Category Archives: Nursing

The Picture They Wouldn’t Publish

Posted on May 10, 2020 | Leave a comment

 

Here is the picture the publisher, McFarland & Co., refused to include in Easing Pain on the Western Front, my study of the American and Canadian nurses of World War I.  It was taken in a French field hospital in 1918, and shows a Red Cross nurse clasping the hand of a French soldier, a poilu, most of whose face has been blown off by artillery. She gazes outward stoically, as if to say: “Yes, I am a nurse, and this is the kind of boy the ambulances bring to us during the rushes.  Soon the surgeons will decide whether he will live and whether they can do anything for him.  For now I hold his hand.”  A more junior sister stands beside her and bears witness.

Why did the publisher exclude this powerful image from a book about the nurses of the Great War?  I was told the problem was one of image quality, viz.,   the picture did not reproduce at 300dpi and was pixelated. So it had to go.

Earlier I had made the case for including WWI photos of nurses in action that did not meet the publisher’s quality threshold in this way:

Not all books are created equal; not all pictures are created equal; and not all pictures are equally relevant to the story an author tells.  Criteria of inclusion should accommodate, at least to some extent, subject matter and narrative.  In the context of this particular book, I find it difficult to imagine anyone finding fault with the publisher for including rare and graphic images, never seen by anyone except a handful of medical historians, that  illustrate – and do so poignantly – my central arguments about the emergence of scientific nursing practice on the Western front.  Certainly, should McFarland choose to allow a small number of lower resolution images, I would gratefully acknowledge the publisher’s kind accommodation in the interest of a more vivid historical presentation.

With the photo at issue, however, I was unavailing.  After all, the publisher opined, it would be criticized, presumably by reviewers, for including such a low-resolution photo in one of its books. Really?  If any of my readers know of a single instance in which a book publisher has been criticized in print for including a rare, low-resolution period photo in a work of history, please let me know.

Now the photo is graphic and unsettling.  Was the subject of the photo the underlying reason the publisher excluded it from the book?  Probably not.  I do think, however, that the horrific image of a faceless soldier fortified the resolve  to exclude it on”low resolution”grounds.  But it is precisely the nature of the picture – what it shows us – that speaks to the subject of this particular book.  I sought its inclusion not as yet another depiction of the horror of modern mechanized warfare, a reminder of what exploding artillery shells do to human faces at close range.  Rather, the photo provides poignant visual representation of a Great War nurse in action, of the steadiness and steadfastness with which she faced up to the care of the faceless.

Even more to the point, the photo shows one key instrument deployed by nurses in this war and, to some extent, all wars: the hand. We behold the nursing hand as an instrument of stabilizing connection, of calming containment.  Easing Pain examines the many uses of the nurse’s hand in diagnosis and treatment.  To which the hand as instrument of touch-mediated attachment must be included. Seen thusly, the photo is a wartime embodiment in extremis of touching and being touched as a vehicle of therapeutic “holding” in the sense of the British pediatrician and psychoanalyst D. W. Winnicott.  The role of the hand in nursing care antedates and postdates the era of nursing professionalization.  I explore the topic at length in my previous book, In the Hands of Doctors:  Touch and Trust in Medical Care.

Here then is the context in which the photo would have been introduced.  References to the nurses quoted therein may be found in the book.

_______________

Nursing hands also monitor the nurse’s own performance, especially the acclimatization of new nurses to the demands of the reception hut.  Shirley Millard reports how her hands “get firmer, faster.  I can feel the hardness of emergency setting in.  Perhaps after a while I won’t mind.” More importantly, nursing hands stabilize soldiers whose fear and pain off the battlefield leave them overwhelmed and child-like.  With soldiers who arrive at casualty clearing stations in surgical shock, massive blood loss is compounded by sepsis, pain, and anxiety, making it incumbent on nurses not only to institute stabilizing measures, but to make the soldier feel “he is in good and safe hands.” Touch is a potent instrument for inducing this feeling.  Soldiers clutch hands as they ask, “Is it all right?  Don’t leave me.”  But it is usually not all right, and it is the nurse’s hand that provides a lifeline of human attachment to relieve a desolation that is often wordless:  “Reaching down to feel his legs before I could stop him, he uttered a heartbreaking scream.  I held his hand firmly until the drug I had given him took effect.”  When panic overwhelms and leaves soldiers mute, the hand communicates what the voice can not:  “He seized my hand and gripped it until it hurt . . . He looked up at me desperately, hanging onto my hand in his panic.”  The hand offers consolation when there are no words:  “The bandage around his eyes was soaked with tears.  I sat on his bed and covered his hand with mine.”

The nurse’s hands mark attachment and impending loss.  Soldiers become terrified at the time of surgery.  The reality of amputation, the painful aftercare it will entail, and the kind of life it permits thereafter can be overwhelming.  It is 1915, and the American Maud Mortimer is in a field hospital at the edge of Belgium, only five miles from the firing line.  A patient with whom she has connected, “Petit Pere, is about to have his leg amputated.  He makes her promise that when he comes around from the anesthesia she will be there, and that she will “hold his hand through the first most painful dressing.”  The amputation complete, he gazes up at her:  “Hold my hand tight and I will scream no more.”

But the attachment can transcend treatment-related trauma and become perduring.  Now it is April 1918, three years later, and a pause in the action permits Helen Boylston’s hospital to ship 26 ward patients to England.  One of her patients, Hilley, begs her to let him remain.  “I went out to the ambulance with him,” she recounts, “and he clung tightly to my hand all the way.  I almost cried.” Such separation, with the hand clinging it elicits, reminds us that a wounded soldier’s parting from his nurses can be a major loss, even when it is a prelude to greater safety and fuller recovery. The vigorous hand clinging of the living, even in loss, is far preferable to the enfeebled squeeze of the dying.  With the latter, the nurse’s  hand becomes an instrument of palliation, interposing human touch between living and dying, easing the transition from one to the other:  “I held his hand as he went . . .  Near the end he saw me crying and patted my hand with his two living fingers to comfort me.” Expressions of gratitude and affection, hand-communicated, are part of the process.  The hand continues to communicate as the body shuts down:  “He was ever so good and tried to take milk and food almost up to the end but he was unable to speak and not really conscious, though he could hold my hand and squeeze it which was so sweet of him.”

________________

EASING PAIN ON THE WESTERN FRONT American Nurses of the Great War and the Birth of Modern Nursing Practice

Paul E. Stepansky

McFarland & Co.    978-1476680019    2020    244pp.    19 photos    $39.95pbk/$19.95 Kindle eBook

Available now from Amazon

 

READ THE PREFACE TO EASING PAIN ON THE WESTERN FRONT HERE

PAUL STEPANSKY IS FEATURED AUTHOR IN THE

PRINCETON ALUMNI WEEKLY  

        LISTEN TO HIM DISCUSS THE BOOK WITH THE EDITOR OF THE JOURNAL OF THE AMERICAN ASSOCIATION OF NURSE PRACTITIONERS IN A SPECIAL JAANP PODCAST

 

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.

Leave a comment

Posted in Nurses in WWI, Nursing, Nursing Care, War & Medicine

Tagged , , , , ,

JUST RELEASED: Easing Pain on the Western Front (McFarland, 2020)

Posted on January 14, 2020 | Leave a comment

We are pleased to announce the publication of Easing Pain on the Western Front: American Nurses of the Great War and the Birth of Modern Nursing Practice, the book that has grown out of Paul Stepansky’s popular series of blog essays, “Remembering the Nurses of WWI.”  It has been lauded as “an important contribution to scholarship on nurses and war” (Patricia D’Antonio, Ph.D.) that is simultaneously “the  gripping story of nurses who advanced their profession despite the emotional trauma and physical hardships of combat nursing” (Richard Prior, DNP).  The Preface is presented to the readers of “Medicine, Health, and History” in its entirety.

____________________

Dr. Stepansky is the featured author in the Princeton Alumni Weekly

Listen to him discuss Easing Pain on the Western Front with the editor of the Journal of the American Association of Nurse Practitioners in this special JAANP Podcast

____________________

PREFACE

Studies in the history of nursing have their conventions, and this study of American nursing in World War I does not adhere to them.  It is not an examination of the total experience of military nurses during the Great war.  Excepting only the first chapter, which addresses the American war fever of 1917 and the shared circumstances of the nurses’ enlistment, little attention is paid to aspects of their lives that have engaged other historians.  I do not review the nurses’ families of origin, their formative years, or their reasons for entering the nursing profession.  Similarly, there is relatively little in these pages of the WWI nurses as women, of their role in the history of the women’s movement, or of their personal relationships, romantic or otherwise, with the men with whom they served.

In their place Easing Pain on the Western Front focuses on nursing practice, by which I mean the actual caregiving activities of America’s Great War nurses and their Canadian and British comrades.  These activities comprise the role of nurses in diagnosis, in emergency interventions, in medication decisions, in the use of available technologies, and in devising creative solutions to treatment-resistant and otherwise atypical injuries. And it includes, in these several contexts, nurses’ evolving relationship with the physicians alongside whom they worked.  Among historians of nursing, Christine Hallett stands out for weaving issues of nursing practice into her excellent accounts of the allied nurses of WWI, with a focus on the nurses of Britain and the British Dominions.  Hallett has no counterpart among historians of American nursing, and as a result no effort has been made to gauge the impact of WWI on the trajectory of nurse professionalization in America, both inside and outside the military.

This study begins to address this lacuna from a perspective that stands alongside nursing history.  It  comes from a historian of ideas who works in the history of American medicine.  It is avowedly historicist in nature, grounded in the assumption that nursing practice is not a Platonic universal with a self-evident, objectivist meaning.  Rather this type of practice, like all types of practice, is historically determined, with the line between medical treatment and nursing care becoming especially fluid during times of crisis.  It is intended to supplement the existing literature on WWI nurses, especially the excellent work of Hallett and other informative studies of British, Canadian, and Australian nurses, respectively.  The originality of the work lies in its focus on American nurses, its thematic emphasis on nursing activities, and its argument for the surprisingly modern character of the latter.  Close study of nursing practice, especially in the context of specific battlefield injuries, wound infections, and infectious diseases, yields insights that coalesce into a new appreciation of just how much frontline “doctoring” these nurses actually did.

The case for modern nursing practice in WWI is strengthened by comparative historical inquiry that renders the study, I hope, a more general contribution to the history of military nursing and medicine.  In each of the chapters to follow, I work into the narrative comparative treatment of WWI nursing with nursing in the American Civil War of 1861-1865, the Spanish-American War of 1898, and/or the Anglo-Boer War of 1899-1902.  The gulf that separates Great War nursing from that of wars only two decades earlier, we will see, is wide and deep.  In the concluding chapter, I invert the case for modernity by looking forward from America’s Great War nurses to the American nurses who served in World War II and Vietnam.  If Great War nurses had little in common with the Civil War nurses who preceded them by a half century, they share a great deal, surprisingly, with their successors in Vietnam a half century later.

The focus on nursing practice, then, far from being restrictive in scope, opens to a wide range of issues – medical, cultural, political, and military. Consider, for example, the very notion of healthcare practice, which is determined by a confluence of factors.  Specific theories of disease, rationales for treatment of specific conditions, putative mechanisms of cure, and the grounds for “proving” cure are all central to the historical study of healthcare practice.  Female nursing practice, with the bodily intimacies it entails, also implicates considerations of gender – of what, keeping to the time frame of this study, early-twentieth-century female hands might do to male bodies, and what the males who “owned” these bodies might comfortably permit female hands to do.  Depending on the historical location of nursing practice, issues of social class, nationality, ethnicity, and race may count for as much or more than gender.

By channeling our gaze onto what nurses of the Great War actually did with wounded, suffering, distraught, and dying soldiers, we learn about the many factors that enter into combat nursing at one moment in modern history.  The focus on nursing practice provides a new perspective on the medical advances of the Great War; the role of nurses in making and implementing these advances; the new professional status that accompanied this process; and the American military’s emerging appreciation of trained nurses, indeed of female officers in general.  The focus on nursing practice draws a different picture of the evolution of military personnel policy and the changing social mores and political pressures that accompanied this evolution.

The fate of WWI combat nurses’ role back on the homefront in the aftermath of war is a separate story that I address but briefly in the concluding chapter.  More work should be done on the relationship between military and civilian nursing practice, especially the fate of combat nurses who return to civilian nursing after wartime service.  To keep to the subject matter of this study, the experience of America’s WWI nurses back in civilian hospitals offers an illuminating window into the frustrations and accomplishments of nurses, indeed of professional women in general, in the American workplace in the two decades between the world wars.

For American readers Easing Pain on the Western Front may prove interesting for another reason.  Our increasing reliance on nurses to meet the health care challenges of the twenty-first century, especially in the realm of primary care, underscores the relevance of the unsuspectedly modern Great War nurse providers.  Indeed, they offer a fascinating point of departure for ongoing debates by nurses, physicians, social scientists, and politicians about the scope of practice of nurse practitioners in relation to physicians.  This is because America’s Great War nurses, no less than the nurses of other combatant nations, had to step up during battle “rushes” that overwhelmed their surgeon colleagues.  At such times, and in the weeks and months of intensive care that followed, they became autonomous clinical providers, true forebearers of the nurse practitioners and advanced practice nurses of the present day.  The fact that their professional leap forward occurred in understaffed casualty clearing stations and field hospitals on the Western front during the second decade of the twentieth century lends salience to their accomplishments.

Notwithstanding the many streams of contingency that flow into nursing practice at a given moment in history, I hasten to point out that I am not a historian of gender and that my comments on gender, not to mention ethnicity and race, are sparing.  I invoke them only in the context of specific nursing activities, especially when they were raised by the nurses themselves.  The same may be said of the nurses’ personal lives.  I ignore neither the emotional toll of combat nursing nor the psychological adaptations to which it gave rise.  But here again these issues are addressed primarily in relation to nursing activities, especially the nurses’ perceptions of and reactions to the wounded, ill, and dying they cared for.  I leave to others more comprehensive study of the gender-related, racial, and psychological aspects of American military nursing in World War I and other wars, noting only that the scholarship of Darlene Clark Hine, Margaret Sadowski, and Kara Dixon Vuic has begun to mine this rich vein of nursing history to great effect.

The cohort of nurses at the heart of this study is not limited to American nurses.  They include Canadian and British nurses as well.  In the case of the former, the ground for inclusion is not especially problematic, since many Canadian nurses trained in the United States; indeed, some both trained and worked in the States prior to their wartime service.  Ella Mae Bongard, for example, a Canadian from Picton, Ontario, trained at New York Presbyterian Hospital, practiced in New York for two years after graduating in 1915, and then volunteered with the U.S. Army Nursing Corps.  She ended up at a British hospital in Étretat, where she served with several of her Presbyterian classmates.  The Canadian Alice Isaacson, who served with the Canadian Army Medical Corps, was a naturalized American citizen.  Among other members of the Canadian Nurse Corps,  Mary Catherine Nichols Gunn trained in Ferrisburg VT and initially worked at Nobel Hospital outside Seattle; Annie Main Gee trained at Minneapolis City Hospital with postgraduate studies at New York Polyclinic; and Eleanor Jane McPhedran trained at New York Hospital School of Nursing and worked in the area for three years after graduating.  In all, the training of Canadian nurses and the nursing services they provided were  very much in line with American nursing.

In the case of several prominent British nurses cited throughout the work – Kate Luard, Edith Appleton, Dorothea Crewdson – I am arguably on less certain ground.  British nurses – veiled and addressed as “Sister” –cannot strictly speaking play a role in American nursing practice during the Great War.   I include them nonetheless for several reasons.  The fact is that many British nurses, no less than the Canadians, served abroad for the duration of the war; usually their wartime service extended beyond the Armistice of November 1918 by up to a year.   The duration of their wartime experience makes their diaries and letters, taken en masse, more revelatory of treatment-related issues than those of their American colleagues, whose term of service  was a year or less.  The reflections of Canadian and British nurses on nursing practice on the Western front lend illustrative force to the same battlefield injuries, systemic infections, and psychological traumata encountered by the America nurses as well.

Shared nursing practices were reinforced by considerable interchange among the allied nurses.  Within months of the outbreak of war, American Red Cross (ARC) nurses, all native born and white per ARC requirements, sailed to Europe to lend a hand.  On September 12, 1914, the first 126 departed from New York Harbor on a relief ship officially renamed Red Cross for the duration of the voyage.  A second group of 12 nurses joined three surgeons on a separate vessel destined for Serbia.  Other nurse contingents followed over the next several months, all part of the American Red Cross’s “Mercy Mission.”

Technically ARC nurses were envoys of a neutral nation, and those in the initial group ended up not only in England and France but in Russia, Austro-Hungary, and Germany as well.   In the last the ARC worked in concert with the German Red Cross, and American nurses like Caroline Bauer, stationed in Kosel, Germany in 1915, expressed genuine fondness for the “brave and good” German soldiers under her care.  For the majority of nurses, however, pre-1917 service in British and French hospitals, despite some initial tensions with British supervisors, reinforced ideological and emotional bonds and introduced American nurses to the realities of combat nursing on the Western front.

Even after America’s entry into the war in 1917, American nurses were typically assigned on arrival to British or Canadian hospitals, where they continued their tutelage under senior Canadian and British nursing sisters until returning to their units once their hospitals were ready for them.  Allowing for occasional exceptions, the same medicines (sometimes with different names) were administered, the same procedures performed, and the same technologies employed by the nurses of the allied nations.  To ignore what the Canadian and British nurses have to say about the same issues of nursing practice encountered by the Americans would enervate the study without leading to any refinement of its thesis.

And so, aided by the testimony of Canadian and British nurses,  I am secure in my thesis as it pertains to American nursing and the birth of modern nursing practice.  That being said, I leave it to scholars more knowledgeable than I about Canadian and British nursing history to validate, amend, or reject the thesis in relation to their respective nations.

Finally, it bears noting that in a work about nursing practice that draws on the recollections of a cohort of American, Canadian, and British nurses, each nurse is very much her own person with a personal story to tell.  The memoirs, letters, and diaries that frame this study provide elements of these stories, of how each nurse’s experience interacted with her family history, training, personality, temperament, and capacity for stress management.

In a general way, reactions to the actualities of nursing on the Western front fall along a spectrum of psychological and existential possibilities. At one pole is the affirmation of the combat nursing life provided by Dorothea Crewdson: “I enjoy life here very much indeed. Wonderfully healthy and free.”   At the opposite pole are the mordant reflections of the writer Mary Borden, for whom “The nurse is no longer a woman.  She is dead already, just as I am – really dead, and past resurrection.”  The gamut of reactions, and the richly idiomatic language through which they were expressed, are woven into my narrative at every turn.  I am most concerned, however, with the nurses’ transition from one mindset to another, especially the abruptness with which the life-affirming brio of Crewdson gave way to the horror, demoralization, and depersonalization of Borden. The happy excitement and prideful sense of participation in the war effort with which American nurses set out for the front often dissipated shortly after they arrived and saw the human wreckage that would be the locus of their “nursing.”

Signposts of personal transformation, which I gather together as epiphanies, represent my point of departure in chapter 1.  But in the chapters that follow, these elements of personal biography are subordinate to my focus on nursing practice through a cohort analysis.  Fleshing out the individual stories that undergirded such transformations – the   chronicles of strong, often overpowering emotions that took nurses to the point of physical or nervous collapse – is the stuff of biography and falls beyond the task I have set myself.  It suffices to recall that nurses, no less than the soldiers they cared for, fell victim to what, in the parlance of the war, was termed “shell shock,” even though medical and military personnel steadfastly refused to pin this label on them.  But most of the time the nurses’ descent into the horrific gave rise to adaptive strategies – compartmentalization, dissociation, psychic numbing, black humor – that enabled them to labor on in the service of their soldiers, their “boys.”.

It is with respect to the nurses’ shared ability to bracket their personal stories in the service of a nascent professionalism – a professionalism that segued into medical diagnosis and procedural caregiving far removed from the world of their training and prewar experience – that they reached their full stature.  In so doing, they provide an historical example, deeply moving, of the kind of self-overcoming for which we reserve the term “hero.”

_______________

EASING PAIN ON THE WESTERN FRONT

American Nurses of the Great War and the Birth of Modern Nursing Practice

Paul E. Stepansky

McFarland & Co.     978-1476680019     2020     244pp.     19 photos     $39.95pbk.

Available now from Amazon 

 

 

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.

 

 

 

Leave a comment

Posted in General, Medicine in WWI, Nurses in WWI, Nursing

Tagged , , , , , ,

Remembering the Nurses of WWI (VI)

Posted on August 7, 2017 | 3 comments

[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]

____________

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.” [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]

__________________

[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.

 

3 Comments

Posted in Influenza Pandemic, Nurses in WWI, Nursing

Tagged , , ,

Remembering the Nurses of WWI (V)

Posted on June 12, 2017 | Leave a comment

“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.  Learn more about the nursing response to shell shock in Easing Pain on the Western Front:  American Nurses of the Great War and the Birth of Modern Nursing Practice (McFarland, 2020)].

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 typhoid 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 some 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.

Leave a comment

Posted in Medicine in WWI, Military Psychiatry, Nurses in WWI, Nursing Care, War & Medicine

Tagged , , ,

Remembering the Nurses of WWI (IV)

Posted on May 3, 2017 | 1 comment

“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.  The nursing care of soldiers exposed to poison gas on the Western Front is explored at greater length in chapter 4 of  Easing Pain on the Western Front:  American Nurses of the Great War and the Birth of Modern Nursing Practice (McFarland, 2020)].

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.  “It is dreadful to be impotent, to stand by grievously stricken men it is impossible to help, to see the death-sweat gathering on young faces, to have no means of easing their last moments.  This is the nearest to Hell I have yet been.”  This is the voice of an anonymous British Red Cross nurse, unsettled by the dying Belgium soldiers she encountered on ambulance runs in the fields of West Flanders in the winter of 1915.  The American nurses at No. 12 General Hospital brushed up against this same hell, and 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 to 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.

1 Comment

Posted in Nurses in WWI, Nursing, Nursing Care, Primary Care, War & Medicine

Tagged , , , , , ,

Remembering the Nurses of WWI (III)

Posted on April 6, 2017 | Leave a comment

“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.  Learn more about the range of battlefield injuries and infectious diseases treated by nurses on the Western Front in Easing Pain on the Western Front: American Nurses of the Great War and the Birth of Modern Nursing Practice (McFarland, 2020)]. 

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.

Leave a comment

Posted in Nurses in WWI, Nursing, Nursing Care

Tagged , , ,

Remembering the Nurses of WW I (II)

Posted on March 11, 2017 | Leave a comment

“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 third 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 could be operating up to 16 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.

Leave a comment

Posted in Nurse practitioners, Nurses in Civil War, Nurses in WWI, Nursing

Tagged , , ,

Remembering the Nurses of WWI (I)

Posted on February 22, 2017 | 1 comment

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

[The first of six essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917.  The outgrowth of these essays is the book, Easing Pain on the Western Front:  American Nurses of the Great War and the Birth of Modern Nursing Practice (McFarland, 2020).  Hear Paul Stepansky discuss the book with the editor of the American Journal of Nurse Practitioners in a special JAANP podcast. 

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.

1 Comment

Posted in Nurses in WWI, Nursing, Nursing Care

Tagged

“Scope of Practice” Minefields

Posted on September 15, 2014 | Leave a comment

“. . . my clinical practice as a women’s health NP began in the mid-1970s.  My colleagues who had gone on to academic careers questioned my commitment to nursing and to nursing values.  A common question was ‘Are you a nurse, or are you a mini-doc?’  My answer was, is, and will always be:  ‘I am a nurse with primary care skills.  I take care of my patients within a nursing framework. . . . my values lie in nursing, not in the medical model.  I care for my patients as a fully prepared, primary care provider of women.” – Judith A. Berg & Mary Ellen Roberts, “Recognition, Regulation, Scope of Practice:  Nurse Practitioners’ Growing Pains” (2012)[1]

“We agree certified nurse practitioners can provide many core primary care services, but it is important that this not be misunderstood as suggesting that nurses are interchangeable with physicians in providing the full depth and breadth of services that primary care physicians provide.  The two professions are complementary but not equivalent.  For diagnostic evaluation of clinical presentations that are not straightforward and for the ongoing management of complex or interacting medical problems, the most appropriate clinician is the physician.” – J. F. Ralston & S. E. Weinberger, “Nurses’ Scope of Practice” (2011)[2]

Entering the debate on the “scope of practice” between nurse practitioners (NPs) and physicians is like parachuting onto a battlefield strewn with semantic landmines and decaying verbiage, while overhead the whistle of incoming word-tipped artillery fire grows louder.  For the opposing forces, the NPs and the MDs, negotiation about the scope of NPs’ provider activities has given way to incendiary propaganda and explosive metaphors.  It is all a matter of logistics, planning, grand strategy, tactical advance and retreat.

When the nursing historian Julie Fairman and her colleagues argue that “physicians’ additional training has not been shown to result in a measurable difference from that of nurse practitioners in the quality of basic primary care services,”[3]  they leave unexamined the meaning of basic.  Someone, after all, has to do the defining, and in so doing, to differentiate basic services from services that, in given circumstances, are not so basic.  Someone also has to stipulate how exactly “quality” is being assessed, qualitatively and quantitatively, in both the short- and long-term.

It is fine to make the commonsensical point that nurse practitioners should be permitted to practice “to the fullest extent of their skills and knowledge,” as recommended by the authors of the Institute of Medicine report of 2010, The Future of Nursing.[4]  But who decides what “fullest extent” actually means in relation to specific clinical contingencies and management challenges?  Is there even consensus on the meaning of NP “knowledge and competence” in contradistinction to the “knowledge and competence” of those who receive medical training?  Literally, then, what are Fairman and her colleagues talking about?

NP advocates make tactical use of the word “partnership” in framing debates about NP expansion.  And yes, certainly we need NPs and physicians to be collaborative partners in providing quality health care.  But the notion of “partnership,” as used by NPs, also subserves polemics.  Partnership, after all, does not entail parity among partners.  In law and business, for example, there are senior partners and junior partners, name partners and equity partners, voting partners and nonvoting partners.  In medicine, there are any number of  procedures (e.g., colposcopy, sigmoidoscopy, nasopharyngoscopy) that fall within the domain of adult primary care, but that many primary care physicians no longer perform, even if they are competent to do so, owing to issues of liability and lack of third party coverage.  This does not mean that primary care physicians, gynecologists, gastroenterologists, and ENTs are not “partners” in care, but rather that “partnership” does not abrogate the need for a division of labor, with the differing responsibilities, obligations, and entitlements that such  division entails.

Physician groups threatened by the legislative incursions of nonmedical providers like NPs are no better and even worse.  The Physicians Foundation is a nonprofit organization of medical groups formed to push back the nonmedical invaders, especially nurse practitioners.  Their report of November, 2012, Accept No Substitute: A Report on Scope of Practice, brims with military metaphors.  The authors, Stephen Isaacs and Paul Jellinek, write of “holding the line” on “expansionary forays” and summarize bulletins “fresh from the front lines.”  “What is the score so far?” they ask.  “Who is winning these scope of practice battles?”  And the military metaphors segue into sports metaphors, with the authors’ dour acknowledgment that physicians “are usually playing defense on scope of practice” brightened by occasional successes in eliminating nonphysician licensing.  In the latter cases, they exult, physicians “are in fact able to move the ball up the field.”[5]

What is one to make of such sophomoric posturing in the face of a serious and growing shortage of primary care physicians?  Where will we find the 51,880 additional primary care physicians that, according to recent published projections, we will need by 2025?[6]  It is easy to appreciate the exasperation of primary care NPs who face such opposition in the face of well-established facts.  To wit:   Only 20% of today’s medical students will choose a primary care specialty; NPs provide more cost-effective care than their physician counterparts; patient surveys reveal satisfaction with the care provided by NPs; and half of all physicians in office practice already work with NPs, certified nurse midwives, and/or physician assistants.  All such facts, be it noted, are ceded by the authors of The Physicians Foundation report.[7]

It is time for physicians to accept not only the reality, but also the socioethical desirability of nonphysician providers.  By the same token, it is time for nurse practitioners to accept the reasonableness of practice limits.  An expanded scope of practice is not a limitless scope of practice.  And, yes, self-evidently, the limits to which NPs are subject will not be identical to the limits imposed on physicians. There are indications for which physician consultation and supervision should be mandatory; there will be procedures that only physicians, including primary care physicians, are trained and legally authorized to perform. Establishing boundaries will always be shaped by power politics and economic self-interest, but it need not be deformed by them.  The process can be elevated by concern for public safety and prudent good sense.  By way of identifying two areas in need of further dialogue informed by complementary needs for patient access and patient safety, consider the topics of chronic disease management and prescriptive authority.

Nurse practitioner advocates tout the important role of NPs in managing chronic disease, and type 2 diabetes is typically given as a case in point.[8]  Certainly NPs can manage diabetics whose glucose levels must be monitored and insulin dosages adjusted.  There is also evidence that specialized NPs are highly effective in collaborative practice with primary care physicians, where they serve as diabetic care coordinators.[9]  What then is the problem?  It arises from the fact that management of chronic disease, especially among the elderly, is rarely a matter of managing a  stable disease entity.  In later life, diabetes, however well monitored and managed, typically leads to neuropathy, retinopathy, and/or kidney disease.

Are NPs trained to manage chronic diseases as independent providers when management ipso facto entails a plethora of intersystemic complications?  Consider another example.  Perhaps an NP-nephrologist can manage end-stage renal disease (ESRD), a chronic disease that can be stabilized for long periods with dialysis.  But what happens when such management, and the prolongation of life it entails, leads to diabetes and heart disease, as it often does?  Is such management still within the “knowledge and competence” of NPs?  As I wrote in “The Costs of  Medical Progress”:

Chronic disease rarely runs its course in glorious pathophysiological isolation.  All but inevitably, it pulls other chronic diseases into the running.  Newly emergent chronic disease is collateral damage attendant to chronic disease long-established and well-managed.  Chronicities cluster; discrete treatment technologies leach together; medication needs multiply.

Well-trained NPs no doubt bring much-needed talent to managing intercurrent disease in certain respects.  I am no expert here, but I am open to the possibility that independent management of chronic disease, particularly among the elderly, may not be commensurate with the discrete “skill set” that NPs acquire, even as this “set” is enlarged by the medley of nonmedical skills inculcated by “nursing education and its particular ideology and professional identity.”[10]  Management of chronic disease, that is, often entails complexity of a distinctly medical sort.  Scope of practice debates should be informed by the fact that diabetes, to keep to the example, is no longer a disease with a stable natural history.[11]  The same can be said of kidney disease and heart disease and many types of cancer.  So the question of what NPs can and cannot do needs to be fleshed out in a more clinically realistic manner:  We need to know whether NP-generalists are as capable as primary care physicians of managing chronic illness in the context of life span issues and specific dimensions of patient care.  Are they as capable as primary care physicians, for example, of prioritizing interventions among older patients with multiple chronic diseases?[12]

Another “fullest extent” problematic concerns prescribing privileges.  NPs and APRNs (advanced practice registered nurses) demand the same authorization to prescribe medications as physicians.  This insistence, globally formulated, masks the fact that prescriptive authority is always qualified in various ways. Perhaps physicians, NPs and APRNs, and legislatures should set the all-or-nothing rhetoric aside and wrestle with the real-world issue of “prescriptive authority of various levels” that gets codified in state law.[13]  Is it within the NP’s scope of practice, for example, to change antibiotics without physician consultation for a child who comes to the pediatrician with fever, sore throat, and pain, and whose symptoms have not abated with first-line antibiotics prescribed by the NP?[14]  To begin to get a handle on this kind of issue, one must at present read the law on NP “scope of practice” in a particular state, as NPs have in fact been enjoined to do.[15]

Here is the point: primary care NPs in all states deserve – and now have – “prescriptive authority,” but reasonable people may differ on the breadth of this authority.  Here is an issue that can be subject to empirical research and meaningful negotiation among all the stakeholders, including the public. To wit, what kinds of drugs are NPs trained to prescribe and, based on survey data, what kinds of drugs do they actually prescribe?  Several studies from the 1980s showed “that NPs prescribe a very limited number of relatively simple medications to predominantly healthy populations.”[16]  Perhaps these studies are badly dated and superseded by  recent studies attesting to the broadened range of drugs now prescribed by primary care NPs. Well and good.  Then the “prescriptive authority” granted to NPs by legislatures should be broader rather than narrower.

But, normatively speaking, should it be equivalent to the prescriptive authority of primary care physicians?  Should NPs be granted authority to prescribe controlled substances without collaborative arrangements with physicians and without limiting stipulations as to dosage and duration of use?  Here is another issue ripe for further negotiation informed by empirical research and considerations of patient safety.  I bring no special expertise to the table beyond noting that NPs, however great their knowledge and competence, do not receive the extensive training in physiology, pathophysiology, and pharmacology that physicians do. I do not find it unreasonable that NP-issued scripts should require some degree of physician involvement, as is now the case in 32 states.[17]

The power differential between organized medicine and organized nursing, including medical specialty societies and NP/ACRP societies, has made matters worse for highly trained nurse practitioners seeking to practice to the fullest extent of their knowledge and competence.  But it has also led some NP representatives to demonize medical groups that seek any drawing of lines, since the very act of drawing a line can only derive from the economic imperative to “hold the line” on NP rights.  Consider the reaction of the editor of Policy Politics Nursing Practice in 2006 to the insistence of medical groups that the difference between nurse practitioners with doctorates and physicians be clarified for the benefit of patients. “Does anyone,” he wrote, “seriously see it as part of a conspiracy to mislead patients by having APRNs refer to themselves as doctor? And are physical therapists (who are moving toward a requirement for doctoral-level education), psychologists, and pharmacists in on the conspiracy, too?”[18]

Well, no, hardly.  But the issue here, shorn of polarizing rhetoric, isn’t about willful misleading; it’s about the cultural valence of the title “doctor” and the everyday meanings people impute to it in connection with healthcare.  A patient who seeks treatment from a licensed primary care provider who is referred to and addressed as “doctor” will, absent some kind of a priori clarification, likely assume the “doctor” in question is a physician.  It is not unreasonable to suggest reasonable efforts at patient education to clarify the different roles and orientations of different kinds of providers.  And what prevents NP groups from adopting their own strategy of patient education?  What prevents them from developing and publicizing endorsements of the “doctor of nursing practice” degree that play to the latter’s  “doctoring” strengths in contradistinction to those of physicians?

If there is a conspiracy out there, it is one perpetrated on the public by both physicians and NPs.  It is a conspiracy of partial explanations.  It is the conspiracy among physicians who refuse to cede that nurse practitioners have arrived, that they are licensed clinical providers who are perfectly capable of providing a great deal of what has traditionally been the province of medicine, especially primary care medicine.  But it is also the conspiracy among NP advocates whose rhetoric masks important distinctions, viz., that “fullest extent” of NP/APRN practice is not coextensive with the typically full extent of care that primary care physicians are trained to provide.  This follows from various considerations, not least of which is that family physicians train a total of 21,000 hours whereas NPs train between 3,500 and 6,000 hours.[19]  There, I’ve done it again.  I’ve made a a series of claims that strike me as reasonable and will win me no friends in either warring camp.

__________________________

[1] J. A. Berg & M. E. Roberts, “Recognition, regulation, scope of practice:  nurse practitioners’ growing pains,” J. Amer. Acad. Nurse Pract., 24:121-123, 2012, at 121.

[2] J. F. Ralston & S. E. Weinberger, “Nurses’ scope of practice,” Correspondence, New Engl. J. Med., 364:281.

[3] J. A. Fairman, et al., “Broadening the scope of nursing practice,” New Engl. J. Med., 364:193-96, at 193.

[4] As quoted in J. A. Fairman & S. M. Okoye, “Nursing for the future, from the past: two reports on nursing from the Institute of Medicine,” J. Nurs. Ed., 50:305-311, 2011, at 309.

[5] S. Isaacs & P. Jellinek, Accept No Substitute:  A Report on Scope of Practice. White Paper for The Physicians Foundation, November, 2012 (http://www.khi.org/documents/2014/aug/26/accept-no-substitute-report-scope-practice/), pp. 1, 2, 3, 6.

[6] S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10:503-509, 2012.

[7] Issacs & Jellinek, Accept No Substitute, pp. 8-13.

[8] G. C. Richardson, et al., “Nurse practitioner management of type 2 diabetes,” Permanente Journal, 18:e134-140, 2014;  M. J. Goolsby, “2006 American Academy of Nurse Practitioners diabetes management survey,” J. Amer. Acad. Nurse Pract., 19:496-98, 2007; Fairman, et al.,  “Broadening the scope of nursing practice,” p. 193.

[9] Richardson, “Nurse practitioner management of type 2 diabetes,” op cit.; K. G. Shojania, et al., “Effects of quality improvement strategies for type 2 diabetes on glycemic control:  a meta-regression analysis,” JAMA, 296:427-40, 2006; S. Ingersoll, et al., Nurse care coordination for diabetes:  a literature review and synthesis,” J. Nurs. Care Qual., 20:208-14, 2005.

[10] On the notion of clinical competence as acquisition of a “skill set,” see, e.g., J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY: Springer Pub., 2002),  pp. 311-12 and J. Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick: Rutgers, 2008), pp. 187, 190.

[11] Chris Feudtner terms it a “cyclical transmuted disease” in Bittersweet: Diabetes, Insulin, and the Transformation of Illness (Chapel Hill: North Carolina, 2003), p. 36.

[12] For exemplary instances of how clinical judgment – and not a clinical “skill set” – enters into the prioritizing of treatment interventions among concurrent chronic diseases, see K. C. Stange, et al., “The value of a family physician,” J. Fam. Pract., 46:363-69, 1998; K. C. Stange, “The generalist approach,” Ann. Fam. Med., 7:198-203, 2009, and E. J. Cassell, Doctoring: The Nature of Primary Care Medicine (NY: Oxford University Press, 1997).

[13] Of course, the issue of  levels of prescriptive authority pertains not only to physicians and NPs, but also to physician assistants, dentists, optometrists, osteopaths, and podiatrists. For the concrete manner in which the state of Florida spells out prescriptive levels for each of these professions, see http://www.thehealthlawfirm.com/resources/health-law-articles-and-documents/prescribing-in-florida.html).

[14] M. Crane, “Malpractice risks with NPs and PAs in your practice,” Medscape, Jan 3, 2013 (http://www.medscape.com/viewarticle/775746).

[15] E.g., C. Buppert, “Scope of practice,” J. Nurse Pract., 1:11-13, 2005.

[16] C. D. DeAngelis, “Nurse practitioner redux,” JAMA, 271:868-71, 1994.  The studies  DeAngelis cites are:  P. Repicky, et al., “Professional activities of nurse practitioners in adult ambulatory care settings,” Nurse Pract., 4:27-40, 1980; D. Munroe, et al., “Prescribing patterns of nurse practitioners,” Am. J. Nurs., 82:1538-40, 1982; J. Resenaur, “Prescribing behavior of primary care nurse practitioners,” Am. J. Public Health., 74:10-13, 1984.

[17] “Nurse Practitioner Prescribing Authority and Physician Supervision Requirements for Diagnosis and Treatment” (http://kff.org/other/state-indicator/nurse-practitioner-autonomy/).

[18] D. M. Keepnews, “Scope of practice redux?,” Policy, Politics & Nurs. Prac., 7:84-86, 2006, at 84.

[19] D. Marbury, “Scope of practice debate,” Med. Econ., September 10, 2013, 26-30, at 27 (http://medicaleconomics.modernmedicine.com/medical-economics/news/scope-practice-debate?page=full).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

Leave a comment

Posted in Diabetes, Medical Politics, Nurse practitioners, Nursing

Tagged , ,

What Do Nurse Practitioners Practice?

Posted on August 22, 2014 | Leave a comment

What should the nurse practitioner’s “scope of practice” be  and how autonomously should she or he be allowed to practice within that scope?  A half century after the first advanced training programs brought nurses into the ranks of clinical providers, these two questions continue to bedevil nursing, medicine, insurance companies, and state legislatures.  The crucial role of nurse practitioners in modern health care delivery, their ability to provide primary care, and the satisfaction of patients who receive this care – these facts are well-established and, for me at least, beyond dispute.

But questions of scope of practice and practice prerogatives (including prescribing privileges) remain contentious, and different state legislatures have codified different answers.   I have no desire to enter debates that will likely continue at medical, nursing, and legislative levels for some time to come.  But let me offer one historian’s perspective on a few aspects of these knotty issues.

The expansion of nursing’s role in the direction of specialized clinical expertise occurred in an amazingly brief stretch of time.  In 1955, The American Nurses Association (ANA) approved a legal definition of nursing practice that prohibited “acts of diagnosis and prescription of therapeutic or corrective measures,” and it was only seven years later, in 1962, that it held its first clinical sessions at its annual convention.[1]  Even then, until 1968, the ANA’s Code for Professional Nurses framed the nurse’s professional responsibilities in terms of the nurse’s relationship to physicians.[2]  Yet, by the mid-60s, spearheaded by reforms in nursing education then underway, the term “nurse practitioner” came into use.  It conveyed a nurse with “specialized expertise,” often in hospital settings, that grew out of additional training beyond the three years of hospital-based training that led to state licensure as a Registered Nurse.

“Specialized expertise” is an evocative but imprecise term.  In nursing, it initially conveyed expertise in one or another aspect of hospital-based care.  In the early 1900s, nurses acquired expertise as x-ray technicians and microscopists, and then again in the 1930s, they “specialized” in monitoring polio patients in their iron lungs.  During World War II, nurses both on the front lines and in stateside hospitals began to perform venipunctures to administer fluids intravenously; after the war, they continued to do so, and some  became specialized IV  therapists, performing and monitoring  IVs all along their units.

But in postwar America it was especially the new technologies brought to bear in treating acutely ill patients that elicited nurse specialization.  Self-evidently, we needed critical care nurses, obstetrical nurses, and dialysis nurses able to exercise independent judgment and initiate (or discontinue) treatments in exigent circumstances, in what the historian Margaret Sandelowski terms “emergent life-threatening conditions.”  By the 1960s, as Sandelowski observes, the new “machinery of care” had fostered a more collegial and collaborative relationship between physicians and nurses.[3]  But this machinery  – vital function monitors, cardiac monitors, electronic fetal monitors, and the like – was integral to medical care in the hospital.  These monitors were not invented by nursing scientists as extensions of nursing care; they were instruments of improved hospital care whose design, manufacture, and intended use fell within the domain of physicians and the medical model.

The nomenclatural challenge proved even greater when advanced nursing practice left the hospital setting and became office-based, especially in the realm of primary care.  Historians of nursing such as Julie Fairman tend to collapse the distinction between hospital-based specialty nursing and independent “nursing practice” in a global narrative of nursing’s coming-of-age in the four decades following the end of World War II.  The storyline of professional self-becoming involves new forms of collegial collaboration between individual nurses and physicians, which, over time, empowered the nursing profession to liberate itself from the bondage of organized medicine, with its long-held belief in the subordinate role of nurses as physician extenders.  What tends to be glossed over is the phenomenology of “expertise” in relation to different professional activities.  Expertise in the implementation of technologically driven, hospital-based monitoring – with the diagnostic and treatment prerogatives associated with it – is not the same as the expertise that inheres in being a “practitioner” of medicine.

Or is it the expertise that inheres in being a “practitioner” of nursing?  In her illuminating history of the nurse practitioner movement in America, Fairman delineates the inter-professional tensions congealed in this question.  Even  Loretta Ford and Henry Silver, she points out, who collaboratively developed the first (pediatric) nurse practitioner training program at the University of Colorado in the mid-1960s, used different, politically laden terminology to describe exactly what kind of nonmedical practitioner they were training.  For the pediatrician Silver, the new provider would be a “nurse associate”; for the nurse educator Ford, she or he would be a “nurse practitioner.”[4]

And the linguistic-cum-political tension was played out in different pairs of descriptors.  Nurse practitioners saw themselves as “taking on” diagnostic and treatment activities traditionally reserved for physicians, whereas physicians saw themselves as “delegating” certain medical tasks to nurses.[5]  The need to define the nurse specialist’s prerogative to diagnose and treat illness as  something other than “medical”  was at the heart of the American Nurses Association’s need to distance itself from another nonmedically trained practitioner who emerged at this same moment in  American history:  the Physician Assistant.  PAs were precisely what newly empowered clinical care nurses, at least in the eyes of their professional organization, did not want to be: a Physician Assistant rather than an autonomous Nurse Practitioner.[6]

In the realm of independent practice, this claim is highly problematic, since diagnosis and treatment of illness is not nursing “practice” in any historically meaningful sense of the term; rather, diagnosis and treatment have always fallen to the physician, as the word “physician” has been understood since the beginning of the thirteenth century, when Anglo-Normans gathered the Latin “physicus” and the French “physic” into the English “physic,” from which the word  “physician” as a medical practitioner came in to use later in the century.  It is easy to see how nursing practice can envelop sophisticated technological skills that are teachable and learnable.  But the art of diagnosis and treatment – and the qualities of learned judgment[7] that fall to this task – have always been the province of medicine.

The historical claim enfolds an epistemic claim, a claim about the nature of different kinds of knowledge.  Nursing knowledge, as codified in Florence Nightingale’s Notes on Nursing: What It Is and What It is Not (1859) and the British and American training programs that adopted her model in the 1870s and thereafter, has never been coextensive with medical knowledge.  For  Nightingale and her cohort of nursing educators, it remained a “gendered” (read: womanly) knowledge of comfort care; such care drew on sanitary science and scientifically informed  bedside observation, both infused with a maternalistic sensibility.[8]  Whether or not the knowledge base that subtends such patient-centered caring is something other than medical knowledge (as Nightingale believed) or a neglected subset of medical knowledge, is beside the point. And the point is this:  The kind of “knowledge and skills”[9] that enter into independent clinical practice – “knowledge and skills” that, to be sure, nurse practitioners and other nonmedical providers can acquire to some extent  – are by their nature medical.  This is why the struggle of nurse practitioners to obtain state licensure that permits them to “practice” without medical supervision has been halting and may never succeed entirely.

It is not simply a matter of power in the sense of Foucault, of organized medicine’s ability to withhold, control, and/or regulate entry into the world of practice.  It is because the science of clinical evaluation, diagnosis, and treatment that emerged in postbellum America was vested in the medical profession, not in the nascent nursing profession.  In the final three decades of the nineteenth century, we behold the paradigm shift in medicine that historians endlessly write about:  Medicine became scientific medicine, and this shift, with its associated educational and organizational changes, coincided with the emergence of a “profession” in the modern sense of the term.  The physician, not his (then) helpmate nurse, was part of the profession vested with the scientific understanding of illness and the cultural authorization to act on this understanding by diagnosing and treating it.[10]

The foregoing helps explain why, in retrospect, the ANA’s insistence that pediatric nurse practitioners retain the prerogative to delineate their own scope of practice was foredoomed.  ANA leaders sought to contest a notion of “practice” that, by the early 1970s, was incontestable.  And the pediatric nurse practitioners knew as much.  Like their nurse anesthetist forebears, who formed the National Association of Nurse Anesthetists in 1932,[11] they walked away from the ANA and formed their own professional association, the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) in 1973.  And the NAPNAP, without further ado, accepted affiliation with the American Academy of Pediatrics, realizing that the ANA’s insistence on complete autonomy for nursing was self-defeating.  The pediatric nurses, if not the ANA leaders, realized that such insistence militated against the idea of team practice, of a pediatrician, pediatric nurse practitioner, and nurse working together, and it contravened the reality that, in all such cases, the pediatrician would be the leader of the team.[12]

The dilemma for nurse practitioners is that they have spent  over a half century trying to define themselves by what they are not.  They are not physicians.  They are not physician assistants or associates.  They are not general nurses who lack advanced postgraduate training and specialty licensure.  So what exactly are they?

In the late 1950s and 1960s, nurse educators like Esther Brown and Hildegard Peplau sought to fill in the lacuna by articulating a new basis for nurse practitioner expertise.  In so doing, they adopted the same orientation as the founders of the “family practice” specialty movement during the same time.  That is, they sought to equate the nurse practitioner’s “expert clinical practice”  with a psychosocial sensibility and an ability to provide holistic psychotherapeutic care.  Social science course work and psychodynamic training, they hoped, would move the nursing practitioner away from medicine and toward this new kind of nursing expertise.

That Brown and Peplau spearheaded this effort in nurse education is hardly surprising, given their respective backgrounds.  Brown, a social anthropologist on the staff of the Russell Sage Foundation, authored Nursing for the Future (1948), a Foundation report that advocated university-based nurse training schools in the service of a vague psychosocial vision of nursing care.  The nurse of the future, she wrote, would “complement the patient by supplying what he needs in knowledge, will, or strength to perform his daily activities and also to carry out the treatment prescribed for him by the physician.”  Peplau, the founder of psychiatric nursing, followed an M.A. at Columbia’s Teachers College, where she completed the first course in advanced psychiatric nursing, with psychoanalytic training at New York’s William Alanson White Institute.[13]  She believed that psychiatric nurses should function as psychotherapists, and, implicitly, that all nurses should bring a broad psychosocial, really a psychotherapeutic, orientation to their work.  Were Brown, Peplau, and their associates successful in reforming nursing training in a manner that subserved a new kind of nursing identity?   No, certainly not in the manner they envisioned.  And further, at the time their educational reforms were introduced in the nursing schools of large public universities, there were serious problems: Graduates overfed with the new social science curriculum were simply unprepared to assume the responsibilities of nursing practice.[14]

_______________________

 My father, William Stepansky, whose remarkable postwar career in family medicine has been woven into many of these essays, was a pharmacist before he was a physician.  He entered Philadelphia College of Pharmacy and Science in 1940, but his education was interrupted by induction into the army in March, 1943, several months before he completed his junior year.  He had not begun pharmacy college with the intention of attending medical school – this seemed an utterly far-fetched dream for the son of poor Russian émigrés who fled the Pogroms in 1921 and struggled to raise a family in the Jewish enclave of South Philadelphia.  His own mother thought him foolish for entering college and crazy (meshuga) when he mentioned his interest in medicine.  In 1946, after two years of service as a surgical technician on the battlefields of France, Belgium and Germany and an additional six months as a laboratory technician in Pilzen, Czechoslovakia, he returned to Philadelphia, where he completed his pharmacy training in 1947.  Only then, with the G.I. Bill in place, did he allow himself to envision a career in medicine, and following an inventive series of initiatives, he gained admittance to Jefferson Medical College, where he joined the freshman class in the fall of 1948.[15]

My father not only retained an active pharmacy license throughout his career, but actually “practiced” pharmacy out of his Trappe office.  He maintained an impressive inventory of basic and not-so-basic drugs, and he concocted, among other things, the marvelous “red medicine” of which I have written.  He became a staff research clinician for McNeil Labs and later participated in clinical drug trials with the Psychopharmacology Research Unit of the University of Pennsylvania.  Pharmacy training certainly proved helpful to him and his rural patients, but it was not at the core of his professional identity.  He was not a “pharmacist practitioner” or an “advanced practice pharmacist.”  He was a physician, a general practitioner of medicine.

Perhaps it is time for the nurse practitioner profession to dispense with the “nurse” appellation altogether.  These men and women are not professional nurses as the notion of nurse professionalism took shape over 150 years, even though they come to  medical “practice” through nursing training and the patient-centered values it instills.  But additional clinical training of several years duration beyond the R.N. or B.S.N. level, I suggest, takes them out of the realm of nursing practice altogether.   So, with a nod to perduring intra- and inter-professional politics, let’s cast aside the terms “medical,” “physician,” “nurse,” and “nursing” altogether, and come up with something more accurate.  Advanced practice nurses should henceforth be designated “licensed clinical providers” or “licensed clinical practitioners,” with the appropriate specialty designation appended to their licenses, e.g., “licensed clinical provider – primary care” or “licensed clinical provider – nephrology” or “licensed clinical provider – oncology.”  There, I’ve said it.  These designations are accurate and neutral and therefore certain to please no one.

 __________________

[1] J. Fairman, Making Room in the Clinic:  Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick:  Rutgers University Press, 2008), pp. 119-21.

[2] L. Freitas, “Historical roots and future perspectives related to nursing ethics,” J. Prof. Nurs., 197-205, 1990, at 202.

[3]  M. Sandelowski, Devices and Desires:  Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), pp. 127-28.

[4] Fairman, Making Room in the Clinic, p. 91.

[5] J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY:  Springer Pub., 2002), pp. 309-333, at p. 323.

[6] Fairman, Making Room in the Clinic, pp. 95ff.

[7] N.B. I do not understand “clinical judgment,” with its reliance on mentoring and tacit knowing, in the same way Fairman understands “clinical thinking,” viz., as a process or skill set. See Fairman, “Delegated by default,” pp. 311-12 and Making Room in the Clinic, p. 187.

[8] For a wonderful popular exposition of  Nightingale’s vision of the nurse transposed to the Bellevue Hospital Training School in the early 1880s,  see F. H. North, “A new profession for women,” The Century, 25:30-37, 1882.

[9] Fairman, “Delegated by default,” p. 323.

[10] These brief remarks allude to, without doing justice to, the brilliant analysis of Thomas Haskell on the emergence of modern professions in postbellum America.  See T. L. Haskell, The Emergence of Professional Social Science:  The American Social Science Association the the Nineteenth-Century Crisis of Authority (Baltimore: John Hopkins, 2000 [1977]), pp. 68-74, 91-121, and passim.

[11] K. Koch, “Agatha Hodgins, Lakeside Alumnae Association, and the founding of the AANA,” AANA Journal, 73:259-62, 2005.

[12] Fairman, Making Room in the Clinic, pp. 175-80.

[13] On Peplau’s graduate training at Teacher’s College and the William Alanson White Institute, see B. J. Callaway, Hildegard Peplau: Psychiatric Nurse of the Century (NY:  Springer Pub., 2002), pp. 167-91.

[14] Dominique Tobbell documents the perceived deficiencies of 1960s graduates of the UCLA and University of Minnesota nursing schools, where the new curriculum was implemented,  in “’Coming to grips with the nursing question’:  the politics of nursing education reform in 1960s America,”  Nurs. Hist. Rev., 22:37-60, 2014.

[15] This paragraph is culled from my memoir of my father’s life and career, P. E. Stepansky, The Last Family Doctor:  Remembering My Father’s Medicine (Montclair, NJ:  Keynote, 2011).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

Leave a comment

Posted in Nurse practitioners, Nursing, Nursing and Gender, Nursing education, Primary Care

Tagged , , , , , , ,