19

Historical Perspectives on the Care of Service Members With Limb Amputations

Chapter 2

HISTORICAL PERSPECTIVES ON THE 

CARE OF SERVICE MEMBERS WITH 

LIMB AMPUTATIONS

JEFFREY S. REZNICK, PhD*; JEFF GAMBEL, MD†; and ALAN J. HAWK‡

INTRODUCTION

BACKGROUND

CIVIL WAR

WORLD WAR I

INTERWAR PERIOD

WORLD WAR II AND THE IMMEDIATE POSTWAR ERA

KOREA AND VIETNAM

CURRENT CONFLICTS

SUMMARY

*Director, Institute for the Study of Occupation and Health, American Occupational Therapy Foundation, 4720 Montgomery Lane, Bethesda, Maryland 

20824-1220

†Colonel, Medical Corps, US Army; Physician, Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue 

NW, Washington, DC 20307

‡Collections Manager, Historical Collections, National Museum of Health and Medicine, Armed Forces Institute of Pathology, Walter Reed Army Medical 

Center, 6900 Georgia Avenue, NW, Washington, DC 20306
20

Care of the Combat Amputee

INTRODUCTION

The other two centers resulted from philanthropy of a 

different form, namely that of US taxpayers displayed 

collectively through the US Congress.3,4 At both sites, 

and no less at the CFI, nonprofit organizations like 

those described in Chapter 7, Military and Veteran 

Support Systems, cooperate with military officials to 

administer “peer visitor,” recreational, and other psychosocial programs for service members with limb loss 

and other injuries and for their families and loved ones.5

This introduction provides historical perspective 

on these present-day connections between philanthropy and military medicine, defining philanthropy 

broadly as the altruistic concern for human welfare 

and advancement manifested by endowment or donations of money, property, or work. The chapter’s chief 

purpose is to inform readers that today’s partnership 

of civilian altruism and military medical rehabilitation has deep roots in the past, taking various forms 

since the mid-19th century and playing an influential, 

if underappreciated, role in the care of service members with limb amputations. Understanding this partnership is critical as care providers consider not only 

current and future surgical and medical care available 

to these men and women (as discussed in Chapters 

8–16) but also the best therapeutic and technological 

means (as discussed in Chapters 17–27) to enable 

their best possible health outcome and participation 

in society despite their physical and psychological 

challenges.

Since the US Civil War, philanthropy and military 

medicine have gone hand-in-hand in various systems 

of care available to US military service members with 

limb amputations.As a new century brings changing 

methods of warfare, this partnership is continued by 

the major military amputee care centers located across 

the United States: the Center for the Intrepid (CFI) at 

Brooke Army Medical Center, San Antonio, Texas; 

the Comprehensive Combat and Complex Casualty 

Care at San Diego Naval Medical Center, California; 

and the Military Advanced Training Center at Walter 

Reed Army Medical Center, Washington, DC. Altruism 

helped establish each of these facilities, and it remains 

vital to their missions of rehabilitating service members 

with limb amputations and reintegrating these men 

and women into civilian society.

The CFI emerged chiefly through a fundraising 

campaign by private citizens Arnold Fisher and Ken 

Fisher, a father-and-son business team who established 

and currently oversee the nonprofit Intrepid Fallen 

Heroes Fund and the Fisher House Foundation. At the 

CFI and around the country, as explained in Chapter 

1, Introduction: Developing a System of Care for the 

Combat Amputee, these charitable organizations work 

alongside others in close cooperation with military officials to provide financial, material, and peer support 

to service members with limb amputations and related 

injuries, and to the families of service members who 

have given their lives in current military operations.1,2

BACKGROUND

As many historians and medical experts have 

documented at length in the professional literature, 

the past 2 centuries have marked significant changes 

in military technology, tactics, and injuries of service 

members.6–11 As firepower on the battlefield evolved 

from the rifled musket and minié ball of the US Civil 

War to the explosive artillery and machine gun of 

World War I to the high-velocity rifle of the Vietnam 

conflict, surgeons faced ever more serious wounds 

requiring treatment. Paralleling these changes in 

firepower were various innovations that combined 

to increase the odds of surviving wounds in theater. 

These included technology of transportation, such as 

the locomotive, automobile, airplane, and helicopter, 

which separately and together improved evacuation 

from the front lines, as well as the field of materials 

science, as armor for individuals and vehicles helped 

reduce injury. Finally, technological innovations in the 

field of medicine, such as radiology, aseptic techniques, 

blood banking, and antibiotics helped improve initial 

and long-term treatment. 

Current military transport evacuates injured service 

members from the area of operations to the continental United States more rapidly than in any other 

time. Patient care during flight continues in the same 

comprehensive and aggressive manner as it does on 

the ground, a practice that was largely absent in the 

past because of technological limits. Upon arrival at 

a US military hospital, service members with injuries 

enter into treatment plans shaped by knowledge and 

practice gleaned from past conflicts and from the best 

standards of civilian care. For example, patients who 

have sustained blast injuries have contaminated and 

dirty wounds. If such wounds are not treated properly, gangrene, sepsis, and death can occur. Aggressive wound irrigation and debridement, placement 

of antibiotic beads in the wound, soft-tissue grafting, 

and vacuum-assisted closure are examples of current 

techniques to salvage injured limbs and maximize 

the length of residual limbs that require amputation. 
21

Historical Perspectives on the Care of Service Members With Limb Amputations

Interdisciplinary approaches to care begin in the acute 

phase and continue through all stages of medical rehabilitation to help patients reach the highest level of 

recovery possible in subsequent years.

With unique perspectives drawn from the US 

Civil War to the current global war on terror, this 

chapter aims to enrich appreciation of the value of 

philanthropy for care of the combat amputee both 

today and in the past, as well as the history of medical 

specialities that constitute the rehabilitation team and 

philanthropic organizations engaged in the care of 

both injured service members and their families and 

loved ones. This historical knowledge puts into perspective the current and future care of injured service 

members, showing that while their immediate care 

is a response to wounds sustained in combat, their 

longer-term physical and psychological rehabilitation 

should involve critical thinking not only about treatment by the various branches of military and civilian 

medical science but also about the engagement of 

civilian philanthropy in renewing their health and 

social participation. 

CIVIL WAR

During the Civil War, amputations constituted 

approximately 75% of all operations performed, and 

among Union forces over 21,000 service members 

survived amputation procedures. Because antiseptics 

and disinfectants were not yet widely recognized, and 

specific treatments involving alcohol and opiates had 

limited success, many patients survived amputations 

only to suffer devastating postsurgical infections. 

The writings of Walt Whitman (Figure 2-1) provide 

a graphic description of Civil War amputation. In 

1863 Whitman traveled from Boston, Massachusetts, 

to Washington, DC, in search of his brother, George, 

whose name was listed in a newspaper casualty roster 

from the battlefield at Fredericksburg. After searching 

nearly 40 Washington hospitals, Whitman traveled 

from Washington to Fredericksburg to find George 

alive with a superficial facial wound. However, Whitman’s personal relief quickly turned to horror at the 

costs of battle (Figure 2-2). As he wrote in his notebook, 

“I notice a heap of amputated feet, legs, arms, hands, 

&c . . . human fragments, cut, bloody black and blue, 

swelled and sickening.”12 Moved by the human devFigure 2-1. Walt Whitman (1819–1892), photographed in 

1863, the same year he traveled from Boston to Washington, 

DC, in search of his brother, George. 

Photograph: Courtesy of Library of Congress, Washington, 

DC. Feinberg-Whitman Collection, LOT 12017, box 1.

Figure 2-2. Amputations at Harewood Hospital, Washington, 

DC. This photograph by Dr Reed Bontecou, titled “Field 

Day,” reflects a scene similar to that witnessed by Whitman 

in Fredericksburg, Virginia.

Photograph: Courtesy of Otis Historical Archives, National 

Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. CP 1043.
22

Care of the Combat Amputee

astation he witnessed, Whitman traveled to Armory 

Square Hospital in Washington, DC (Figure 2-3), where 

he developed his own approach to wartime philanthropy by looking after many combat-wounded soldiers, 

recording their stories, composing letters for them, 

corresponding with their loved ones, giving them 

small gifts, and comforting them through conversation. 

Hundreds of men benefited from Whitman’s philanthropic spirit, including Private Oscar Cunningham 

of the 82nd Ohio Infantry, who, during the battle of 

Chancellorsville in May 1863, received a gunshot 

wound to the right thigh that resulted in a compound 

fracture. The bullet was extracted at Armory Square 

Hospital on June 15th by Dr D Willard Bliss (Figure 

2-4), the hospital’s chief surgeon, whom Whitman later 

described as “one of the best surgeons in the army.”13

Extensive abscesses formed following the procedure, 

and on May 2nd, 1864, Bliss amputated Cunningham’s 

leg and, shortly thereafter, forwarded a portion of it 

to the Army Medical Museum for preservation as 

a specimen that could teach future surgeons about 

military medicine of the day (Figures 2-5). Just after 

Cunningham’s amputation Whitman stated in his journal that “he is in a dying condition—there is no hope 

for him—it would draw tears from the hardest heart 

to look at him—he is all wasted away to a skeleton, & 

looks like some one fifty years old—you remember I 

told you a year ago, when he was first brought in.”14

Whitman continued, describing Cunningham in his 

own way as “the noblest specimen of a young western 

man I had seen, a real giant in size, & always with a 

smile on his face—O what a change, he has long been 

very irritable, to every one but me, & his frame is all 

wasted away.”14

Figure 2-3. Armory Square Hospital, Washington, DC, where Whitman began defining his approach to wartime philanthropy. 

Photograph: Courtesy of Otis Historical Archives, National Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. CP 2241.
23

Historical Perspectives on the Care of Service Members With Limb Amputations

Cunningham died on June 4, 1864. He was one of 

the first soldiers to be buried in what was then the new 

Arlington National Cemetery. His lower thigh bone 

remains preserved in the modern iteration of the Army 

Medical Museum, the National Museum of Health 

and Medicine, Armed Forces Institute of Pathology, 

as a reminder not only of surgical technique but also 

of the suffering endured by so many soldiers during 

the Civil War, as well as the comfort offered by Walt 

Whitman to hundreds of them. 

Unlike Cunningham and thousands of other 

soldiers with limb amputations, thousands more 

survived the war with limb loss (Figures 2-6 through 

2-8). Those who served the Union received prostheses 

from the federal government, and those who served 

the Confederacy received such technology from individual southern states. In both instances, however, 

many of the residual limbs produced by surgery were 

not conducive to fitting and wearing artificial limbs. 

Ragged tissue and protruding bones, or bones left close 

to the surface of the skin, caused immense pain and 

frustration for amputees who tried to use prostheses. 

Images of the period, in the form of photographs and 

paintings, fall short of conveying the difficulties faced 

by veterans with limb loss. 

 These challenges—combined with the sheer number of amputees produced by the war, and later by 

factories and railroad accidents—helped drive wartime 

and postwar entrepreneurialism in the nascent field of 

prosthetics.15 In the 15 years before the war, 34 patents 

were issued for artificial limbs and assisting devices; 

during the 12 years from the beginning of the war to 

1873, 133 patents for limbs were issued, nearly a 300% 

increase.16 Among these was a patent held by James Edward Hanger, a Confederate soldier who, after losing 

his leg at the battle of Philippi, returned to his hometown of Churchville, Virginia. There, he developed 

what became known as the “Hanger limb” (Figure 2-9), 

which changed the so-called American leg by adding 

rubber bumpers to the ankle, and later a rubber foot, 

a forerunner of the solid-ankle, cushioned heel foot. 

Other patents of the day, often described prominently 

in advertising literature, included those held by George 

R Fuller of Rochester, New York (Figure 2-10), and AA 

Marks of New York, New York (Figure 2-11). 

While Whitman exemplified individual philanthropy, contemporary voluntary aid organizations 

represented the philanthropy of communities in helping combat amputees acquire prostheses and other 

necessary aid, primarily because large numbers of 

combat casualties, and even larger numbers of sick 

soldiers, quickly overwhelmed the Army Medical 

Corps following the battle of Bull Run in 1861.17,18 The 

acting Army Surgeon General, Colonel RC Wood, 

described the situation:

The pressure upon the Medical Bureau has been very 

great and urgent; and though all the means at its disposal have been industriously used, much remains 

to be accomplished by directing the intelligent mind 

of the country to practical results connected with the 

comforts of the soldier by preventive and sanitary 

means. The Medical Bureau would, in my judgment, 

derive important and useful aid from the counsels 

and well-directed efforts of an intelligent and scientific commission, to be styled ‘A Commission of Inquiry and Advice in respect of the Sanitary Interests 

of the United States Forces,’ and acting in co-operation with the Bureau, in elaborating and applying 

such facts as might be elicited from the experience 

Figure 2-4. DW Bliss. At Armory Square Hospital, Whitman 

observed the work of Dr D Willard Bliss, the chief surgeon, 

whom Whitman described as “one of the best surgeons in the 

army.” After the war, Bliss praised Whitman for his service 

to the nation’s soldiers. “No one person who assisted in the 

hospitals during the war accomplished so much good to the 

soldier and for the Government as Mr. Whitman.” Quotation 

from: Donaldson T. Walt Whitman the Man. New York, NY: 

Francis P Harper; 1896: 169.

Photograph: Courtesy of Otis Historical Archives, National 

Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. NCP 1858.
24

Care of the Combat Amputee

and more extended observation of those connected 

with armies, with reference to the diet and hygiene 

of troops, and the organization of Military Hospitals, 

etc. This Commission is not intended to interfere 

with, but to strengthen the present organization, introducing and elaborating such improvements as the 

advanced stage of Medical Science might suggest.19

Thus was born the US Sanitary Commission, which, 

alongside the US Christian Commission, mobilized 

thousands of volunteers in support of Union soldiers 

(Figure 2-12). 

Different approaches initially emerged among 

these groups, but they were eventually resolved as 

both volunteers and military officers settled into appreciating their respective contributions.20 The medical 

department, quartermasters corps, and various civilian 

relief agencies cooperated to evacuate the wounded 

after the battle of Gettysburg. Finding 2,000 wounded 

men awaiting transportation at the nearby railroad, Dr 

Edward P Vollum, a medical inspector with the office 

of the Surgeon General, immediately began organizing 

their evacuation to hospitals in New York, New York; 

Baltimore, Maryland; and York, Pennsylvania. Vollum 

described the collaborative effort: “Before leaving, the 

wounded were fed and watered by the Sanitary Commission, and often hundreds of wounded, laid over 

for a night or part of the day, were attended and fed 

by the commission whose agents placed them in the 

cars. At Hanover Junction, they were again refreshed 

and fed by the Christian Commission, at Baltimore the 

agents of several benevolent societies distributed food 

bountifully to the wounded in the cars immediately 

on their arrival; and at Harrisburg, the commissary 

department had made arrangements for feeding any 

number likely to pass that way.”21

By the end of the war, the Sanitary Commission had 

played a central role in establishing programs and policies to help reintegrate disabled soldiers into postwar, 

civilian society. One of its representatives described the 

commission’s work:

It seemed to us, that our pride, as a democratic nation 

ought to point . . . towards such a shaping of public 

opinion as would tend to reduce dependence among 

our returning soldiers to the lowest possible point; to 

quicken the local and family sense of responsibility, so 

as to make each neighborhood and each household, 

out of which a soldier had gone, and returned helpless and dependent, feel itself privileged and bound 

to take care of him . . . to encourage every community 

to do its utmost towards favoring the employment of 

returned soldiers, and especially, partially disabled 

ones in all light occupations . . . In short, we desired 

to favor in every way the proud and beneficent tendency of our vigorous American civilization, to heal 

its wounds by the first intention; to absorb the sick 

and wounded men into its ordinary life, providing 

for them through those domestic and neighborly 

sympathies, that local watchfulness and furtherance 

due to the weakness and wants of men well known to 

Figure 2-5. (a) Lower thigh bone of Private Oscar Cunningham, 82nd Ohio Infantry, which is preserved today in the modern 

iteration of the Army Medical Museum, the National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, DC. (b) [following page] Description of Cunningham’s injury by Dr Bliss, from his surgeon’s report, which 

accompanied Cunningham’s remains when Bliss sent them to the Army Medical Museum for preservation.

Photographs: Courtesy of Anatomical Collections, National Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. Accession no. 1000755.

a
25

Historical Perspectives on the Care of Service Members With Limb Amputations

b
26

Care of the Combat Amputee

their fellow citizens, and which is given without pride 

and received without humiliation; and this source of 

relief failing, then from the ordinary charities of the 

towns and counties from which they had sprung.22

More than rhetoric, these words represent an important 

opening chapter in the history of wartime and immediate postwar care for service members generally and 

those with limb amputations in particular. 

Figure 2-6. (a) Among the thousands who survived the US Civil War with limb loss was Private Columbus G Rush, Co C, 

21st Georgia Regiment, who was wounded in an assault on Fort Sheridan, in the lines before Petersburg, Virginia, March 

25, 1865, by a fragment of a shell. (b) Private Rush fitted with prostheses. Descriptive text on the reverse of this photo states 

that “with the aid of two canes he was enabled to walk about the wards of St. Luke’s Hospital, New York, where he was 

transferred after amputation was completed at Lincoln Hospital, Washington, DC.”

Photographs: Courtesy of Otis Historical Archives, National Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. SP 132 (a); SP 133 (b).

a

b

WORLD WAR I

In May 1918 the French and Belgian ministries of 

war worked with their American and European counterparts to convene the second annual international 

conference and exhibition on the “after-care” of soldiers disabled in the ongoing war. Meeting in London, 

England, leading medical authorities, philanthropy 

representatives, labor leaders, and public figures exchanged views on two vital questions: (1) how could 

soldiers injured in the war be healed effectively, and 

(2) how could they be successfully reintegrated into 

civilian society after returning home? Officials at the 

previous conference (held in Paris in May 1917) had 

examined these questions in detail, but the military 

campaigns of 1917 made efforts to rehabilitate the 

wounded all the more vital for the welfare of the 

soldiers as well as their families, communities, and 

nations.

Philanthropy was a key component of this conference. Its face was in part that of John Galsworthy 

(Figure 2-13), the British writer (and later a 1932 Nobel 

laureate in literature), who since the war began had 

donated time, writing talents, and thousands of dollars 
27

Historical Perspectives on the Care of Service Members With Limb Amputations

of his literary earnings to support what he called “the 

sacred work”: the rehabilitation of servicemen severely 

injured physically or psychologically in battle.23 In the 

introduction to the official conference proceedings, 

Galsworthy characterized its goals: 

In special hospitals orthopaedic [sic], paraplegic, 

neurasthenic, we shall give him back functional ability, solidity of nerve or lung. The flesh torn away, the 

lost sight, the broken ear-drum, the destroyed nerve, 

it is true we cannot give back; but we shall so re-create and fortify the rest of him that he shall leave hospital ready for a new career. Then we shall teach him 

how to treat the road of it, so that he fits again into 

the national life, becomes once more a workman with 

pride in his work, a stake in the country and the consciousness that, handicapped though he be, he runs 

the race level with his fellows and is by that so much 

the better man than they.24

These observations encapsulate the contemporary 

work being undertaken in Britain’s network of military orthopaedic hospitals, approaches that eventually 

informed US systems of care for service members with 

limb loss. 

The flagship of Britain’s network was Shepherd’s 

Bush Military Orthopaedic Hospital, located in London, where rehabilitation before discharge involved 

not only prosthetics but also therapeutic work. In the 

“curative workshops” of Shepherd’s Bush and its counterpart institutions throughout the United Kingdom, 

medical staff used water, weights, and electricity in 

an effort to repair both body and mind. At the same 

time, they promoted another form of rehabilitative 

work as a way to prepare disabled soldiers for reentry 

into civilian life. Vocational labor, medical authorities held, helped to return soldiers to civilian life as 

healthy individuals, as able-bodied breadwinners, and 

Figure 2-7. Another Civil War veteran with limb loss, Private Eben E Smith, Co A, 11th Maine, was wounded at Deep Bottom, Virginia, August 16, 1864, by a musket ball through the right leg. He survived the amputation of his right leg at the 

hip. Painting by Peter Baumgras.

Photograph: Courtesy of Otis Historical Archives, National Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. CWMI 006.
28

Care of the Combat Amputee

as productive citizens.25,26 In achieving this objective, 

philanthropic support was critical, and it came chiefly 

in the form of the Joint War Committee of the British 

Red Cross and Order of St John. In October 1916, this 

entity awarded an initial £1,000 grant to Shepherd’s 

Bush. This sum was followed by a £10,000 grant in 

1918. Supplementing these funds throughout the war 

were thousands of pounds donated directly by the 

public to both Shepherd’s Bush and its associated 

facilities across the country.27

By 1918 comparable rehabilitation programs had 

emerged in the United States, chiefly as a result of contact between British and American medical personnel. 

Among the surgeons at Shepherd’s Bush was Joel Goldthwait, a Harvard-trained orthopaedic surgeon from 

Boston General Hospital, who in late 1916 led a team 

of 2 dozen American orthopaedic surgeons in studying 

methods used by the Allies to heal combat-wounded 

soldiers. Goldthwait was particularly impressed with 

the organization and administration of the institution’s 

curative workshops. The use of work as both treatment 

and retraining, Goldthwait believed during the closing 

months of 1917, could be implemented in the United 

States to help deal effectively with the increasing number of American disabled soldiers returning home, a 

number that eventually exceeded 4,000. 

Goldthwait’s recommendations to the surgeon 

general yielded plans to train teachers and medical 

aides to assist in the rehabilitation of America’s service members disabled in the war. Called “reconstruction aides” (Figure 2-14), these individuals aimed to 

“to hasten the recovery of the patients . . . promote 

contentment and make the atmosphere of these hospitals such that the time spent in convalescence will 

pass most pleasantly because the minds and hands 

of the patients are properly occupied in profitable 

pursuits.”28 The work of these individuals received 

the support of most physicians and orthopaedic 

surgeons, and contributed greatly to the wartime 

and postwar expansion of the fields of occupational 

therapy and physical therapy.

A leading institution within America’s network 

of rehabilitation centers was the Red Cross Institute 

for Crippled and Disabled Men in New York. In part 

through a $265,000 federal appropriation but largely 

through the generosity of wartime philanthropy directed to the Red Cross by the philanthropist Jeremiah 

Millbank, the institute offered a range of vocational 

training in constructing artificial limbs, welding, painting, business accounting, and mechanical drafting. It 

also included complementary departments of research, 

employment, surveys, and public education that, by 

October 1919, produced 7 million public-information 

pamphlets, sponsored 300 public lectures, and completed over 500 industrial surveys involving 1,500 

factories and 100 trade associations, all to the end of 

empowering the disabled soldier to “win his own way 

to self-respect and self-support.”29,30

Posters produced by the institution and displayed in 

its lobby, as well as in public spaces around New York 

City, incorporated images of physical reconstruction 

efforts being undertaken in US and Allied military 

hospitals (Figure 2-15). Conveying the philosophy of 

occupation as a vital means to helping the disabled 

reclaim participation in the fabric of postwar life, the 

images illustrate the historical roots of occupational 

therapy, physical therapy, and vocational rehabilitation (see Chapter 6). 

Figure 2-8. Another Civil War veteran with limb loss, Private Robert Fryer, Co G, 52nd New York, was wounded at 

Hatcher’s Run, Virginia, and subsequently required amputation of his third, fourth, and fifth metacarpals.

Photograph: Courtesy of Otis Historical Archives, National 

Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. CP 1041.
29

Historical Perspectives on the Care of Service Members With Limb Amputations

Figure 2-9. Six men, likely Civil War veterans, standing with the aid of their “Hanger limbs” near a JE Hanger storefront. 

Photograph commissioned by the JE Hanger Company. Undated but likely ca 1870–1880.

Photograph: Courtesy of Library of Congress, Washington, DC. CM Bell Collection of Glass Negatives.

INTERWAR PERIOD

the group, Marx called a national caucus of 250 

disabled veterans, drawing together one of the first 

major associations to advocate for improved public 

services on behalf of disabled veterans. Disabled 

American Veterans remained active through World 

War II and continues its efforts today in cooperation 

with federal agencies and a constellation of other 

philanthropic organizations, including the American 

Legion, Paralyzed Veterans of America, and Vietnam 

Veterans of America Foundation.

Between World War I and World War II military 

“reconstruction centers” decreased in size substantially, and many disabled veterans found agencies 

like the Red Cross Institute ill-prepared to help them 

reenter civilian society. During this period Captain 

Robert S Marx (Figure 2-16), a wounded veteran, established an organization called Disabled American 

Veterans of the World War I. Under the leadership 

of Marx, the organization became a champion of the 

disabled veterans’ cause. A year after he established 
30

Care of the Combat Amputee

WORLD WAR II AND THE IMMEDIATE POSTWAR ERA

By the Second World War, improvements in armor, 

aircraft, and radio communications that allowed for 

combined air/land operations tipped the scales in favor 

of offensive operations. Instead of the trench warfare 

that characterized World War I, combat tactics emphasized mobility. The new nature of combat changed the 

type of wounds sustained by soldiers. Lower extremity 

injuries involving bone and soft tissue represented 42% 

of the 20,747 battle casualties sustained by the Fifth 

US Army between August 1, 1944, and May 2, 1945, 

in contrast to 47% of casualties during the First World 

War. Upper extremity injuries accounted for 26% of 

the same sample during World War II, compared with 

Figure 2-11. Advertising literature published by artificial 

limb manufacturer AA Marks of New York, New York. Undated but likely ca 1900.

Photograph: Courtesy of Warshaw Collection of Business 

Americana, National Museum of American History, Washington, DC.

Figure 2-10. Advertising literature published by artificial 

limb manufacturer George R Fuller of Rochester, New York. 

Undated but likely 1870–1890. 

Photograph: Courtesy of Warshaw Collection of Business 

Americana, National Museum of American History, Washington, DC.

39% of World War I casualties.31,32 Improvements in 

surgical technique, whole blood for transfusion, and 

antibiotics increased the chances of those wounded in 

the abdomen, while better methods for treating gunshot 

fractures, notably improved methods of traction and 

internal fixation of fractures, minimized the number of 

amputations performed. 

Approximately 18,000 Americans sustained an amputation as a result of combat in World War II. However, the reason for loss of the limb had changed. One 

study concluded that 20% of the amputations resulted 

from arterial damage, while 80% were the result of “irreparable damage,” usually from a land mine or artillery.33 “When the limb was irretrievably shattered and 

mangled or was almost completely avulsed,” reported 

Mather Cleveland, senior consultant in orthopaedic 

surgery in the European theater of operations during 

World War II, “the attending surgeon had no choice but 

to amputate it. In effect, a nearly complete traumatic 

amputation had already been performed, and it was 

his clear duty to complete it.”34 Germany’s routine use 

of land mines as a defensive measure during the Italian campaign of 1944–1945 increased the number of 

US lower limb amputations. In 1943 land mines were 

responsible for approximately 15% of all amputations, 

but caused almost 36% in 1944–1945.35

By this period, rehabilitation of the combat-injured 

service member began in the combat zone. Military 
31

Historical Perspectives on the Care of Service Members With Limb Amputations

medical authorities encouraged surgeons to focus 

on the whole patient as opposed to a single procedure. Circular letter no. 46, issued in August 1944 by 

Headquarters, North African Theater of Operations, 

contained details of this protocol, emphasizing “that 

casualties who required amputation should be told 

before operation, whenever their condition permitted, why this procedure was necessary. It was also 

suggested that, as soon as the patient was surgically 

comfortable and mentally receptive, an interview with 

a psychiatrist or chaplain might be useful. These instructions were based on the fact that about 1 in every 5 

patients could be expected to exhibit psychic reactions, 

often depressive in type, a few days after operation.” 

Additionally, the circular indicated that “particular 

attention was to be paid in this and other interviews 

to what the soldier might reasonably expect in the way 

of aid. He was to be told of the amputation centers 

which had been established in the Zone of Interior, the 

prosthetic appliances which were available, and the 

economic and other aid which he could be assured of 

receiving. Fortification of this kind before the patient 

became the target of sympathetic family and friends,” 

the circular letter pointed out, “might tip the scales in 

favor of rehabilitation, while its omission might result 

in lifelong disability and resentment.”36p328

As in previous conflicts, philanthropy played an 

important role in the rehabilitation of World War II 

service members who suffered limb amputations. 

Dr Howard Rusk (Figure 2-17) embraced the “whole 

patient” concept in his techniques to help injured Air 

Force personnel. As he described the first Air Force 

rehabilitation center at Pawling, New York: “I guess 

you might describe [it] as a combination of a hospital, 

Figure 2-12. A US Sanitary Commission rest house in Washington, DC, where volunteers gathered in support of sick and 

wounded soldiers. Undated but likely 1863–1864.

Photograph: Courtesy of Prints and Photographs Division, Library of Congress, Washington, DC. Civil War Glass Negative 

Collection. LC-B811-1201.
32

Care of the Combat Amputee

Figure 2-13. John Galsworthy (1867–1933), the British writer and later Nobel laureate who donated his time, writing talents, 

and thousands of dollars of literary earnings to support what he called “the sacred work”: the rehabilitation of servicemen 

who were severely injured physically and psychologically in World War I. Photograph dated 1919.

Photograph: Courtesy of Prints and Photographs Division, Library of Congress, Washington, DC. George Grantham Bain 

Collection, Biography file.

Figure 2-14. Occupational therapy at Walter Reed Hospital during the First World War. A reconstruction aide supervises the 

work of one soldier while her colleague observes the group.

Photograph: Courtesy of Otis Historical Archives, National Museum of Health and Medicine, Armed Forces Institute of 

Pathology, Washington, DC. Reeve 4272.
33

Historical Perspectives on the Care of Service Members With Limb Amputations

a country club, a school, a farm, a vocational training 

center, a resort, and a little bit of home as well. The 

discipline was minimal and the program informal. 

Old regular Army people would have shuddered, but 

fortunately General Arnold didn’t have the traditional 

Army man’s outlook [as he] reaffirmed his full support of the program and his conviction that it would 

prove its worth, not only by returning men to healthy 

lives, but by returning many of them to duty.”36 Rusk’s 

approach helped establish many of the principles of 

rehabilitation later incorporated into the programs of 

the Institute of Rehabilitation at New York University, 

an institution that had a large impact nationally and 

internationally on the field.37

The efforts of Major General Norman Thomas Kirk 

(Figure 2-18) were also instrumental in the care of 

America’s combat amputees during and after World 

War II. Based on his experiences in World War I, 

when he established himself chiefly at Walter Reed 

as a leading authority on amputations, Kirk helped 

establish multidisciplinary amputee centers around 

the country to provide up-to-date surgical, medical, 

prosthetic, and rehabilitative care. Later, as Army 

Surgeon General, Kirk asked the National Research 

Council to set up a committee on prosthetic devices 

to provide leadership and coordination of the emerging federal programs in the Army Surgeon General’s 

Office of Scientific Research and Development and 

Veterans Administration.38 According to historians 

and rehabilitation experts alike, these initiatives were 

dramatically successful, helping to make 1945 to 1975 

one of the most productive periods in US prosthetics 

and rehabilitation research, benefiting both combat 

and civilian amputees.39–41

Philanthropy also joined military medicine through 

the activities of Dr Bernard Baruch (Figure 2-19), who 

funded the Baruch Committee on Physical Medicine in 1943. Chaired by Dr Ray Lyman Wilbur and 

composed of subcommittees on education, teaching, 

research, public relations, rehabilitation, hydrology, 

occupational therapy, prevention, and body mechanics, 

this group aimed to expand the medical specialty of 

physical medicine and rehabilitation and maximize its 

contribution to the care of injured soldiers and sailors. 

Baruch’s generosity advanced the field of physical 

medicine as well as rehabilitative care for service 

members with limb amputations, paving the way 

to recognition that amputations are lifelong injuries, 

with sequelae requiring adequate support from federal 

agencies like the Veterans Administration as well as the 

philanthropic societies that are equally invested in the 

successful rehabilitation of veterans with disability. 

KOREA AND VIETNAM

The Korean conflict was marked by extreme mobility during the 1st year of the war as North Korean 

and United Nations troops engaged along the Korean 

Peninsula. As the forces counterbalanced each other, 2 

years of trench warfare followed. During this period 

medical authorities applied lessons learned from 

World War II in the form of helicopter ambulances and 

the mobile Army surgical hospital to help ensure that 

seriously wounded soldiers received prompt medical 

care and better odds of survival. The issuance of soft 

body armor complemented this effort. Of the final 

7,200 United Nations soldiers wounded in Korea, 56% 

sustained injury to their extremities. As in the Second 

World War, surgeons performed amputations primarily on “extremities hopelessly destroyed by trauma 

or infection or both.”42 The number of cases requiring 

amputation decreased as a result of improved vascular surgery. Of the 16,890 simple and compound 

fractures sustained by soldiers during the war, only 

1,477 amputations were performed, in addition to 

1,120 traumatic amputations. Over 70% of the wounds 

resulting in amputations were caused by explosive projectiles, grenades, and land mines.43 During the Second 

World War, one study found that 50% of 2,471 arterial 

wounds resulted in amputation. Vascular surgery was 

attempted in 81 cases with a failure (and subsequent 

amputation) rate of 36%. A study during the Korean 

conflict reported that only 26 (13%) of the 194 vascular 

repairs failed, resulting in amputation.44 

The Vietnam War brought a different style of 

warfare. Lighter weapons increased the amount of 

firepower that could be carried by infantry. New rifles 

such as the Colt M-16 and the Kalashnikov AK-47 

fired high-velocity bullets that pulverized bone. US 

forces frequently operated from fixed firebases and 

sent patrols to monitor surrounding territory, and 

rather than risk direct contact, the Viet Cong preferred 

to deploy a wide variety of land mines, booby traps, 

and punji sticks along major paths and patrol routes. 

These weapons increased crippling wounds to the 

lower extremities by 300% compared to World War II 

and 70% compared to Korea. Over 5,200 US soldiers 

lost limbs in Vietnam.9,10,45 

During the period ca 1950 to 1975 service members 

with limb loss had a much higher survival rate than 

in World War II and previous wars primarily because 

of improved resuscitation and surgical repair of damaged blood vessels, as well as better evacuation of 

soldiers from the frontlines to better equipped and 

more sanitary care facilities. However, as Colonel 
34

Care of the Combat Amputee

a b

c d
35

Historical Perspectives on the Care of Service Members With Limb Amputations

Paul W Brown observed in his history of Vietnam-era 

amputee care that until the early years of Vietnam, the 

approach to wartime amputee care had changed little 

from that of World Wars I and II and the Korean War: 

heal the stump, fit it with a prosthesis, train the patient 

in its use, and discharge him to civilian life. Although 

advances in prosthetics and orthotics contributed to 

better function, and the addition of vocational counseling and driver education to some degree rendered the 

adjustment to civilian life easier, progress in programs 

to help amputees live lives as normal as possible had 

not been significant. All management programs had 

been directed toward what was lost, not toward what 

had been retained. Only when the number of amputees 

began climbing rapidly in 1967 were methods explored 

to expand their total rehabilitation through motivational therapeutic programs. Such an initiative was 

described by Dr Timothy Dillingham in the previous 

edition of this textbook:

a unique aspect of care at the Fitzsimons General 

Hospital was the amputee skiing program. Over 

100 amputees treated during 1968 and 1969 learned 

to ski using adaptive aids. These casualties gained 

confidence and an enhanced sense that even with 

their disabilities they could find challenges and enjoyment through skiing and other recreational activities. 

[One contemporary] described the incredible psychological trauma involved with amputation, and the 

Fitzsimons program stressed treatment of the whole 

Figure 2-16. Judge Robert S Marx, National Commander, 

Disabled American Veterans of the World War, ca 1921.

Photograph: Courtesy of Library of Congress, Washington, 

DC. National Photo Company Collection, LC-F8-14813.

Figure 2-15 (preceding page). Wartime exhibition posters developed and used by the Red Cross Institute for Crippled and 

Disabled Men and the Red Cross Institute for the Blind during World War I. (a) A soldier recovering from war wounds at 

Walter Reed Hospital and learning the craft of engraving. (b) Disabled French soldiers using “working prostheses” to perform manual labor in a woodworking shop and on a farm. (c) Two scenes of men in hospitals recovering from war wounds 

through occupational therapy. (d) Two scenes in which disabled French and Serbian soldiers are being taught useful skills 

to enable them to find employment upon discharge from military service. 

Photographs: Courtesy of Prints and Photographs Division, Library of Congress, Washington, DC. POS – WWI – US, no. 

43 (a); no. 30 (b); no. 44 (c); no. 46 (d).

Figure 2-17. Dr Howard Rusk, who embraced the “whole 

patient” in his techniques to help injured Air Force personnel 

during World War II. Photograph ca 1950.

Photograph: Courtesy of History of Medicine Division, National Library of Medicine, Bethesda, Maryland. 
36

Care of the Combat Amputee

individual with the goal of returning the soldier to an 

optimal level of function. The recreational activities 

had a positive impact on the mental well being of the 

soldier and were a vital part of the rehabilitation plan.46 

The roots of rehabilitative athletics can be traced in 

part to the years immediately following World War II, 

when the English neurologist Sir Ludwig Guttmann 

organized a sports competition for veterans with spinal cord injuries. This competition eventually became 

known as the Stoke Mandeville Games. In 1952 competitors from the Netherlands took part in these games, 

giving an international character to the initiative and 

paving the way to the first Paralymic Games, held 

in Rome, Italy, in 1960.47 Today the Paralympics are 

one of the greatest influences on the development of 

prostheses and their use by people with amputations. 

Whereas the 1960 games involved 400 athletes from 23 

countries and limited, if any, media coverage or support by the prosthetics field, the Athens Games of 2004 

involved 3,806 athletes from 136 countries competing 

under the eye of major media coverage—broadcast by 

the CBS television network and sponsored by Getty 

Images among other companies—as well as corporate 

support of Visa, Otto Bock HealthCare, Samsung, 

and Edelman, the world’s largest independent public relations firm.48 The Paralymics have also become 

one of the largest and most important showcases of 

the physical potential of people with disabilities and 

the power of prosthetic technology. In conjunction 

with affiliated nonprofit organizations, including the 

Challenged Athletes Foundation, Disabled Sports 

USA, and Orthotic and Prosthetic Assistance Fund 

(among many others described in Chapter 25), and 

with federal initiatives such as the National Veterans 

Winter Sports Clinic and National Disabled Veterans 

Wheelchair Games, both sponsored by the Department of Veterans Affairs and Paralyzed Veterans of 

America, the Paralympics help promote opportunities for disabled veterans and others to participate in 

Figure 2-19. Bernard Baruch, who generously funded the 

Baruch Committee on Physical Medicine in 1943.

Photograph: Courtesy of Library of Congress, Washington, 

DC. George Grantham Bain Collection, LC-B2-4110-12.

Figure 2-18. Norman Kirk, who, during World War II, used 

his experiences in World War I to help establish multidisciplinary amputee centers around the country to provide 

up-to-date surgical, medical, prosthetic, and rehabilitative 

care.

Photograph: Courtesy of Otis Historical Archives, National 

Museum of Health and Medicine, Armed Forces Institute 

of Pathology, Washington, DC. Medical Illustration Service 

Library. MIS57-07732-33.
37

Historical Perspectives on the Care of Service Members With Limb Amputations

competitive sports, at local, national, and international 

levels. And as an opportunity for the prosthetic industry to sponsor individual athletes as well as entire 

teams, the Paralympics help advance developments 

in prosthetic design and function. Today, dozens if 

not hundreds of disability-focused nonprofit organizations complement the mission of the Paralympics, 

which, in addition to providing athletic opportunities 

and advancing the field, expands public awareness 

of ability despite limb loss. The charitable work of 

these organizations is a current chapter in the history 

of philanthropy and military medical care working 

in tandem toward the rehabilitation of the service 

members with limb amputations.

CURRENT CONFLICTS

Current conflicts have reversed this declining trend 

of amputations among wounded service members, 

and recent studies have shown that major limb amputation rates for the current US engagements are 

similar to those of previous conflicts.49 The nature 

of combat has changed as sensors, precision-guided 

munitions, and robotic weapons have made military 

formations of the opposing forces, even those taking advantage of the civilian population for cover 

and concealment, increasingly vulnerable. Suicide 

bombers and mechanical ambushes have proven to 

be a deadly tactic against a highly mobile military 

force. The land mine of World War II and punji stick 

of the Vietnam War have given way to the improvised explosive device. To treat the wounds caused 

by these new weapons military surgeons are using 

new medical technology such as hemostatic bandages that stop massive bleeding and miniaturized 

resuscitation devices that place the technology of an 

intensive care unit near or on the frontlines of battle. 

Emerging prosthetic technology holds greater promise than ever before. But so too does the altruism of 

private citizens and civilian organizations involved 

in providing rehabilitation and support programs to 

service members with limb loss and other injuries, 

and to their families and loved ones. 

SUMMARY

If history is any guide, the partnership of US military medicine and the generosity of citizens will take 

on new forms as researchers follow the “roadmap for 

future research” described in Chapter 28, and assess 

its outcomes both for individuals with amputations 

and those with polytrauma and related conditions of 

21st century warfare. History helps put this research 

and practice into perspective, showing that rehabilitation should involve critical thinking not only about 

medicine but also about the role of society in caring for 

military service members with limb amputations and 

in defining renewed occupations, social participation, 

and overall health of service members despite their 

physical and psychological challenges. This role is 

reflected by the diversity of professionals on the rehabilitation team, including anthropologists, economists, 

demographers, historians, psychologists, sociologists, 

and statisticians, and the current and potential future 

contributions of social scientists to rehabilitation research and to the reintegration into society of men and 

women who have sustained severe injury in service 

to the nation.

The history surveyed here is valuable in much the 

same way as taking a medical history is central to care 

of an individual with limb loss. That process involves 

discovery of the past, or as one physician described it, 

“acceptance of the truth that to care for the patient today, 

the patient of the past must be examined too.”50 This 

history reveals how today’s service members with limb 

amputations receive care within systems with roots as 

much in past medical lessons learned as in the altruism 

of individuals and communities who care deeply about 

the rehabilitation of these veterans and their renewed 

health and participation in postwar, civilian society. 

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