Category Archives: Medicine in WWI

Remembering the Nurses of WWI (V)

“They were very pathetic, these shell shocked boys.”

[The fifth 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]

Every war has mental casualties, but each war has its own way of understanding them.  Each war, that is, has its own nomenclature for what we now term “psychiatric diagnosis.”  To Napoleon’s Surgeon in Chief, Dominique-Jean Larrey, we owe the diagnosis nostalgie   (nostalgia); it characterized soldiers whose homesickness left them depressed and unable to fight.   This was in 1815.  During the American Civil War, nostalgia remained in vogue, but a new term, “irritable heart” (aka  “soldier’s heart” or “Da Costa’s Syndrome”) was coined just after the war to label soldiers whose uncontrollable shivering and trembling had been accompanied by rapid heart beat and difficulty breathing.  During the 10-week Spanish-American War of 1898, soldiers who broke down mentally amid heat, bugs, bullets, and rampant yellow fever were diagnosed with “tropical weakness.”

And this brings us to World War I, the war that bequeathed the diagnosis of shell shock.  At first, the nurses of WWI were no less baffled by variable expressions of shell shock – most cases of which, it was learned, arose a distance from the exploding shells at the Front – than the doctors.  The term was coined in 1915 by the British physician and psychologist Charles Myers, then part of a volunteer medical unit in France.  Myers immediately realized the term was a misnomer:  he coined it after seeing three soldiers whose similar psychological symptoms followed the concussive impact of artillery shells bursting at close range, only to discover that many men with the same symptoms were no where near exploding shells.   In May, 1917, the American psychiatrist Thomas Salmon, with the approval of the War Department, traveled to England to observe how the British treated their shell shocked soldiers; he returned home convinced that shell shock was a real disorder, not to be taken for malingering, and a disorder that was amenable to psychological treatment.  Salmon was the Medical Director of the National Committee for Mental Hygiene, so his report to the Surgeon General carried weight, and the Army began making arrangements for treating the mental casualties that, he predicted, could flood overseas and stateside hospitals following America’s entry into the war.[1]

Nurses were unconcerned with the animated debate among physicians on the nature of shell shock.  Was it a kind of brain concussion that resulted from the blast force of exploding shells? A physiological response to prolonged fear?  A psychological reaction to the impact of industrial warfare?  A product of nervous shock analogous to  that suffered by victims of railway accidents in the later nineteenth century?   A Freudian-type “war neurosis”  that plugged into earlier traumas  that the soldier had suffered?  They did not care.  Theirs was the everyday world of distressed soldiers, whose florid symptoms overlaid profound anxiety and for whom the reliving of trauma and its aftermath occurred throughout the day.  Theirs was the world, that is, of management and containment.

A shell shocked soldier in a trench during the Somme offensive of September, 1916

The management part could be bemused, good-naturedly patronizing, a tad irritated.  Shell shock victims, after all, made unusual demands on nurses.  The patients were always falling out of bed and otherwise “shaking and stammering and looking depressed and scared.”  Simple tasks like serving meals could be a project, as attested to by the British nursing assistant  Grace Bignold, who, prior to becoming a  VAD in 1915, worked as an orderly at a London convalescent home.  There, she recalled,

One of the things I was told was that when I was serving meals . . . always to put the plate down very carefully in front of them and to let them see me do it.  If you so much as put a plate down in front of them in the ordinary way, when they weren’t looking, the noise made them almost jump through the roof – just the noise of a plate being put on a table with a cloth on it? [2]

Accommodation by the orderlies at mealtime paled alongside the constant burden on ward nurses who had to calm hospitalized shell shock soldiers when exploding shells and overhead bombs rocked the hospital, taking patients back to the Front and causing a recurrence of the anxiety attendant to what they had seen or done or had done to them or to others.  And both, perhaps, paled alongside the burden of nurses in the ambulance trains that transported the shell shocked out of the trenches or off the battlefield.  “It was a horrible thing,” wrote the British VAD and ambulance nurse, Clair Elise Tisdall,

because they sometimes used to get these attacks, rather like epileptic fits in a way.  They became quite unconscious, with violent shivering and shaking, and you had to keep them from banging themselves about too much until they came round again.  The great thing was to keep them from falling off the stretchers, and for that reason we used to take just one at a time in the ambulance. . . . these were the so-called milder cases; we didn’t carry the dangerous ones.  They always tried to keep that away from us and they came in a separate part of the train.”[3]

The latter were the “hopeless mental cases” destined, Tisdall recalled, for “a special place,” i.e., a mental hospital,  in England a “neurasthenic centre.” But how to tell the difference?  The line between “milder” and “severe” cases of shell shock was subjectively drawn and constantly fluctuating; soldiers who arrived in the hospital with some combination of headaches,  tremors, a stutter,  memory loss, and vivid flashback dreams might become psychosomatically blind, deaf or mute or develop paralyzed or spastic limbs after settling into base hospitals and the care of nurses.  In their diaries and letters home, the nurses’ characterizations were not only patronizing but sometimes unkind:  shock patients, often incontinent, were “very pathetic”;  they formed “one of the most pitiful groups” of soldiers.  Dorothea Crewdson referred to them as “dithery shell shocks” and “old doddering shell shocks.” A patient who without warning got out of bed and raced down the hall clad only in his nightshirt was a “dotty poor dear.”  “It is sad to see them,” wrote Edith Appleton.  “They dither like palsied old men, and talk all the time about their mates who were blown to bits, or their mates who were wounded and never brought in.  The whole scene is burnt into their brains and they can’t get rid of the sight of it.”[4]

It is in the containment aspects of their care of the shell shocked that the nurses evinced the same caring acceptance they brought to all their patients.  After, all, shell shocked patients, however they presented, were wounded soldiers, and their suffering was as real and intense as that of comrades with bodily wounds.  The nursing historian Christine Hallett, who writes of the WWI nurses with great sympathy and insight, credits nurses working with the shell shocked with an almost preternatural psychoanalytic sensibility in containing the trauma that underlay their symptoms.  The nurses, she claims, aligned themselves with the patients, however disruptive their outbursts and enactments, since they “sensed that insanity would be a ‘normal’ response for any man who fully realized the deliberateness of the destruction that had been unleashed on him.”  Hence, she continues,

Nurses conspired with their patients to ‘ignore’ or ‘forget’ the reality of warfare until it was safe to remember.  In this way they ameliorated the effect of the ‘psychic splintering’ caused by trauma.  They contained the effects of this defensive fragmentation – the ‘forgetting’ and the ‘denial’ – until patients were able to confront their memories, incorporate them as part of themselves and become ‘whole’ beings again.[5]

I follow Hallett in her insistence that nurses usually ignored the directive not to “spoil” shell shocked patients.  All too often, they let themselves get involved with them at the expense of maintaining professional distance.[6]  

But then the nurses were equally caring and equally prone to personal connection with all their patients, mental or not.  They were not psychotherapists, and the dizzying demands of their long days and nights did not permit empathic engagement in the psychoanalytic sense, beyond the all-too-human  realization that the shell shocked had experienced something so horrible as to require a gentleness, a lightness of touch, a willingness to accept strange adaptive defenses that, with the right kind of nursing,  might peel away slowly over time.  Here, for example, is one of Hallett’s examples of “emotional containment” on the part of  the Australian army nurse Elsie Steadman:

It was very interesting work, some of course could not move, others could not speak, some had lost their memory, and did not even know their own names, others again had very bad jerks and twitching.  Very careful handling these poor lads needed, for supposing a man was just finding his voice, to be spoken to in any way that was not gentle and quiet the man ‘was done,’ and you would have to start all over again to teach him to talk, the same things applied to walking, they must be allowed to take their time.”[7]

This sensitivity, this “very careful handling” of the shell shocked, was no different than the sensitivity of the mealtime orderlies, who knew to “put the plate down very carefully in front of them,” always making sure that the shell shocked saw them do it.  And of course there were accommodations out of the ordinary, a remarkable example of which comes from Julia Stimson, the American chief nurse of British Base Hospital 21 (and amateur violinist). Writing to her parents in late November, 1917, she related “an interesting little incident” that began when a patient knocked on her door and asked for the Matron:

He was so wobbly he almost had to lean up against the wall.  “Somebody told me,” he said, “that you had a violin.  I am a professional violinist and I have not touched a violin for five months, and today I couldn’t stand it any longer, so I got up out of bed to come and find you.”  I made him come in and sit down.  As it happened I had a new violin and bow, which had been bound for our embryo orchestra, here in my office.  The violin was not tuned up, but that didn’t matter.  The man had it in shape in no time and then he began to play and how he could play!  We let him take the violin down to his tent, and later sent him some of my music.  He was a shell shock, and all the evening and the next few days until he was sent to England he played to rapt audiences of fellow patients.[8]

With the shell shocked, the therapeutic gift of the WWI nurses resided less in their ability to empathize than in their acceptance that their patients had experienced horrors that could not be empathized with.  Their duty, their calling, was simply to stay with these soldiers in an accepting manner that coaxed them toward commonality among the wounded, the sense that their symptoms and the underlying terror were not only understandable but unexceptional and well within the realm of nursing care.  In this sense – in the sense of a daily willingness to be with these soldiers in all their bodily dysfunction, mental confusion, and florid symptomatic displays – the nurses strove to normalize shell shock for the shell shocked. After all, the shell shocked, however dithery, shaking, and stammering, were depressed and scared “only at times.”  Otherwise, continued Dorothea Crewdson, “they are very cheery and willing.”  Mary Stollard, a British nurse working  with shell shocked soldiers at a military hospital in Leeds, noted that many of the boys were very sensitive to being incontinent.

They’d say, ‘‘I’m  terribly sorry about it, Sister, it’s shaken me all over and I can’t control it.  Just imagine, to wet the bed at my age!”  I’d say, “We’ll see to that.  Don’t worry about it.”  I used to give them a bedpan in the locker beside them and keep it as quiet as possible.  Poor fellows, they were so embarrassed – especially the better-class men.”[9]

But such embarrassment was a relic of civilian life.  It had no place among battle-hardened nurses who coped daily with the sensory overload of trench warfare:  the overpowering stench of gangrenous infections and decaying flesh; the sight of mutilated soldiers without faces or portions of torso, not to mention missing arms and legs; the screams of gassed soldiers, blind and on fire and dying in unspeakable pain.  Alongside such things, how off-putting could incontinence be?  The fact is that shell shocked soldiers, no less than the nurses themselves, were warriors. Warriors are wounded and scarred in many ways; nurses themselves fell victim to shell shock, even if they were not officially diagnosed as such.[10]   Knowing full well that shell shocked soldiers declared physically unfit and shipped back home were often subject to stigma and humiliation,  Ellen La Motte offered this dismal prognosis for one who had lost the ability to walk and could no longer serve the nation:  “For many months he had faced death under the guns, a glorious death.  Now he was to face death in another form.  Not glorious, shameful.”[11]

_________________________

[1] Earl D. Bond, Thomas W. Salmon – Psychiatrist  (NY: Norton, 1950), 83-84.

[2] Julia C. Stimson, Finding Themselves:  The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 41; Dorothea Crewdson, Dorothea’s War:  A First World War Nurse Tells her Story, ed. Richard Crewdson (London: Weidenfeld & Nicolson, 2013), loc 4383; Grace Bignold, in Lyn MacDonald, The Roses of No Man’s Land (London: Penguin, 1993), 233.

[3]  Claire Elise Tisdall, in MacDonald, Roses of No Man’s Land, 233-34.

[4] Mary Stollard, in MacDonald, Roses of No Man’s Land, 231-32; Stimson, Finding Themselves, 41; Crewdson, Dorothea’s War, loc 967; Edith Appleton, A Nurse at the Front:  The First World War Diaries, ed. R. Cowen (London:  Simon & Schuster UK, 2012), 184.

[5] Christine Hallett, Containing Trauma:  Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 163.

[6] Hallett, Containing Trauma, 165, 177.

[7] Hallett, Containing Trauma, 172-73.

[8] Stimson, Finding Themselves, 163.

[9] Crewdson, Dorothea’s War,  loc 4383; Stollard, in MacDonald, Roses of No Man’s Land, 232.

[10] E.g., Crewdson, Dorothea’s War, loc 4914; In “Blind,” Mary Borden writes of herself as “jerk[ing] like a machine out of order.  I was away now, and I seemed to be breaking to pieces.”  She was sent home as “tired.”  Mary Borden, The Forbidden Zone (London: Hesperus, 2008[1929], 103).  On the military’s unwillingness to diagnose women as “shell shocked,” see Hannah Groch-Begley, “The Forgotten Female Shell-Shock Victims of World War I,” The Atlantic, September 8, 2014 (https://www.theatlantic.com/health/archive/2014/09/world-war-ones-forgotten-female-shell-shock-victims/378995).

[11] 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), 239.

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.

An Irony of War

“There are two groups of people in warfare – those organized to inflict and those organized to repair wounds – and there is little doubt but that in all wars, and in this one in particular, the former have been better prepared for their jobs” (Milit. Surg., 38:601, 1916).  So observed Harvey Cushing, the founder of modern neurosurgery, a year before America’s entry into World War I.  Cushing’s judgment is just, and yet throughout history “those organized to repair wounds” have risen to the exigencies  of the war at hand.  In point of fact, warfare has spurred physicians, surgeons, and researchers to major, sometimes spectacular, advances, and their scientific and clinical victories are bequeathed  to civilian populations that inherit the peace.  Out of human destructiveness emerge potent new strategies of protection, remediation, and self-preservation.  Call it an irony of war.

Nor are these medical and surgical gifts limited to the era of modern warfare.  The French army surgeon Jean Louis Petit invented the screw tourniquet in 1718; it made possible leg amputation above the knee.  The Napoleonic Wars of the early nineteenth century brought us the first field hospitals along with battlefield nursing and ambulances.  The latter were of course horse-drawn affairs, but they were exceedingly fast and maneuverable and were termed “flying ambulances.”  The principle of triage — treating the wounded, regardless of rank, according to severity of injury and urgency of need – is not a product of twentieth-century disasters.  It was devised by Dominique Jean Larrey, Napoleon’s surgeon-in-chief from 1797 to 1815.

The American Civil War witnessed the further development of field hospitals and the acceptance, often grudging, especially among southern surgeons, of female nurses tending to savaged male bodies.  Hospital-based training programs for nurses were a product of wartime experience.  Civil War surgeons themselves broached the idea shortly after the peace, and the first such programs opened  in New York, Boston, and New Haven hospitals in 1873.  The dawning appreciation of the relationship between sanitation and prevention of infection, which would blossom into the “sanitary science” of the 1870s and 1880s, was another Civil War legacy.

And then there were the advances, surgical and technological, in amputation.  They included the use of the flexible chain saw to spare nerves and muscles and even, in many cases of comminuted fracture, to avoid amputation entirely.  The development of more or less modern vascular ligation – developed on the battlefield to tie off major arteries extending from the stumps of severed limbs – is another achievement of Civil War surgeons.  Actually, they rediscovered ligation, since the French military surgeon Amboise Paré employed it following battlefield amputation in the mid-sixteenth century, and he in turn was reviving a practice employed in the Alexandrian Era of the fourth century B.C.

In 1900 Karl Landsteiner, a Viennese pathologist and immunologist, first described the ABO system of blood groups, founding the field of immunohematology.  As a result, World War I gave us blood banks that made possible blood transfusions among wounded soldiers in the Army Medical Corps in France.  The First World War also pushed medicine further along the path to modern wound management, including the treatment of cellulitic wound infections, i.e., bacterial skin infections that followed soft tissue trauma.  Battlefield surgeons were quick to appreciate the need for thorough wound debridement and delayed closure in treating contaminated war wounds.  The prevalence of central nervous system injuries – a tragic byproduct of trench warfare in which soldiers’ heads peered anxiously above the parapets  – led to “profound insights into central nervous system form and function.” The British neurologist Gordon Holmes provided elaborate descriptions of spinal transections (crosswise fractures) for every segment of the spinal cord, whereas Cushing, performing eight neurosurgeries a day, “rose to the challenge of refining the treatment of survivors of penetrating head wounds” (Arch. Neurol., 51:712, 1994).  His work from 1917 “lives today” (ANZ J. Surg., 74:75, 2004).

No less momentous was the development of reconstructive surgery by inventive surgeons (led by the New Zealand ENT surgeon Harold Gillies) and dentists (led by the French-American Charles Valadier) unwilling to accept the gross disfigurement of downed pilots who crawled away from smoking wreckages with their lives, but not their faces, intact.  A signal achievement of wartime experience with burn and gunshot victims was Gillies’s Plastic Surgery of the Face of 1920; another was the founding of the American Association of Plastic Surgeons a year later.  After the war, be it noted, the pioneering reconstructive surgeons refused to place their techniques at the disposal of healthy women (and less frequently healthy men) desirous of facial enhancement; reconstructive facial surgery went into short-lived hibernation.  One reason reconstructive surgeons morphed into cosmetic surgeons was the psychiatrization of facial imperfection via Freudian and especially Adlerian notions of the “inferiority complex,” with its allegedly life-deforming ramifications.  So nose jobs became all the rage in the 1930s, to be joined by facelifts in the postwar 40s. (Elizabeth Haiken’s book Venus Envy: A History of Cosmetic Surgery [1997] is illuminating on all these issues.)

The advances of World War II are legion.  Among the most significant was the development or significant improvement of 10 of the 28 vaccine-preventable diseases identified in the twentieth century (J. Pub. Health Pol., 27:38, 2006);  new vaccines for influenza, pneumococcal pneumonia, and plague were among them.   There were also new treatments for malaria and the mass production of penicillin in time for D-Day.  It was during WWII that American scientists learned to separate blood plasma into its constituents (albumin, globulins, and clotting factors), an essential advance in the treatment of shock and control of bleeding.

No less staggering were the surgical advances that occurred during the war. Hugh Cairns, Cushing’s favorite student, developed techniques for the repair of the skull base and laid the foundation of modern craniofacial surgery by bringing together neurosurgeons, plastic surgeons, and ophthalmic surgeons in mobile units referred to as “the trinity.”   There were also major advances in fracture and wound care along with the development of hand surgery as a surgical specialty.   Wartime treatment experience with extreme stress, battlefield trauma, and somatization (then termed, in Freudian parlance, “conversion reactions”) paved the way for the blossoming of psychosomatic medicine in the 1950s and 1960s.

The drum roll hardly ends with World War II.  Korea gave us the first air ambulance service.  Vietnam gave us Huey helicopters for evacuation of wounded soldiers.  (Now all trauma centers have heliports.)  Prior to evacuation, these soldiers received advanced, often life-saving, care from medical corpsmen who opened surgical airways and performed thoracic needle decompressions and shock resuscitation; thus was born our modern system of prehospital emergency care by onsite EMTs and paramedics.  When these corpsmen returned to the States, they formed the original candidate pool for Physician Assistant training programs, the first of which opened its doors at Duke University Medical Center in 1965.  Vietnam also gave us major advances in vascular surgery, recorded for surgical posterity in the “Vietnam Vascular Registry,” a database with records of over 8000 vascular wound cases contributed by over 600 battlefield surgeons.

The medical and surgical yield of recent and ongoing wars in the Persian Gulf will be recorded in years to come.  Already, these wars have provided two advances for which all may give thanks:  portable intensive care units (“Life Support for Trauma and Transport”) and Hem-Con bandages.  The latter, made from extract of shrimp cells, stop severe bleeding instantaneously.

Now, of course, with another century of war under our belt and the ability to play computer-assisted war games, we are better able to envision the horrific possibilities of wars yet to come.  In the years leading up to World War I, American surgeons – even those, like Harvey Cushing, who braced themselves for war – had no idea of the human wreckage they would encounter in French field hospitals.  Their working knowledge of war wounds relied on the Boer War (1899-1900), a distinctly nineteenth-century affair, militarily speaking, fought in the desert of South Africa, not in trenches in the overly fertilized, bacteria-saturated soil of France.  Now military planners can turn to databases that gather together the medical-surgical lessons of two World Wars, Korea, Vietnam, Iraq, Afghanistan, and any number of regional conflicts.

Military simulations have already been broadened to include political and social factors.  But military planners should also be alert to possibilities of mutilation, disfigurement, multiple-organ damage, and drug-resistant infection only dimly imagined.  Perhaps they can broaden their simulations to include the medical and surgical contingencies of future wars and get bench scientists, clinical researchers, and surgeons to work on them right away.  Lucky us.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.