Chicago, IL, University of Chicago Press, 2011, ISBN: 9780226482538; 3272pp.; Price: £28.00
Florida International University
Date accessed: 21 September, 2017
In 1919, Douglas C. McMurtrie, Director of the Red Cross Institute for Crippled and Disabled Men, remarked that, ‘beyond reaches of history, the disabled man has been a castaway of society’. McMurtrie, who was also editor of the American Journal of Care for Cripples, considered various species and civilizations: ‘The disabled wolf is torn to pieces by the pack; primitive society abandoned, expelled, put to death its disabled and deformed members’.
In modern times, McMurtrie said, dynamics had changed, but the state of affairs was far from perfect. An individual with a disability was a source of charity and sympathy, and rarely received ‘the opportunity to make good and get back on his own two feet’.
McMurtrie argued that real progress was evident only in the first decades of the 20th century, when vocational schools and training programs were established in various countries for children and adults with disabilities. Finally, medical and educational experts had come to accept that ‘it was better to train the disabled for work which they could perform than to be content with paying them compensation and permitting them to remain in idleness’.(1)
Beth Linker ushers her readers into this crucial moment of transition by exploring the origins and lasting effects of efforts to heal American First World War soldiers. The nature of a bold and varied rehabilitation program for U.S. service members, she argues, was rooted in contemporary notions of disability, work, manliness, and professionalization. Furthermore, she maintains, it had implications for the future of American hospitals and medical practice, veterans’ benefits, and vocational education.
Linker grounds her story in a concise and telling history of veterans’ welfare in the United States. Throughout the 18th and 19th centuries, she shows, debates about the extent and nature of veterans’ benefits highlighted larger social and political tensions about class, work, and personal responsibility. Here, and throughout the rest of the book, Linker offers rich backgrounds and profiles of reformers, politicians, and others who contributed to public discussions. Recounting the work of Theda Skocpol, Linker notes that in spite of a variety of efforts to trim spending, veterans’ pensions ballooned in the first decades of the 20th century.(2) By the First World War era, she argues, a variety of groups – Progressive reformers, legislators, medical professionals – worried that cash payments permitted former soldiers ‘to remain in idleness’, as Douglas McMurtrie had put it. Rehabilitation, on the other hand, could create proactive and independent citizens. The 1917 amendments to the War Risk Insurance Act were the product of such beliefs. By guaranteeing that service members would be healed and returned to society as breadwinners, the legislation offered a solution to what Linker calls ‘the problem of the pensioner’ (p. 10).
Although the army rehabilitation program marked a break with past veterans’ policies, Linker shows it had deep historical roots, as did the general goal of creating a certain type of citizen. Orthopedic surgeons, she notes, played a central role in shaping military rehabilitation efforts, largely because their pre-war practices jibed with the ideals encapsulated in the War Risk Insurance Act: that people with disabilities should be made into productive members of society. Around the 1900s, these medical specialists created institutions that urged patients to overcome their physical ills through activity and work, as opposed to rest therapy. By tracing the professional paths of the doctors who were eventually most involved in army rehabilitation plans, Linker highlights a theme prevalent throughout the rest of the book: civilian practices influenced military programs, which, in turn, legitimized and reinforced ongoing civilian trends.
After offering background on veterans’ benefits and orthopedics, Linker trains her focus on the actual practice of wartime rehabilitation. She looks first at the army’s physical therapy program. Unlike the traditional image of sympathetic and nurturing women in waiting, who soldiers were meant to marry and support, physical therapists were required to have ‘brains and brawn’. ‘They became’, she says, ‘role models of how women should respond to the war wounded in the new, post-pension era’ (p. 63). Most importantly, the army trained them to resist coddling patients; their therapeutic massages, for example, were meant to be slightly painful, lest they be perceived as pleasurable. The indirect message, it seemed, was that patients could not be bystanders in their treatment, or become accustomed to passively receiving services.
Beyond impacting the care administered in hospitals, Linker argues, wartime rehabilitation affected how the institutions were organized. The ideological foundations for the War Risk Insurance Act – that the state should support medicalized care, not pensions – brought rehabilitation into military hospitals and, Linker says, led to a long-term expansion of the mission of civilian hospitals as well. Here, she looks specifically at two of the army’s largest general hospitals – Walter Reed and Letterman – and details their massive expansion during the war years. New hospital spaces, such as curative workshops aimed at helping soldiers develop job skills, Linker argues, indicated that the institutions were turning away from domesticity and becoming more ‘traditionally masculine’ (p. 96). Contrary to the convalescent care offered in Soldiers’ Homes, she says, such facilities were meant to foster in patients the ‘will to work’ (p. 94).(3)
In addition to drawing connections between First World War-era army rehabilitation and the histories of medical care and veterans’ benefits, Linker makes a political argument. Government efforts at rehabilitation, she says, were (and remain) aimed at erasing the true costs of war. That point is made eloquently in a chapter about the provision of care and supplies for First World War soldiers who underwent amputations. By offering easy and quick access to prosthetic limbs, Linker says, government officials hoped to restore disabled soldiers. Their goal was to ensure that, in the wake of this war, men would not stroll the streets with empty shirt sleeves and pant legs; instead, they would wear publicly sponsored limbs, which would closely resemble actual body parts, rather than pegs or hooks. Underlying this effort, Linker argues, was the hope that a veteran would have no right to claim sympathy or, perhaps more importantly, government aid.
In her discussion of the provision of limbs, Linker offers details about the business of war, and how the army went about securing affordable prosthetics that could be fitted to a variety of body types. There was strong resistance to the idea, she shows, from prosthetists. They perceived themselves as skilled professionals who designed limbs based on specific patients’ needs, then directed an extended and personalized fitting process. These craftsmen argued that standardization of such an individualized process was impossible, and they resented the prospect of rescinding their work to – indeed, being forced to work for – medical doctors who wished to fit patients with mass-produced prosthetics in hospitals. In spite of this vocal opposition, the army contracted with the ‘little-known’ E-Z Fit Artificial Limb Company to provide one-size-fits-all limbs at incomprehensibly low prices (p. 108). (An E-Z Fit prosthetic leg, for example, cost the government $20, as opposed to the typical going price of $200.) The resulting program was riddled with problems; soldiers endured longer hospital stays because prosthetics were used too early or were ill-fitting. Many found the devices so uncomfortable that they opted not to wear them, or to use more traditional implements instead, including the peg legs and hooks that rehabilitation specialists so despised. In spite of these systemic failures, Linker argues, wartime care for amputees had a lasting impact: from the First World War on, prosthetic limbs would be created on a mass scale, and provided and fitted in hospitals.
Linker is concerned not only with the organization and practice of rehabilitation, but also with how it was perceived and represented. She focuses on Walter Reed’s wartime magazine, Carry On, to provide a glimpse of the image of rehabilitation put forth by the Office of the Surgeon General. Its articles and images, she argues, painted a rosy picture of the prospects of rehabilitation, and aimed to convince soldiers that it was unmanly and unpatriotic to accept pensions and remain idle. Linker contrasts these ideas with the lived reality of hospital care by analyzing soldier complaints about conditions at Walter Reed and Letterman during and immediately after the war. Far from being fully satisfied with their treatment, Linker demonstrates, soldiers complained about a variety of issues, including the quality of the care they received and discharge rules. These complaints, she argues, laid the foundation for mass veterans’ protests in the early 1930s.
In her final chapter, Linker details why educators, as opposed to medical doctors, came to oversee wartime vocational education in the army. The contentious battle over authority, she argues, had larger implications: it fostered a disconnect between medical care and vocational rehabilitation that came to shape health care for American civilian workers. Here, Linker offers some surprising details about the medical doctors who served under the Surgeon General during the First World War: even as the American Medical Association vocally opposed ongoing efforts to establish a system of national health insurance, the civilians-turned-officers fought for the extension of medical and rehabilitative care for industrial workers. They even argued that civilians should have access to the army rehabilitation program, and that the 1920 Civilian Vocational Rehabilitation Act should – much like wartime military care – include not only professional training, but also the provision of medical services.
The efforts of the medical officers were, however, in vain. Vocational educators argued in Congress in the spring of 1918 that rehabilitation should consist of two distinct phases – medical and vocational – and that civilian educators, not military doctors, should have control over professional training. Army doctors, who were at the top of their profession in the civilian medical world before their wartime service, resented the effort to usurp control. But legislators, Linker says, were eager to appear as proactive soldiers’ advocates and make a break from the status quo; they thus approved the educators’ request. The educator-dominated model of vocational rehabilitation, Linker says, laid the groundwork for a civilian vocational rehabilitation act (and a larger health system) that decoupled medical care and insurance from industrial training.
Linker carries her argument forward by focusing on the 21st-century reverberations of First World War policies. As the United States has engaged in wars in Iraq and Afghanistan, she notes, its government ‘holds out the hope that through technological advancement, the United States can magically mend the wounds of war,’ and ‘wipe away disability’ (p. 175). She ends on an ironic note: the First World war effort to minimize a massive pension system, she says, laid the groundwork for something much more expansive.
War’s Waste has wide-ranging implications, but no single volume can tell the story of all wounded soldiers and veterans. Linker focuses most closely on care for soldier-amputees. At the book’s outset, she acknowledges that this population constituted five per cent of the war-disabled, whereas individuals with tuberculosis and other orthopedic conditions made up, respectively, 15 and 25 per cent of those wounded. While ‘artificial limbs allowed caregivers and society as a whole to engage in the illusion that the human ravages of war could be erased with a technological fix’, Linker notes, ‘more complex and gruesome conditions … brought the ideal of rehabilitation into question’ (p. 7).
Indeed, the ‘ideal of rehabilitation’ had its limits. In many ways, rehabilitative care for amputees was, as Linker puts it, ‘the gold standard’ (p. 7). But doctors and bureaucrats of the time viewed skeptically those with chronic conditions, ills that existed prior to service, and injuries and illnesses that could not be connected to frontline fighting. They worried about squandering government resources on seemingly unworthy dependents. And, as Linker briefly notes, soldiers of color had a decidedly different encounter with government health services than their white counterparts. In short, patients’ experiences during and after the war were highly varied – predicated, in part, on the nature of one’s injuries and military record, as well as social and ethnic background.
Linker’s illuminating picture of professionalization, changing notions of disability, and treatment of soldier-amputees goes a long way in explaining the nature of health care for American service members and veterans, but leaves room for further exploration. A variety of forces – powerful veterans’ groups; class, racial, and political tensions; the perceived threat and societal impact of untreated chronic diseases; and competing ideals regarding dependency and the role of government – also helped shape soldiers’ and veterans’ medical services in this period and beyond. Those factors, which are outside the scope and intentions of Linker’s work, might be considered alongside this rich social and intellectual history.
War’s Waste is deeply researched, beautifully written, and tightly argued; it should be required reading for those who study the United States’ veterans’ welfare state, war and society, and disability. Scholars of the First World War – especially those who focus on health and medicine, or the American war effort in general – will also find much of value here. Finally, the book would interest soldiers, veterans, and military and Veterans’ Administration caregivers who are curious about the deep historical roots of some of the services they access and provide.
- Douglas C. McMurtrie, The Disabled Soldier (New York, NY, 1919), pp. 1, 26–7.Back to (1)
- Theda Skocpol, Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States (Cambridge, MA, 1992).Back to (2)
- The formative work on Soldiers’ Homes is Patrick J. Kelly, Creating a National Home: Building the Veterans' Welfare State, 1860–1900 (Cambridge, MA, 1997).Back to (3)