When American soldiers are injured in war, their countrymen expect that the military medical system will do what it can to restore them. Whether it’s psychological treatment for post-traumatic stress disorder or advanced prosthetic limbs, the US has committed itself to making injured soldiers whole.
The idea that we can undo wartime injuries and restore broken bodies is expensive. The effort to do so for veterans of the Iraq and Afghanistan wars is expected to cost approximately $1 trillion over the next 40 years, according a recent analysis out of Harvard. It also has a history—one rooted, in fact, in anxieties about the financial repercussions of war. As Penn historian of medicine Beth Linker explains, it dates to World War I—which broke out 100 years ago this past July—and marked a dramatic change in the way the United States regarded wounded soldiers and the costs of war.
At the start of World War I, says Linker, who directs the health and societies program in the Department of History and Sociology of Science, “a host of rehabilitation experts [set out] to solve what they saw as a problem of men being disabled from war and never re-entering the workplace.”
She detailed the rise of the rehabilitation ethic in her 2011 book War’s Waste, explaining that it developed in reaction to the staggering long-term costs of caring for disabled Civil War veterans.
Following the end of the Civil War, the US government enacted a generous set of laws to provide for the welfare of disabled soldiers. Their provisions included pensions, subsidized housing, and—for those who needed it—a stipend for the purchase of artificial limbs: $75 for a leg, $50 for an arm. As a consequence, Linker observes, “A veteran could receive a check three times a year and he never had to return to work.”
By the outbreak of World War I, the pension system had spun out of control. Pensions accounted for nearly half of federal expenditures. This largess was fiscally painful and conflicted with the values of America’s newly industrial economy. “In the Progressive era, manliness was defined by a man’s ability to labor,” Linker says, “and [pensions] kind of flew in the face of what it meant to be masculine.”
When the US formally joined the war in Europe in 1917, the thought of adding a whole new generation of wounded soldiers to the welfare rolls was untenable. In October of that year, President Woodrow Wilson signed the War Risk Insurance Act, which fundamentally changed the kinds of benefits granted to disabled soldiers. Instead of cash payments, Linker explains, “any man disabled in war had the right to receive medical care until he was maximally restored.” Put another way, wounded soldiers wouldn’t need pensions because their medical care would be so good they’d be able to go back to work.
To achieve this ambitious goal, the US military had to midwife a whole new field of medicine. At the start of US involvement in World War I, there were only about 100 orthopedic surgeons in the United States, most of whom only worked in pediatrics. “World War I comes along and orthopedic surgeons become leaders in the rehabilitation movement because they’ve already spent time with disabled children,” Linker says.
In addition, the military recruited large numbers of women to serve as physical therapists. (Linker worked for seven years as a physical therapist before graduate school; her research was sparked in part by curiosity about the roots of that profession.) The newfound emphasis on rehabilitation, Linker writes, also led the military to renovate hospitals and install space for “hydrotherapy, mechanotherapy, electrotherapy, massage, and exercise.”
Trench warfare in Europe disfigured the human body in just about every conceivable way. The US military, however, committed disproportionate attention to injuries that could be addressed with prosthetic limbs. Prosthetic limbs, more than any other orthopedic intervention, held out the promise of returning soldiers to a degree of pre-casualty normalcy. Amputee-soldiers were actually required to wear artificial limbs, and threatened with dishonorable discharges if they bucked the rehabilitation regimen. Physical therapists led wounded soldiers in “stump pounding” drills to toughen the skin at the amputation site and prepare it for prosthetic wear.
At the start of World War I, the manufacture of prosthetic limbs was a cottage industry: private artisans would spend months or even years curing individual pieces of wood to make customized limbs. The scale of the injuries in World War I—and the scale of the military’s ambitions around rehabilitation—required a shift to mass production. In 1917 the Army Office of the Surgeon General put its resources behind an innovative form of prosthetic limb—the so-called “Liberty Limb,” which was made of modular parts manufactured in bulk from compressed wood fibers.
The Liberty Limb made it possible to provide prosthetic limbs for all amputee soldiers, but it didn’t guarantee the limbs would work.
“In fact, a lot of these disabled veterans preferred not to wear limbs,” Linker says. “Limb-wear is a very tricky business. The residual limb has to stay healthy and free of infection, but as soon as you put an artificial limb on, it gets hot, sweaty, and you get sores if it doesn’t fit properly. More often than not, there were more complications with limb-wear, and patients could not tolerate it.”
The American military entered World War I operating with the belief that, in the words of one administrator, “disabilities may be reduced or caused to disappear entirely” with as little as six weeks of physical therapy and vocational training. It was a pie-in-the-sky view that didn’t square with the severity of the injuries soldiers brought back from Europe.
“[Reformers] had an ideology,” Linker notes. “And as with most ideology, it’s hard to actually put it into practice. I don’t think the rehabilitation project was a bad thing. The ideology failed in the sense that they thought we can remove cash payments to veterans because we can cure them.”
It’s easy to view the World War I enthusiasm for rehabilitation as naiveté, but Linker and other scholars argue that it’s still at the heart of the way the military operates today.
At the end of War’s Waste, Linker quotes 2004 Congressional testimony from Brett Giroir, deputy director of the Defense Advanced Research Projects Agency. He went before Congress to advocate for funding for a new, advanced rehabilitation center that would prepare “amputees to return to normal life, with no limits whatsoever”—a statement that just as easily could have been made 100 years ago. Linker also observes that during the Afghanistan and Iraq wars, President George W. Bush frequently was photographed jogging with amputee soldiers wearing C-legs, effectively reinforcing the World War I-era narrative of maximal rehabilitation.
Of course, rehabilitation is a wonderful thing in and of itself. Linker thinks so, too, though she also argues that the potential of rehabilitation is often oversold in a way that makes war seem more palatable.
“I think rehabilitation can perversely be used as a way to persuade people that continual warfare is just fine,” she says. “The message is that we can send courageous men and women off to war [with the assumption that] when they come home, they might be injured, but we can fix them, and everything goes on normal and fine.”