Category Archives: Influenza Pandemic

Covid-19 and Trump’s Medieval Turn of Mind

“We ought to give it [hydroxychloroquine] a try . . . feel good about it. That’s all it is, just a feeling, you know, smart guy. I feel good about it.” – Donald J. Trump, March 20, 2020

“I see the disinfectant, where it knocks it out in a minute. One minute. And is there a way we can do something like that, by injection inside or almost a cleaning?  Because you see it gets in the lungs, and it does a tremendous number on the lungs. So, it would be interesting to check that.” – Donald J. Trump, April 23, 2020

“So, supposing we hit the body with a tremendous —  whether it’s ultraviolet or just very powerful light — and I think you said that that hasn’t been checked, but you’re going to test it. And then I said, supposing you brought the light inside the body?” – Donald J. Trump, April 23, 2020

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Viewed from the standpoint of history of medicine, the Great Influenza (aka the Spanish Flu) of 1918-1919 and the Coronavirus pandemic of today, separated by a century, share a basic commonality. Both are pandemics of the modern era, where treatments for specific diseases grow out of the findings of laboratory science and scientific medicine. The development of serology, which transferred to humans, via injection, whatever antitoxins resided in the purified blood of immune animals, had by 1918 proven effective, albeit to varying degrees, with diseases such as rabies, diphtheria, tetanus, and typhoid fever.

Today we anxiously await the development of a Covid-19 vaccine.  In 1918, health professionals and the public waited impatiently for new serums to combat gas gangrene and the pandemic flu.  And given the state of medical progress of the time – viruses had yet to be identified and differentiated from bacteria – their optimism was reasonable.  By the spring of 1918, 5000 units of an anti-gangrene serum had reached AEF hospitals in Europe, of which 2,500 units had been used by the time of the Armistice.  For the Spanish Flu, two different injectable serums were available to overseas American nurses by the fall of 1918.

The predictable failure of these serums should not obscure the fact that in 1918 management of the Spanish Flu was squarely in the hands of mainstream scientists and physicians.  Then President Woodrow Wilson stood back from the whirl of  suffering and death around him.  He maintained a steely silence about the whole business, refusing to mention the pandemic in even a single public address.  His preoccupation with the war and ensuing Paris Peace Conference was total, and precluded even the simplest expression of sympathy for stricken Americans and their families.  Here he anticipated by a century President Donald Trump.

Wilson held his peace.  Now we behold President Donald Trump, who, in his own preoccupation with self-promotion and self-congratulations, buttressed by denial of the pandemic’s magnitude, cannot remain silent.  Not even for a day. But what is he telling us?  How is he helping us cope with the fury of another global pandemic? His musings – contradictory, impulsive, and obsessively self-serving – would have stunned Americans of 1918. For Trump seems to have dispensed with scientific medicine altogether.  To understand his “spin” on the pandemic, we must go back much further than the Great Influenza and look again at the Black Death of the mid-14th century.

In October, 1347, a vessel, probably originating off the Crimean Peninsula, docked in Messina, Sicily.  It was laden with infected rats, themselves laden with infected fleas.  Together, the rats and fleas brought the Black Death, likely a combination of bubonic and hemorrhagic plague, to Europe.  Physicians of the time, wedded to Hippocratic and Galenic notions of illness and health, confronted plague with the therapeutics derived from this paradigm.  Bleeding (venesection) was typically the first order of business, since blood was associated with body heat.  Bleeding would cool down a body overheated by fever and  agitation, thereby restoring balance among the four humors that corresponded to the four elements of the universe: black bile [earth], yellow bile [fire], phlegm [water], and blood [air].

When bleeding and the regulation of Galenic non-naturals (food and drink, motion, rest, evacuation, the passions) failed to restore health, physicians turned to what was to them an observable fact:  that plague was literally in the winds.  It was contained, that is, in miasmic air that was unbearably foul-smelling, hence corrupt and impure.  For some, the miasma resulted from a particular alignment of the planets; for many others it was pinned on the Jews, a poisonous race, they believed, that sought to poison the air.  But for most European physicians, no less than for priests and laymen, the miasmic air came directly from an enraged God who, disgusted with sinning humankind, breathed down the corrupt vapor to wipe them out.

How then, were 14th-century physicians to combat a pollution of Divine origin?  Galen came to the rescue, with heat  again at the center of  plague therapeutics.  Heat, it was known, had the ability to eliminate foul-smelling air, perhaps even lethally foul-smelling air. What was needed to combat plague was actually more heat, not less.  Make fires everywhere to purify the air.  This was the advice Guy de Chauliac, surgeon to the Papal Court in Avignon, gave Pope Clement VI, whose presumed sanctity did not prevent him from isolating himself from Court and servants and spending his days seated between two enormous log fires.  Among the infected, a more draconian application of heat was often employed:  doctors lanced plague victims’ inflamed buboes (boils) and applied red hot pokers directly to their open wounds.

Medieval thinking also led to treatments based on Galen’s theory of opposites.  Purities cancel impurities.  If you want to avoid the plague, physicians advised, drink copious amounts of the urine of the non-infected; collecting and distributing healthy urine became a community project throughout the continent.  If you were of means and would rather not drink urine, the ingestion of crushed sapphires would work just as well.

English peasants adopted a more benign path to purification:  they stuffed their dwellings with sweet scented flowers and aromatic herbs.  Here they followed the example of Europe’s plague doctors, those iconic bird-men who stuffed the huge beak extensions of their masks with dried flowers and odoriferous herbs to filter out pestilence from the air they breathed. Good smells, after all, were the opposite of airborne foulness.

a 14th-century plague doctor, dressed to ward off the miasma

On the other hand, in another variation of Galenic thinking, physicians sought a dissonant foulness powerful enough to vanquish the foulness in the air. Villagers lined up to stick their heads in public latrines.  Some physicians favored a more subtle variant. They lanced the infected boils of the stricken and applied a paste of gum resin, roots of white lilies, and dried human excrement. The synergism among the ingredients, they believed, would act as a magical restorative.  This, in any event, was the opinion of the eminent Italian physician Gentile da Foligno, whose treatise on the Black Death was widely read and who, inter alia, was among the first European physicians to study plague victims by dissecting their corpses.  Needless to say, the treatment did him no good, and he died of Plague in 1348.  Other physicians developed their own topical anodynes.  Snakes, when available, were cut up and rubbed onto a plague victim’s infected boils.  Pigeons were cut up and rubbed over the victim’s entire body.

Now, 672 years after the Black Death wiped out more than 40% of world population, we behold an astonishing recrudescence of the medieval mind:  we are led through a new plague by a presidential medievalist who “feels good” about nonscientific remedies based on the same intuitive search for complementarities and opposites that medieval physicians proffered to plague patients in the mid-14th century.  Heat kills things; heat obliterates atmospheric impurities; heat purifies. Perhaps, then, it can rid the body of viral invaders.  Disinfectants such as bleach are microbe killers. We wipe a counter top with Clorox and rid it of virus.  Can’t we do the same thing by injecting bleach into the human body? What bleach does to healthy tissue, to internal organs, to blood chemistry – these are science questions an inquiring 8th grader might put to her teacher.  But such questions could not arise to a medieval physician or to Donald Trump. They simply fall outside the paradigm of Galenic medicine.

Injecting or ingesting bleach has an internal logic no greater than that of the 14th-century Flagellants, who roamed across continental Europe in a frenzy of penitential self-abuse that left them lacerated if not dead.  It made perfectly good 14th-century sense – though not, be it noted, to Clement VI, who condemned the practice as heretical.  Withal, the Flagellants believed that self-mortification and the excruciating pain it entailed could assuage a wrathful God and induce Him to stop blowing death down on humankind.  But science belied their self-purifying intentions. The roving Flagellants, leaving paths of infected blood and entrails behind them, became a vector for the transmission of plague.  For our medieval president, the path is one of toxic verbal effluvia no less dangerous than infected blood and entrails in spreading Covid-19.

We want to believe that no one living in 2020 can possibly lend credence to anything Trump has to say about infectious illness, virology, pandemics, scientific research, and post-medieval medicine.  When it comes to Covid-19, he is an epistemic vacuity whose medieval conjectures would never make it past the family dinner table or the local bar. But he is the president, and he speaks with the authority of high office.  So his musings, grounded in Galenic-type notions and feelings, have an apriori valence.  As such they will continue to lead many astray – away from prudent safeguards, away from mainstream medicine,       indeed, away from an appreciation of the scientific expertise that informs these safeguards and treatments.

Hippocratic-Galenic medicine, with its notions of balance, synergy, complementarity, and opposites, retains its appeal to many.  But prescientific, feeling-based intuitions about disease are always dangerous, and positively deadly in a time of global pandemic. In the aftermath of Trump’s pronouncement about the logic of injecting  household disinfectants to combat Covid-19, poison control centers across the country were flooded with inquiries about the advisability of imbibing household bleach.  As to hydroxychloroquine, “More Deaths, No Benefit from Malaria Drug in VA Virus Study,” reported AP News on the first use of hydroxychloroquine in a small-scale nationwide study of VA patients hospitalized with Covid-19.

Is this surprising?  Whether or not hydroxychloroquine or any other drug or household disinfectant or chopped up animal remains is safe and effective against Covid-19 is an empirical question subject to laboratory research and clinical study.  But who exactly sets the agenda?  Who, that is, decides which existing pharmaceuticals or household products or smashed animal parts are worthy of scientific investigation?  Experts with knowledge of pharmacology, infectious disease, and virology or an intellectually null and void president for whom science matters only as a handmaiden to political objectives?  Pity those who follow him in his medieval leap of faith.

By fanning the flames of Hippocratic-Galenic notions about heat, light, the neutralizing effect of opposites, the shared efficacy of substances with complemental or analogical properties, Trump himself has become a vector for the transmission of plague. Bleach kills microbes on a counter top.  Shouldn’t it therefore kill the Covid-19 virus in the human body?  Hydroxychloroquine kills the protozoan parasite Plasmodium that causes malaria.  Shouldn’t it therefore kill Covid-19 viruses within the human body?  Wouldn’t a really “solid” seasonal flu vaccine provide people with a measure of resistance to Covid-19?  No, no, and no. Would that Mr. Trump would “feel good” about a more benign medieval variant, perhaps donning a garland of garlic cloves at press briefings.  Better still, following the example of the plague doctors, he could wear a mask in public, if only to satisfy those of us whose heads are not buried in medieval muck.  Given the clear and present danger of his treatment preferences to public health, however, we would be best served if he were simply muzzled until election day.

 

Copyright © 2020 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 (VI)

[The sixth and final essay about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917.  The startling parallels between the medical and nursing responses to the Great Pandemic of 1918 and the Coronavirus Pandemic of 2020 are elaborated in Easing Pain on the Western Front:  American Nurses of the Great War and the Birth of Modern Nursing Practice  (McFarland, 2020)].    

PLAGUE

Influenza.  The Plague. The Great Pandemic of 1918.  The Spanish Flu, which, as best we can determine, originated not in Spain but in Camp Funston in northeastern Kansas and Camp Oglethorpe in northwestern Georgia in March and April, 1918.  From there it spread to other army camps, then to France via troops disembarking at Brest, then to the rest of Europe, then to the rest the world.  By the time the epidemic had passed, world population was reduced by 50 to 100 million, or from 3% to 5%.[1]  

During 1918 and 1919, 47% of all deaths in the United States were from influenza and its complications, with over 675,000 deaths in all.   The first wave of the disease in March and April 1918 was relatively mild, as the virus learned to adapt to humans via passage from person to person.  But the second wave, which began in August, was deadly.  Philadelphia officials foolishly refused to cancel a Liberty Loan Parade scheduled for September 28.  Within three days, every hospital bed in the city’s 31 hospitals was filled; within 10 days the pandemic exploded to hundreds of thousands ill, with hundreds of deaths each day. By October 12, 4,500 Philadelphians had died from the flu; a few weeks later the total was nearly 11,000.  Neighboring New York City lost over 21,000 during the same period.

One characteristic of the Spanish flu was that, unlike typical influenza, it targeted younger victims, aged 20-40.  The fault was in their very youth, as   their immune systems mounted a massive response to the virus, filling their lungs with so much fluid and debris that the exchange of oxygen became impossible.  Victims lapsed into unconsciousness and drowned on their own internal secretions.  Others remained alive long enough to have bacteria swarm into their compromised lungs and compound viral infection with bacterial pneumonia; the result was either death or a lengthy convalescence.

The American Expeditionary Force (AEF) consisted of healthy young men.  Influenza hit them hard.  At home, things grew desperate in army training camps and cantonments.  It was the first and only time the number of seriously ill soldiers exceed the military’s total hospital capacity; the army had to take over barracks and use them as hospitals.  It was no better overseas, where the virus took advantage of the conditions of trench warfare to evolve into its lethal form.  By the U.S. War Department’s own reckoning, the flu eventually sickened 26% of the AEF – over a million men – and accounted for  82% of the army’s total deaths from disease.[2]

Influenza patients at a naval training station in California, 1918

The serious shortage of nurses to care for stricken soldiers spurred the American Red Cross to action.  It struggled to ship out the 1,000 nurses a week requested by the army. On the home front, it set aside its policy of racial exclusion and enrolled African American nurses for “special service.” In early December, two emergency detachments of nurses of color set out for army hospitals at Camp Sherman in Ohio and Camp Grant in Illinois, respectively. There they were assigned to general wards filled with white soldiers.  To the surprise of skeptical white chief nurses, their service was exemplary, whatever the drudgery assigned them.[3]

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The story of the pandemic of 1918 is the story of modern medicine not yet modern enough to grasp the characteristics of viruses:  their structure; the manner in which they invaded and infected cells; even whether they were liquid or particle in nature.   The best laboratory techniques of the time could identify viruses only as the mysterious “something”  left over after infected blood samples or respiratory secretions were passed through a Chamberland filter, whose minute pores filtered out all known bacteria.  Since, with  hoof-and-mouth disease and  yellow fever, filtered solution or “filtrate” had been shown to make healthy animals sick, it must contain an imperceptible, nonspecifiable something  that passed on the disease.  But this eliminative logic had no operational consequences; it was a therapeutic dead end.  So researchers played to the strength of their time, a golden age for linking specific bacteria to specific illnesses:  they searched for a bacteriological culprit for The Great Flu.  And they thought they had found one.  Plausibly, they believed the Spanish flu was caused by the Bacillus influenzae discovered by the German bacteriologist Richard Pfeiffer in 1892.  And they were wrong.

Bacteriology  in 1918 might be adequate, at least some of the time, to the secondary bacterial infections (especially pneumonia) that followed the weakening of the immune system caused by the virus.  But in the face of the virus itself,  it was helpless.  Only in 1934, when a new flu epidemic raged in Puerto Rico, would Thomas Francis of the Rockefeller Institute, utilizing a technique for viral transmission in animals developed by his colleague, Richard Shope, isolate the Type A influenza virus.

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If the warring armies of 1918 were hit hard by the flu, it was often the nurses, no less than the infected soldiers, who took it on the chin. This included the nurses of the Allied Expeditionary Force.  During the initially mild phase of the epidemic, ignorant of what was to come, overseas nurses were content to add the flu to the list of infections they combatted and to which, often enough, they fell victim.  Being bedridden themselves was simply a vicissitude of the job – a cost of the business of frontline nursing.  “It’s not that I mind being in bed,” wrote Helen Boylston in February, 1918.  “I don’t even mind having flu and trench fever.”  Two months later, she recorded that the flu was 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.” But she kept her suffering to herself and soldiered on:  “But I’m not talking about it, because I don’t want to be sent to Villa Tino[for rest and treatment].”   Of course, when the influenza struck in full force in the fall of 1918, nurses, whatever their resolve, were not spared.  In the U.S., 127 army nurses died from flu, and an untold number, probably another 100, died in Europe.  Katherine Magrath, the chief nurse of Base Hospital 68 in Nièvre in central France, buried 12 of her nurses in a single month. After each funeral, she avoid looking at the faces of her surviving nurses lest she wonder “which would be the next to be absent from the dismal scene.” [4]

Unable to treat the flu at its source, the nurses did what they had grown accustomed to doing for the desperately ill:  They bore witness to suffering and tried to ease it.  Their witnessing was different from that of the doctors.  In their diaries, for example, they record the sensory experience of hands-on care of those who grew sicker and then died.  Influenza cases had swamped the nurses, wrote Shirley Millard at the beginning of April, 1918. And the soldiers, “When they die, as about half of them do, they turn a ghastly dark gray and are taken out at once and cremated.”  Forty of 160 patients had the flu, and the staff was coming down with it  So reported Hoosier nurse Maude Essig from Base Hospital 32 in the French resort town of Contrexéville in November.  “The odors,” she added, “are bad.”[5]

Treatment of the flu-ridden called forth everything in the nurses’ toolbox. They quickly learned the course of the illness, and they took from the toolbox everything they had to strengthen the heart, ease respiration, and attenuate suffering.  If they could not tame the virus, they could, with luck, keep patients alive long enough for their immune systems to rally and join the struggle.  During the early days of the pandemic, Beatrice Hopkinson wrote in her diary how flu-ridden patients were stripped of their clothing in one tent, bathed in disinfectant and distributed among different wards.  But disinfectants, she and others quickly learned, were unavailing.  Patients who were very ill often died from pneumonia within days, Hopkinson found.[6]  For those whose fate was not sealed, the trick was to bring down their high fevers with alcohol baths and to keep their hearts beating and their lungs exchanging oxygen and carbon dioxide.  Here is how nurses coped with a signal corps switchboard operator – one of the first “Hello Girls” – stricken with influenza on board the transport ship Olympic in September 1918:

Risking their own lives, nurses placed warm mustard packs on her chest to dilate the capillaries, stimulate her nervous system, and help her cough up the mucus that could drown her.  They aspirated her lungs, sponged her body with alcohol, applied camphorated oil every hour, gave  her salt-solution enemas, and spoon-fed her concoctions of milk, eggs, and whiskey.  The first week, Conroy received four hypodermic injections of digitalis to control her pulse and strengthen her heartbeat.[7]

None of these ministrations attacked the virus, but they kept Conroy alive, and after 17 days her fever finally broke.  She, no less than the nurses who saved her, went on to contribute to the war effort in France.

In 1916, prior to the epidemic, nurses who began to feel “influenza-ish” might resort to brisk walks and a “good hot mustard bath.”  But when they took ill after the epidemic set in, they resorted to large doses of quinine and aspirin or, alternatively, to quinine and “a stiff dose of whiskey” to keep going.[8] By the fall of 1918, their wards had become “influenza departments,” and they wondered how long they could resist infection.  Inevitably, nurses became patients, taking to their beds to await transfer to nearby convalescent homes set aside for them, referred to colloquially as “Sick Sisters,” for treatment and recuperation.[9]  For some, only physical collapse on the wards could remove them from the second battlefield.

The flu paid no heed to the Armistice that ended hostilities on November 11, 1918.  It raged on in base hospitals. It subsided in intensity in the final month of the year only to  return with renewed virulence in the new year. The nurses, for their part, remained in base hospitals throughout France and Belgium, serving not only bedridden soldiers but the local populace as well.  Then, pooling their efforts with the women physicians serving in American Women’s Hospitals (AWH) sponsored by the Medical Women’s National Association, they fanned out from northern France and Belgium to Serbia, the Near East, and even Russia.  Working hand in hand with medical colleagues, the nurses established public health programs for civilian populations that had gone without medical, surgical, dental, and nursing care since 1914.  Divided into mobile units, AEF nurses and AWH physicians established weekly house call and dispensary routes that took them to battle-scarred villages throughout the regions they served.  During the seven months that AWH No. 1 was based in Luzancy in northcentral France, for example, its units  made 3,626 house calls to the 20 villages on their regular schedule and to 45 outlying villages as well.  In virtually every village, chronic disease management shared center stage with dental and gynecological care.  And among the diseases with which nurses and physicians continued to do battle, typhoid fever and influenza had pride of place.[10]

We have considered the manner in which nursing interventions could become curative by simple dint of their frequency and intensity  – not to mention the confident bravado with which they were administered.  No where was this in greater evidence than with the soldiers and civilians stricken with virulent flu in the fall of 1918 and winter of 1919.  Nurses in the Allied Expeditionary Force, no less than their sisters-in-arms in the British Expeditionary Force, stayed on and nursed on, no matter the  apparent inevitability of death.  There was this implicit hope that caring interventions could at any point turn the tide, if only in the sense of gaining a brief reprieve during which the body’s depleted healing resources might rally.

Nurses were great naturalists.  Fevers might break.  Hearts might resume normal rhythms.  Lungs might expel enough infectious matter to resume respiration. To be sure, the worst of the influenza victims almost always died.  But then so did the worst of the postsurgical patients, the worst of the gassed patients, the worst of the soldiers with multiple injuries and multiple amputations. It mattered not.  Nursing professionals professed an ethic of caring grounded in, but not limited by, the scientific medicine of the time.  When all else had failed, when surgeons and physicians had given up on a patient, nursing care could still be a clinical tipping point that loosened the grasp of the grim repeater.  Always the nurses gave it their all.  Bits from the wreckage might still be saved despite the “unutterable woe.”[11]  Let one nurse, Britain’s Kate Luard, distinguished recipient of the Royal Red Cross Medal and Bar, speak for all in a diary entry from 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.[12]

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[1]There is abundant secondary literature on the Great Pandemic of 1918.  An excellent, readable  overview is John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (NY: Viking, 2004).  Those interested in the pandemic’s impact on the American Expeditionary Force and the war in general should begin with Carol R. Byerly, Fever of War:  The Influenza Epidemic in the U.S. Army during World War I (NY: New York University Press, 2005).  A lively account of the search for the virus that caused the pandemic in the decades after the war is Gina Kolata, Flu:  The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It (NY: Farrar, Straus and Giroux, 2011).

[2] Cited by Byerly, Fever of War, 6.

[3] Lavinia L. Dock, et al.,  History of the American Red Cross (NY: Macmillan, 1922), 404-410.

[4] Helen Dore Boylston, Sister: The War Diary of a Nurse (NY: Ives Washburn, 1927), loc 694; Mary T. Sarnecky, A History of the U.S. Army Nurse Corps (Phila:  University of Pennsylvania Press, 1999),  121.

[5] Shirley Millard, I Saw Them Die: Diary and Recollections (New Orleans, LA: Quid Pro, 2011), loc 472; Alma S. Wooley, “A Hoosier Nurse in France:  The World War I Diary of Maude Frances Essig” ( https://scholarworks.iu.edu/journals/index.php/imh/article/view/10683/15077), entry of October 7, 1918.

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

[7] Elizabeth Cobbs, The Hello Girls:  America’s First Women Soldiers (Cambridge:  Harvard University Press, 2017), 134.

[8] Edith Appleton, A Nurse at the Front:  The First World War Diaries, ed. R. Cowen (London:  Simon & Schuster UK, 2012), 102; Maude Essig, “World War I Diary,” entry of October 27, 1918; Boylston, War Diary, loc 1348.

[9] Dorothea Crewdson, Dorothea’s War: A First World War Nurse Tells her Story, ed. Richard Crewdson (London: Weidenfeld & Nicolson, 2013), loc 5344, 5379.

[10] On the role of American women physicians in WWI and its aftermath, see Ellen S. More, “’A Certain Restless Ambition’: Women Physicians and World War I,” Amer. Quart., 41:1989, 636-660; Lettie Gavin, American Women in World War I  (Niwot, CO: University Press of Colorado, 1997), 157-178; and Kimberly Jensen, Mobilizing Minerva: American Women in the First World War (Urbana:  University of Illinois Press, 2008), 77-97. Statistics on AWH No. 1’s service while based in Luzancy are given in Jensen, Mobilizing Minerva, 110.

[11] [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 R. C. Cabot (Boston:  Butterfield, 1916), 21.

[12] John & Caroline Stevens, eds., Unknown Warriors: The Letter of Kate Luard, RRC and Bar, Nursing Sister in France, 1914-1918 (Stroud: History Press, 2014), loc 1277.

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.

 

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