American Hospital of Paris Ambulance

The beginning of the 20th century there were many American’s who visited and lived in Paris - tourists, students, travelers, and expats in France. During the summer months, their numbers reached up to 100,000 in Paris alone.

The Association of the American Hospital of Paris was created in 1906 by several members of the American expats community in Paris. Their wish was to create a Paris-based hospital which would provide American expatriates residing in France with American-trained medical care in their own language, regardless of their financial means. On January 30, 1913, the United States Congress officially recognized the American Hospital of Paris, granting it federal status.

America did not enter WWI until 1917 but the American expats, working with the American Hospital established a volunteer ambulance service staffed by American doctors, surgeons and nurses. The ambulance service helps over 10,000 allied soldiers. A nearby school, the Lycée Pasteur of Neuilly-sur-Seine, is transformed into a temporary hospital and serves as a base for the ambulance service.

 

Military Nurses in WWI

WWI Care of Wounded Nurses.jpg

Effects of War

 It is a sad, sobering fact that war results in increasing medical knowledge and skills of all medical personnel – physicians, surgeons and nurses. Is so much suffering worth these gains in knowledge? Some answer ‘yes’ as they consider the improvement in care to victims of accidents and disasters a positive result of medical knowledge gained.

In the beginning of the conflict military nurses were intended to work in the rear and not face dangerous conditions near the battlefield. However, the plans had to be discarded when reports of injuries due to “gas” attacks, artillery weapons that left large numbers of soldiers with injuries requiring skilled nursing care. Surgical and gas treatment teams were organized to take specialty care closer to the patients; nurses were key elements of those teams.[i] These female nurses challenged conceptions of how close women could be to battle and how they could face danger. CEUfast Blog[ii]

“Nurses treated patients near or just behind the front lines at field hospitals, evacuation stations, or clearinghouses—even in churches that were turned into hospitals. They could be found at base stations, which were generally far removed from battle; however, they also served in troop transports and transport ships. Some nurses even drove ambulances.” – CEUf fast Blog[i]

Nurses treated numerous types of wounds, as well as infections and mustard gas burns. They were also faced with soldiers suffering from emotional injuries, including shell shock. Some were trained in social work, including psychiatric training, in order to help current soldiers and those returning home deal with their experiences.

“The battlefield conditions presented extreme challenges for nurses. Patients had massive wounds to the face and head incurred as they poked their heads out of trenches, massive wounds to extremities that would require amputations, and also burns from poisonous gases. Injuries from battles on French farm fields featured both shards of shrapnel and embedded soil and manure. Antibiotics were not available, - rubber gloves and wound irrigation solutions were recent innovations. Nurses managed infections with great success under these trying circumstances, especially considering there was no electrical power and bandages from wounds had to be washed by hand and re-used.” [i]

Nurses Work Load and Working Conditions

In May 1917, U.S. medical teams became the first American troops to arrive in the war zone, and many remained through mid-1919.

War nursing’s more common hazards included infected fingers, sickness, and physical strain. “My back is busted in two tonight. Slowly, [moving] down the ward, doing the dressings and making the beds,” Boylston wrote in her diary. This frequent changing of dressings and application of antiseptic, though physically exhausting, served a critical medical function in the pre-antibiotic era: It became the most effective method for healing infected war wounds and prevented many limb amputations. Helen Boylston[i]

From the Journal of [ii] Elizabeth Weaver:

“During Miss Williams absence on Surgical team I had charge of Ward A. At this time the doctors were busy in the Operating Room practically day & night, consequently the nurses had to do the dressings on the ward. All day long from morning until night I went from bed side to bed side doing dressings. I had an orderly to assist me. …strenuous days. These patients were rushed directly from the front. I always dreaded removing bandages for fear of hemorrhage. I never knew what I was going to find, there were many missing limbs, horrible deep wounds.”[iii]

“After June 15 the hospital was well filled & work became more strenuous for the nurses. On Oct 10, 1918 we had 2275 patients & only 49 nurses, some of the nurses being on Emergency teams, several sick & several at Camp # 44 The mail from the States at this time was very irregular. I sometimes would not hear from home for a month, some of the boys had not received mail for 4 or 5 months”.

“Base Hosp #20 was originally planned as a 500 bed hosp. but gradually grew in size until at one time we had 2275 pts. The nursing force however was not increased at any time; consequently the work was extremely heavy at times & certainly most difficult as the patients were housed in so many different buildings.” Elizabeth Weaver

Johns Hopkins nurses joined the American Red Cross in 1914 and were already serving throughout Europe. Base Hospital 18, in France was staffed mainly with Hopkins nurses and physicians. The correspondence from nurses serving in these units, often published in the Johns Hopkins Nurses Alumnae Magazine, poignantly describes the hardships and horrors faced by both soldiers and their caregivers.[i]

Alice Fitzgerald, 1906, served with a base hospital of the British Army in France in 1916. She wrote often to the Alumnae Magazine about her experiences:[ii]

September 30, 1916 Just as I was going to get leave, I received orders to move, and am now at 2/2 London Casualty Clearing Station, the nearest to the front, and the nearest any nurse gets. Let me tell you that we are all but in the trenches: in fact, we are surrounded by trenches, because we are on ground evacuated by the Germans. We are so situated that we have shell fire on three sides and the noise is simply fierce at times; so far the shells have not reached us but bombs have and the other night we were missed by about 30 yards. …Talk of hard work! I have 2 tents holding 70 patients each and they have to lie on stretchers and pretty close, and making dressings practically on the floor, nearly breaks my back, but I get through somehow or other and am not much the worse for wear. … The most comfortable and comforting time of the day or night is when I get into my sleeping bag with a hot water bottle and tuck in for the night with my tent flap well open and try to go to sleep to the music of the bombardment.” - Alice Fitzgerald

Mary Adams, 1911, describes the heavy work and many wounded in an undated letter from the February 1917 edition of the Alumnae Magazine[i].

I had five tents each with eight of these beds but before the evening was over four more were added to each tent so that I had 12 in each. So close were the beds you could not step between. I made dressings until 12 midnight using lantern light. The next day we were up earlier than usual and I found my number of tents increasing so that I soon had 150 patients. As soon as I had finished their dressings I helped in other lines and that day it was 2 a.m. before I got to bed, barely taking time for meals.

The rush lasted for several days, sending patients to England as soon as possible and getting new ones in, so that it was one continuous convoy in and out.” Mary Adams




References

[i] https://magazine.nursing.jhu.edu/2016/10/hopkins-nurses-in-world-war-i-views-from-the-field/[i] Johns Hopkins Nurses in WWI https://www.newswise.com/articles/world-war-i-nurses-in-the-trenches[ii]Ibid
[i]From: Helen Dore Boylston’s An American Nurse in France In 1927 she published Sister: The War Diary of a Nurse her account of experiences WWI https://medium.com/americanexperiencepbs/american-nurses-in-world-war-i-under-appreciated-and-under-fire-a97ef816ac2a

[ii] Weaver, E. Elizabeth op.cit

[iii] Weaver, E. Elizabeth (Emma Elizabeth), 1878-1966.:

Journal of E. Elizabeth Weaver, Army Nurse Corps, World War I, 1917-1919; From the collection of the US Army Heritage and Education Center, Carlisle, PA

[i]Symposium presented February, 2016 by the University of Kansas School of Nursing and the Department of the History and Philosophy of Medicine, in partnership with the National World War I Museum in Kansas City. http://www.kumc.edu/news-listing-page/lworld-war-and-its-impact-on-the-nursing-profession.html

[i] Ibid

[i] https://e-anca.org/History/Topics-in-ANC-History/Contributions-of-the-US-Army-Nurse-Corps-in-WWI - Quote from Stimson, Julia C. The Medical Department of the United States Army in the World War. Volume XIII, Part Two, The Army Nurse Corps. Washington, D.C.: U.S. Government Printing Office, 1927

[ii] https://ceufast.com/blog/nursing-and-medicine-during-world-war-i


Common Medical Conditions in WWI

WWI nurses – on both sides – cared for soldiers suffering from one or more of the following common medical and surgical conditions:

Trench Foot

Soldiers standing in trench - wet boots

Soldiers standing in trench - wet boots


Trench Foot is caused by prolonged exposure to damp, cold conditions and poor environmental hygiene. The blood vessels constrict in an attempt to keep warm by reducing blood flow to the extremities. This reduces the amount of oxygen and nutrients to the feet which can result in tissue and nerve damage. Trench foot is relatively unknown in the modern army, but was a frequent occurrence in the trenches of the Great War. “

Trench+Foot+1.jpg

Trench Foot

Non Freezing Cold Injury (NFCI) also known as Immersion Foot.

Trench foot doesn’t require freezing temperatures and can develop in temperatures up to sixty degrees Fahrenheit and even affect people indoors. Any wet environment, be it from excessive sweating to wearing damp socks and shoes can cause Immersion Foot. The medical term for this condition is Non Freezing Cold Injury (NFCI) also known as Immersion Foot.

Trench Foot could be extremely painful and lead to amputation of toes or the entire foot; recovery could take up to six months. During WWI, trench foot was first treated with bed rest. Soldiers were also treated with foot washes made from lead and opium. As their conditions improved, massages and plant-based oils (such as olive oil) were applied. If the symptoms of trench foot got worse, amputation was sometimes necessary to prevent circulation problems from spreading to other areas of the body.[i]

Prevention - the best treatment for Trench Foot

Prevention - the best treatment for Trench Foot

Gas: Mustard, Chlorine and Phosgene

Chemical Warfare - Gas Montage.jpg

WWI saw large-scale use of chemical weapons, commonly called, ‘gas’ attacks – their effect on humans and animals was horrific – leading to a formidable fear factor .when. a gas cloud could be seen slowly approaching over the battlefield .Gas masks were mandatory for humans and animals. Chemical warfare with gases was subsequently absolutely prohibited by the Geneva Protocol of 1925. Chemical attacks have been occasionally been used since then but never in WWI quantities.[i]

[ii]Three substances were responsible for most chemical-weapons injuries and deaths during World War I: chlorine, phosgene, and mustard gas. According to the U.S, Centers for Disease Control and Prevention (CDC), Phosgene gas causes breathing difficulties and heart failure. Mustard gas damages the respiratory tract and causes severe eye irritation and skin blistering. Chlorine gas is yellow-green, smells like bleach; when it makes contact with moist body tissues, it produces an acid that can cause severe tissue damage,

A British soldier in the Royal Army Medical Corps described survivors of a poison gas attack:

"Complexion here was an ashed blueish grey, the expression most anxious and distressed with the eye-balls staring, and the lids half closed. Respiration was extremely laboured and noisy with frequent efforts to expel copious amounts of tenacious yellowish green frothy fluid which threatened to drown them, and through which they inhaled and exhaled air into and out of their lungs with a gurgling noise," Capt. Edward L. Reid recounted in a written report.[i]

Gas Attack seen coming -Nurses in WWI prepare for gas attacks

Excerpts from Elizabeth Weaver’s Diary:[i]

July & Aug. We are terribly busy, patients coming in from all fronts, many direct from the battle-field, many terribly mangled & shot to pieces. Now 2200 patients – 38 nurses. You can imagine the nature of our duties. We certainly need more nurses. We have mustard phosgene & chlorine gas cases. The mustard gas causes horrible body burns.[ii]

…in a blanket, no clothing his body burned black & literally raw, face black, eyes completely swollen shut & he was suffering agonies. This was a case of mustard gas burns. Another patient, gasping & coughing, blue in the face, intense pain in his chest on every respiration. This, of course was a case of phosgene gas poisoning”

[i] Weaver, op.cit

[ii] Weaver, op.cit

[i] LiveScience op.cit

[i] https://www.womensmemorial.org/exhibits/detail/?s=world-war-i-nurses-the-journal-of-emma-elizabeth-weaver
Emma Elizabeth Weaver (1878-1966) of the University of Pennsylvania Base Hospital served in France and Germany between 1918 and 1919 and kept a journal of her service.

[ii] Photo Man and Horse from LiveScience https://www.livescience.com/58569-chemical-weapons-world-war-one.html

 Orthopedic Injuries

Like in previous wars, soldiers on both sides of the conflict suffered exposed extremities, fractures (both open and closed), traumatic amputations, and vascular injuries during World War I.[i] “For fracture treatment, assuming infection could be controlled; traction remained the mainstay with Balkan frame wards dominating every base and general hospital. Weight and pulley traction allowed effective nursing, infection control with Carrel Dakin irrigation, and healing of the fracture.”[ii]

Hospital orthopedic ward - Balkan Frames

Hospital orthopedic ward - Balkan Frames

Orthopedic injuries needed and extension devices for traction. Julia Stimson, Chief Nurse at Base Hospital #21, described their hut (ward) “our surgical hut looks like a carpenter shop. We have about ten beds under a wooden canopy frame to which poor shattered legs of our blown-to-pieces men are fastened. When a leg is broken in half a dozen places and there are several gaping infected wounds besides, it is something of a trick of carpentry and mechanics to make the poor fellows comfortable, put on extension so the legs won’t contract, and yet make it possible to irrigate the wounds.”[i]


[i] Contributions of the U.S. Army Nurse Corps in World War I

https://e-anca.org/History/Topics-in-ANC-History/Contributions-of-the-US-Army-Nurse-Corps-in-WWI



[i] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523509 Clin Orthop Relat Res. 2015 Sep; 473(9): 2771–2776. Published online 2015 May 1. doi: 10.1007/s11999-015-4327-5

[ii] Ibid

 Wound Care: Prevention and Treatment of Infection

George Crile, a volunteer physician from Cleveland’s Lakeside Hospital, wrote in his diary in January 1915:

The key dilemma was that doctors had no effective antiseptic to kill the rampant bacteria, such as Clostridium perfringens, which causes the rapid necrosis known as gas gangrene. The soldiers lived in the filth of the trenches, and if they were wounded, their injuries were immediately corrupted with it. Théodore Tuffier, a leading French surgeon, testified in 1915 to the Academy of Medicine that 70 percent of amputations were due to infection, not to the initial injury.” [i]

Carel+Dakin+Solution.jpg

To prevent infection, rubber tubes were placed through the wounds to irrigate with antiseptic Dakin’s solution (sodium hypocholorite) in the ‘Carrel-Dakin Method’

J%26J+Carrel+-Dakin+Solution+packet.jpg

Mixing of the solution required precise measurement of ingredients. Realizing that the exceptional conditions required for making this solution were not available to many hospitals and practitioners, Johnson & Johnson have met the situation by preparing the Carrel-Dakin Solution in a way that is practical and useful under all conditions.


[i] Ellen Hampton Feb 24, 2017. How World War I Revolutionized Medicine downloaded 5/19/ 2019https://www.theatlantic.com/health/archive/2017/02/world-war-i-medicine/517656/

 

 Influenza, 1918

Soldiers suffering from influenza at the hospital in Camp Funston, Kansas in 1918. Camp Funston was where the influenza epidemic which would kill more than 50 million people worldwide, including 675,000 Americans, first made a major appearance. Troops from the camp carried the virus to other Army bases during World War I. (Photo Credit: National Archives)

According to Constance J. Moore,[i] in the pre-antibiotic era, “nursing rather than medical therapeutics were the most important interventions for patients to recover from the influenza”. Since there were only palliatives measures for the flu and the pneumonia, isolation practices, asepsis rules, and strict routines were the priority standards of care. A nurse reported, “Our chief duties were to give medicines to the patients, fix ice packs, feed them at [meal] time, rub their back or chest with camphorated sweet oil, [and] make egg-nogs.”

A massive number of nurses were mobilized to deal with the patients. African American nurses, who regrettably were not allowed to serve as Army nurses in support of the war effort, were finally given appointments to serve in the Army at military bases[i]. Religious orders also sent nuns to help nurse the afflicted in cantonment hospitals.


[i] Constance J. Moore, Colonel, ANC (Retired), ANCA Historian The Army Nurse Corps and Spanish Influenza in 1918 https://e-anca.org/History/Topics-in-ANC-History/ANC-and-Spanish-Flu

[i] Although the pandemic demonstrated the resilience and dedication of African American nurses, they were not allowed to maintain their appointments as Army nurses in the post-war era. This restrictive rule was finally eliminated 20 years later during World War II.


 Shell-Shock

WWI Shell Shocked soldiers

WWI Shell Shocked soldiers

According to a special report from the Smithsonian, “shrapnel from mortars, grenades and, above all, artillery projectile bombs, or shells, would account for an estimated 60 percent of the 9.7 million military fatalities of World War I… It was soon observed that many soldiers arriving at the casualty clearing stations who had been exposed to exploding shells, although clearly damaged, bore no visible wounds. Rather, they appeared to be suffering from a remarkable state of shock caused by blast force. “[i]

The experience of being exposed to blast force, or being “blown-up,” in the phrase of the time, is evoked powerfully and often in the medical case notes, memoirs and letters of this era. By 1917, medical officers were instructed to avoid the term “shell shock,” and to designate probable cases as “Not Yet Diagnosed (Nervous).” Processed to a psychiatric unit, the soldier was assessed by a specialist as either “shell shock (wound)” or “shell shock (sick),” the latter diagnosis being given if the soldier had not been close to an explosion. Transferred to a treatment center in Britain or France, the invalided soldier was placed under the care of neurology specialists and recuperated until discharged or returned to the front. Officers might enjoy a final period of convalescence before being disgorged back into the maw of the war or the working world, gaining strength at some smaller, often privately funded treatment center—some quiet, remote place such as Lennel House, in Coldstream, in the Scottish Borders country.

Nurse, reading to a shell-shocked patient.

Nurse, reading to a shell-shocked patient.

Stigma of psychiatric problems

One important factor was the stigma that was (and still is) associated with psychiatric symptoms. The shame of suffering from a mental illness and the “taunt of having nothing to show” encouraged soldiers without obvious wounds to (subconsciously) express their trauma through physical symptoms. For doctors, who were well aware of the stigma of a mental diagnosis and its damaging effect on a man’s self-respect, it became usual practice to attach to traumatized soldiers the biological label of shell shock[i]


[i] Stefanie Linden, Psychiatrist and Clinical Research Fellow, Cardiff University, World War I records reveal myths and realities of soldiers with ‘shell shock’ November 20, 2014 http://theconversation.com/world-war-i-records-reveal-myths-and-realities-of-soldiers-with-shell-shock-34383

shell shocked soldier and info.jpg

Impact of WWI on the Nursing Profession

”In the Great War, the volume of casualties from trench warfare drastically changed the role of nurses on the health care team. Much of the time, the doctors were in surgery, dealing with horrific injuries to soldiers' extremities, heads and faces. The nurses performed triage as patients came in on ambulance trains, directed corpsmen who had little medical training, managed entire wards of patients and performed a variety of procedures, including irrigating wounds and managing infection.” - Symposium on the Impact of WWI on the Nursing Profession [i].

According to Moya Peterson, Ph.D., RN, [i]

"The nurses had never seen injuries like this, and they had to care for the soldiers, sometimes large numbers of soldiers at once, on the fly," said Peterson who served on the planning committee for the symposium and has written extensively about the history of nursing in war time. "Up to this point in the nursing field, nurses were not in a position to make decisions on their own. They operated only at the direction of a doctor. Now, with 10, 20 or even 80 patients in their care at once, they made decisions they wouldn't have before."

[i] Ibid

[i] Moya Peterson, Ph.D., RN, clinical associate professor at the KU School of Nursing, Feb 2016 Symposium on Impact of WWI on Nursing Profession.

http://www.kumc.edu/news-listing-page/lworld-war-and-its-impact-on-the-nursing-profession.html