Contents

CHAPTER IV

IN THE AMERICAN EXPEDITIONARY FORCES

ORGANIZATION

CHIEF NURSE

Until November 13, 1917, there was no representative of the Army Nurse Corps either in the office of the chief surgeon, A. E. F., or in that of the surgeon, line of communications. At that time, however, in response to a cablegram request of October 2, 1917, from the commander in chief, A. E. F., for a competent member of the Nurse Corps to be sent to France to act as superintendent of nurses, A. E. F., a chief nurse reported to take charge of nursing affairs.¹Another member of the Nurse Corps had accompanied her from the UnitedStates to act as her assistant.

OFFICE OF THE CHIEF NURSE

The office of the chief nurse, A. E. F., was established in the surgeon's office, line of communications, rather than in the office of the chief surgeon, A. E. F., since, at the time in question, the administrative jurisdiction of all base hospitals in the American Expeditionary Forces was in the office of the sur-geon, line of communications, and it was not intended that nurses would serve in any other type of hospital, more especially in hospitals that would be located in the zone of the advance.¹

In the office of the surgeon, line of communications, the office of the chief nurse, A. E. F., became a part of the personnel division. Here, the chief nurse, with, for the most part, the one assistant mentioned above, functioned until the office of the surgeon, line of communications, was merged with the office of the chief surgeon, A. E. F., in Tours in March, 1918. Subsequently, the chief nurse was a part of the personnel division of the latter office.¹

The greater part of the time of the chief nurse was taken up with administrative duties.¹ These duties, however, did not include the assignment of nurse personnel, both original and by transfer, for such assignments were made by the officer in charge of the personnel division, a practice which had obtained prior to the arrival of the chief nurse in the American Expeditionary Forces.¹ Because of this manner of handling the nurse personnel, the chief nurse, A. E. F.,in order to keep herself informed as to the changes among the personnel, and to have a record in her own office of where each nurse was located, was obliged to depend upon the daily reports which were sent in from the various hospitals.¹ Thus there was at hand a means of checking the monthly returns of nurses, which also were rendered from hospitals.¹

In addition to such routine work as that referred to above, there was atall times a great deal of correspondence between the chief nurse, A. E. F., and the chief nurses of hospitals.¹ This correspondence had to do with interpre-

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tation of regulations and other instructions concerning the Nurse Corps, made necessary by reason of the fact that most of the chief nurses of the hospital units were relatively inexperienced in such matters.¹

Because practically all of her time was devoted to administrative matters, the chief nurse found few opportunities for inspecting local nursing conditions; however, from time to time such inspections were made by her.¹

DIRECTOR AND ASSISTANT DIRECTORS

On July 9, 1918, Congress authorized the appointment of one director and two assistant directors of the nursing service, A. E. F., in France.² The same quota was authorized for Base Section No. 3, England. However, no appointments were made under this allowance until November 2, 1918, when the original chief nurse of Base Hospital No. 21, who had been assigned to duty as the chief nurse of the American Red Cross in Paris, was appointed to the position of director of nursing service, A. E. F.3 She reported to the chief surgeon for duty on November 15, 1918, and on December 2, 1918, the former chief nurse, A. E. F., returned to Washington to become an assistant superintendent of the Army Nurse Corps.³ The chief nurse of Base Section No. 3, England, received an appointment as assistant director of nursing service, A. E. F.,on November 18, 1918, and the former assistant to the chief nurse, A. E. F., became an assistant director on December 14, 1918.³

INSPECTION TRIPS

In so far as the nursing service was concerned, the director of nursing service, A. E. F., emphasized the importance of the connection between the chief surgeon's office, A. E. F., and the hospitals, and affected a closer relationship by means of constant inspection trips to the various hospital centers and also to hospitals operating separately. ³ These inspections were made from the point of view of the comfort and welfare of the nurses, as well as of their efficiency, and a complete inspection included conferences with the commanding officer and chief nurse of each organization, both separately and together, with opportunity for frank discussion of problems. Close inquiry was made in all cases into the matter of quarters, food, recreation, and all other living conditions, and especial attention was paid to the problems of sick nurses. On these trips occasions always were made to discuss nurses who presented particular problems to the chief nurses, but about whom it had not been considered advisable to send in official derogatory reports. When such cases were found, efforts were made to relieve the situation, and in many instances the transfer of such individuals was all that was necessary. Generally the director of nursing service included as a feature of her inspection trips talks to as large groups of nurses as possible, and in these talks she would call their attention to the importance of maintaining the proper standards of conduct and of continuing to observe the usual peace-time conventions instead of permitting thoughtless but dangerous relaxation. They were told of conditions in other units, and in every instance they were told of the interest of the chief surgeon, A. E. F., in their well-being. The nurses were given an opportunity to declare themselves in the matter of abstinence from alcoholic liquors. and whenever a vote was taken most gratifying

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affirmative results were obtained.⁴ Every nurse who wished to talk privately to the director was given the opportunity to do so, and frequently such interviews extended late into the night.⁵ In many instances groups of as many as from five to eight hundred nurses were addressed. Such instances occured at the large hospital centers where there were sometimes as many as 10 hospitals comprising the center. ³

Between the time of her appointment in November, 1918, and her return to the United States in June, 1919, two-thirds of the director's time was spent in traveling among the hospitals. Aided in a few cases by two of her assistants, she visited nearly 100 hospitals or stations where nurses were present in the American Expeditionary Forces.⁶

DISTRIBUTION OF NURSES

The original plan for an American Red Cross base hospital provided for50 nurses and 25 nurses' aides.⁷ However, when the first base hospitals were sent overseas a ruling was made by War Department that aides could not accompany them, thus causing the number of nurses to be increased to 65.⁸ Upon arrival of the first six of these hospitals at their destinations early in 1917, this number was found to be inadequate, as these nurses replaced British staffs of more than that number; ⁹therefore steps were taken to raise it to 100 nurses.

In the first six months after America entered the war there were approximately 1,100 nurses in the American Expeditionary Forces, about half of whom were stationed in six British general hospitals. ³ Subsequent to this time more nurses arrived, but in insufficient numbers; so, to prevent a serious shortage, on May 3, 1918, the commander in chief A. E. F. requested the War Department for 555 additional nurses.³ This need was met as soon as transportation facilities could be provided. During the month of September, 1918, over1,300 nurses arrived in the American Expeditionary Forces.³

Base hospitals which were numbered from 50 to 100 were organized by the Army, and each hospital included 100 nurses. Those which were numbered above 100, with the exception of Base Hospital No. 102, the Italian unit; Base Hospital No. 114; the orthopedic unit; Base Hospital No. 115, the head surgery unit; Base Hospital No. 116, the fracture unit; and Base Hospital No. 117, the psychiatric unit, were organized in the American Expeditionary Forces, and their nursing staffs were taken from the larger groups already in operation. ³

HOSPITAL CENTERS

No attempt is made here to go into the organization of hospital centers, ^a except to state that a hospital center comprised a group of base hospitals, each of which had its quota of nursing personnel assigned in the same manner as in the case of an isolated base hospital.

Until shortly after the signing of the armistice there was no local member of the Nurse Corps who had supervisory control over all the nurses at one center. In order that the director of nursing service might keep more closely informed as to the nurses and their living and working conditions the plan was adopted of assigning center chief nurses to 11 of the large hospital centers.³ These

^a Consult Volume II, Administration, American Expeditionary Forces, for details concerning hospital centers.

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center chief nurses were regarded as assistants to the director. According tothe plan of the director of nursing service, A. E. F., the duties of a center chief nurse were to be as follows: ³

1. To assist the commanding officer of a center in such matters pertaining to the nurses of the center as he may see fit to assign to her.
2. To assist in the distribution and readjustment of nurses within the center, accordingto the pressure of work in the various hospitals.
3. To keep informed by frequent visits of the conditions in the hospitals of the center as they affect the nursing personnel, such as quarters, the mess, means of recreation, care of sick nurses, etc.
4. To bring to the attention of the director of nursing service, after consultation with the commanding officer of the center, any matters which seem to need especial adjustment.
5. To act as chairman of a committee of chief nurses of the center. This committee will make suggestions for regulations governing the conduct and social relations of nurses, which shall be, as far as possible, uniform for the entire center. These suggestions should be presented to the commanding officers for their approval and indorsement. The object of this committee will be to promote the welfare of the nurses within the center, and to maintain a high standard of service and conduct within the Army Nurse Corps.
6. To act as hostess of the center. In that capacity she will meet each new chief nurse arriving at the center and see that the latter has all information that will assist her in the performance of her duties. She will also, in cooperation with the commanding officers and chief nurses of the center, endeavor to promote a wholesome social life among the nurses.

This plan was based on the British system, which had proved satisfactory. Although, as stated above, it was not put into operation in the American Expeditionary Forces until shortly after the armistice was signed, it proved to be a decided success.³

CAMP HOSPITALS

Army nurses were assigned to camp hospitals,³ which in most instance3were in isolated areas but which functioned much in the same fashion as base hospitals, only on a smaller scale.

EVACUATION HOSPITALS

The evacuation hospitals of the American Expeditionary Forces had from1,000 to 1,500 beds. Under ideal conditions they were located at a rail head, within from 8 to 10 miles of the front lines, so that the wounded could be brought to them in a short time by ambulance and either be operated on at once or sent by train to hospitals to the rear.¹⁰ In actual functioning, from the nursing point of view, there was little difference between them and the base hospitals, except that, generally speaking, the turnover of their patients was more rapid.

MOBILE HOSPITALS

Mobile surgical hospitals were institutions which were destined for activity near the front lines. They were usually established in tents;¹¹ so their personnel had to be skilled in the rapid setting up and taking down of tents, as these hospitals were forced to be able to move on very short notice. They had complete equipment for operations, their own laundries, sterilizing trucks, and electric-lighting plants. Many of them had portable equipment on trucks which could be incorporated into a tent system in such a way as to function as a room. For instance, X-ray and sterilizing trucks could be attached to

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the operating-room tents. The whole equipment could be taken down, packed onto trucks, transported a considerable distance, and set up again on the same day. ¹¹

The staff usually included 20 nurses, or 19 nurses and the chief nurse.¹¹Necessarily, conditions in so far as the nurses in these organizations were concerned, were of the most primitive. A special tent was used for the nurses' quarters, and it usually contained very little more than beds and the nurses' locker trunks in which they kept all their necessities and on which they placed their wash basins and pitchers.¹¹

Mobile surgical hospitals could make few provisions for comfort or convenience. The mess tent usually contained, for dining-room equipment, trestles with boards over them for tables, and benches for chairs. If oilcloth was available, that was used for table covering, and the easily transportable enamel plates and bowls were the table furnishings.¹¹

Screens and mosquito netting could not be installed in these rapidly moving units, and as they frequently had to be set up in areas which had been fought over there was often much annoyance to be endured from flies.¹¹ In some mobile hospitals recreation tents for the nurses' use were provided by the American Red Cross.¹¹

FIELD HOSPITALS

Nurses were not intended for assignment to field hospitals, but there were occasions in which nurses found themselves on duty with such hospitals after having been assigned to duty on special surgical teams which were moved about as the need arose. Under such conditions formal reports of this service were never submitted, as there were no chief nurses on duty with these teams, but the nurses' individual records indicate that a number of nurses had varying lengths of service in connection with field hospitals.³

HOSPITAL TRAINS

Hospital trains formed the connecting link between the front-line and the base hospitals. Each train unit was complete, frequently organized as such in the United States; however, nurses were not attached to the hospital trains until several months after the hospital-train service had been functioning. The duties of the three nurses assigned to each of the trains were outlined in general instructions which were issued to the officers in charge of the trains: ³

The senior of the three nurses assigned to the train will act as matron. Nurses willcarry out the orders of the medical officers, and are to be obeyed next after them.

The nurses were assigned quarters within the staff coach, and one of themwas obliged always to be on duty. When it was possible for a nurse to leave, she could be gone no longer than two hours.³

The duties of the nurses on hospital trains were performed under difficulties. It was necessary for them to accustom themselves to the restricted quarters, the constant motion, and the uncertainty and irregularity of the hours of duty. The character of the duty on the hospital trains made it imperative that extreme care be exercised in the selection of nurses for such details. The limited space, the necessity for close association of officers and nurses, and the isolation from other groups of workers made hospital train duty a severe test of the persons

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assigned to it. Professional skill, great physical endurance, adaptability to unusual living and working conditions, ability to meet emergencies, and the possession of steadfast high principles were some of the qualifications found to be most desirable in a nurse on duty with a hospital train.³

Experience proved that certain improvements could be applied to the nursing branch of this service, such as frequent inspections by a representative of the nursing service, means of recreation, limitation of period of duty on a train, and a system whereby nurses' clothing could be replenished at definite points on the route, and thus do away with the necessity of the nurses washing their own clothing.³

NURSES' LIVING CONDITIONS

QUARTERS

The degree of relative comfort which could be attained by the American nurses living and serving in war-ridden France was surprising. Frequently it

FIG. 6.- Nurses' quarters of the semipermanent barracks type

was necessary to use unequipped and poorly arranged rented buildings, because of the inadequacy of new construction. Such buildings included factories, schools, barracks, and hotels.³ Very few of these buildings contained running water, toilet facilities, or sewer connections, and the heating systems were almost uniformly poor. With characteristic American spirit, the nurses adapted themselves to most uncomfortable conditions, even at severe risks to their health. Wet; cement floors which caused mildew to any articles left thereon; leaky roofs, which admitted wind and rain; impossible toilet and washing facilities; and the necessity in many cases for nurses to do their own laundry were at few of the discomforts attendant upon living in the unsuitable quarters.³ Gradually, as soon as it became possible, regulation brick or wooden barracks were constructed which provided, among other improvements, heat in the hallways and indoor toilets and washrooms. Such barracks usually allowed one room for each two nurses, and the contrast of such quarters to those provided in most of the rented buildings was, marked.⁹

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FOOD

Since nurses on duty in hospital were rationed, at times it was inevitable that the ration be limited in variety, quantity, quality, and attractiveness, and at such times only keen appetites sharpened by hard work made it possible to eat the meals. It was demonstrated that the mess was generally more successful when the officer in charge was assisted in its planning by a nurse detailed to that duty.³ Cooks and waitresses were drawn from the enlisted ranks and from the French towns. The comfort in many of the nurses' messes depended upon the ideas of the chief nurse and the cooperation of the commanding officer in securing

FIG. 7.- Nurses' quarters. Camp Hospital No. 91, La Baule, France

supplies. In many cases nurses ate off bare boards with the crudest of enamel dishes; in others, they were supplied with attractive china, tablecloths, and all the proper dining-room equipment.³ Through the efforts of the nurses themselves, curtains, lamp shades, and growing plants were secured, which added greatly to the attractiveness of the dining rooms. In the same way, the question of service was entirely a matter of locality and cooperation.³ The employment of women to serve as maids and cooks for the nurses' mess was the most satisfactory arrangement.³

Occasionally it was necessary for the nurses to stand in line and to be served their meals in their mess kits as were the soldiers.⁵ Fortunately this did not happen very often as it was most unsatisfactory.⁵

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LAUNDRY

For the nurses the question of laundry led to much discomfort. Some of the hospitals were able to provide their own laundries, some secured Frenchwomen to do the work, and sometimes the work was done in French laundries in neighboring towns.³ In many cases, however, the nurses themselves had to launder their own clothing, including their uniforms.³ This was a hardship, particularly during the times when their physical strength was taxed to the utmost in caring for their patients. The director of nursing service on her inspections of nurses' quarters noted but few rooms in which during the winter months, flannels were not hanging to dry. The lack of proper facilities for laundry work and the dampness of the winter months made it necessary for

FIG. 8.- Nurses’quarters, Base Hospital No. 29, Tottenham, England

many of the nurses' rooms to be "festooned" with wet flannels from one weekend to another.³

Mobile hospitals which were equipped with portable laundries seemed to solve the problem in the best way.³

RECREATION

Opportunities for recreation for nurses were often very limited.³ Muddy roads frequently eliminated walking in places where that was the only chance for diversion. Dim lights prevented reading, writing, or sewing in the nurses' rooms, and even when general living rooms were provided they frequently were too cold and too poorly lighted to permit of any enjoyment from playing cards or other indoor games. In the hospital centers the American Red Cross grad-

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ually provided recreation huts equipped with libraries, moving-picture apparatus, and musical instruments; in some places they even built special huts for the nurses' recreation houses.³ These recreation houses were like private club-houses and were fitted with assembly rooms, libraries, kitchens, sewing rooms, and laundries. Here the nurses could entertain with simple meals, teas, dances, and other social activities. The next step in the direction of improvement was

FIG. 9.- Interior of nurses' quarters, semipermanent barracks type

when Young Women's Christian Association secretaries were assigned to duty as hostesses of the recreation huts. About 30 were detailed to such duty, and they proceeded to organize classes and courses,' and to provide entertainments.³ This proved a great help at a time when some form of diversion was imperative to uphold the morale and to stimulate the spirits. The presence of these women was of the greatest assistance to chief nurses whose energies could be devoted to purely professional work.³

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Cessation of hostilities led the way to further relaxation, and likewise afforded more time for recreation. The sense of relief which pervaded the minds of all found expression at times in ways which required a controlling rein, but never did outside amusements cause the nurses to lose their enthusiasm or interest in the welfare of their patients.³

CARE OF SICK NURSES

The methods of caring for sick nurses varied according to the hospital concerned, and usually to the number of nurses who needed hospital treatment.³ In some instances nurses were cared for in their quarters; in others, a special part of the nurses' quarters was set aside as an infirmary, attendant nurses

FIG. 10.- Nurses' mess hall, Base Hospital No.17, Dijon, France

being assigned to duty there. Still other hospitals assigned a ward or a portion of a ward exclusively for the care of sick nurses. When base hospitals were grouped in centers, the general practice was to establish a center infirmary to which all the sick nurses of all hospitals of the center were sent for treatment.³

Disabled nurses were classified by medical boards and evacuated as were officers and men.³ Sick nurses who had to be returned to the United States were sent to port hospitals at Savenay, Bordeaux, or Brest, and their conditions passed upon there. If it was decided that they should be returned to the United States, and transport accommodations were available, they were returned without delay.¹² In cases where nurses were sent back to the United States in this manner, statements were sent to the Surgeon General's Office, at Washington, D. C., to the surgeon, port of embarkation, and to the chief surgeon, A. E. F., setting forth the facts as to the reasons for return.¹³

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LEAVES OF ABSENCE

Members of the Army Nurse Corps in the American Expeditionary Forces were granted leaves of absence under the same conditions as were officers and men. These provisions made allowance for seven days of leave every four months, not inclusive of travel time;¹⁴ however, during the active months of the war it was not possible for nurses to be given their leave allowances regularly. Nurses who did obtain leave usually went to Paris, though some went to the Riviera.³ After the armistice began, however, leave areas were unrestricted, and thus, unlike the nurses who served with the British Expeditionary Force in France, who were allowed to go to England and only to certain portions of France while on leave, the nurses on duty with the American Expeditionary Forces had almost unlimited opportunity for traveling and sightseeing.³ Chief nurses were

FIG. 11.- Nurses laundering their wearing apparel

instructed by the chief surgeon's office, A. E. F., to urge as many members of their staffs as could be spared without detriment to the service to avail themselves of leave.³ This was especially important for the morale of the nurses, because of the inevitable reaction after so many months of strain incident to war duties.³

DIFFICULTIES EXPERIENCED INCIDENT TO TRAVEL

Travel in France under the most favorable of circumstances was filled with difficulties. Trains were almost invariably overcrowded; there were no porters; cabs were very scarce; frequently no hotel accommodations were available at a particular place, and the necessity of sleeping in railway stations or in ambulances or in other uncomfortable situations and of getting food wherever it was possible to snatch it was common to officers, nurses, welfare workers, and soldiers; in fact, to anyone who endeavored or was required to travel.

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Long waits in cold, damp stations often were followed by protracted trips in slow French trains, too often in second and third class coaches. Second and third class coaches frequently were delivered, despite the fact that, in accordance with instructions, first-class coaches had been ordered from the French for the transportation of nurses.³ The officers who received this unsuitable kind of transportation for nurses were often in a quandary as to whether to accept it or to refuse it. Although inadequate, if it were refused, it might cause unwarrantable delays in transferring nursing personnel.

There are letters of record from nurses giving accounts of their travels in France during the early part of the war, when conditions were very poor.³ Some of these stories tell of train trips of unknown lengths undertaken by

FIG. 12.- Interior of nurses' recreation hut, Base Hospital No. 27, Angers, France

nurses on their way to other stations in which rations were issued to them consisting largely of tinned food. Candles were also issued, as the trains had no lighting arrangements. Most of the nurses considered these trips in the nature of a lark, but were glad that it was not necessary to continue them for extended periods. Little harm was done by trips of this sort, but certain risks were taken, particularly in connection with the lack of facilities for the care of sudden acute illnesses among the nurses.³

One of the greatest causes for discomfort of nurses during traveling was the frequent lack of any toilet facilities whatsoever.³ Only where exceptional thoughtfulness was displayed by the officers in charge of transportation was this distressing state of affairs rectified., Instances are on record where one or two nurses traveling at the front on surgical teams were the only women on a

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train filled with officers and troops. They were required to travel in compartments with the officers, and no privacy was afforded them at any time during the journey, whether it was for the period of 1 hour or 24.³ It took moral courage and sensible frankness to meet this problem and to deal with it effectively.

Instances are known of the great resourcefulness shown by various chief nurses in the conduct of their nursing staffs from one place in Europe to another. During the early part of the war it was not unusual for the entire personnel of base hospitals to be landed at Liverpool and there for the nursing staff to be separated from the officers and men.³ Under conditions such as these it became the responsibility of the chief nurse to conduct groups varying in size from 65 to 100 women with all their baggage from that place in the north of England to somewhere in France.³ One chief nurse who had never before been in Europe and who had no knowledge of the French language, and for whose group no previous provision had been made, made all of the arrangements for getting 100 nurses onto a train in Liverpool which took them to London. In London she conducted them from one railroad station to another in the underground tube, and by vigorous methods succeeded in persuading the station master to add other coaches to a train about to leave for Southampton in order that her group might not be obliged to remain in London for the night. At Southampton she secured accommodations for them and on the next day arranged for their transportation to Havre. Here, for the first time, she secured the assistance of American officers, through whose help she placed her group on a French train with sufficient food to last them for a trip of nearly 30 hours. Such an instance as this was not very remarkable during the early months of the war.³

Early in January, 1919, the director of nursing service, A. E. F., wrote the following letter to the chief surgeon, A. E. F., regarding assistance to nurses who were traveling :³

Incidents are constantly occurring when nurses traveling on orders to base ports for embarkation, frequently for reasons of physical disability, are encountering great difficulties and discomforts. These difficulties are due to the crowded conditions of the trains, the nurses' unaccustomedness to traveling alone in a foreign country, and, more important yet, their physical disability. Such disability is usually not of such a nature that the nurses should be sent as patients. Nurses are obliged to carry their own heavy bags and to scramble for seats when they are not fit to do so, especially when changing trains. Many nurses change trains at Tours on their way to ports of embarkation. Can arrangements be made to assist such nurses at Tours? Can arrangements also be made to assist such nurses at all times of the arrival of trains at Bordeaux, Brest, and Nantes (for Savenay)? Incidents have also occurred where nurses traveling on orders from one station to another have been obliged to spend the night in railway stations. A few days before December 23 a group traveling from Rouen to Chatillon-sur-Seine (Camp Hospitals 38 and 64) spent the night in the station at Troyes, as it was impossible to obtain accommodations in hotels. Can any instructions be given or any foresight taken that will prevent such occurrences?

To obviate some of these difficulties for the nurses, commanding officers of hospitals which nurses were leaving were instructed to see that the commanding officer of a hospital situated in the town near the next station at which nurses might be required to change cars or to leave the train should be notified in order that he might send a detail to look after nurses' baggage and to make any further

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necessary arrangements for them.¹⁵ Hundreds of nurses were benefited by thisorder and were met by ambulances to take them to hospitals overnight, and were sent on their way the next day in comfort.³

PROBLEMS OF CHIEF NURSES

Chief nurses had a greater variety of problems to deal with in France than most of them had ever before encountered. Not only did they have the routine administrative activities to deal with, such as the distribution of nurses and the supervision of their duties, but they frequently had very serious practical problems to solve.³ As stated above, housing conditions were frequently anything but comfortable. Often it was necessary for the chief nurse herself to make purchases for the nurses' mess, when some one else could not be delegated to attend to this duty regularly; also to hire, train, and supervise employees, most of whom could not speak English, for not only were Frenchwomen and girls employed as cleaners, maids, cooks, etc., but numbers of Belgian refugees were used in the same way.³ These problems, however, were of relatively minor significance as compared with those which arose in connection with oversight of the general conduct of the nurses.

The maintenance of morale among our nurses and the observance of the customary social amenities of life were matters which presented many difficult phases. It should be realized that in France in almost every station where nurses were on duty there were none of the usual social inhibitions or traditions or things that "weren't done." In the United States the customs or institutions of a locality or a community presented many brakes to impulses and desires, but in France for our nurses none of these things obtained, and the only influences that could be brought to bear upon situations were those which were in each nurse's individual background or in the careful supervision and regulation by the chief nurse. In civil hospitals at home chief nurses had training-school committees in many instances or boards of lady managers to whom they could turn for advice, and superintendents of nurses who were confronted by big problems could bring them up for discussion at conferences of nurses holding similar positions, but in France, particularly in isolated localities, the chief nurse was in a most difficult and lonely position because of the lack of such counselors and guides. Though, generally speaking, a great amount of support and assistance was given to the chief nurses by many of the commanding officers with whom they were associated, and also by many members of the medical staffs, where such cooperation or interest on the part of the masculine administrative group was lacking, the position of the chief nurse was probably one of the hardest in which a professional woman was ever placed. It must be remembered, too, that there were many different ideas regarding conduct and social regulation. The British had their customs and traditions in these matters; the French had theirs; and the Americans who, even in small groups, came from very different parts of the country, had theirs. Even in the same hospital center ideas of conduct and local restrictions for the behavior of the nurses of the separate units varied markedly. In this connection the value of center chief nurses was notable, for they, in conference with the individual chief nurses of the units in the center, could formulate suggestions in these

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matters which would be uniform for all the units in a center. As center chief nurses were gradually appointed such suggestions as these were carried out with marked success.³

There were few units which did not lose one or more nurses by death, and even those that did not went through the agonizing experience of serious illness among the nursing staff. When it is recalled that most of the nursing groups were units that came from some parent organization in the United States, and contained women who had been friends for years, and that in many instances the parents of members of the staffs had personally confided the welfare of their daughters to the chief nurse, the anxiety and the responsibility of chief nurses can perhaps be partly imagined.³

In the case of death among the nurses, upon the chief nurse fell the duty of writing to the parents and describing the details as best she might, of readjusting the duties among already overworked women, of assisting at funeral ceremonies, of keeping up morale, and also of arranging for the nursing of other sick members. It takes but little imagination to picture the frame of mind of a chief nurse who had gone through this process twelve times in one month, as once happened during the period of the influenza epidemic. The cumulative effect of so many funerals would have had serious consequences under normal conditions, and 3,000 miles from home, in a foreign land without the usual means of diversion, it took strong character to withstand the pressure.³

BASE SECTION NO. 3, ENGLAND

In June, 1918, an Army chief nurse and an assistant were assigned to duty in the office of the chief surgeon of Base Section No. 3, England. These two executives relieved two nurses who had been on duty in that office since the February preceding. Their duties consisted of the general supervision of all the nursing personnel of United States Army hospitals in Great Britain.³

Ten hospitals with American Army nurses functioned in this section, and three of these were American Red Cross military hospitals. During the influenza epidemic of October, 1918, 300 nurses who were en route to France were attached temporarily to the hospitals in this section where they were most vitally needed. This did not entirely relieve the pressure, so 100 members of the British voluntary aid detachment were procured through the British War Office and were distributed among the hospitals.³

Though authority was contained in the Army appropriation bill of July,1918, to appoint one director and two assistant directors of nursing service in England, since there were comparatively so few nurses in Base Section No.3 it was not necessary to utilize this allowance.³

During the war period 24 American-trained nurses, the majority of whom were British subjects, were transferred from the American Red Cross nursing service to the Army Nurse Corps while they were on duty in Base Section No.3.³

The chief nurses of this section, in addition to the usual problems incident to service in a foreign country, had also the difficulty of being much isolated and of having very little opportunity to confer with other nurse officials regarding matters of administration and discipline.³

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IN THE ARMY OF OCCUPATION

On December 2, 1918, a part of the personnel of Evacuation Hospital No.3, including 25 members of the Army Nurse Corps, proceeded by ambulance to Trier, Germany, for duty with the American Army of Occupation. This detachment took over a German hospital, the German nursing staff remaining on duty for about a week thereafter. Soon after several other evacuation hospitals were established in Germany. These organizations were really advanced base hospitals and did the work of such.¹⁶

Each hospital in the Third Army had as a rule the proportion of 1 nurse to every 10 patients, and the maximum number of nurses on duty in the Army of Occupation at one time was approximately 700.¹⁶ Some months after their arrival, it was decided upon the recommendation of the director of nursing service, A. E. F., to assign to the office of the surgeon of the Third Army a chief nurse whose duties were outlined as follows: To be responsible for incoming nurses reporting to the surgeon's office for assignment; to handle all papers relating strictly to the Nurse Corps; to submit recommendations to the personnel officer regarding assignments and transfers of nurses; to keep the surgeon of the Third Army fully informed regarding all matters concerning the nurses; to systematize and standardize the rules, regulations, and social policies governing nurses in the army area; to keep in touch with the director of nursing service, A. E. F., regarding her policies; by frequent visits, to keep informed of the conditions in the hospitals of the army area, as they affected the nurses, such as quarters, mess, recreation, care of sick nurses, etc.

The problems which arose in connection with the nursing staff in the Army of Occupation had a distinctly individual character, due to the nature of the work, which was not heavy, and to the circumstances of life in an occupied area. There were no precedents for conditions of this sort, and as had happened elsewhere in the American Expeditionary Forces, they had to be worked out one by one as they arose, rather than in accordance with any policies that previously had been formulated. Opportunities for sightseeing trips or for participating in social occasions of all kinds were not unique in the nursing service but were apparently the order of the day in all branches of the Army. From the time of the advent of the first nurses into Germany endless invitations poured in from every near-by section to social functions of all sorts. Celebrations and festivities of every nature were organized, and there seemed to be no reason why nurses should not go from one part of the occupied area to another. This practice, however, produced complications with regard to temporary living conditions, and it was necessary in consequence to curtail the practice so far as nurses were concerned. At a conference of commanding officers of the hospitals of the Third Army it was decided that nurses should attend no social affairs excepting those in their own hospitals. Each hospital usually had one or two dances to which the nurses were privileged to invite anyone they chose.¹⁶

It was necessary because of the natural resentful attitude of some of the populace to require nurses never to be on the streets after 7 in the evening unless in groups of two or more, accompanied by proper escorts. They might be out after 9 o'clock only with written permission from their chief nurse, approved by the commanding officer.⁶

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Great insistence had to be placed on the wearing of the Army Nurse Corps uniform at all times as a matter of protection and identification.⁶

Nurses were instructed not to enter cafes and not to dine in officers' quarters or messes. They were not allowed to dine in hotels which were operated by Germans and which used German food supplies, but there was no objection to their dining in hotels which were under American control. Social relations with the enlisted men were not permitted, and nurses were forbidden to ride in Government motor vehicles, except when they were on duty.⁶

DISPOSITION OF NURSES AFTER THE ARMISTICE BEGAN

After the armistice began the immediate effect of a decline in enthusiasm and morale was widely felt among the nursing staffs, as well as among officers and men. This was evidenced by the large numbers of requests for transportation to the United States which were received at the office of the chief surgeon, A. E. F.¹⁷ The urgent need for nurses, however, did not decrease until several weeks after the armistice began, but plans were formulated rapidly by which entire groups of nurses could be returned to the United States. At this time increased activities of the American Red Cross among returning refugees, prisoners, rapidly developing institutions for children's work, and tuberculosis patients, with Red Cross commissions in the Balkan States and the Near East, gave opportunities for those nurses who wished to remain longer in Europe to be relieved from active duty with the Army Nurse Corps and to be taken over for service directly under Red Cross commissions. The close cooperation between the office of the Red Cross nursing service at Paris and that of the nursing service of the Army made it possible for this transfer of status to be made with the least possible loss of time and without confusion.

CONCENTRATION AND EMBARKATION CAMP

To facilitate the return of nurses to the United States, beginning in January, 1919, Camp Hospital No. 91, at La Baule, functioned as a centralization point for the Army Nurse Corps under orders to return to the United States.¹⁸ This location was chosen because La Baule is a seaside resort not far from the Savenay Hospital center and the port of St. Nazaire, and but a short distance by train from Brest. The nurses who were sent to La Baule to prepare for return to the United States were housed in four large hotels, built of brick or stone, of excellent construction, but without arrangements for central heating. They were, on the whole, very comfortable except in the cold, damp, and rainy season of January, February, and March.¹⁸

The average length of stay for the units at La Baule was from 10 to 15days, as it required much time to complete the records and make arrangements for the journey to the United States.¹⁸ Frequently the four hotels were taxed by the many units reporting there simultaneously. During the first month that nurses were sent there for concentration the following organizations had arrived to await evacuation: ¹⁸

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Entertainment was provided by the American Red Cross and also by the administrative staff of the hospital in the form of bus rides to St. Nazaire, auto trips, dances twice a week, and moving-picture shows.¹⁸

When the time came for the units to be transferred to Brest, each group was placed under the supervision of an officer. As many of the base-hospital units had been broken up, and as a chief nurse frequently would arrive at the center with a small group, it was decided to send groups of 50 nurses home and, if a chief nurse was available, to put her in charge of a group.¹⁸ If no chief nurse was available, a nurse was assigned as acting chief nurse and given charge of a group.¹⁸ Although many nurses were sent from La Baule to St.Nazaire and Bordeaux for embarkation, the majority went through Brest.¹⁸

Another important concentration camp for nurses was at the Vannes Hospital center. This center included not only Vannes, but also Auray, Plouharnel, Carnae, and Quiberon.¹⁹ At Vannes the one hospital, Base Hospital No. 136, was in old French buildings which formed three sides of a quadrangle and which previously had been French barracks. The buildings were very dirty and required an unusual amount of work to convert them into a decently livable place. There were no proper toilet arrangements, no electricity, and gas in but a few of the buildings. The only advantages of the place were an abundance of room, plenty of potable water, and freedom from mud. This hospital was the nucleus of the center.¹⁹

On May 30, 1919, there were 1,157 nurses at Vannes awaiting orders to return to the United States.²⁰

The Kerhoun Hospital center had a capacity for 4,000 evacue es. Ninety per cent of its activity was devoted to receiving, preparing, and evacuating patients to the United States. In February, 1919, it was decided to set aside here a block of 13 wards, with a capacity for 500 nurses, to care for nurses properly who were being returned to the United States.²¹ In addition to providing quarters and food, it was found necessary to pay, clothe, and provide laundry facilities for these transient nurses. A large stock of nurses' clothing was obtained, and frequently as many as 500 nurses were outfitted in one afternoon. From February 1 to April 30, 1919, 3,960 nurses were accommodated here, awaiting transportation to the United States.²¹

The quarters for the casual nurses were in barracks, some of which were located at a distance from the latrines and showers. The showers were installed in a barrack-type bathhouse, where the nurses could also use laundry facilities. A French woman attended to the fires and to cleaning the bathhouse.⁶

The casual nurses were assigned to a separate mess hall which had a capacity of 370. At one time cafeteria service was used, but later it seemed practicable to have the food served the nurses at the table. On account of laundry conditions no tablecloths were used.⁶

The question of the entertainment of the transient nurses at Kerhuon was an important one. Naturally they were eager to return home and chafed at the

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delay incident to the departure of the vessels on which they received transportation. They were allowed to go to Brest at any time when there was possibility of their unit receiving orders, and special ambulances conveyed them to town twice every day. The American Red Cross hut was increased to twice its size and provided one of the best dance halls in the vicinity. Tea was served there every afternoon, and when there were more than 100 casual nurses present tea was served in the individual barracks. The orchestra played every afternoon at the teas and also during dances in the evenings.²¹

Special barracks were set aside for the accommodation of sick casual nurses, and a nurse was placed in charge of each of these barracks.²¹ Improvements were gradually applied to the system of caring for sick nurses.⁶

In the Kerhuon Hospital center there were constantly from 400 to 500 transient nurses, and from 2,000 to 3,000 ambulatory patients.²¹ The problem

FIG. 13.- Embarkation center for nurses, Vannes, France

of the relationship of nurses and enlisted men in a place of this sort where so many were congregated without adequate occupation or amusement was an especially difficult one. Prior to April 1, 1919, association between nurses and enlisted men was confined by orders strictly to official business.²¹ When the order prohibiting restriction of association was received, all restrictions were removed, and the result was well-nigh disastrous. Transient nurses and patients were to be found everywhere about the walks and grounds. Within 48 hours the sections of the center used by permanent and transient nurses as quarters had to be placed out of bounds to enlisted men on the urgent request of the nurses themselves.²¹ The indiscriminate association of nurses and patients, morning, afternoon, and evening, resulted in a distinct lowering of discipline, not only to the patients, but also to the enlisted personnel. Prohibition of association between nurses and enlisted men was reestablished only when it became manifest that it was absolutely essential to do so. It became a question of

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reestablishing the prohibition or discontinuing having transient nurses here; the former action was taken in the middle of May, 1919, after which time no further trouble was experienced.²¹

The overcrowding of nurses in uncomfortable quarters, the long delay, and the lack of occupation caused great unrest and dissatisfaction among them although every effort had been made at the chief surgeon's office, A. E. F., to expedite the departure of portions of this large group of nurses to the United States, the relief of the situation was hardly perceptible. At about this time the officer in charge of transportation, chief surgeon's office, A. E. F., requested the director of nursing service to go to Brest in order that she might ascertain for herself the exact situation with regard to available facilities for the return of nurses to the United States.³ The director had a conference with the transportation officers at Brest, and when they showed her lists of sailings for the following few weeks of vessels with 20,000 berths and at the same time showed lists of Americans, including troops, members of the Army Nurse Corps, and various welfare workers, and the question was asked just what could be suggested, there was, of course, no answer forthcoming, except to urge that nurses be sent back as soon as possible. Since only a certain portion of women could be accommodated on each transport, naturally the officers in charge of transportation were greatly put to it to choose between the types of women workers who should be given preference.³

HEALTH OF NURSES-CASUALTIES

On the whole the health of nurses in the American Expeditionary Forces was very good. The influenza epidemic of 1918 affected members of the Nurse Corps as it did the men of the Army. Only two nurses were wounded at all seriously, and none were killed by the enemy. By the time the first nurses in France had been there a year only six deaths had occurred among them, and at this time there were 2,500 nurses in the American Expeditionary Forces. Up through August, 1918, there were 15 deaths; but in September there were 8 more, in October, 41, and in November, 12. Deaths of nurses by months were as follows:²²

TABLE

As was to be expected, although it is probable that such things were not in most people's calculations in connection with the war, a normal amount of accidents occurred among the nurses. One was killed in an airplane accident, another was run over by a train, another was thrown from a horse, and a number were killed in automobile accidents.²² Exercise of all sorts and diversions of

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every description were necessary, and death under such circumstances was in line of duty. It should be noted that the proportion of suicides among the nurses was abnormally low. Of the 10,066 nurses in the American Expeditionary Forces but one of them committed suicide.²²

REFERENCES

(1) Correspondence on file, Record Room, S. G. O., 201 (Bell, Bessie S.).
(2) Act of Congress approved July 9, 1918. (Public, No. 193, 65th Cong.) H. R. 12281.
(3) History of Nursing Activities, A. E. F. on the Western Front During War Period May 8, 1917-May 31, 1919. By Julia C. Stimson, director, Nursing Service, A. E. F. On file, Army Nurse Corps Section, Personnel Division, S. G. O.
(4) Letter from Julia C. Stimson to Surgeon General, January 15, 1919. On file, Inspection Reports by Nursing Service, A. E. F., 1918-1919, Army Nurse Corps Section, Personnel Division, S. G. O.
(5) Julia C. Stimson: Finding Themselves. The Macmillan Co., New York, 1919, page 97.
(6) Inspection reports by nursing service, A. E. F., 1918-1919. On file, Army Nurse Corps Section, Personnel Division, S. G. O.
(7) Special Regulations No. 61, W. D.
(8) First indorsement, S. G. O., to the Surgeon General of the Army. Subject: Organization of Base Hospitals Through the Red Cross. On file, Record Room, S. G. O., 322.37 (Misc.)
(9) Report on work in France of the United States Army Nurse Corps. Appendix (i), prepared July 12, 1919, by Dame E. Maud McCarthy, matron in chief, British troops in France and Flanders. On file, Army Nurse Corps Section, Personnel Division, S. G. O.
(10) Lecture No. 146, by Bailey K. Ashford, M. C., commandant, Army Sanitary School:"The Evacuation Hospital." On file, Historical Division, S. G. O.
(11) Histories of mobile hospitals. On file, Historical Division, S. G. O.
(12) Letter from Bessie S. Bell to Dora E. Thompson, May 18, 1918. On file, Army Nurse Corps Section, Personnel Division, S. G. O.
(13) Letter from chief surgeon, A. E. F., to commanding officer, Base Hospital No. 8, A. E. F., May 3, 1918. Subject: Nurses Returning to United States. On file, Army Nurse Corps Section, Personnel Division, S. G. O.
(14) General Orders No. 6, A. E. F., January 8, 1918.
(15) Circular No. 65, Chief Surgeon's Office, A. E. F., January 15, 1919.
(16) Report on the hospitalization for the Army of Occupation in Germany, undated, by Maj. H. C. Maddux, M. C., United States Army. On file, Historical Division, S. G. O.
(17) History of American Red Cross Nursing Bureau. On file, Army Nurse Corps Section, Personnel Division, S. G. O.
(18) History of Camp Hospital No. 91. On file, Historical Division, S. G. O.
(19) History of Vannes Hospital Center. On file, Historical Division, S. G. O.
(20) Account of services in Army Nurse Corps overseas, by Mrs. L. L. Vandervort, former chief nurse, Army Nurse Corps. On file, Army Nurse Corps Section, Personnel Division, S. G. O.
(21) History of Kerhuon Hospital Center. On file, Historical Division, S. G. O.
(22) Based on sick and wounded reports made to the Surgeon General.