Remembering the Nurses of WWI (IV)

“Mustard gas burns.  Terrific suffering.”

 [The fourth of a series of essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917]

Now, sadly, chemical weapons are back in the news.  But large-scale chemical warfare  reaches back over a century.   In WWI, Germany released 5,730 cylinders of chlorine gas across a four-mile stretch of no-man’s-land into the Allied lines during the Second Battle of Ypres in April, 1915. Thus the birth of chemical warfare.  Britain replied in kind, releasing cylinders of chlorine gas during the Battle of Loos the following summer, and  Germany upped the horror in July, 1917, delivering artillery shells filled with dichlor-ethyl-sulphide or “mustard gas” just prior to the Third Battle of Ypres.

Chlorine gas attacked the airways.  Severe respiratory swelling and inflammation killed many instantly and the rest struggled to nearby casualty clearing stations with acute congestion of the lungs, pneumonia, and blindness.  Soldiers who had inhaled the most gas arrived  with heavy discharge of a frothy yellow fluid from their noses and mouths as they drowned in their own secretions.  For the rest, partial suffocation persisted for days, and long-term survivors had permanent lung damage, chronic bronchitis, and occasionally heart failure.  Mustard gas burned the skin and respiratory tract, stripping the mucous membrane off the bronchial tubes and causing violent inflammation of the eyes.  Victims were left in excruciating pain and utterly helpless.[1]

Nurses, no less than physicians, were initially confused about the nature of the gas and the severity of its effects.[2]  But they quickly came up to speed and realized that soldiers suffering from poison gas posed a nursing challenge no less formidable than those dying from gangrenous wounds.  Nurses were accustomed to losing patients, but not to being powerless to provide comfort care, to  ease  patients’ agony during their final days.  How to nurse on when nursing was unavailing, when the burns were so terrible that “nothing seems to give relief”?[3]

WWI nurses in gas masks treat soldiers after a gas attack

Of course, nurses did what little they could.  Inflamed eyes were repeatedly irrigated with alkaline solution.  Respirators soaked in hyposulphate could be provided to patients able to use them.  At American Base Hospital 32, soldiers who had breathed in mustard gas were given a mixture of guiacol, camphor, menthol, oil of thyme, and eucalyptus that caused them to expectorate inflammatory material.   According to Maude Essig, an American Red Cross Nurse who worked at the hospital, the nurses helped devise it.[4]

According to Essig, the mixture provided some temporary relief to soldiers with burning throats and mouths.  But nurses otherwise echoed a shared sense of impotence when it came to making gassed patients comfortable.  During the Second Battle of Ypres, when chlorine gas was first used by the Germans, Canadian nurse Agnes Warner recalled the initial wave of gassed troops:  “There they lay, fully sensible, choking, suffocating, dying in horrible agonies.  We did what we could, but the best treatment for such cases had yet to be discovered, and we felt almost powerless.”[5]   Shirley Millard was graphic in describing the severe burn patients who rendered nursing futile.  “Gas cases are terrible,” she wrote at war’s end in November, 1918.

They cannot breathe lying down or sitting up.  They just struggle for breath, but nothing can be done . . . their lungs are gone . . . literally burnt out.  Some with their eyes and faces entirely eaten away by the gas, and bodies covered with first degree burns.  We try to relieve them by pouring oil on them.  They cannot be bandaged or even touched.[6]

Whereas soldiers with even the worst of battlefield wounds usually did not complain,  the gas cases “invariably are beyond endurance and they cannot help crying out.” Millard’s judgment was affirmed by many others.  Maude Essig wrote of a “star patient,” one Leo Moquinn, who “was terribly burned with mustard gas while carrying a pal of his three-quarters of a mile to safety after the gas attack.  Except for his back, she added, his “entire body is one third-degree burn.  He cannot see and has  developed pneumonia and he is delirious.”[7]  Such were the burn patients.

Essig’s reference to pneumonia alludes to the multitude of infectious diseases that accompanied battlefield wounds and complicated (or prevented) recovery. Pneumonia could be rampant during winter months; gangrene and tetanus were prevalent year round.  Typhoid was partially  controlled by the antityphoid serum injections troops received, usually prior to disembarkation but otherwise in the reception huts of clearing stations and field hospitals. But bronchitis, trench fever, diphtheria, cholera, dysentery, meningitis, measles, mumps, erysipelas,[8] and, finally, influenza, were not.  Nurses recorded deaths resulting from various combinations of the foregoing, such as Edith Appleton’s “poor little boy, Kerr,” who died of gas, pneumonia, and bronchitis.[9]

Infected shrapnel and gunshot wounds could be irrigated or bathed continuously in antiseptics, first developed in the 1870s and packed in sterile dressings available in sealed paper packages since 1893.[10]  But in the preantibiotic era, nursing care of systemic infections was limited to the same palliatives we employ today:  rest, warmth, hydration, nutrition, aspirin (and, back then, quinine), all amplified by the nurse’s caring, maternal presence.

Trench foot, a combination of fungal infection, frostbite, and poor circulation, was endemic during the winter months, when soldiers lived in trenches flooded with icy water, often waist-high, for days on end.  They struggled into clearing stations with feet that were “hideously swollen and purple,” feet “that were “raw with broken blisters and were wrapped in muddy, dripping bandages.”[11] But trench feet, however disabling, at least  permitted more active measures.   In addition to giving morphine, there was a treatment protocol to follow, such as this one at a British Military Hospital in the winter of 1917:

We had to rub their feet every morning and every evening with warm olive oil for about a quarter of an hour or so, massage it well in and wrap their feet in cotton wool and oiled silk – all sorts of  things just to keep them warm – and then we put big fisherman’s socks on them.  Their feet were absolutely white, swollen up and dead.  Some of their toes dropped off with it, and their feet looked dreadful.  We would say, ‘I’ll stick a pin in you.  Can you feel it?”  Whenever they did feel the pin-prick we knew that life was coming back, and then we’d see a little bit of pink come up and everybody in the ward would cheer.”[12]

It is the dizzying  confluence of multiple battlefield injuries, many gangrenous, with the effects of poison gas and intercurrent infectious diseases that threatened to, and occasionally did,  overwhelm the WWI nurses.  Reading their diaries and memoirs, one sees time and again how the nurses’ calling, amplified by the camaraderie of other nurses, surgeons, and orderlies who felt similarly called, overpowered resignation and despair.  In a diary entry of September 14, 1916,  Kate Luard referred to the “very special nursing” required by soldiers with multiple severe injuries.  She had in mind

The man with two broken arms has also a wound in the knee – joint in a splint – and has had his left eye removed today.  He is nearly crazy.  Another man has compound fractures of both legs, one arm, and head, and is quite sensible.  Another has both legs amputated, and a compound fracture of [the] arm.  These people – as you may imagine – need very special nursing.[13]

If one adds to such clusters the serious general infections that often accompanied battlefield injuries, one has some sense of what nurses were up against, and just how special their nursing had to be.   When influenza, the deadly Spanish flu, began to swamp clearing stations and hospitals in the spring of 1918, nurses simply added it to the list of challenges to be met with the resources at hand. And they did so in the knowledge that as many as half of the infected would die.[14]  Beatrice Hopkinson, a British auxiliary nurse, recorded the new protocol developed at her General Hospital in St. Omer to meet the rush of influenza patients:

During those early days of the flu the treatment was to strip the patients in one tent, their clothing going immediately to the fumigator.  Then, the patient was bathed in disinfectant and taken to the different wards.  Some of the patients were very ill and died with pneumonia after a few days.[15]

The early days of the pandemic gave way to the later days, and after the Armistice was signed on November 11, 1918, nurses occasionally felt boredom, even mild malaise, when the demands of “special nursing” relented and they increasingly found themselves nursing “mostly mild influenza cases.”[16]

I admire the nurses of WWI because they did what was required of them absent any preexisting sense of what they could be required to do, absent, that is,  anything approaching a  “job description.” Without medical residents, internists, and infectious disease specialists to fall back on, they collapsed specialism into global care-giving identities.  This meant they managed multiple war wounds and  intercurrent infections, prioritizing among them and continuously adjusting treatment goals in the manner of highly skilled primary care physicians.  By the same token, they realized the importance of compassion in the face of ameliorative impotence.  Somehow they found  time to be present, to slip into a ward with a soldier dying of gas gangrene every few minutes “to do something perfectly useless that might perhaps give a ray of comfort.”[17]

Ironically, given the environment in which they labored and their “patient population” of soldiers in extremis, the nurses embodied the values of primary care medicine, since they took upon themselves the role of primary caregivers obligated to stay with their patients through thick and thin, to summon senior colleagues and surgeons as needed, and to ease life transitions, whether to recovery,  convalescence, lifelong disability, or death.[18]   And they did so whatever the weight of multiple assaults on their own bodily and mental integrity.

Nurses, technically noncombatants, suffered alongside the troops.  During rushes, their clearing stations, hospitals, and living quarters were under land and air assault and occasionally took direct hits.  They contracted infectious diseases, especially flu,[19] during which they usually carried on with the aid of simple analgesics until they felt better or worse.  When Helen Boylston became feverish in November, 1918, a symptom she attributed to diphtheria, she braced herself for a long-awaited evening dance with “quantities of quinine and finally a stiff dose of whiskey, and I felt ready for anything.” But not ready enough, it turned out.  She collapsed at the dance with a bad chill and had to be carried to her bed.  When she went on duty the following day, she became delirious in the ward and was lugged off by an orderly and subsequently seen by a doctor. “So here I am,” she wrote in her diary.  “I’ve developed a heart and a liver, and am as yellow as a cow-lily.  I have to lie flat on my back and be fed.  For three days I lay motionless all day long, not caring to move or to speak, I was so tired.”  Boylston was soon joined by a second nurse with diphtheria, placing the camp “in a panic,” with every staff member now given daily throat cultures.[20]

Despite training in the use of gas masks in the event of direct shelling, mask-less nurses suffered the effects of poison gas from daily proximity to patients on whom the shells had landed.  Their own vulnerability to gas attack and attenuated exposure to the poison lent special intensity to their care of burn victims.  They understood, with Maude Essig, that mustard gas burns indeed meant “terrific suffering.”[21]  Whether infected or poisoned, they usually labored on until they collapsed or were so near collapse that medical colleagues ordered them out of the wards, whether to bed, to a general hospital for treatment, or to a nearby convalescent homes for recuperation and a desperately needed “time out.”[22]

Civil War nurses too eased transitions to death, but their nursing goal during a soldier’s final days was to reconfigure mortal battlefield injury into the promise of a beneficent afterlife.   So they stayed with the dying, soliciting final confessions of sinful living, allowing soldiers to reminisce and reflect, and soliciting (and writing down) words of comfort  to sustain family members in believing that their soldier had died a “good death.”[23]  World War II, on the other hand, witnessed the development of new vaccines, a national blood bank program, the widespread availability of sulfa drugs in 1941 and penicillin in 1944, major advances in the control of shock and bleeding and in battlefield surgery, and much greater speed of evacuation of the seriously wounded to European and stateside base hospitals.  Taken together these advances created a buffer between nurses and the prolonged witnessing  of soldiers dying in unrelievable pain.

It was the nurses of WWI who took it on the chin.  They could not sustain themselves and their patients with the naturalistic view of the afterlife popular during the Civil War.[24]  Nor did they have the benefit of more “modern” technology and organization to shield them, if only somewhat, from the experiential onslaught of  dying soldiers.   It was not death per se but the agony of dying – from infected battle wounds and/or systemic infections,  gas gangrene, chlorine and mustard gas,  rushed amputations followed by reinfection and blood loss –  that took them to their own existential no-man’s-land, the kind we encounter in the writings of Mary Borden and Ellen LaMotte.

In the summer of 1917, the nurses at No. 12 General Hospital on the outskirts of Rouen struggled with a gas victim whose paroxysms of coughing came every minute and a half “by the clock,” and who had not slept in four days.  To quiet him, they rigged up a croup tent under which they took turns holding a small stove that heated a croup kettle from which the soldier could breathe the steam.  When sleep finally came, they were “ready to get down on their knees in gratitude, his anguish had been so terrible to watch.”  To their head nurse, Julia Stimson, they remarked that “they could not wish the Germans any greater unhappiness than to have them have to witness the sufferings of a man like that and know that they had been the cause of it.”[25]

It was bearing witness to unrelievable suffering that was the worst assault borne by the nurses.  Indeed, they could think of no greater punishment for enemy combatants than to witness what they witnessed, often for weeks on end.  And yet the nurses of WWI were not stymied by seeming impotence in the face of pain.  They labored on until the breaking point in the service of soldiers who, all too often, were already broken.  This makes them warriors of care and, in a devotion to patients that was literally and not metaphorically self-less, heroes of the first rank.

_______________________

[1] Christine E. Hallett, Veiled Warriors:  Allied Nurses of the First World War (Oxford: OUP, 2014), 79-80, 203.

[2] E.g., Julia C. Stimson, Finding Themselves: The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 80; John & Caroline Stevens, eds., Unknown Warriors:  The Letters of Kate Luard, RRC and Bar, Nursing Sister in France 1914-1918 (Stroud: History Press, 2014), loc 1945.

[3] Maude Frances Essig, My Trip with Uncle Sam, 1917-1919:  How We Won World War I, unpublished journal written during the summer, 1919, entry of March 24, 1918.

[4] Agnes Warner, My Beloved Poilus’ (St. John: Barnes, 1917), loc 861.

[5] Warner, My Beloved Poilus’ , loc 814.

[6] Shirley Millard, I Saw Them Die: Diary and Recollections (New Orleans, LA: Quid Pro, 2011), loc 514.

[7] Essig, My Trip with Uncle Sam,  entry of March 24, 1918.

[8] Erysipelas is an acute bacterial infection of the upper dermis, usually of the arms, legs, and/or face, that is accompanied by red swollen rashes.  Without antibiotic treatment, It can spread through the blood stream and cause sepsis.

[9] Edith Appleton, A Nurse at the Front:  The First World War Diaries, ed. R. Cowen (London:  Simon & Schuster UK, 2012), 111.

[10] Rodney D. Sinclair & Terence J. Ryan, “A Great War for Antiseptics,” Australas. J. Dermatol, 34:115-118, 1993.  These nineteenth-century antiseptics included salicylic, thymol, Eucalyptus oil, aluminum acetate, and boric acid.

[11] Helen Dore Boylston, Sister: The War Diary of a Nurse (NY: Ives Washburn, 1927), loc 154.

[12] Kathleen Yarwood (VAD, Dearnley Military Hospital), in Lyn MacDonald, The Roses of No Man’s Land (London: Penguin, 1993 [1980]), 197-198.

[13] Luard, Letters, loc 1245.

[14] Millard, I Saw Them Die, loc 472.

[15] Beatrice Hopkinson, Nursing through Shot & Shell: A Great War Nurse’s Story, ed. Vivien Newman (South Yorkshire: Pen & Sword, 2014), loc 1999.

[16] Hopkinson, Nursing Through Shot & Shell, loc 2609.

[17] [Kate Norman Derr] “Mademoiselle Miss”: Letters from an American Girl Serving with the Rank of Lieutenant in a French Army Hospital at the Front, preface by Richard C. Cabot (Boston:  Butterfield, 1916), 76-77.

[18] For an exposition of these values and how they gained expression in American medicine in the nineteenth and twentieth centuries, extending through “general practice” of the 1950s and ’60s, see Paul E. Stepansky, In the Hands of Doctors:  Touch and Trust in Medical Care (Santa Barbara: Praeger, 2016).

[19] “The flu is back again and everybody has it, including me.  I’ve run a temperature of one hundred and two for three days, can hardly breathe, and have to sleep on four pillows at night.” Boylston, Sister, loc 630.

[20] Boylston, Sister, loc 1350, 1357.

[21] Essig, My Trip with Uncle Sam, entry of March 23, 1918.

[22] E.g., Luard, Letters, loc 1247:  “Sister D, the Mother of all the Abdominals, has her marching orders and goes down to Rouen to a General Hospital tomorrow.  Her loss is irreparable.”  Edith Appleton  recounts taking care of three sick nurses and a sick VAD at one time:  “I have begun to feel like a perpetual night nurse to the sick sisters as I have another one to look after tonight with an abscess in her ear”(A Nurse at the Front, p. 123).  Maude Essig contracted erysipelas in the spring of 1918 and reported feeling “awfully sick” the following fall, when she relied on “quinine and aspirin in large doses” to keep going (My Trip with Uncle Sam, entries of April 9, 1918, April 14, 1918, and October 27, 1918).

[23] Drew Gilpin Faust, This Republic of Suffering:  Death and The American Civil War (New York: Vintage, 2008), chapter 1.

[24] Faust, Republic of Suffering, pp. 178, 187.

[25] Stimson, Finding Themselves, pp. 80-81.

Copyright © 2017 by Paul E. Stepansky.  All rights reserved.  The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.

Remembering the Nurses of WWI (III)

He’s saved, and that makes up for much.”

[The third of a series of essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917]

Of course the surgeons of WWI could only save so many lives.  During battle “rushes,” when they operated up to 16 hours a day, they had to husband operative energy for soldiers who were savable, especially those whose saving could land them back in the trenches.  Many cases were deemed hopeless and simply handed back to the Sisters, to provide what meager palliative care they could while the soldiers awaited death in the tent set aside for them, the Moribund Ward.  But the Sisters sometimes refused to let matters rest, recognizing that the surgeons, often operating at breakneck speed in a state of exhaustion, did not have the last word on life and death.  So soldiers out of  surgeons’ hands might still find themselves in  nurses’ hands, where they were beneficiaries of  nursing so intensive and prolonged that, against all odds, it segued into a curative regimen.

Mary Norman Derr, an American nurse trained by the French Red Cross in 1914 and assigned to a French Army Hospital near the trenches of the Marne in 1915, recalled an Arab soldier who arrived at the hospital barely conscious.  His seven suppurating wounds led to two successive operations, after which  surgeons  pronounced him hopeless and handed him back to Nurse Derr:

It is one of the few dressings I have had that really frightened me; for it was so long, and every day for a week or more, I extracted bits of cloth and fragments of metal, sometimes at a terrifying depth.  Besides my patient was savage and sullen, all that is ominous in the Arab nature.  Gradually, however, the suppuration ceased, the fever fell, and suddenly one day Croya smiled.[1]

An American Red Cross nurse at work outside a French field hospital, 1915

MGH-trained Helen Dore Boylston, working in the post-surgical bone ward of her Base Hospital in the winter of 1918, was no stranger to surgical aftercare.   Boylston enjoyed her 40 patients, and singled out a pluck Australian of over sixty with a leg “torn to pieces.”  “He’s a Crotchety old darling, always raging and roaring about something,” she wrote her family:

One day, when I was here before, he complained of a pain in his thigh and began to run quite a temp.  As his leg was laid wide open anyhow, I took a look along the bone, Dad meantime cursing the roof off.  I found a walled-in pus pocket, and picking up a scalpel told Dad he’d better look out of the window for a minute, as I was going to have to hurt him.  Then, before he knew what I was about, I had slit the thing open.  At least two cupfuls of pus poured out, and his relief was tremendous at once.  Of course his temp dropped, too.  I put in a packing and watched it for a few days.  It cleared up promptly.  That was absolutely all.”[2]

Nor did interventionist nursing end with bedside surgery.  Nurses often believed rehabilitation was possible when doctors did not, and they proved their point with paralyzed soldiers who, so the surgeons declared, would never walk again.  Consider Agnes Warner, a Canadian nurse working at the American Hospital in Neuilly, France.  Casualties from Alsace poured into the hospital in the spring of 1915, at which time a surgeon remarked that one of her patients, her “poor paralyzed man,” would never walk again.  Unfazed by the pronouncement and unwilling to rest content giving the patient English lessons to help pass the time, she devised a program of rehabilitation that incorporated electrical stimulation, which only became available at the Hospital in late June.  Three weeks later, she had her paralyzed man out on the balcony, where he enjoyed fresh air for the first time in six months.  She was assigned another patient paralyzed from the waist down a month later, and then in mid July she proudly reported on both patients:

My paralyzed man stood up alone last Sunday for the first time and now he walks, pushing a chair before him like a baby.  He is the happiest thing you can imagine; for seven months he has had no hope of ever walking again. . . . My prize patient, Daillet walks down stairs by himself now . . .We are all proud of him.  The doctor who sent him here from Besancon came in the other day to see how he was getting on and he could not believe it when he saw him.[3]

Worst of all were soldiers whose gaping wounds and limbless stumps were saturated with anaerobic bacteria of the genus Clostridium– soil-dwelling bacteria that thrive in the absence of oxygen – from the heavily fertilized fields of Flanders and Northern France.  The bacteria entered cavities through dirt and debris picked up by exploding shell fragments; bullet wounds and shrapnel typically drove into the body with pieces of bacteria-infested clothing.  The result was the dreaded gas gangrene, easily detected by the darkened muscle, bubbling sound, and overpowering stench[4] emanating from the infected limb or body cavity.  Nurses could smell such cases a mile away (so to speak),  and dreaded removing original aid station bandaging, often four or five days old, that revealed the “hideous and hopeless color of gangrene.”[5]  Prompt treatment in a Casualty Clearing Station (CCS), which typically meant amputation of an infected limb and antiseptic irrigation, might save a soldier’s life.  But left unattended in trenches and on battlefields for three, four, even five days, soldiers arrived at clearing stations with septicemia (blood poisoning), which foretold an agonizing death, often within hours, almost always within a few days.

Among the multitude of stressors that made up ward nursing in CCSs and field hospitals, ministering to dying gangrenous soldiers was at the top of the list.  What is remarkable is that even here nurses occasionally rejected the medical verdict and resolved to nurse on with those awaiting death in the Moribund Ward.  This was true of Kate Luard, who, in the midst of the Battle of Arras in May, 1917, battled on for her dying soldiers.  She was, she wrote home, “engaged in a losing battle with gas gangrene again – in the Moribund Tent – a particularly fine man, too.”  But then, a month later, she began working with “two given-up boys” who could not be revived the preceding day.  Still, the boys seemed to her “not hopeless” and she resolved to “work” on them.  The result repaid the effort,  “and after more resuscitation they are now both comfortably bedded in one of the Acute Surgicals, each with a leg off and a fair chance of recovery.”  A few days later, she wrote that her “two resuscitated boys in the Moribund Ward are all right.”  To be sure, many dying soldiers were revived only to develop gangrene above their amputations and die,  but Luard never stopped trying.  If one of her  gangrenous boys was “going wrong” on a particular day,  she would counter that “moribund head cases are smoking pipes and eating eggs and bread and butter. The kidney man is being dressed with [the antiseptic] Flavine and has had a leg off and is nearly convalescent!”[6]

The vast majority of nursing saves went unrecorded, perhaps noticed at the time by a colleague, a supervisor, even the Head Matron.  Without the wartime diaries and letters the nurses left behind, we would have little inkling of their quiet struggles to keep forsaken soldiers alive.  Such struggles take us far from the world of high-tech nursing, even in its low-tech WWI incarnation.  What we behold, rather, is hard-core, soft-touch nursing, abetted by a Rube Goldberg inventiveness in making use of materials at hand, somehow garnering materials not easily obtainable, and then patiently titrating treatments (including food intake) in a manner responsive to states of severe, even deathlike, debilitation.

A little Night Sister in the Medical last night pulled a man round who was at the point of death, in the most splendid way.  He had bronchitis and acute Bright’s Disease, and Captain S. and the Day Sister had all but given him up; but at 10:30 p.m., as a last resource, Captain S. talked about a Vapour Bath [steaming up his room], and the little Sister got hold of a Primus [stove] and some tubing and a kettle and cradles, and got it going, and did it again later, and this morning the man was speaking and swallowing, and back to earth again.  He is still alive tonight, but not much more.[7]

You will like to hear of the living skeleton with wounds in back and hands and shoulder that they brought me filthy and nearly dead from another pavilion.  That was nine days ago.  I diagnosed him as a case of neglect and slow starvation, and treated him accordingly – malted milk, eggs, soap, and alcohol to the fore.  His dressing took one and a half hours every day, and all nourishment given a few drops at a time, and early all the time, for he was almost too weak to lift an eyelid, much less a finger.  This morning he actually laughed with me and tried to clench his fist inside the dressings to show me how strong he was.  He’s saved, and that makes up for much.[8]

I happened on a corpse-like child [a teenage soldier] the other day being brought into the Moribund Ward to die and we got to work on resuscitation, with some success.  He had been bleeding from his subclavian artery and heard them leave him for dead in his shell-hole.  But he crawled out and was eventually tended in a dug-out by ‘a lad what said prayers with me,’ and later the hole in his chest was plugged and he reached us – what was left o of him.  When, after two days, he belonged to this world again, I got Capt. B. to see him, and he got Major C. to operate and tied the twisted artery which I had re-plugged – he couldn’t be touched before – and cover with muscle the hole through which he was breathing, and he is now a great hero known as ‘the Prince of Wales’.”[9]

Nor was orthopedic inventiveness beyond the pale.  In fracture wards up and down the Front, war nurses were  adepts of the Balkan frames affixed to beds, virtuoso adjusters of the heavy weights and cables that maintained constant traction of fractured long bones suspended from above.  But they improvised as well.   Kate Derr provides an example of the ingenious contraption rigged up by war nurses for a soldier with badly damaged joints.  She wrote home from Vitry in April, 1917 of her “lastingly satisfactory” work on a soldier who had “double anthrotomie [deep lacerations] of the knees.”  She explained that

when he came the insteps were bent like a ballet-dancer’s.  Even admitting his recovery, which seemed impossible, he would be obliged to go about on the points of his toes, the knees being permanently stiff.   At first, after ‘peeling’ with every conceivable dissolvent, I began just the slightest effleurissage [circular stroking] which developed into massage, and then I invented an apparatus . . . A board about 14 inches square was padded with cotton and swathed neatly in a bandage.  This was laid vertical against the soles of the feet which I tried to place as nearly as possible in a normal position.  Then I attached a bandage (having no elastic, which would have been better) to the head rail of the bed on one side, passed it around the board and up the other side, fastening it again to the rail as taut as possible.  The knot was tightened twice a day.  Result – in two weeks those refractory feet had regained a proper attitude.[10]

Such dedication to severely injured patients persisted in the face of bombings that reached and sometimes destroyed the clearing stations and field hospitals in which the nurses worked.  Nurses too were casualties of war and disease.  In Belgium in the fall of 1917, enemy bombs destroyed the 58th General Scottish Hospital adjacent to Beatrice Hopkinson’s own 59th.  Hopkinson watched while orderlies from her hospital “stooped over bunches of twigs in various places and picked up something, putting it in the sheet.  They were the arms and legs and other pieces of the patients that had been bombed and blown right out into the [outlying] park.”[11]  Back in her own hospital, with bombs continuing to fall, she confided to her diary that “My knees just shook and, had I allowed it, my teeth would have rattled; but I had to be brave for my patients’ sake.  When they saw the womenfolk apparently without fear it kept them brave.”[12]

Nurses like Hopkinson, Warner, Luard, and Derr did not see themselves as brave.  Rather, their sense of duty was so powerful that it sequestered fear and compelled action in ways that would have been incomprehensible to their non-nursing selves.  “I never realized what the word ‘duty’ meant until this War,” Hopkinson remarked.  Hers was the courage of  the Hippocratic caregiver, who subordinates self-interest to the patient’s well-being.  For the nurses of WWI, such subordination extended to self-preservation itself.  I admire them because their sense of mission remained unswerving as moribund wards swelled and they failed, time and again, to “pull round” those too far gone to be pulled.  Living and working amid the bodies of those they failed to save – perhaps because they lived and worked among those they failed – the nurses remained certain of who they were and what they did.  They were vindicated by their calling.  Thus Kate Luard during the Battle of Arras in the fall of 1916:

There is no form of horror imaginable, on any part of the human body, that we can’t tackle ourselves now, and no extreme of shock or collapse is considered too hopeless to cope with, except the few who die in a few minutes after admission.[13]

And with the resolve to nurse on, even during bombing raids that imperiled them, came defiant resiliency.  The clearing stations right off the Front were, in the words of the American nurse and poet Mary Borden, the second battlefield – a battlefield littered with care giving paraphernalia that combatted and succumbed to the inexorability of death.  So why did the nurses labor on?  “He’s saved, and that makes up for much,” declaimed Kate Derr in the fall of 1915.  To which Kate Luard added her own gloss a year and a half later:

Some of us and Capt. B. have been having a bad fit of pessimism over them all lately, wondering what is the good of operations, nursing, rescues, or anything, when so many have died in the end.  But even a few miraculous recoveries buck one up to begin again.[14]

____________________

[1] [Kate Norman Derr] “Mademoiselle Miss”: Letters from an American Girl Serving with the Rank of Lieutenant in a French Army Hospital at the Front, preface by Richard C. Cabot (Boston:  Butterfield, 1916), 67.

[2] Helen Dore Boylston, Sister: The War Diary of a Nurse (NY: Ives Washburn, 1927), 237.

[3] Agnes Warner, ‘My Beloved Poilus’ (St. John: Barnes, 1917), loc 119,221, 324, 782.

[4] On the stench of gas gangrene, which suffused entire wards, see, for example, Edith Appleton, A Nurse at the Front:  The First World War Diaries, ed. R. Cowen (London:  Simon & Schuster UK, 2012), 194-95, 240:  “One feels the horrible smell in one’s throat and nose all the time.”

[5] Shirley Millard, I Saw Them Die: Diary and Recollections (New Orleans, LA: Quid Pro, 2011), loc 1192.  Even among gangrenous patients who survived, changing the dressings twice a day was an “agonizing procedure.”  Beatrice Hopkinson, Nursing through Shot & Shell: A Great War Nurse’s Story, ed. Vivien Newman (South Yorkshire: Pen & Sword, 2014), loc 409.

[6] John & Caroline Stevens, eds., Unknown Warriors:  The Letters of Kate Luard, RRC and Bar, Nursing Sister in France 1914-1918 (Stroud: History Press, 2014), loc 1790, 1704, 1713, 1722.

[7] Luard Letters, loc 306-315.  Sadly, ‘the Prince of Wales’ died several days later.

[8] Derr, “Mademoiselle Miss, p. 47.

[9] Luard Letters, loc 2232.

[10] Derr, “Mademoiselle Miss,” pp. 95-96.

[11] Plus ça change, plus c’est la même chose.  See Ann Jones’s graphic description of the work of army specialists in Mortuary Affairs who retrieve and bag body parts and liquefied innards of our fallen soldiers in Afghanistan.  Ann Jones, They Were Soldiers:  How the Wounded Return from America’s Wars – The Untold Story (Chicago: Haymarket, 2013), chapter 1 (“Secrets: The Dead”).

[12] Hopkinson, Nursing through Shot & Shell, loc 1442, 1498.

[13] Luard, Letters, loc 1273.

[14] Mary Borden, The Forbidden Zone (ed. H. Hutchison (London: Hesperus[1928] 2008), 83; Derr, “Mademoiselle Miss,”47; Luard Letters, loc 1767.

Copyright © 2017 by Paul E. Stepansky.  All rights reserved.  The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.

Remembering the Nurses of WW I (II)

“saving bits from the wreckage”

[The second of a series of essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917]

The term “blood bath” is always used metaphorically, even in its wartime sense of  a bloody massacre in which lives are lost.   Often it is used more loosely still, as in the crushing of opponents in sports or business or the purging of employees at a company.  “There Could Be a Bloodbath in Sports Media” reads one headline.[1]

For World War I nurses working in Casualty Clearing Stations (CCSs) and field hospitals on the Western Front, however,  blood bath could take on a startling literality.  Here is Beatrice Hopkinson writing in the fall of 1917 at the height of the fourth battle of Ypres (Passchendaele), after a general hospital close to her own took a direct hit.   She and an orderly began washing sheets and bedding of the bombed-out hospital in a big bath tub:  “Soon we seemed to be dabbling in a sea of blood.  When the lights were allowed on we looked at one another and we, too, looked as though we had been in a slaughterhouse.  Our clothing was blood stained up to our chins; arms and faces too.”  Things could be worse still in the operating room, which during major rushes became “a slaughter house,” a blood bath where ambulance drivers, aiding the exhausted nurses, “would seize a mop and pail and swipe up some of the blood from the sloppy floor, or even hold a leg or arm while it was sawn off.”[2]

Hours before the fate of wounded soldiers was decided, it was nurses – not emergency room physicians or combat-trained EMS providers – who triaged incoming wounded, determining which soldiers required emergency treatment for shock; which immediate surgery; which a ward bed to sleep and await treatment; and which quiet removal to the moribund tent to die.  Surgeons, who during battles might be operating 12-14 hours a day, had nothing to do with the process.  It fell to the trained nurses, the Sisters, to deploy what resources they had to do the sorting, and then to  stabilize as quickly as possible those wounded who could be stabilized.

What resources could they summon?  How, for example, did they identify wounded soldiers in shock?  Absent blood pressure meters and stethoscopes, much less lab studies and scans, they relied on their hands; their hands became instruments of differential diagnosis.  Here is Mary Borden’s powerful rendering of her work in the reception hut of a Belgium Casualty Clearing Station:

It was my business to sort out the wounded as they were brought in from the ambulances and to keep them from dying before they got to the operating rooms:  it was my business to sort out the nearly dying from the dying.  I was there to sort them out and tell how fast life was ebbing in them.  Life was leaking away in all of them; but with some there was no hurry, with others it was a case of minutes. . . . My hand could tell of itself one kind of cold from another.  They were all half-frozen when they arrived, but the chill of their icy flesh wasn’t the same as the cold inside them when life was almost ebbed away.  My hands could instantly tell the difference between the cold of the harsh bitter night and the stealthy cold of death.  Then there was another thing, a small fluttering thing.  I didn’t think about it or count it.  My fingers felt it.  I was in a dream, led this way and that by my cute eyes and hands that did many things, and, seemed to know what to do.[3]

Thus the hands-on method of recognizing what was termed, in the idiom of the time,  “wound shock.”  For soldiers who arrived off the battlefield in shock, it was nurses who sought to stabilize them by mastering the complicated procedure of pumping saline solution either subcutaneously or intravenously.  Why complicated?  The patients had to be kept warm, with saline kept at 120 degrees and air kept out of the tubes.  And the entire procedure had to be performed aseptically in huts or tents that, depending on the season, could be stifling or freezing.

Of course, soldiers off the Front might bleed out even before shock set in.  Blood transfusions were not available in WWI until the United States entered the war in 1917, bringing with it transfusion advocates like Boston’s Oswald Robertson, who was invited to British field hospitals to teach transfusion technique and also to show how citrated blood collected from Type O (universal) donors could be stored and shipped.  But even in large base hospitals, transfusion remained “a complicated job under the very best of circumstances.”[4]  It was never an option in most reception huts of CCSs and field hospitals.  So nurses managed hemorrhage with what they had:  artery compression, tourniquets, and a variety of constrictive bandages.  Skill and reaction time often determined whether soldiers even made it to the surgeons.  Following what stabilization the nurses could provide, surgical cases were rushed to the X-ray hut and then to the attached “theatre hut.” There surgeons relied on still other nurses, the “theatre sisters,” to assist them at the operating table.

Nurses’ role as surgical assistants usually continued  in the operating theatres of the  base hospitals to which survivors were subsequently sent for more extensive repair.  In the chaotic overflow of wounded that followed major battles, when as many as seven operating tables might be in continuous use around the clock for two weeks, they really had no choice.  “In ten days,” reported Helen Boylston from her front line field hospital in late March, 1917, “we have admitted four thousand eight hundred and fifty-three wounded, sent four thousand to Blighty [England], have done nine hundred and thirty-five operations.”  And then, with obvious pride,  “– and only twelve patients have died.”[5]

“One doctor and one nurse work at each table,” Julia Stimson wrote her parents from Base Hospital 21 near Rouen several months later,

and you can imagine what surgical work the nurse has to do, no mere handing of instruments and sponges, but sewing and tying up and putting in drains while the doctor takes the next piece of shell out of another place.  Than after fourteen hours of this, with freezing feet, to a meal of tea and bread and jam, and off to rest if you can in a wet bell tent in a damp bed without sheets, after a wash with a cupful of water.[6]

Even the auxiliary nurses were co-opted for surgical duty.  Kate Norman Derr, the well-off daughter of a former Medical Director in the U.S. Navy, was studying art in France when war broke out in 1914.  Resolved to aid the French cause, she volunteered at local hospitals before earning a nursing certificate from the French Red Cross.  In September, 1915 she reported to a French field hospital in the Marne Valley where, assigned to the operating ward, she assisted the surgeon in the 25 or more operations performed daily.  Horrified by the wounds she encountered, she nonetheless relished her newfound surgical identity.  “I think you would sicken with fright if you could see the operations that a poor nurse is called upon to perform,” she wrote her family, referring to “the putting in of drains, the washing of wounds so huge and ghastly as to make one marvel at the endurance that is man’s, the digging about for bits of shrapnel.  I assure you that the word responsibility takes a special meaning here.” For Derr, it was the struggle itself, “the sense that one is saving bits from the wreckage,” that shoved aside the sense of being “mastered by the unutterable woe.”[7]

Surgical technique was taught by surgeons who then relegated certain aspects of complex multi-wound operations to the nurses.  Shell fragments and shrapnel often lodged in different parts of a soldier’s body, in which case surgeons concentrated on the most penetrative, life threatening wounds while the nurses, forceps in hand, dealt with the more manageable, if far from minor, wounds.  The complex wound management that followed surgery, on the other hand, was almost entirely in the nurses’ hands.  It began once more in reception huts, where nurses determined which wounds required a surgeon’s attention and which they could handle themselves.  For smaller wounds – the term is relative – nursing care became surgical care:  nurses irrigated wound beds with saline solution and then debrided the wounds, using sterile probes to locate and remove shrapnel, bone fragments, embedded clothing, and debris.  Finally, they dressed the wound with the antiseptics then available – iodine, carbolic acid, hydrogen peroxide, perchloride of mercury, sodium hypochlorite, boracic acid, salicylic acid, chloride of zinc, potassium permaganate, either alone or in combination, in liquid or paste form.  Given the plethora of options and toxicity of the more effective antiseptics, choosing the optimal dressing for a particular soldier was no simple matter.

For soldiers with large and infected open wounds – the “gaping wounds” or “horribly bad wounds” or  “wounds so huge and ghastly of which the nurses wrote[8] – it was nurses who mastered the intricacies of the novel and highly effective Carrel-Dakin irrigation method, which saved countless lives and limbs.  Here a weak solution of sodium hypochlorite continuously circulated in the wound via a complicated setup in which a glass container fixed at the head of the bed fed tubes with four or five separate nozzles, each connected to another small rubber tube packed into a different part of the wound.  The whole affair was held in place with bandages and an adjustable clamp on the main tube to regulate the amount of antiseptic fed into the wound.[9]

Madame Carrel demonstrating the Carrel-Dakin method in a French field hospital in 1917

In cases of compound fracture, nurses themselves usually followed cleaning, irrigation, debridement, and wound dressings with splinting.  Back on the ward, with or without a surgeon’s assistance, they began Carrel-Dakin treatment and monitored the fractures, alert, for example, to obstructed circulation.  Taking these nursing activities in their totality, Christine Hallett has every reason to conclude that WWI nurses emerged from their European tours as wound care practitioners, adding that, in the rushes that  followed major battles, professional boundaries dissolved and their work merged with that of surgeons.[10]

Nurses of the Civil War were no less heroic, if in a different way.   They were heroic simply in overcoming the resistance of surgeons and military officers to their presence right off the battlefield, exposed to the naked bodies of wounded men.  They were heroic in battling corrupt quartermasters and stewards who withheld supplies and food parcels from the wounded, not to mention racist orderlies who brutalized the wounded, especially African-Americans.  And they were heroic in providing comfort care in the tradition of Florence Nightingale, struggling against the system to keep the wounded dry, warm, and adequately fed, “mothering” them with the same compassion as their granddaughters on the Front.

But Civil War nursing lacked the procedural underpinnings of Great War nursing.  There was no “scientific nursing” to do because scientific nursing only emerged after the war.  The authority they achieved was moral and occasionally administrative.  In the latter cases, when nurses became powerful Head Matrons and even founders of their own field hospitals, their authority was typically wrestled from surgeons and officers who never stopped hoping they would pack up and go home.  Nurses from elite families – Hannah Ropes, Sophronia Bucklin, Kate Cumming, Clara Barton – sounded off and got results.  But the results were moral, not professional, victories.  There was no system of triaging for nurses to implement; no protocol in place for cleaning and irrigating infected wounds with saline solution before dressing them with potent antiseptics.  Nor were Civil War nurses trained to perform minor surgery in reception tents or to assist surgeons in the operating tent.  Very occasionally, a Civil War nurse would rise above the morale-sapping gender prejudice of her camp and find herself alongside an operating surgeon, but she was the heroic exception to the rule.

The heroism of the nurses of WWI has to do with the manner in which they rose to their historical moment, bringing into their operational domain major developments in scientific medicine of the past half century.  Consider only the birth of bacteriology; the derivative understanding of antisepsis, asepsis, and sterilization; the development of antiseptics and serum therapy; and major advances in wound management and surgical technique.  These developments, conjoined in a combat workplace that relied on collegial staff relationships, enlarged nurses’ responsibilities in a procedural direction.  Unlike Civil War nurses, the nurses of World War I initiated medical treatments and performed medical procedures, and they did so without abandoning their traditional obligation to provide care that was calming, comforting, and reassuring.  Indeed, with the catastrophic wounding of body and mind made possible by World War I weaponry, the provision of comfort often deepened into supportive psychotherapy and end of life counseling.  Psychiatric nursing was born in the CCSs and field hospitals of WWI.  The well-trained nurse practitioners of today, empowered in many states to practice medicine (or is it “medicalized” nursing?) with little or no medical supervision, have nothing on their gallant forebears of a century ago.

____________________________

[1] http://thebiglead.com/2015/11/18/fanduel-draftkings-commercials-new-york-attorney-general.

[2] Beatrice Hopkinson, Nursing through Shot & Shell: A Great War Nurse’s Story, ed. Vivien Newman (South Yorkshire: Pen & Sword, 2014), loc 1434; N.A.,  A War Nurse’s Diary: Sketches from a Belgian Field Hospital (Cornwall, UK: Diggory, 2005), loc 805-820.

[3] Mary Borden, The Forbidden Zone (ed. H. Hutchison (London: Hesperus[1928] 2008), 95-96.

[4] Julia C. Stimson, Finding Themselves: The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 123.

[5] Helen Dore Boylston, Sister: The War Diary of a Nurse (NY: Washburn, 1927), loc 497.

[6] Stimson, Finding Themselves, 142.

[7] Kate Norman Derr, “Mademoiselle Miss”:  Letters from an American Girl Serving with the Rank of Lieutenant in a French Army Hospital at the Front, preface by Richard C. Cabot (Boston: Butterfield, 1916), 33.  My great thanks to Alan Kohuth for sending me his original copy of Dere’s letters.

[8] For example, Edith Appleton, A Nurse at the Front:  The First World War Diaries, ed. R. Cowen (London:  Simon & Schuster UK, 2012), 161, 203; Helen Dore Boylston, Sister: The War Diary of a Nurse (NY:  Washburn, 1927), loc 463; Derr, “Mademoiselle Miss,” 33.

[9] The Carrel-Dakin method was devised by Alexis Carrel, a French surgeon, and Henry Dakin, an English chemist, who met in the lab of a field hospital near the forest of Compiegne in France in late 1914.  Carrel developed the solution and Dakin devised the apparatus to deliver it.  The components of the solution, incidentally, had to be combined in a precise ratio to provide wound sterilization without causing tissue irritation – another procedural feat of the WWI nurses, who prepared and tested every batch of solution from scratch.  Their task was greatly simplified in 1917, when Johnson & Johnson of New Brunswick, New Jersey began producing the components in sealed ampoules and vials in the prescribed ratios.  Successful use of the method was reported in several articles in the British Medical Journal during the final years of the war.  One in particular paid tribute to the Sisters, “whose careful attention to detail largely contributed to the success obtained in the use of the Carrel-Dakin method.”  J. S. Dunne, “Notes on Surgical Work in a General Hospital – With Special Reference to the Carrel-Dakin Method of Treatment,” BMJ, 2:283-284, 1918, quoted at 284.

[10] Christine E. Hallett, Containing Trauma:  Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 56-59, 46.  Anyone writing about nursing in World War I owes an enormous debt to Hallett, whose two exemplary studies, Containing Trauma (op. cit.) and Veiled Warriors: Allied Nurses of the First World War (NY: OUP, 2014) provide far greater detail of each of the nursing activities I touch on here.

Copyright © 2017 by Paul E. Stepansky.  All rights reserved.  The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.

Remembering the Nurses of WWI (I)

“Real war at last.  Can hardly wait.  Here we go!”

[The first of a series of essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917]

It was the all-too-common story of the WWI nurses, the narrative thread that linked the vagaries of their wartime experiences.  The war was to be the adventure of a lifetime. The opportunity to serve on the Western Front was not to be missed, not by hospital-trained nurses and not by lightly trained volunteer nurses.  For both groups, the claim of duty was suffused with the excitement of grand adventure.  Beginning in the spring of 1917, the war abroad was the event of the season.  Julia Stimson, a Vassar graduate who, as superintendent of nursing at Barnes Hospital, led the St. Louis base hospital unit to Europe in May, 1917, was overwhelmed with the honor bestowed on her and the opportunities it promised.  “To be in the front ranks in this most dramatic event that ever was staged,” she wrote her mother, was “all too much good fortune for any one person like me.”  For 28-year-old Shirley Millard, a Red Cross volunteer nurse from Portland, Oregon rushed to a field hospital near Soissons in March, 1918, the prospect of nursing work at Chateau Gabriel, close to the Front, was a dream come true:  “It is so exciting and we are all thrilled to have such luck.  Real war at last.  Can hardly wait.  Here we go!” “I haven’t the least fear or worry in the world.  Am ready for anything,” averred Minnesotan Grace Anderson, a reserve nurse and nurse-anesthetist who embarked from New York harbor in July, 1918.  Serving in a base hospital or, more exciting still, in a field hospital or casualty clearing station only miles from the Front, was to be invited to the Grand Cotillion.  Volunteer and army nurses alike were typically well-bred young women of substance, often upper-class substance. They were adventuresome and patriotic and given over to a sense of  duty informed by literary culture, not battlefield experience.  So they experienced  happiness on receiving the call; they would make their families proud.[1]

But their sense of exhilaration at being invited to the Patriotic Ball quickly gave way to stunned amazement at the “work” before them.  The wounds of French, British, and, soon enough, American troops were literally unimaginable to them and then, in the fevered atmosphere of post-battle “rushes,” wrenchingly imaginable, indeed omnipresent. They grew familiar with the horrid stench of gas gangrene, which crackled beneath the surface of the infected body part or parts and almost always presaged quick death. Under the mentoring of senior nurses, the Sisters, young American women learned how to prep patients for surgery.  In the process, they encountered cases in which “there are only pieces of men left.”  And yet, having no choice, they quickly made their peace with the stumps of severed limbs and concavities of missing stomachs, faces and eyes and began to help clean, irrigate, and dress what remained, before and after surgery, if surgery could even be attempted.  Like their seniors, they learned to remain unflinching in the face of the many soldiers who arrived “unrecognizable as a human being.”  And they retained composure before soldiers as young as sixteen or seventeen  — “children,” they would say — who arrived at Casualty Clearing Stations (CCSs) caked in mud and blood and covered with lice – children with three, five, nine, even eleven wounds.  They learned to accept that many soldiers would die in a matter of hours or days, but to join this realization to an obligation to provide what comfort they could.  They ended up working hard to keep the dying alive long enough to warm up and pass under morphine and chloroform, all the while holding their nurse-mother’s hand.[2]

They could not operate on Rochard and amputate his leg, as they wanted to do.  The infection was so high, into the hip, it could not be done.  Moreover, Rochard had a fractured skull as well.  Another piece of shell had pierced his ear, and broken into his brain, and lodged there.  Either wound would have been fatal, but it was the gas gangrene in his torn-out thigh that would kill him first.”[3]

Here is  “a poor youngster with both legs broken, both arms wounded, one eye shot out and the other badly damaged,” there a “poor lad” who “had both eyes shot through and there they were, all smashed and mixed up with the eyelashes.  He was quite calm, and very tired.  He said, ‘Shall I need an operation?  I can’t see anything’.”  Within a week of arrival at her field hospital, Shirley Millard wrote of “bathing [a soldier’s] great hip cavity where a leg once was,” while “a long row of others, their eyes fastened upon me, await their turn.  And she followed with the kind of litany offered by many others:  “Gashes from bayonets. Flesh torn by shrapnel.  Faces half shot away.  Eyes seared by gas; one here with no eyes at all.  I can see down into the back of his head.” Helen Dore Boylston, an MGH-trained nurse who served with the Harvard Medical Unit from 1915 on, presents an indelible image that affected her for life and  affects us still:

There were strings of from eight to twenty blind boys filing up the road, clinging tightly and pitifully to each other’s hands, and led by some bedraggled limping youngster who could still see . . . I wonder if I’ll every be able to look at marching men anywhere again without seeing those blinded boys, with five and six wound stripes on their sleeves, struggling painfully along the road.[4]

A soldier with gangrenous wounds oozing everywhere might morph into a “mass of very putrid rottenness long before he died.”  Such was the experience of Edith Appleton, who continued:  “The smell was so very terrible I had to move him right away from everyone, and all one could do was dress and redress. Happily I don’t think he could smell it himself but I have never breathed a worse poison.”[5]

All too soon after arrival, then, the cheery young American nurses beheld the fearless young soldiers – or remnants thereof – who came to clearing stations and base hospitals in funereal processions of ambulances. The fearless young men had become “wretched, restless beings.”  For Shirley Millard, “The crowded, twisted bodies, the screams and groans, made one think of the old engraving in Dante’s Inferno.  More came, and still more.”  In Helen Boylston’s field hospital, a “rush” during the German offensive of late March, 1918 brought 1,100 wounded to her base hospital in 24 hours, with three operating teams performing some 90 emergency operations that night and the nights to follow.  The operating room nurse, she recalled, “walked up and down between the tables with a bottle of aromatic spirits of ammonia in one hand and a bottle of brandy in the other, ready to pounce on the next person who wilted.” At Beatrice Hopkinson’s CCS 47, just outside Amiens, the situation was even worse.  During the March rush many thousands of patients passed through the doors in only a few days and kept seven operating tables working day and night.[6]

And so the narratives captured in these diaries, journals, and memoirs turn a corner into blackness, as the nurses themselves undergo a kind of existential decomposition.  The volunteer nurses in particular, many little older than the combatants, became war-weary and war-wise in ways that choked off the childish exhilaration with which they had embarked. They found themselves at the threshold of their own nonnegotiable no-woman’s land. The nurse, wrote Mary Borden in The Forbidden Zone,

is no longer a woman.  She is dead already, just as I am – really dead, past resurrection.  Her heart is dead.  She killed it.  She couldn’t bear to feel it jumping in her side when Life, the sick animal, choked and rattled in her arms.  Her ears are deaf; she deafened them.  She could not bear to hear Life crying and mewing.  She is blind so that she cannot see the torn parts of men she must handle.  Blind, deaf, dead – she is strong, efficient, fit to consort with gods and demons – a machine inhabited by the ghost of a woman – soulless, past redeeming, just as I am – just as I will be.[7]

Nurses bore up, but in the process many were ground down, their pre-war values pulverized into dust.  Comprehending trench warfare in bodily perspective, they became freighted with the pointlessness of the horror, the multitude of mutilated, infection-saturated, and lifeless young bodies.  It was, for Helen Boylston, less tragic than unutterably stupid.

Today a ditch is full of Germans, and tomorrow it is full of Englishmen.  Neither side really wants the silly muddy ditch, yet they kill each other persistently, wearily, ferociously, patiently, in order to gain possession of it.  And whoever wins, it has won – nothing.[8]

They pondered the paradox of pain – the impossibility of knowing its nature in another along with the inability to nurse without imagining it.  They grew into a capacity for shame – shame in  their own strength, in their ability to stand firm and straight alongside a bedside “whose coverings are flung here and there by the quivering nerves beneath it.”  They empathized with shell-shocked patients who, having endured the prospect of “glorious death” under the guns, were sent home “to face death in another form. Not glorious, shameful.”  And finally there was the shame, thinly veiled, attendant to witnessing the unremitting pain of the dying.  “No philosophy,” reflected Enid Bagnold, “helps the pain of death.  It is pity, pity, pity, that I feel, and sometimes a sort of shame that I am here to write at all.”[9]

And then, as hostilities drew to a close, there were the larger reflections, the alterations of life philosophy that grew out of nursing their boys. For Helen Boylston,

The war has done strange things to me.  It has given me a lot and taken away a lot.  It has taught me that nothing matters, really.  That people do not matter, and things do not matter, and laces do not matter, except for a minute.  And the minute is always now.[10]

For Shirley Millard, Armistice Day and the immediate dismissal of her unit of volunteer nurses marked her epiphany:

Only then did the enormous crime of the whole thing begin to come home to me.  All very well to celebrate, I thought, but what about Charley?  All the Charlies? What about Donnelly, Goldfarb, Wendel, Auerbach? And Rene?  And the hundreds, thousands of others.”[11]

The enormity of the crime and the absurd reasoning that justified it coalesced in the wartime essays of Ellen LaMotte and Mary Boyden, one recurrent theme of which is the impossibility of a good death in war, where the very effort to “restore” bodies and minds that are shattered, literally and figuratively, becomes oxymoronic.  War, they insist, occurs in an alternate universe where any claim to morality is, from the standpoint of ordinary life, self-willed delusion.  In this universe, surgeons function as cavalier automatons and even life-saving surgery is specious, because the lives saved, more often than not, are no longer human lives, psychologically or physically. In this alternate universe, death withheld, ironically, is the ultimate act of inhumanity.[12]

What makes the nurses of World War I gallant is that so many of them were able to bracket their encroaching horror, with its undercurrents of anger, depression, and numbing – and simply care for their patients.  They were able to function as nurses in a nurses’ hell.  Military directives pushed them to an even lower circle of the Inferno, since the nurses’ primary task, they were told over and over, was to get injured troops back to the Front as soon as possible.  They were to fix up serviceable (and hence service-able) soldiers so that they could be reused at least one more time before breakdown precluded further servicing and the soldier’s obligation to serve further.

But the nurses knew better and unfailingly did better.  Nursing practice, it turns out, had its own moral imperative, so that military directives were downplayed, often cast to the wind.  As the nursing historian Christine Hallett observes, the emotional containment nurses provided for suffering and needy soldiers did not – indeed could not – preclude caring.[13]  In essays to follow, I hope to explore further the remarkable elements of this caring, which blurred the boundary between comfort care and healing and took nursing practice into the domains of emergency medicine, infectious disease management, surgery, and psychotherapy.  It is as agents of care and caring that the nurses of World War I rose to the status of gallants.  Flying in the face of military priorities and surgical fatalism, they bravely dispensed cure in a manner true to the word’s etymology, the Latin curare, a taking care of that privileges the patient’s welfare above all else.

_____________________

[1] Julia, C. Stimson, Finding Themselves: The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 3-4.; Shirley Millard, I Saw Them Die: Diary and Recollections, ed. E. T. Gard (New Orleans: Quid Pro, 2011), location in Kindle edition (loc), 388; Shari Lynn Wigle, Pride of America: The Letters of Grace Anderson, U.S. Army Nurse Corps, World War I (Rockville, MD: Seaboard, 2007), 9.

[2] Agnes Warner, ‘My Beloved Poilus’ (St. John: Barnes, 1917), loc 75; Beatrice Hopkinson, Nursing Through Shot & Shell: A Great War Nurse’s Story, ed. V. Newman (South Yorkshire: Pen & Sword, 2014), loc 1425; Helen Dore Boylston, Sister: The War Diary of a Nurse (NY: Washburn, 1927), loc 463; Enid Bagnold, A Diary Without Dates (London: Heinemann, 1918),  125: “Among his eleven wounds he has two crippled arms.”

[3] Ellen N. La Motte, The Backwash of War: The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse (NY: Putnam’s, 1916), 51-52.

[4] Edith Appleton, A Nurse at the Front: First World War Diaries, ed. R. Cowen (London: Simon & Schuster UK, 2012), 138, 161; Millard, I Saw Them Die, loc 428; Boylston, Sister, loc 463.

[5] Dorothea Crewdson, Dorothea’s War: A First World War Nurse Tells her Story, ed. Richard Crewdson (London: Weidenfeld & Nicolson, 2013, 2013), loc 1189; Appleton, Nurse at the Front, 189.

[6] Crewdson, Dorothea’s War, loc 1192; Millard, I Saw Them Die, loc 388; Boylston, Sister, loc 1101; Hopkinson, Nursing Through Shot & Shell, loc 1719, 1780.

[7] Mary Borden, The Forbidden Zone, ed. H. Hutchison (London: Hesperus, 1928/2008), 44.

[8] Boylston, Sister, loc 648.

[9] Bagnold, Diary without Dates, loc 25, 104; LaMotte, Backwash of War, 139.

[10] Boylston, Sister, loc 1373.

[11] Millard, I Saw Them Die, loc 1562.

[12] All the brief essays in LaMotte’s The Backwash of War and Borden’s The Forbidden Zone circle around these and related themes.  Among them,  I was especially moved by LaMotte’s  “Alone,” “Locomotor Ataxia,” and “A Surgical Triumph,”  and Borden’s “Rosa,” “Paraphernalia,” and “In the Operating Room.”

[13] Christine E. Hallett, Containing Trauma:  Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 177.

Copyright © 2017 by Paul E. Stepansky.  All rights reserved.

Food and Candy

No one leaves Montclair’s Human Needs Food Pantry without food.  Even folks from surrounding communities who are not among our registered clientele leave with a bag of groceries, a loaf of bread, often a pastry or a half gallon of juice, and an item or two from the table of donated cans and cartons adjacent to the check-in desk.  Mike sees to it.  He fills out an emergency food slip for anyone who comes through the door.  Then he explains what info the person needs to bring back to him (e.g., a rent receipt) to qualify for weekly groceries. Mike writes out such a slip for one man who brings it to me.  After I tell him that, in addition to his bag of food, he may also take two items from the table and a loaf of bread from the rack, he looks me straight in the eye, squeezes my hand, and with disarming directness says:  “Thank you for feeding me.”

Mike is the director and one of the good guys.  His associate Janet is another remarkably good and caring person.  Mike is a retired police chief who knows all about hunger and need.  I man the front desk, greeting our clients, many now by name, retrieving their file cards, filling out the sign-in forms, and telling them how many supplementary items they may take from the adjacent table and how many breads they may take from the bread rack on the opposite wall.  Then I yell out to Chris the size of the household so that he knows how many bags of groceries to place on his table for them.  I do this over 120 times during a three-hour shift.  Earlier in the day, before the pantry opens its doors to social workers at 12 and then to clients at 12:30, my wife Deane and I wait while Tyrell loads our SUV with the bags we will deliver to our list of clients unable to make it to the pantry – the elderly indigent, sometimes bedridden, often living alone.

This is my world every Tuesday, when I stop trying to understand the connection between medical history and present-day health care and seek out connection with people who need food and all kinds of care, medical and otherwise.  Some future historian can try to place my experience in sociohistorical context.  I simply want to give them food, to ask them how they’re doing, to tell them their children are beautiful, and to wish them a good week.

There is something primal about giving food to people who need it and appreciate getting it, people who are down on their luck but not down on their lives.  “How are you,” I ask the people I serve.  “I am blessed,” they sometimes reply.  Working at the pantry has helped me reengage issues that have nothing to do with scholarly writing, to reorder my priorities in a life-affirming way.  At a time when American political discourse has, in a different, twisted way, turned primal, hateful, exclusionary, it takes me to a place where real-world suffering can be addressed one family at a time through food and the nutrient of human connection.

Giving food to people is cleansing.  It changes the way one feels about food, even the way one shops and eats.  More importantly, it enlarges one’s sense of shared humanity with the low-income folks in one’s own community, almost all of whom, I have found, are dignified, convivial, and grateful.  It takes me away from the sickening world of Donald Trump, whose inborn caring instincts flattened out long ago under the weight of narcissistic bloat.  Our clients offer me a smile, a fist bump, a hand shake, occasionally a hug.  They touch me with their hands but also with their eyes and their words.  They ask me how I’m doing, and – knowing that I am a volunteer – thank me for doing this work, which, some tell me, is “the Lord’s work.”  I do not know these people outside the food pantry.  But within its walls, they are admirable – veterans, working single moms, unemployed or underemployed dads, the disabled, the down on their luck, the elderly indigent, the recently incarcerated.

Yes, we touch one another, and an offering of food and candy is the conduit to the touching.  There is nothing extraordinary about food-mediated touch – it happens all the time, not only in the real world but in the world of medicine as well.  Even Freud, who wanted the psychoanalyst to be as emotionally detached from his patients as the operating surgeon, invited many of his patients to lunch and dinner; he even fed his aristocratic Russian patient Sergei Pankejeff (aka the “Wolf Man”) during their analytic sessions.  Doctors of our own time occasionally give needy patients food or money when food stamps have run out, and it becomes a matter of choosing between food and medication co-pays.  Even nonprofits have gotten into the act.  Through the Fruit and Vegetable Prescription Program (FVRx), for example, physicians now write fresh produce scripts for their low-income patients to fill at local farmers markets.[1]

A tiny Asian woman, well into her 70s but wondrously youthful, marches up to the desk each week and, with warm-hearted brio, greets my coworker and me with:  “Hello beautiful woman and most handsome gentleman.”  When she becomes ill and her neighbor comes to pick up her food, I always send her my love, and when she finally returns some months later, I walk around the desk and we hug. The smiles of some of the  women captivate me, I admit it.  I have complimented several of them so often that they come to the desk smiling and laughing, knowing I will gaze at them for an extra second before turning to my file box.  We have established rapport through a smile and a fleeting gaze of appreciation – an expression of my own gratitude to these women who come to us for food. When I remark to another woman how pretty she looks in her stylish jacket and hat, she almost breaks down, telling me she can’t remember when anyone last paid her a compliment, and that I have made not only her day but her week.

My exchanges with my friend Herb are of a different sort.  He is one of our regulars for whom the pantry is a place not only to receive food but to linger and socialize – a convivial time-out from the lives they will return to. We all know who these folks are and, to a person, we accept their prolonged visits, talk to them supportively, and let them feel at home with us.   At one point Herb shared his multiple health concerns with me, and I responded with, as they say, advice and sympathy.  Herb is, inter alia, an unhappy diabetic, chafing under the weight of seriously poor numbers and recent medical injunctions about diet and lifestyle.  Being an insulin-dependent diabetic myself, I warm to Herb’s plight, and we begin an ongoing dialogue about being diabetic.  But Herb remains irreconcilable and, as if to put the cherry on the icing of his medical misery, he waits for me outside the pantry one day with his most recent medical labs in hand.  Will I look at the report and tell him what it means?  Well, Herb, I’m not a doctor, but sure, why not, let’s take a look at your numbers and see how you’re doing.  Now, a year later,  Herb still takes candy from the basket when he arrives at the desk, but now he looks at me and asks, either with his words or his eyes, how many he may take.   Diabetic self-control was not built in a day.

It is the children especially who affect me.  They come with their mothers or fathers or grandmothers, the babies and toddlers in strollers, the older kids standing patiently in line with the adults.  They usually wait for more than an hour to sign in. When candy or snack bars come our way, we place them in a basket on the desk and – with the adult’s permission – ask the children to help themselves.  But what happens when we have none?  I solved the problem by bringing with me each week a large bag of candy – starbursts and skittles are special favorites – and offering every child a small handful.  I always check with the moms, but with only a few exceptions over the years, they always smile, tell me its fine to give their children candy, and thank me.  I do not have the impression these kids eat candy on a regular basis.  So I become the pantry’s “candy man,” the dispenser of goodies, and the kids are (perhaps) a tad more accepting of the long wait in line, knowing that a special treat awaits them at the desk they will finally arrive at.

A little girl of four, virtually Dickensian in her placid soulfulness, stands silently by my side as I write furiously to complete her mother’s paperwork.  Then, without uttering a word, she lightly places a finger on my forearm.  “I know you’re here, sweetheart,” I remark as I continue to write at breakneck speed.  “As soon as I’m done with Mom’s form, I’ll give you some candy.”  And she waits, and I give her the candy, and she thanks me, takes her mother’s hand, and is off to the counter for their food bags.  I wish a young man of nine or ten a good school year and extend my hand.  He takes it and looks up mildly startled because the hand that clasped his own is filled with starbursts.  Another little girl is so exhilarated with her handful of starbursts that she runs around the pantry, crying out for all to hear, “I have a cherry, and I have a grape, and I have a lemon, and I have an orange.”  A little fellow of six or seven stares long and hard at the large basket of candy on the desk and gingerly takes a single small piece.  “Take more,” I urge him. “Take a few.  Go ahead.”  “No, it’s okay,” he replies.  “One is enough.”  But it’s not, not on my watch.  So I tell him to come around the desk where I am sitting and reach back for my big bag of candy, and then I instruct him, warmly but firmly, to take a handful.  He seems momentarily confused, but then slowly, deliberately, reaches down into the bag and emerges with a handful of treats.  “See,” I tell him, “that wasn’t so hard, was it?”  To which he leans in closely and whispers into my ear, “I only took a little handful.”

Giving food to adults and candy to children is no small matter.  It is a relational cement that binds us to others.  When friends or relations or colleagues or acquaintances experience major life events, good or bad, we send them food baskets.  When we want to acknowledge a special kindness or favor, we send food.  We express condolences through food, and we express loving gratitude as well.  Growing up the son of a beloved small-town family doctor in the 1950s and ’60s, I well remember the steady flow of home-baked goods that transformed our kitchen into a bakery every holiday season.  The cakes, pies, and cookies not only expressed gratitude for medical care; they reaffirmed a human connection made tangible through the very sweetness of their baked offerings.  As such, they affirmed my father in his calling as physician and healer.  So it is with the children at the food pantry.  When we offer a low-income child a bit of candy, we convey our appreciation of the child’s essential rightness and affirm the beautiful potential that inheres in this or that child, which is to say in any child.

So here is my advice to anyone repulsed by what has passed as presidential politics these past several months.  Go to your community food pantry or food bank or soup kitchen and become a volunteer.  Connect with the adults and connect with the children, and make sure to bring your own candy to give the kids.  Enter their lives and learn from them about your own.  In giving food to those who need it, you will feed your own humanity, and it is arguable which party to the transaction goes home better nourished.

________________________________

[1] See  Danielle Ofri, “When Doctors Give Patients Money” (http://well.blogs.nytimes.com/2014/01/30/when-doctors-give-patients-money/?_r=0) and Sally Wadyka, “Food as Medicine:  Why Doctors are Writing Prescriptions for Produce” (http://blog.foodnetwork.com/healthyeats/2015/03/26/food-as-medicine-why-doctors-are-writing-prescriptions-for-produce/).

Copyright © 2016 by Paul E. Stepansky.  All rights reserved.

PRAISE FOR PAUL STEPANSKY’S  IN THE HANDS OF DOCTORS: TOUCH AND TRUST IN MEDICAL CARE  (PRAEGER, 2016).

       “This book takes many conversations occurring in the world of medicine and reframes them in historical perspective. The result is a body of work with pearls of wisdom strung between the pages. . . . In the Hands of Doctors is an engaging and relevant read for anyone interested in the nuances of the doctor-patient relationship; a historical framework for understanding today’s questions in the medical humanities; or a thoughtful narrative on cultivating humanity in the modern practice of medicine.”   – Ali Rae, review on the website of The Arnold P. Gold Foundation

       “An engaging, richly documented, brilliant critique of the bond between doctor and patient, ranging from classical times through the present. The need for the bond continues, Stepansky argues; patients trust doctors, not teams, medical homes or health care systems. . . . This is a superb introduction to the role of the doctor in a continuing historical context.”- Rosemary Stevens, Ph.D., DeWitt Wallace Distinguished Scholar, Weill Cornell Medical College

       “Paul Stepansky’s In the Hands of Doctors is a unique and compelling reexamination of American medical practice and patient expectations in historical and cultural context.  Examining the many ways in which we seek health, literally from the doctor’s touch, Stepansky draws on his skills as a respected cultural historian and his perspective growing up the son of a rural general practitioner in the 1950s and 1960s. The result is a multilayered, nuanced, and accessible study that focuses on what physicians have offered and patients have sought, especially since the Second World War. . . . This book deserves a wide audience not only of health practitioners and patients, but also of medical historians and medical humanities scholars.” – Howard I. Kushner, Ph.D., Nat C. Robertson Distinguished Professor, Emeritus, Rollins School of Public Health, Emory University

available from Amazon.com and other online sellers

Patient Ratings and ER Burnout

[You can now preorder Dr. Stepansky’s new  book, In the Hands of Doctors:  Touch and Trust in Medical Care,** at Amazon.com]

The lot of ER physicians is not an easy one, and their tendency to early-career burnout, relative to physicians in other specialties, has been well documented over the past quarter century.  Surveys show that a majority of ER Docs (usually around 60%) report moderate to high degrees of burnout, of which feelings of emotional exhaustion and depersonalization along with a low sense of personal accomplishment are all components.[1]  In recent years their “burnout syndrome” has been aided and abetted by the unregulated patient ratings services that glut the internet.

How has this come about?  It results from the fact that salaried ER Docs working in hospital emergency rooms face a ratings-related predicament inapplicable to colleagues outside hospital walls.  To wit, the hospitals that employ and pay ER Docs  are now obligated to survey discharged patients on their hospital experience, and this includes patients discharged from hospital emergency rooms.  So ER Docs are  participants in a development that has come to embrace inpatient hospital care in general.  In the U.S., beginning in 2006, hospital patients have, on discharge, been asked to complete the 27-item “Hospital Consumer Assessment of Healthcare Providers and System” (HCAHPS) survey, with the understanding that the survey was designed to provide data about patients’ perspectives on care that can be compared among hospitals and, in so doing, create incentives for hospitals to improve quality of care.[2]  For ER units, the American Board of Emergency Medicine’s Maintenance of Certification requirement of a “communication/professionalism activity” can become an additional circle of ratings hell.  It may include collection of patient feedback (e.g., Press-Ganey scores), and if the feedback is not sufficiently positive, the unit’s contract may be in jeopardy.[3]

More onerously still, a portion of ER Docs’ compensation may be tied to the “quality” of services they provide, with such quality linked to the patient ratings they receive.  This means that ER Docs are under mounting pressure to send happy ER patients off into the survey-ready night.  And happy ER patients, unsurprisingly, are those whose pain has been taken to heart, and whose ER Docs have ordered the studies and prescribed the meds the patients’ themselves know they require.

This development is not anecdotal and is borne out by recent surveys that attest to the tendency of ER Docs to overprescribe and order unnecessary studies in order to send happier patients out of ER rooms to the patient-satisfaction forms that await them.  And the tendency to give way to patient insistence on inappropriate care has been consequential:  it has led to dramatically inflated costs to Medicare among patients who make ER visits.  And here is the irony:  high patient satisfaction ratings by patients have not been shown to correlate with measurable indices of higher quality care.  A 2012 survey of 52,000 respondents to the national Medical Expenditure Panel Survey by researchers at the University of California, Davis, for example, showed that over a seven-year period (2000-2007) respondents in the highest patient satisfaction quartile not only spent more on prescription drugs, but were 12% more likely to be admitted to the hospital.  They also accounted for 9% more in total health care costs than survey respondents who did not give their providers such stellar ratings.[4]

For ER patients, especially, the kind of “patient satisfaction” associated with surveys is not the “satisfaction” associated with patient-centered care, much less long-term trusting relationships rooted in procedural and expressive touch.  Rather, it is a commodified, point-of-service satisfaction that revolves around pain management and brings in its wake another irony:  ER Docs reliant on happy patients who give them positive ratings are, to their own dismay, becoming less concerned with patients’ compliance with their medical directives (now “recommendations” or “suggestions”) than with their own compliance with their patients’ expectations.  And patients, in turn, increasingly rely more on met expectations than on objective medical outcomes in rating their doctors.

The predicament of ER Docs amplifies a general trend in primary care, where office visits are brief and pressure on clinicians to maximize “throughput” (i.e., to see as many patients as possible during office hours) is intense.  In doctors’ offices, as in emergency rooms, there is pressure to make patients happy by, for example, prescribing addictive opioids rather than taking the time to discuss alternative treatments.  So ER Docs and PCPs alike are in a tightening bind:  their desire to satisfy patients and avoid poor satisfaction scores may trump medical judgment, in which case they “may find themselves in the role of ‘customer service’ providers rather than medical professionals or healers.”[5]  Unsurprisingly, we have a new round of survey data on burnout syndrome that adds a new burnout factor to those documented in the 1990s:  the association between utilization of patient satisfaction surveys, on the one hand, and job dissatisfaction and attrition among physicians, especially ER and primary care physicians, on the other.[6]  An online survey of over 700 ER doctors reported in Emergency Physicians Monthly, for example,  found that 59% of the ER Docs admitted increasing the number of tests they ordered because of patient satisfaction surveys.  When the South Carolina Medical Association asked its members whether they ever ordered a test they felt was inappropriate because of such pressure, 55% said “yes,” and nearly half of the 131 respondents admitted improperly prescribing antibiotics and narcotics in direct response to patient satisfaction surveys.[7]

So let’s end this dismal reportage by noting a final unsettling irony.  We now face a veritable epidemic of opioid addiction for which the emergency room has become ground zero.  Between 2004 and 2011, visits to ERs for misuse or abuse of prescription opioids increased 153%.  And yet, at the very moment in history that the nation belatedly confronts this epidemic, with states, state-wide hospital organizations and, most recently, the Center for Disease Control (CDC) all issuing restrictive guidelines for prescribing painkillers such as Vicodin and OxyContin,[8] we have ER Docs and their colleagues in primary care reaching for prescription pads in their quest for happy (or happy enough) patients who will give them a favorable nod and let them move on to the next patient.  These Docs are not overprescribing with reckless abandon.  Far from it.  The surveys all suggest they are miserable overprescribers boxed into a corner by throughput pressures  and the addictive quest for positive ratings.

_________________________

[1] K. L. Keller & H. J. Koenig, “Management of stress and prevention of burnout in emergency physicians,” Ann. Emerg. Med., 18:42-47, 1989; S. Lloyd, et al., “Burnout, depression, life and job satisfaction among Canadian emergency physicians,” J. Emerg. Med., 12:559-565, 1994; R. Goldberg, et al., “Burnout and its correlates in emergency physicians: four years’ experience with a wellness booth,” Acad. Emerg. Med., 3:1156-1164, 1996.

[2] See “The HCAHPS Survey – Frequently Asked Questions” (https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/downloads/hospitalhcahpsfactsheet201007.pdf).

[3] E. Schwarz, “The CDC Weighs In With Opioid Prescribing Guidelines,” Emergency Physicians Monthly, March 30, 2016 (http://epmonthly.com/article/the-cdc-weighs-in-with-opioid-prescribing-guidelines/).

[4] J. J. Fenton, et al., “The Cost of Satisfaction:  A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality,” Arch. Intern. Med., 172:405-411, 2012.

[5] J. T. Chang, et al., “Patients’ global ratings of their health care are not associated with the technical quality of their care,”  Ann. Intern. Med., 144:665-672, 2006; D. S. Lee, et al., “Patient satisfaction and its relationship with quality and outcomes of care after acute myocardial infarction,” Circulation, 118:1938-1945, 2008; A. Zgierska, M. Miller, & D. Rabago, “Patient satisfaction, prescription drug abuse, and potential unintended consequences,” JAMA, 307:1377-1378, 2012, quoted at 1378; A. Lembke, “Why doctors prescribe opioids to known opioid abusers,” N. Engl. J. Med., 367:1580-1581, 2012.

[6] A. Zgierska, D. Rabago, & M. M. Miller, “Impact of patient satisfaction ratings on physicians and clinical care,” Patient Prefer. Adherence., 8:437-446, 2014.

[7] These studies are cited by Kai Falkenberg in “Why rating your doctor is bad for your health,” Forbes, January 21, 2013 (http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health). 

[8] “Doctors told to avoid prescribing opiates for chronic pain” (http://www.usatoday.com/story/news/2016/03/15/cdc-issues-new-guidelines-opiate-prescribing-reduce-abuse-overdoses/81809704/).

Copyright © 2016 by Paul E. Stepansky.  All rights reserved.

__________________________

**ADVANCE PRAISE FOR IN THE HANDS OF DOCTORS

 

“An engaging, richly documented, brilliant critique of the bond between doctor and patient, ranging from classical times through the present. The need for the bond continues, Stepansky argues; patients trust doctors, not teams, medical homes or health care systems. Along the way he discusses what it means to “care” for someone as a professional, whether empathy can be taught, the narrowed scope of family medicine as a field, and how far science and the procedural aspects of medicine are antagonistic to, or simply part of, the humanity inherent in medicine. He offers his own ideas for change. This is a superb introduction to the role of the doctor in a continuing historical context.”- Rosemary Stevens, Ph.D., DeWitt Wallace Distinguished Scholar, Weill Cornell Medical College; author, American Medicine and the Public Interest: A History of Specialization and A Time of Scandal: Charles R. Forbes, Warren G. Harding and the Making of the Veterans Bureau

“Paul Stepansky’s In the Hands of Doctors is a unique and compelling reexamination of American medical practice and patient expectations in historical and cultural context.  Examining the many ways in which we seek health, literally from the doctor’s touch, Stepansky draws on his skills as a respected cultural historian and his perspective growing up the son of a rural general practitioner in the 1950s and 1960s. The result is a multilayered, nuanced, and accessible study that focuses on what physicians have offered and patients have sought, especially since the Second World War.  Stepansky laments the impact of specialization on what he terms “true doctoring,” even while recognizing its great benefit in treating illness.  Eschewing nostalgia, while acknowledging the complexity of today’s health care delivery, Stepansky nevertheless offers a way back to the type of care his father provided.  This book deserves a wide audience not only of health practitioners and patients, but also of medical historians and medical humanities scholars.” – Howard I. Kushner, Ph.D., Nat C. Robertson Distinguished Professor, Emeritus, Rollins School of Public Health, Emory University

“In the Hands of Doctors is an original contribution to medical history and, in addition, a book that will appeal to all those in the caring professions: psychotherapists, psychiatrists, psychologists, social workers, nurse practitioners, and others.  Dr. Stepansky gives new meaning to the roles of touch, empathy, and friendship as these are involved in medical practice, and he presents original ideas about the shape of such practice as it moves into the next decades.  In short, a clearly written and profoundly argued book.” – Louis Breger, Ph.D., Professor of Psychoanalytic Studies, Emeritus, California Institute of Technology

“One of the greatest challenges confronting 21st-century medical education is how to train physicians who are not only competent but also compassionate, and who know how to demonstrate that caring to the patient.  In this engaging and deeply personal book, Paul Stepansky gives us a valuable historical perspective on caring in medicine and offers suggestions that will be useful for medical educators, practicing physicians, nurse practitioners, and patients alike.” – Joel D. Howell M.D., Ph.D., Victor Vaughan Professor of the History of Medicine, University of Michigan

 

 

Why I Care About Caring

When it comes to doctoring in America, there is a long-established and growing rift between being well treated and feeling well cared for.  On the one hand, patients want doctors who know them and are caring of them. They are frustrated with the kind of care dispensed in very brief office visits. They are unhappy having their bodies parsed into organs and systems that elicit matter-of-fact diagnoses and impersonally rendered treatments. They may want the “facts,” but they want them conveyed by a human being who understands their apprehension, uncertainty, and confusion in the face of them. The facts are never neutral in their psychological impact on the patient’s sense of self. They establish that the patient is in some manner and to some degree damaged, and therefore in need of a physician able to bring expert knowledge to bear in helping the patient overcome his illness and dis-ease and regain his peace of mind and wholeness. This means that patients expect their physicians to be able and willing to give them enough time to come to know them as persons whose apprehension, uncertainty, and confusion are deeply personal. To the extent that the doctor humanizes the encounter by providing the patient with sympathy and support, perhaps even empathy, the patient feels he is in the hands of a knowing and caring doctor. This is the viewpoint of the bioethicist Edmund Pellegrino.

On the other hand, patients expect their doctors to respect their right to make their own medical decisions. And they want doctors who not only grant them autonomy in principle but cede autonomy in action.  In order to make informed decisions about their bodies, they need the facts, all of them. And so patients expect to be told, directly, perhaps even collegially, what may ensue if they accept or reject one or another of the treatment recommendations that follow from the facts.  But that is where medical care ends. The patient alone must decide what to do with the facts of the matter, the facts of his or her bodily matter as the doctor has scientifically arrived at them.  Armed with information, explanation, and expert risk assessment, the patient will choose a course of treatment, which the physician and/or his colleagues will then implement to the best of their ability. To the extent the physician implements the patient’s treatment plan absent any intrusion of his or her own preferences and values, he or she treats the patient well and truly, and leaves the patient, in turn, feeling well treated and well cared for.  This is the perspective of the bioethicist Robert Veatch.

Between these polar viewpoints on what it means to be a doctor and a patient, respectively, I interpose the notion of medical caring, which is less simple than it appears.  Medical caring can humanize the doctor-patient relationship without imposing values and goals that are antithetical to the patient.  At its best, medical caring is a reaching out to the patient that transcends the banalities (and uncertainties) of diagnosis and treatment in ways that patients throughout history have welcomed, and this because patienthood often compromises personhood.  Here I side with Pellegrino:  In some primal way, we call on doctors when we feel not fully ourselves, or less than ourselves, or anxious about our ability to remain ourselves, and we look to doctors to return us to the normal selves we want to be.

Medical caring has its own historical trajectory; it is responsive not only to the medical knowledge of a given time and place, but also to the cultural and political arrangements through which a society provides for the coming together of doctors and patients. It is from these arrangements that the mindsets of patients and doctors arise and, with varying degrees of success, arrive at a concordant notion of what it means for the one to be in the care of the other.

In a society that increasingly commands patient empowerment in the service of unilateral decision making, a focal concern with medical caring adds the cautionary reminder that we deprive physicians of their own right to counsel, admonish, and persuade at our peril. At a certain point, however variable among different patients and different doctors, the legal assertion of rights begins to undermine the doctor’s prerogative to doctor in ways responsive to the patient’s needs and expectations. Doctors, after all, are also moral agents with a Hippocratic obligation to draw on their humanity, however flawed, in ministering to their patients.  And patients, for their part, have the right to rely on physicians in ways that are human but not strictly factual as to diagnosis and treatment. To relinquish voluntarily a measure of autonomy to a trusted physician is an act of autonomy.

The notion of medical caring captures the sense that doctors are not just “doctors” in some timeless, generic sense, any more than patients are just generic purchasers of medical treatment as a commodity.  The same doctors who, mindful of patient rights, seek to make contact with their patients in more than bland informational ways are themselves the patients of other doctors, as are their loved ones, so the predicament of the patient, whose decision-making autonomy is often compromised, will not be so alien to the doctor as proponents of value-free medicine believe.  Doctors are all patients, or patients in potentia. And patients, for their part, come in all shapes and sizes, maturationally, temperamentally, characterologically, and otherwise.  Some will neither want nor possess the ability to be autonomous decision makers. In a caring relationship, doctor and patient together, with or without participation of the patient’s significant others, make the determination together, person to person.

A historical perspective on medical caring is cautionary in another respect. It reminds us that concepts such as “paternalism” and “autonomy” are themselves historical constructs, not timeless Platonic forms. Bioethicists who use these terms in essentialist ways overlook the historical and cultural location of doctor-patient relationships. The “paternalism” of physicians in ancient Rome, in Renaissance Florence, in seventeenth-century Paris, in nineteenth-century London, in postbellum America, in America of the mid- twentieth century – these are not the same thing.  And none of them is tantamount to what paternalism – or maternalism, or avuncular regard or brotherly or sisterly concern – may still mean in an age of digital medicine, the internet, and patient rights.

It bears remembering, finally, that the feeling of being well cared for by a doctor is responsive not only to the treatment options of a given time and place, but also to cultural assumptions that enter into doctor-patient relationships. Different norms of caring typify different periods in the history of medicine. Patients in the eighteenth century who were bled to syncope (fainting) felt well cared for. Several decades into the nineteenth century, many insisted on being bled, and some would seek out new doctors when their own refused to drain them further. Plenty of caring surgeons of the late nineteenth century applied vaginal leeches and performed ovariotomy on women who, without signs of serious gynecological disease, demanded that doctors recognize their complaints and do something to relieve their suffering. Within a medical paradigm in which even minor pelvic abnormalities explained symptoms of depression and nervous exhaustion (neurasthenia), surgery counted as a caring intervention and was widely understood as such.  Similarly, paternalistic obstetricians of the late nineteenth century who treated postpartum women suffering from exhaustion and agitated depression (“puerperal insanity”) by legitimating their symptoms and ordering compulsory “time outs” from stifling domestic obligations were caring physicians within the gendered constraints of Victorian society.  Prefrontal lobotomy was widely considered a caring intervention for schizophrenics during the 1930s and ’40s.  The surgery, for its many proponents, restored a measure of function (however compromised) to patients who would otherwise have ossified in the chronic wards of mental hospitals.  Now the care of schizophrenic patients is far different and, from a twenty-first century vantage point, far more humane.

But this is beside the point.  It is easy to dismiss bleeding to syncope, vaginal leeching, prefrontal lobotomy, and innumerable other treatments as relics of the past, misguided, unscientific, often harmful. But such judgments, such exercises in presentism, do not negate the caring intent with which such treatments were administered by doctors and received by patients.  There is more to medical caring than meets the contemporary eye.  This is why my forthcoming book, In the Hands of Doctors: Touch and Trust in Medical Care,** puts aside the triumphal march of medical treatment in the nineteenth and twentieth centuries and focuses instead on the history of caring and feeling cared for.  It is with respect to these intertwined dimensions of doctoring that the past is more than past.  The period in American history covered in the book, roughly from the end of the American Civil War through the 1960s – guides us to a deeper understanding of what “modern” patients want and expect from doctors and what, if anything, their doctors can do for them beyond diagnose and treat.

By mining the vagaries of caring and feeling cared for over time, we gain historical perspective and move a little closer to the intersubjective bedrock of what it has meant, and continues to mean, to be a doctor and to place oneself in the doctor’s hands.  What we discern can be unsettling, as the examples above suggest. But taken together, they provide a luminous counterpoise to the progressively depersonalized, cost-driven, productivity-obsessed medicine of the past 40 years.  I offer my work as an example of how thinking with history validates Francis Peabody’s tired but never tiresome insistence that “the secret of the care of the patient is in caring for the patient.”

**Paul E. Stepansky, In the Hands of Doctors:  Touch and Trust in Medical Care (Santa Barbara:  Praeger Publishers, scheduled for release in May, 2016).

Copyright © 2015 by Paul E. Stepansky.  All rights reserved.