach known as rehabilitation.

The years 1890 – 1920 were an important period in disability history because they acted as a bridge between nineteenth century supernatural views of disability and the post 1920 medical model of disability. During this time period cripples were referred to as people who had mobility impairments, such as paraplegics and amputees, but were also financially dependent on other members of society for support. Cripple's reliance on charity caused them to become immoral characters that drained the lifeblood of the economy, it was believed. The path to elimination of cripple's dependency was through rehabilitation, according to the reformers of the time.

Some reformers, referred to as "social rehabilitationists", promoted the need for social and cultural change, and did not see any real need to change the disabled person through surgery or physical therapy. Other reformers, referred to as "medical rehabilitationists", took on the opinion that the person with the disability was the problem, and focused their efforts on orthopedic surgery and moral education, as well as other solutions involving the repair of the person. Scholars in the field of disability studies believe that the actions of the medical rehabilitationists helped to define the medical model of disability.

Medical rehabilitationists freed society of any complicity in the exclusion of people with disabilities from employment, marriage, access to schools or government buildings. Social rehabilitationists disagreed with this view of disability. Neither groups rejected the ideas of the other entirely, and were apparently not aware of the differences between their ideas. Reformists from both groups expressed elements of each other's approaches in their writings. It was the orthopedic surgeons of the time that give us an idea of the reasons why an age devoted to science took so long to meet with a medical paradigm.

Orthopedic surgeons didn't have the credibility in the early twentieth century to dominate the rehabilitation movement of the time. Despite recognition as early as 1890 as the specialists best able to deal with cripples, and their uncontested position in medical circles, they did not gain standing in the rehabilitation movement until after the first world war. Orthopedic surgeons of the nineteenth century were often called, "sawbones", and in the early twentieth century they had to share leadership with everyone from teachers, businessmen and social scientists to other reform-minded people.

These leaders, with an interest in the rehabilitation of cripples, asked questions like, "Do older, nineteenth century notions of divine causation still have validity in the twentieth century?", and "Are they victims of stereotypes and social discrimination?" In large, east coast cities such as New York and Boston, reformers rejected the idea of supernatural causes in relation to cripples, and explained disability as a product of the interaction between physical impairment and social prejudice. The rehabilitationists decided that the one largest problem the cripple had was rejection from the workplace, and that change was needed in regard to the cripples in society, beginning when they were children.

Individual philanthropists, and organizations such as the Shriners and Rotarians, began work to create institutions they believed would improve the lives of crippled children in the 1890's. They gained the help of orthopedists in order to achieve their goal. Nondisabled people directed the effort not only to rehabilitate crippled children, but after World War I – veterans as well. The institutions that came into being during this time period gave orthopedists a base to develop their specialty from. The reputation of the orthopedist rose greatly, increasing medical authority over disability, and prompting a greater following of the medical model of disability. There were events; however, that slowed the rise of the orthopedist, as well as the medical model, the rehabilitationists agenda, and the American public's view of disability.

Doctors didn't dominate rehabilitation. A number of the philanthropists and reformers that created the rehabilitation movement wound up sharing control with different medical practitioners in their two main areas of work; hospital-schools and vocational rehabilitation. There were a number of different leaders such as businessmen, doctors, nurses, politicians, publicists, sociologists and even a few people with disabilities. The tendency to blame dependence on the cripple also began to extend to employers. Rehabilitationists of all kinds felt that if adult cripples were poor candidates for rehabilitation, children were the best subjects for their attention.

Hospital-schools pursued their work with crippled children even though it was a new and developing medical specialty. Orthopedists had a broad control over these children; they didn't resist medical authority to any great degree. The hospital-schools also insisted that the parents of the child to be admitted give the institution temporary custody of the child. For the orthopedist, indigent children were the ideal patients for their new medical specialty. Rehabilitationists in general liked the focus on children because of the appeal they had to philanthropists.

Hospital-schools were supported in part by fundraising campaigns, and one problem that complicated fundraising was that medical rehabilitationists continually presented one set of views to the popular media, and another set of views to trade and academic journals. To the popular press the medical rehabilitationists stated that the cripple was not at fault for their dependency. To the trade and academic journals, they contradicted their claims, and placed blame on the person with a disability for their dependency. By presenting the disabled individual as capable, rehabilitationists helped to open up jobs that were needed for their success. Yet by finding faults in the disabled person, orthopedists justified their work and the institutions. The cripple might benefit from the institution, but emerge to find conflicting views among their fellow Americans.

In the hospital-schools the focus was definitely on boys, but in some institutions girls may have outnumbered the boys. Knowing that the main goal of the hospital-school was employment, the fact that there were as many girls in the hospital-schools before 1920 is surprising. Americans of the time objected to the employment of large numbers of women, and while girls at the hospital-schools were taught traditionally female jobs like sewing or teaching, they were also encouraged to finish high school and perhaps go to college. At the time, most girls from working class families ended their education before high school. Why did rehabilitationists give such consideration to girls in the hospital- schools? During the time period, Americans believed that a crippled woman was not fit for marriage, and would need to support herself. Rehabilitationists at the time felt that girls had a place in hospital-schools.

Rehabilitationists built seventy hospital-schools in the thirty-four years between 1890 and 1924. The hospital-schools ranged in size from thirty bed facilities to huge institutions with hundreds of beds. Despite their physical size, they were all committed to providing crippled children with education and medical treatment. During the early years of the hospital-schools, education was at least an equal part of the agenda. Orthopedists were not fully trusted with the fate of crippled children; they generally only performed operations that posed little or no threat to the child's life.

Reformers used the term "rehabilitation" in reference to surgical and therapeutic treatment, but also in terms of change to public attitudes toward people with disabilities. Their interest in working for change in the American public's view of disability was different from their predecessors, and it complicated America's move toward the medical model of disability. An emphasis on pointing out flaws in American society in order to explain problems with disability influenced emerging social sciences such as sociology and psychology. The social sciences concluded that childhood is when social values are instilled; values that were much more difficult to replace later in life. Rehabilitationists felt that "a poor diet, unhealthy air, cramped living conditions, and disability all conspire to hinder the development of critical values in the working-class child."

Yet by 1914 only one-fourth of the hospital-schools had a doctor as chief administrator. Out of the twenty-three institutions with listed medical laypersons in charge, twenty-one superintendents were listed with the title Miss, Mrs., or Sister; two were listed as Mr. or Father. Traditional gender roles of the time made women the choice to care for crippled children. The women of the time who were superintendents of the hospital-schools left few written records stating their ideologies concerning the institutions, but it is clear that they worked to develop institutions that paid more than a passing glance to the education and medical care of crippled children.

Orthopedists, meanwhile, were trying to change the public's opinion of them and their work. Their authority was consistently being challenged by American public opinion, especially among working-class families that the hospital-schools were constructed for. Orthopedists were shunned as charlatans whose goal it was to turn crippled children into objects for experimentation. The fact is, at the hospital-schools where indigent and crippled children were admitted, doctors referred to their patients as "clinical material." Doubt concerning the abilities of the orthopedist and their treatment did not stay in the lower classes; it moved into the middle and upper classes as well. Orthopedists began to doubt themselves.

World War I created a wealth of "clinical material", enabling the orthopedists to develop their skills. Many soldiers suffered an impairment of one or more limbs, and these impairments became known as "orthopedic handicaps." Many American doctors went to the battlefields of Europe, even before America became involved in the war. Battlefield surgery helped orthopedists to create methods for repairing injured muscles, tendons, and bones. When these doctors returned to America they brought home increased knowledge and confidence, and also a greater respect in the eyes of their critics. Some of these doctors returned to work at the hospital-schools.

Before 1920, hospital-schools accepted all children, regardless of whether their "condition" was amenable to surgery. After this time, hospital-schools began to accept only those crippled children who would benefit from surgery. The move toward the medical model of disability was under way, and hospital-schools like The Michigan Hospital-School became part of a larger hospital. The focus changed from education and medical care to curing cripples. The hospital-schools of America made a transformation from hospital-school to a part of the medical view of disability, or disappeared.