[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]
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%.
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.
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.
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.
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.” 
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.”
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. 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.
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. 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. 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.
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.” 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.
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).
 Cited by Byerly, Fever of War, 6.
 Lavinia L. Dock, et al., History of the American Red Cross (NY: Macmillan, 1922), 404-410.
 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.
 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.
 Beatrice Hopkinson, Nursing through Shot & Shell: A Great War Nurse’s Story, ed. Vivien Newman (South Yorkshire: Pen & Sword, 2014), loc 1999.
 Elizabeth Cobbs, The Hello Girls: America’s First Women Soldiers (Cambridge: Harvard University Press, 2017), 134.
 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.
 Dorothea Crewdson, Dorothea’s War: A First World War Nurse Tells her Story, ed. Richard Crewdson (London: Weidenfeld & Nicolson, 2013), loc 5344, 5379.
 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.
 [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.
 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.
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