It is proposed in the Report to write a short account of the work of the Nursing Staff in connection with Casualty Clearing Stations in 1914 and early in 1915, as compared with the later and more elaborate and detailed work of 1917 and 1918.  Were it possible to write one, there is no doubt that a detailed history of each unit or group of units written from the Nursing point of view would be interesting to many. Though no provision for Sisters at Casualty Clearing Stations was made in War Establishment, and none were supplied at the outbreak of the War, it was soon found, as it had been for Ambulance trains, that their services were much needed at these units.

     In September 1914, those Nurses who were sent up to Villeneuve St. Georges to await their appointment to Ambulance Trains, had a foretaste of what was to be their work in advanced units at this early period of the War. Villeneuve St. Georges is a very large railway junction not far from Paris. Some distance away from the station itself are large sheds, and in some of these sheds in September 1914, a Medical Unit, which I believe was No 3, Casualty Clearing Station, or a section of it, established itself. Opposite, across some lines were other sheds, and in and about these, large numbers of the London Scottish Troops were billeted, French sentries guarded the railway line, and groups of Indians were often to be seen squatting by their fires near the sheds. A little further away, on a siding, the O.C. Ambulance Trains had established his Office and an Ambulance Train Store in Railway trucks.
      A Sister, Miss G. Knowles Q.A.I.M.N.S., and one Staff-Nurse, Miss N. Chrichton C.H.R. were sent up to Villeneuve for station duty on September 10th 1914. They arranged quarters for themselves in a shed adjoining that in which the Casualty Clearing Station was established. It was a very large place and used for other purposes as well, one part being portioned off for British prisoners kept under guard. The 2 Nurses were given what had formerly been a ticket office, situated at the nearest corner of the hut to the left, as one came in from the road. In this stuffy little ticket office, they made their quarters, making use of their Active Service outfit. The shed occupied by the unit was divided off into the Hospital portion and that forming the accommodation of the personnel of the unit. There was little equipment other than the authorised Field Medical panniers and brown blankets.

      During the battle of the Aisne, all trains carrying wounded passed through Villeneuve to Rouen and the other Bases. When time permitted, all cases came off the trains at Villeneuve, and were attended to in the shed, where it was decided which cases could travel to the Bases, and which were not in a fit condition to proceed further. The majority of the latter were taken by a fleet of Ambulances, sent by the American Ambulance at Neuilly, into Paris where they were admitted either at the Ambulance or at other hospitals. Later, when No 4, General Hospital was established at Versailles, the patients were taken there. The walking cases were fed and dressed, and immediately returned to the train. Those in too critical a condition to be moved, remained in the shed on stretchers. Many were brought dead from the trains, and the bodies were taken to a small mortuary, attached to a convent close by. What nursing could be done was carried out under extreme difficulties, and consisted chiefly in reviving the patients with hot feeds and in changing their dressings. It was pitiable to see the condition in which they were brought in; some had been lying wounded in the open 5 or 6 days without receiving any attention, and they were not only suffering from extreme shock, but their wounds had become infected. As the Ambulance Trains had no store of clothing of any description at that time, the patients frequently arrived wrapped solely in a blanket. The American ambulance supplied a certain amount of clothing for them, and as quickly as possible stores were obtained from the Red Cross in Paris, Rouen and other Bases.

      The few Medical Officers and orderlies who were attached to this unit, were greatly assisted in their work by the London Scottish, many of whom volunteered to work as orderlies, and 4 qualified men who were serving in the ranks, together with their Regimental surgeon, gave their services as long as they were needed. Fortunately for Miss Knowles, on September 19th, there began to arrive groups of Nurses for duty on Ambulance Trains, and who had been sent up to Villeneuve St Georges to await the arrival of the trains they were to join, and they, too, worked in the sheds.

     Miss Knowles joined No 1, Ambulance Train as Sister in Charge on 27.9.14., and her duties at the station were taken over by Miss M. S. Barwell, Q.A.I.M.N.S.R. who remained at this post until October 18th, when Sisters at Villeneuve were no longer required. During this month about 50 Sisters passed through Villeneuve on different dates, the majority for duty on Ambulance Trains. With the exception of about six, they were members of the staff of No.6, General Hospital which on account of its lost equipment had not been able to establish itself. As it had not been foreseen that Sisters would be required at Villeneuve St Georges, and the decision to send them there and to post them definitely to Ambulance Trains from this junction was taken so rapidly that it was quite impossible to arrange accommodation for them, not even in billets, the best that could be done under the circumstances was to obtain at about ten minutes walk from the station, a small empty house very sparingly furnished, in which all the Sisters were housed while awaiting their trains.
      Arrangements were made with the nuns of a convent close by the station for the Nurses to take their meals there. They made them as comfortable as they could, arranging a table for them in their own large kitchen - no other room was available. The Sister in Charge of the Nursing arrangements at the Medical unit in the sheds was also responsible for all arrangements in connection with the Nurses working temporarily there until they joined the trains.

      Sisters were first appointed to Casualty Clearing Stations on October 30th, 1914, when Miss I. Buyers and 4 other Nurses were posted to No 4, C.C.S. at Poperinghe. Before this date Sisters on Ambulance Trains, when waiting at railheads to load, frequently went to the nearest C.C.S. and assisted in looking after the patients, notably so at No. 4, C.C.S. which in September was situated in a church near the station at Braisne.
      When the British Army moved from the Aisne to the North, No.2, C.C.S. was at the time at Fère en Tardenois. No. 7, Ambulance Train was sent up to this railhead with orders to remain there and assist No. 2, C.C.S. by taking in wounded and stragglers from the Army on its march past. The Sisters from this train also visited 2, C.C.S. daily.

     In October, the question arose as to whether sisters should be posted to Casualty Clearing Stations or not. In many instances it had been felt that their services would be of great value to the wounded. A letter on this subject was received from the Adjutant General and it was decided that Sisters should be appointed to these units, and that those so employed should be members of the Queen Alexandra's Imperial Military Nursing Service only.
     The authority to post Nurses to Casualty Clearing Stations was received by wire on the afternoon of the 29th October, when 5 Sisters were asked for, for 3, Clearing Hospital [as they used to be called] and 5 for No.6, Clearing Hospital.

      The following are the units to which Sisters were posted during 1914, and the dates they joined:

Unit:                     Location        Date of posting Sisters

4 Clearing Hospital Poperinghe      30. 10. 14.
1 Clearing Hospital St. Omer         01. 11. 14.
3 Clearing Hospital Hazebrouck     05. 11. 14.
5 Clearing Hospital Hazebrouck     05. 11. 14.
2 Clearing Hospital Bailleul            10. 11. 14.
6 Clearing Hospital Merville          26. 11. 14.
8 Clearing Hospital Bailleul           28. 11. 14.
7 Clearing Hospital Merville          16. 12. 14.
9 Clearing Hospital St. Omer        30. 12. 14.

     The Sisters were in all cases billeted with the inhabitants and as near the hospital as possible, particularly in the case of the Sister in Charge; it was very often possible to arrange accommodation for her, and at times for one or two others, with the nuns living near, or actually in the building. At a later date, houses, or part of houses were taken for the Nursing Staff, and they formed their own messes. Later still, when the units were tented or hutted, separate quarters were provided for the Sisters, as for the Officers also for the Men. Different arrangements were made, according to locality and other considerations, with regard to meals; some had their meals in hotels or cafés; others were able to organise a mess-room in the hospital itself.

     In most cases the Clearing Hospitals had taken up their position in buildings in either schools or seminaries, or such like establishments, where no equipment of any kind was available. The Clearing Hospital itself was little better off for equipment than a Dressing Station. There were no beds; stretchers and blankets were provided, and for the rest there were only the barest necessities and these very scanty in number.
During November, the hospitals, particularly No. 4, at Poperinghe, were very busy taking in the casualties from the 1st Battle of Ypres. There was a constant stream of patients, evacuations took place every day, and only the worst cases were kept. The Sisters worked all day, and usually till after midnight. This unit moved to Lillers on December 3rd.

      During December, the work was, as the Sisters described it "terrible"; at Hazebrouck, Lillers and Merville, everywhere it was the same, patients pouring in in dreadful conditions. The stretchers were placed in rows on the floor, with barely room to stand between each. The admissions and evacuations were incessant and almost all that could be done in the time was to feed the patients, dress their wounds and bathe their feet. Only the most urgent operations were done; the others were sent to the Base as quickly as possible.
The difficulties in connection with the work of Clearing Hospitals in 1914 and early in 1915 were due not only to the lack of elementary comforts, but also to the very limited number of Sisters working there. That the number was so small was partly that their employment there at all was an experiment, and partly owing to the uncertainty of the Military situation, it was considered advisable that a very minimum number only should be attached to each unit. Experience had more than proved how valuable and necessary was the presence of Sisters at these units.

      From my frequent inspections of these advanced units, I was satisfied that normally, when no heavy fighting was being done, five Sisters could accomplish the work required of them, but when the fighting was severe, this number was hopelessly inadequate. One unit alone, in 24 hours, had admitted 1200 patients, another1500 and so on, and they would continue passing the wounded through at this rate for some considerable time. It was, therefore, decided on March 11th 1915, to have a pre-arranged system for rapidly increasing temporarily the number of Sisters at Casualty Clearing Stations in the event of large numbers of wounded having to be dealt with in any particular unit.

     It was arranged that four groups of 3 Nurses each should be held in readiness at Boulogne. they were instructed to have an emergency kit ready to start at a moment's notice, and were to be sent up by motor transport if necessary.
     Early in April, this arrangement was modified. The Hospitals at Boulogne were usually the first to feel the excessive pressure of work, after the Casualty Clearing Stations, and could with greater difficulty than the other Base Hospitals, spare Nurses at the time they were required at the Front; consequently the groups were no longer formed from these hospitals, but from those at Etaples and Rouen, each of which Bases was required to supply 3 groups of 3 nurses each.
     This second system also presented certain difficulties. It was not quick enough; it depleted Hospitals already below establishment and who in turn were to feel severe pressure of work before the groups had time to rejoin them. It was therefore suggested to the D.G.M.S. early in May 1915 that this system should be revised, and the following proposals were made:

1. That as the tendency in Casualty Clearing Stations was to retain for permanent duty Nurses sent up for emergency work, some hard and fast rule should be laid down for a fixed establishment.

2. That a permanent Reserve of Nurses should be stationed at Malassises to be detailed for emergency work at Casualty Clearing Stations, whenever required, and immediately on completion of this duty to return to Malassises

     These proposals were approved and the number of Nurses to be appointed to Casualty Clearing Stations was fixed at 7. On account of the greater accommodation for Officers than at other units, an exception was made in the case of No. 2, C.C.S. to which 9 Nurses were appointed. This system proved very satisfactory, and has been followed throughout the War. In the course of time, in order to meet emergencies in Army Areas, a Reserve of Nurses has been held at different points, at Boulogne, at St Omer, Malassises, Abbeville, Amiens, St Pol, and Frevent.

     In consequence of the nature of the work and the conditions under which it had to be executed, together with the fact that these units were subject to enemy air raids and to shell fire, it was decided in January 1915 that Nurses should not remain longer than three months in front areas, after which period they should be given leave before assuming other duties. Later the length of this duty was fixed at 6 months, and though there were many exceptions, particularly in the case of the Sisters in Charge, this rule was kept throughout the war as strictly as it was possible.

     As these Clearing Hospitals closed down temporarily, either owing to the frequent shelling of the towns, or the severity of the air raids, or other causes, it was found necessary to make some definite rule as regards the temporary disposal of the Nursing Staff. With the approval of the D.G.M.S. a general rule was made that the Nursing Staff of units parked, preparatory to moving, should report to the Matron of No. 10, Stationary Hospital, at St Omer, and were to be either accommodated there or at Malassises until they were again required. This opportunity was taken to send on leave or to Convalescent Homes, those who needed a rest, and to replace them, if necessary, with fresh staff.

      No. 4, C.C.S. left Poperinghe on November 24th as the buildings, a convent and a school in which it was established, were being given over to the French. The Nurses were sent down to St Omer, and temporarily assisted the staff of 1, C.C.S. (established in the town) until December 2nd, when they rejoined No. 4, Casualty Clearing Station at Lillers, then established in an orphanage and school. On November 20th, a bomb dropped a few yards from the main building, and had broken the windows, and caused casualties among the civilian population, who were admitted and treated in the hospital.

     No. 1, Casualty Clearing Station, (established in a Convent) was shelled out of Bethune in January 1915, and the Nurses went to St Omer until the unit re-formed at Choques on January 28th.

      No. 3, Casualty Clearing Station (established in two convents and a seminary) at Poperinghe was badly shelled and bombed in April 1915. For three successive days in the last week the shelling was continuous and shells fell in and around the Hospital. there were large numbers of casualties among the civilian population, and large numbers of men, women and children were taken into No. 3, C.C.S. It was therefore decided on the 28th, to evacuate all patients, and the Nursing Staff was sent down to St Omer until the unit re-opened at Bailleul in May 1915. This system has been followed throughout the war, and as more Armies were formed, and the line held by the British Troops was more extended, similar arrangements were made at different points. Those from the extreme north, reported at Boulogne, further south, they reported at St Omer, and further south still, they reported at Abbeville.

     The Nursing Staff of Casualty Clearing Stations was always specially selected, and nurses, as far as possible, were not sent to Army Areas until they had served at least six months in the country, and gained experience of active service conditions. As far as possible also, they were not returned to Front areas, after they had done a tour of duty there, until they had served six months at the Base. The selection of Nurses for Casualty Clearing Station work was largely based on their Confidential Reports, but depended also on their previous service and their record of health. Before issuing an order, a Nurse's previous record was always referred to.

     As in the case of Base Hospitals and Ambulance Trains, in September 1915 with the approval of the D.G.M.S., rules were issued, in addition those of the Standing Orders of the Q.A.I.M.N.S., for the guidance and assistance of the Sisters in Charge of Casualty Clearing Stations and, as necessity arose, these were revised at different periods.

These rules bore on matters of discipline and such matters as:

1. The necessity for keeping records of the Nursing Staff, and of keeping me informed of all matters in connection with them.

2. Questions of off-duty time, regular meal times and uniform.

3. The care of Sisters reporting sick, who if more than 24 hours off duty on account of ill health, were to be sent to a Base.

4. The duty of the Sisters towards Dangerously Ill patients, and the necessity of notifying each case to the chaplains, and of keeping their relations constantly informed of their condition and of writing immediately in the case of a death.

5. Their duties towards the dead.

6. The necessity of especially caring for the Mortuary.

     Before making any general remarks, or writing of the later period of the War, it is thought necessary to make allusion to one of the most trying experiences which took place at this early period, and one full of the greatest difficulties to contend with from a Nurse's point of view. Reference id made to the 2nd Battle of Ypres, and the 1st gas attack of May 1st 1915. It was exceptionally trying on account of the extraordinarily large number admitted, and the unusually high percentage of deaths, but particularly so as every effort made, seemed of no avail to relieve the sufferings of the patients. Every conceivable remedy was tried, even to the administration of chloroform. The staff worked almost unceasingly, 20 hours on end, but could see little result for their work. The Hospitals at Bailleul were full, the grounds were full, and the fields around were full of patients gasping for breath, shouting out for drinks, and unable to lie still on their stretchers. Large jugs full of Mist. Expect. Stim. were taken round unceasingly the whole time. It was a dreadful experience for all.

     In order that the wonderful organisation and administration in connection with the work of the C.C.S.'s [in the development of which the Nursing staff had a share], may be fully appreciated, it is felt that a few more details, typical of all units, will be of assistance in forming some sort of idea of the conditions existing in the early period of the War.

In the Operating Theatre there was the travelling Table, 1 Steriliser for instruments, 1 table for instruments, and perhaps 3 jugs of sterilised lotions. Dressings were not sterilised. For the Anaesthetist's requirements packing cases were used.
In the Wards there were rows of stretchers with brown blankets only and on bare floors. One unit was proud of the four bedsteads it had found, and another of its 50, where those patients who were to be kept at the hospital for some length of time could be made comfortable.
     There were no trolleys or dressing tables, an empty petrol can served for the soiled dressings, and a clean piece of paper as a tray for the fresh dressings, and the floor or next stretcher for a table.
The cases, acute and light, were all mixed in the same ward.
     Every attempt to better conditions had been made from the beginning, and though at first only in little things, by the spring of 1915, great improvements were to be seen as a result of the initiative and devotion of both Medical Officers and Sisters.

     One of the greatest boons was the provision early in 1915, of trestles on which the stretchers were placed. These trestles were originated, I think at 1, Casualty Clearing Station by the late Major Symons, R.A.M.C., O.C., and they were not only a comfort to the patients, but an assistance to the Nurses in the performance of their work. Quantities of comforts, such as sheets, draw-sheets and feather-pillows, pillow-cases, socks, bed-socks, operation stockings, pyjamas, dressing gowns, water pillows, and multitudes of other necessary comforts were obtained from personal funds of the B.R.C.S., Queen Mary's Needlework Guild, and other sources, and a larger and more adequate supply of ward equipment and appliances of every kind was obtained from the Army Ordnance Store. Certainly before the autumn of 1915, there was no lack of any of the essential things so necessary for the adequate nursing of wounded men.

     Great improvements continued to be made, and by the Spring of 1916 some of the Clearing Stations were like the best equipped General Hospitals. By this time, also, a great many were partly hutted and partly under canvas, and the minority in buildings. The Operating Theatres, which had begun with the barest of necessities, were now well equipped with every modern convenience. Further and great improvements greatly facilitated the Nursing Work. the whole work of the unit was organised into separate departments. There was the reception department where the cases were sorted, and all patients provided with hot drinks; the special pre-operative wards with the resuscitation wards attached, and the hot chamber for keeping blankets and shirts warm. There were special wards for chest and abdominal cases; two or more operating theatres, some with 8 and even 12 tables. Some units had special departments for ophthalmic work, aural work, neurological work. Some units were entirely given up to the care of medical cases, and at others, an altogether separate section would be attached, where abdominal cases only were operated on and treated.

     Though the work accomplished by the Nursing Sisters of Casualty Clearing Stations during 1918, has been written of fully in the annual report of that year, this account would not be complete without again touching upon it.
     During the Retreat of March and April, these large well established hospitals all along the Front, at a moment's notice, closed rapidly, packing up all equipment possible and retired in some parts almost onto the Lines of Communication. It was found necessary to considerably reduce the equipment in order that they might move more easily. During the Advance the units moved very quickly indeed, and in some cases were not in the same spot for more than two or three days, when they moved again, and in less than 48 hours, Sisters, Officers and Men were all working in absolute order and with a wonderful spirit. How this was done, and the perfect way it was done, was a complete surprise to everyone.

     In July 1915, the question arose as to whether Sisters in Charge of Casualty Clearing Stations should be appointed Acting Matrons, and whether they should draw charge pay. At this time it was not considered necessary that Acting Matrons should be appointed to these units, but it was recommended that the Sister in Charge should draw Charge pay. War Office Letter 24/Misc/1890/F.2 of 16.8.15., ruled that a Matron or Acting Matron should not be appointed to a C.C.S. but that the Sister in Charge should draw charge pay if the unit was equipped for 100 beds or over.
     On July 25th, 1916, I asked that this decision might be re-considered, and the following considerations were brought forward in support of this application:

1. The Casualty clearing Stations were at this period equipped for beds varying from 200 to 1000 in number.

2. The number of patients passing through these units in one week amounted to thousands.

3. The Nursing Staff varied from 7 to 20.

4. Owing to the nature of the work and the tax on the administrative powers of the Sister in Charge, endeavour was made to appoint the most senior people for this work some of whom in civil life, were Matrons and Assistant Matrons of Hospitals.

5. Every unit had an operating theatre, some several and numbers of serious abdominal operations were performed.

6. The mental and physical strain in some cases was very severe.

     I regret very much to say that it was not considered advisable to forward this application to the War Office. The Sisters in Charge of Casualty Clearing Stations have had exceedingly responsible work to perform. These camp units rapidly developed, and to all intents and purposes were General Hospitals as regards the administration of the Nursing Department.
     When the work was at high pressure, the Nursing Staff, at different times, has been as much as 45, and great consideration and tact needed to be exercised in its management, as it was generally made up of very senior women, and these comprised members engaged on the special duties of surgical teams and Anaesthetists as well as the regular staff.  The Overseas Services recognised the difficulties in connection with this post, and the C.A.M.C. appointed their Charge Sisters, Acting Matrons, and the A.A.N.S. appointed theirs Head Sisters.
     It is a source of regret to me that the valuable and responsible work carried out with such unflinching courage by the British Sisters who had laid the foundation stone of this work in 1914, was not similarly recognised.


[signed] E. M. McCarthy
British Troops in France and Flanders