NURSING SERVICES

 

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MEDICAL SERVICES FOR WOMEN WORKERS.

 

THE nursing services on the Western front were composed of members of the Q.A.I.M.N.S. and its Reserve, of the T.F.N.S. and its Civil Hospital Reserve, of the Q.A.M.N.S.I., of the Military Nursing Services of Canada, Australia, New Zealand, South Africa, Portugal, and the United States of America and of members of Voluntary Aid Detachments, British, Canadian, Australian, and American, and of the Almeric Paget Military Massage Corps. The harmonious manner in which all these elements worked together throughout the war speaks volumes for the tactful and able manner in which they were administered under the Director-General by the Matronin- Chief, Dame Maude McCarthy. The constant moves, necessitated by the conditions of service, the eventual shortage of trained nurses, and the interests of individuals in matters of leave and appointments involved administrative talent of an exceptionally high order. The difficulties with which the nursing services had to contend were great, and the work was of a particularly arduous and trying character, more especially for those on duty in casualty clearing stations and ambulance trains during periods of battle, and in hospital centres during the influenza epidemic of 1918, and in those raided by aircraft in 1917 and 1918. Eloquent tribute has been paid and is due to the great courage and devotion of the members of the nursing services during these strenuous and tragic times.

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Miss McCarthy accompanied the Expeditionary Force to France as Principal Matron, but at first was inadequately provided with office or office staff. It was not until the end of 1915 that suitable arrangements were made for her in the office of the D.M.S., L. of C, at Abbeville. She had then an

authorized establishment and was eventually graded as Matronin-Chief with a staff of one matron, one sister and eight members of V.A.Ds. The office of the Matron-in-Chief was separated from that of the D.M.S., L. of C, in August 1918 when Miss McCarthy went to Boulogne. This arrangement of a separate office gave her greater freedom of control and more adequate accommodation.

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In January 1918, an inspecting matron of the Canadian Army Nursing Corps, Miss Ridley, was attached to the Matronin-Chief's office. In the latter months of that year principal matrons were appointed to the staffs of Ds.M.S. of Armies to control the nursing services in the casualty clearing stations, but appointments had not been made to all the armies by the time of the armistice. Similarly, principal matrons were appointed to the larger hospital centres on the lines of  communication.

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The numbers under the Matron-in-Chief's control varied from time to time but increased automatically with the increase in the number of hospitals and the employment of members of

the nursing services on duties other than those of actual nursing in the wards. In August 1914 there were 516 nurses with the British Expeditionary Force in France. The numbers steadily rose until, at the time of the armistice, 5,440 were employed on the lines of communication, and 954 in casualty clearing stations. The former figure included 1,754 trained nurses from the United Kingdom, 682 from Canada, 339 from Australia, 34 from New Zealand, 79 from South Africa, 33 from Portugal, 790 from the United States of America, 1,729 members of V.A.Ds. and 33 members of the Almeric

Paget Military Massage Corps. In addition, some 300 trained or V.A.D. nurses were employed in the voluntary hospitals. Of the 954 employed in casualty clearing stations, 175 were employed in the casualty clearing stations of the dominion contingents and belonged to their nursing services.

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It will thus be seen that untrained or partially trained members of the V.A.Ds. formed a considerable proportion of the total. They were, however, employed only in the hospitals on the lines of communication, and a proportion was definitely fixed of three V.A.D. nurses as the equivalent of two trained staff nurses. Further, the establishment of the different types of hospital was determined as follows :—

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After the armistice, the number was reduced to 73 for a general hospital of 1,040 beds and to 27 for a stationary hospital. Many of the members of the V.A.Ds. became very proficient, and steps were taken to distinguish those who had served with satisfaction in France for one year by a red proficiency stripe on the sleeve of their uniform, and in March 1918 by promoting by selection 100 to the grade of assistant nurses, distinguished by the letters " A.N." on the uniform.

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The first detachment of V.A.D. nurses arrived in France on 17th April 1915, and from that time onwards they continued to arrive in batches of 25 to 50. But before then some had been employed by the British Red Cross Society in a hospital established at Malassise, near St. Omer, for cases of enteric fever amongst the Belgian civil population in the Ypres sector. When this hospital became No. 7 General Hospital in May 1915 they were withdrawn.

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The V.A.D. nurses were paid by Government and employed on a definite contract for service overseas, the pay and emoluments amounting to £144 15s. or £157 15s. per annum, made up of £20 to £30 pay, £54 15s. field allowance, £65 for board and laundry, and £5 or £8 for uniform.

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The Canadian contingent nurses began to arrive in France on 7th November 1914. Twenty then came over for duty with Imperial units and were followed by contingents for duty with the various Canadian hospitals and casualty clearing stations. The numbers reached a maximum of 828 in March 1918.

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Similarly, when the Australian hospitals began to arrive in France from Egypt in the spring and early summer of 1916, a large staff of nursing sisters came with them, 91 being allotted to each general hospital. In addition, 111 members of the Australian Army Nursing Service were sent to France in

February 1917 for duty in Imperial units, and others followed. They were distributed to the various hospitals, but in June of the same year the Australian authorities requested that they should be grouped under a matron of their own service in three of the Imperial hospitals. Consequently 100 were appointed to No. 25 General Hospital, 20 to No. 5 Stationary Hospital and 35 to No. 38 Stationary Hospital. This change was not popular and led to administrative embarrassment, as it interfered with the control of the Matron-in-Chief in distributing trained nurses to hospitals to the best advantage.

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It involved staffing these three units with trained nurses only and diminished the proportion of trained nurses in the other units to which these Australian nurses had been distributed previously and where their services had been much appreciated.

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Nurses from the United States of America accompanied all the medical units staffed with American personnel, the first to arrive being those who accompanied the Harvard and Chicago voluntary units which formed the staffs of Nos. 22 and 23 General Hospitals in June 1915. Each of these units had a staff of one matron, 26 sisters, and 48 staff nurses.

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But in addition to the nursing staffs of the hospitals 186 American nurses were sent to France early in 1918 in two groups of what were called " casual groups " They were intended for duty in British units in army areas. They came without kits and difficulty was experienced in finding accommodation for them. They could not be sent to army areas as there were no units there to which they could be attached without interference with the trained staffs already in them.

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They were eventually absorbed in replacing casualties in the nursing staffs of the American units serving in British general hospitals.

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The Portuguese nurses were employed in special huts for officers, attached to the Portuguese General Hospital which was opened at Ambleteuse, near Boulogne, in April 1918. The nursing services of the Portuguese General Hospital itself, however, were carried out by a matron and members of British nursing services.

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The South African nurses came to France with No. 1 South African General Hospital in July 1916, and the New Zealand nurses with No. 4 New Zealand Stationary Hospital from Egypt at the same time.

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The Indian Contingent had with it seventeen members of the Q.A.M.N.S.I. They formed part of the nursing staff of the three British general hospitals from India, but as a portion of these were converted into general hospitals of the Expeditionary Force, the members of the Q.A.M.N.S.I. were distributed, some to No. 18 Casualty Clearing Station, others to the Meerut Casualty Clearing Station, while two were appointed for duty as operation-room sisters in each of the Indian general and stationary hospitals. All were withdrawn from France in November 1915 except six who remained with the Lahore British General Hospital at Calais till the end of March 1916, when they too were withdrawn.

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The general work of the nursing services extended from casualty clearing stations in army areas to the hospitals on the lines of communication, while their special work included administrative duties, embarkation duties, employment as anaesthetists, dietitians and in surgical laundries, as well as

in a variety of other work such as the nursing of civil sick and wounded and repatriated prisoners of war during and after the advance to victory.

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On mobilization nursing sisters were only employed in general hospitals, but in a very short time a nursing staff was appointed to stationary hospitals, casualty clearing stations and ambulance trains. By the end of August 1914 two were attached to each ambulance train, the number being increased to three in May 1916. Appointments of nursing sisters to casualty clearing stations were definitely sanctioned when these units became stabilized at the commencement of trench warfare towards the end of 1914, but some were employed in railway rest stations during the retreat from Mons previous to this, as for example in No. 3 Casualty Clearing Station at Le Mans and in rest stations at Angers, Villeneuve St. Georges, and elsewhere on the Atlantic L. of C.

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The number allotted to each casualty clearing station was at first five but was raised to seven in May 1915. Additional nurses, however, reinforced this staff during battle periods, as many as 386, for example, having been attached to twelve casualty clearing stations of the Fifth Army in August 1917, or an average of thirty-two in each casualty clearing station. Nursing sisters were also appointed to certain advanced operating centres and officers' wards which had been established in connexion with the work of field ambulances.

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When ambulance flotillas were formed in 1915 two nursing sisters were appointed to each barge. Amongst the special duties assigned to members of the nursing services outside hospitals the most important were the duties connected with the reception of nurses arriving in France. Nurses disembarked as a rule at Boulogne, and early in the war the necessity of appointing an " embarkation sister " became obvious. Her duties consisted of receiving new arrivals, arranging for their transport and the care of their kits and heavy baggage and providing billets or other accommodation.

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In January 1915, a nursing sister was appointed for sole duty as embarkation sister with an office in the Hotel du Louvre, Boulogne, and in addition to the duties noted above she was responsible for notifying the arrival of nurses to the Matron-in-Chief, noting particulars of their service and qualifications, checking irregularities in uniform and obtaining movement orders. The chief difficulties which arose were in connexion with accommodation, storage of kits, and transport when large numbers arrived simultaneously.

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Nurses arriving at Havre were comparatively few in number up to March 1918 and arrangements for their reception were made by the Principal Matron of No. 2 General Hospital, which was conveniently placed at the landing stage (Quai d'Escalade). But in the spring of 1918 large numbers commenced to disembark at Havre chiefly as reinforcements for the U.S.A. Army and for eastern theatres of war. As many as 2,717 passed through Havre for the American Army, and 1,121 to and 2,039 from eastern theatres of war in that year. Consequently, an embarkation sister was appointed at Havre

in March 1918 with duties similar to those of the embarkation sister at Boulogne.

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Owing to the shortage of medical officers the question of training nursing sisters in the administration of anaesthetics was taken up by the D.G.M.S. in September 1917. The consulting physicians and surgeons, with the exception of one or two, considered that this duty could be performed satisfactorily by lady anaesthetists. In the general hospitals staffed by American personnel anaesthetics were regularly administered by trained nursing sisters, and this circumstance led to the suggestion that British nursing sisters might also be trained for that purpose. Arrangements were consequently made for courses of training to be commenced in January 1918. The course was open to all nursing sisters and members of V.A.Ds. who volunteered and were considered suitable.

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Each course was to last three months and be theoretical and practical ; the first two months being in selected hospitals at the base and the last month in casualty clearing stations. The training in the latter included such practical subjects as the observation of patients before operation in order to judge the indications for and the choice of an anaesthetic, the administration of chloroform, ether, nitrous oxide, and oxygen, general considerations as to the extent of anaesthesia and posture during an operation and conduct in emergencies. 

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The first course, which commenced in January 1918, was attended by 76 nurses in 25 different centres, the number trained at any one hospital at the same time being limited to three. Two courses were held and 159 trained. The Army Nursing Board at the War Office did not, however, sanction the employment of members of V.A.Ds. as anaesthetists, so these dropped out of the training. Also, the D.M.S. of the Australian Imperial Force refused to sanction the employment of members of the Australian Nursing Service who had gone through the course of training as anaesthetists. The numbers of those trained, available to replace medical officers, was consequently, somewhat reduced. However, at the end of the first course 21 lady anaesthetists were appointed to hospitals at the base, and 46 to casualty clearing stations, thus, setting free a considerable number of medical officers for other duties. The result, in the opinion of the consultants and surgical specialists, was an unqualified success. But the withdrawal of highly trained and competent nurses to act as anaesthetists threw an additional strain on the administration of the nursing services, more especially as it came at a time when nursing sisters had to be allotted permanently to special wards, such as those for fractured thighs, thus, reducing the numbers available for relief and exchanges in other units.

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In May 1918, following the example of the American and Canadian hospitals, members of the nursing services were appointed to act as dietitians in hospitals. Nursing sisters and V.A.D. members with a knowledge of cooking were asked to volunteer for these duties, and six were appointed to selected hospitals as an experiment. The results were highly promising, both from a financial and from a culinary point of view, but the scheme was not given a fair chance and fell through.

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Another scheme which was entrusted to the nursing services was the management of a laundry for surgical dressings at Etaples in January 1918. This scheme, however, also lasted for a short time only, as the buildings which had been taken over were required in the following April for other purposes. During the advance to victory and after the armistice several members of the British nursing services were employed in Belgian and French hospitals for the care of civil sick and

refugees, and also in British medical units specially appointed to receive such cases. The patients were of all ages, both sexes, and with every kind of ailment. At Bruges, Grevillers, Arras, Douai, St. Pol. Cambrai and Valenciennes, work of this kind was carried out in hospitals staffed by British nursing sisters.

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In 1917, owing to the decision that cases of fractured femur were to be retained in France, the D.G.M.S. applied in June for the services of members of the Almeric Paget Military Massage Corps. Ten arrived in September of that year and ten more in January 1918. Other parties arrived in  September and October 1918 and at the time of the armistice there were 33 in France.

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As in the case of medical officers the nursing services in the later years of the war felt the shortage of trained nurses. There was always a difficulty in meeting emergent demands, more especially from Ds.M.S. of Armies during battle ; but to a certain extent this was obviated by a reserve of nurses

being maintained at Abbeville, Boulogne, St. Omer, St. Pol, Frevent and Amiens, in readiness to meet emergencies. The demobilization of the nursing services was ordered on 9th March 1919, when the nursing staff was to be reduced by one half, two thirds of whom were to be trained nurses. They were to be sent home at the rate of 400 weekly. The requirements then were 483 for the Army of the Rhine, and 577 with 253 members of the V.A.D. for France and Flanders. But, before demobilization orders had been passed, 2,475 members of the nursing services had left France. They were sent home through a demobilization hostel in Boulogne and a dispersal hostel at Folkestone.

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The health of the members of the nursing services was on the whole good, but the constantly sick in hospital varied from 2 to 95 per cent, of the strength. The deaths from sickness were four in 1915, five in 1916, 12 in 1917, and 17 in 1918. The chief causes of mortality were cerebro-spinal meningitis and pneumonia, the former disease causing two deaths in 1915, and 10 in 1917, while the latter disease was responsible for 10 of the 17 deaths in 1918.

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There were numerous casualties from enemy action. In 1915 and 1916 they were of a very slight character, but they were of exceptional severity in 1917 and 1918. In 1917 the number of these casualties was 44, of whom 3 were killed and one died of wounds during an aircraft raid on St. Omer,

and one was killed by shellfire in the casualty clearing stations at Brandhoek, between Ypres and Poperinghe, on the night of 21st August. The casualties at St. Omer occurred in No. 58 General Hospital, when a staff nurse and two V.A.D. members, together with 18 patients were killed, and a staff nurse died of wounds, while two other staff nurses and 58 patients were wounded, during the night of October 30th and November 1st.* In 1918 the casualties from enemy action were 41,

nine being killed, six of whom were members of the Canadian Army Nursing Corps. These casualties occurred during the bombing of No. 1 Canadian General Hospital at Etaples on the 19th May and of No. 3 Canadian Stationary Hospital at Doullens on the 29th May

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* Amongst the many heroic deeds of the nursing services during this trying time one may be specially cited on account of its tragedy and pathos. During the air raid on No. 58 General Hospital, Sister Climie of the T.F.N.S. remained in her ward, singing to a nervous patient, who had just been admitted from the front line, in order to try and calm him. She continued singing, quietly sitting on his bed, when the bombs were falling, until one fell in the ward and killed her. Her patient escaped uninjured, and afterwards testified to the calm courage and devotion of the sister

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A ward for sick or injured nurses was opened at first in No. 2 B.R.C.S. Officers' Hospital at Rouen, but it was afterwards removed, in January 1915, to No. 8 General Hospital. Wards were also opened at No. 14 General Hospital, Wimereux, and afterwards in the Chateau Mauricien there, and at No. 24 General Hospital and in a villa at Etaples. In addition to these several convalescent homes were established.

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In January 1915 H.R.H. Princess Louise handed over her villa in Hardelot Forest, near Boulogne, as a convalescent home for nursing sisters. Mrs. Bryce Miller opened another convalescent home for them at Paris Plage in June of that year, and in October 1916 Captain and Mrs. George Warre

received convalescents in their villa at Roquebrune, near Mentone. There was also a convalescent home for them at Etretat, established by the B.R.C.S., and a convalescent home for Australian nurses, maintained by Mrs. Angus, near Captain Warre's villa in Mentone.

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Nurses' hostels were opened at Boulogne and Rouen and a number of rest and recreation clubs was organized on behalf of H.R.H. Princess Victoria by Lady Algernon Gordon-Lennox at Wimereux, Etaples, Rouen, Abbeville, Le Treport, Boulogne, Calais, St. Omer, Paris, and Deauville. The first club of this nature was, however, opened in March 1915 in Boulogne by Mrs. Robertson Eustace. Lady Algernon Gordon-Lennox remained in France as director of Princess Victoria's rest clubs

from January 1915 to June 1919, after arranging for a club to be opened in Cologne.

 

The British Red Cross Society opened similar clubs for V.A.Ds. in 1918 at Boulogne, Dieppe, Rouen, and Trouville, chiefly for the general service members of these detachments. These general service members commenced to arrive in France for duty as cooks, dispensers, clerks, and cleaners in military hospitals in November 1917. By the end of December of that year 219 were employed in the hospitals at Rouen, Le Treport and St. Omer, and by August 1918 as many as 862 were employed in various hospitals. A few were also employed in other units. They were under the control of the principal matron or matron of the hospitals in which they were employed.

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The medical services for the Women's Army Auxiliary Corps, afterwards Queen Mary's Army Auxiliary Corps, were specially organized under a Chief Medical Controller, Dr. Laura Sandeman, who arrived in France in October 1917 and was attached to the Office of the D.M.S.,L. of C. The women of this corps were employed in L. of C. units, messes, and institutions in the same manner as the General Service V.A.D. members in medical units. The strength of the Corps with the British armies in France was 7,717 in August 1918, and a few were also employed with the American Expeditionary Force.

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Members of the Women's Army Auxiliary Corps first came to France early in 1917, and until a special medical service had been organized for them under Dr. L. Sandeman the sick amongst them were treated by officers of the R.A.M.C. in special women's wards of general and stationary hospitals.

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Thus, in July 1917 the following hospital accommodation had been provided for women workers :—

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Those marked with an asterisk were for infectious cases.

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There was thus a total of 219 hospital beds for women workers, and additional accommodation was being considered at Rouen, for infectious cases, and at Etaples and Calais. There were also convalescent homes for 50 in the Havre area, and additional homes for 50 in Boulogne and for 80 at Etaples were being considered.

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On Dr. Sandeman's arrival in France the medical services were provided by medical women under the medical organization for their employment published in an Army Council Instruction of November 1917. The organization provided for a chief medical controller at the headquarters of the L. of C, with

an assistant medical controller at Boulogne for northern areas and at Rouen for southern areas. Under them lady doctors were employed at Boulogne, Calais, and St. Omer, Etaples, Rouen and Dieppe, Havre and Etretat, and Abbeville.

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It had been estimated that 6 per cent of the strength would be constantly off duty on account of sickness, 2 per cent, for illness requiring hospital treatment, 2 per cent, for minor ailments for which it would be unnecessary to transfer them from their units, and 2 per cent, for no definite illness but in need of rest. The hospital accommodation already provided was sufficient for the serious cases and steps were taken to increase the accommodation in convalescent homes for those in need of rest. For the patients suffering from minor ailments sick bays or detention wards were prepared. For this purpose a room or hut was fitted with accommodation for 2 per cent, of the strength in all isolated units and in units of over 100 members, extra furnishings being provided by the  British Red Cross Society to make the wards comfortable and attractive. Patients were only to remain in a sick bay for

forty-eight hours, and, if further treatment was then necessary, they were transferred to the hospitals. The larger sick bays included a small isolation ward, a ward kitchen, and a bedroom for the V.A.D. nurse in charge. In smaller units of less than 100 a hostel forewoman with knowledge of nursing, or a nursing orderly of the R.A.M.C, was included in the strength.

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In addition to the women workers of the Q.M.A.A.G., parties of the Women's Royal Air Force were sent to France after the armistice and Dr. Lily Baker was attached to the headquarters of the Royal Air Force as medical officer in charge of them. The daily sick were seen by medical officers attached to the R.A.F. and those needing hospital treatment were sent to women's wards in No. 24 General and No. 46 Stationary Hospital, Etaples, No. 14 Stationary Hospital, Wimereux, and No. 4 Stationary Hospital, St. Omer. In other respects, the services were similar, in their organization, to those of the Q.M.A.A.C.

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