Dame Maud McCarthy (1859–1949): Matron-in-Chief,British Expeditionary Forces France and Flanders,First World War

Introduction

The work of these people under the greatest of difficulties is beyond all praise

Dame Emma Maud McCarthy, France, 30 November 1915 ¹

Nurses see firsthand the true horrors of war. Broken bodies and damaged minds require the greatest of care, professionalism and compassion. The first World War was a conflict without precedent. Never before had the world witnessed such a massive and bloody war and never before had there been a need for such large-scale medical facilities to cope with the slaughter. This paper seeks to explain the important role played by one nurse, Dame Emma Maud McCarthy (Figure 1) (known as Maud), Matron-in-Chief, British Expeditionary Force, France and Flanders, and the remarkable contributions she made not only to military nursing and its administration but also to nursing as a whole through her nursing knowledge, her professionalism and her compassion. By using primary source material such as McCarthy’s war diary, official reports and correspondence, an understanding of the way she influenced nursing in First World War France can be achieved. Initially, this study will outline the early nursing career of Dame Maud, her Australian education and her contributions in the South African War in the late 19th century. With the onset of the First World War, McCarthy’s role within nursing was intensified dramatically as hospitals on the Western Front needed to be established immediately and new challenges met. With the new warfare came overwhelming casualties and, for nurses on the Western Front, this meant an intensification of care unseen in any previous conflict. Through the writings of McCarthy, the challenges that faced nurses are clear. They were confronted with new horrors wielded upon soldiers by the latest weaponry. Throughout the adverse conditions the administrative wheel of war was kept turning, the hospitals had to be run efficiently and effectively, and McCarthy was the leading instrument in this accomplishment. This paper will provide not only a challenging look into the horrific conditions faced by the nursing services on the Western Front but also give insight into the way in which the nursing facilities were led by McCarthy – with professionalism and compassion. OPEN IN VIEWER

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Figure 2.

Dame Maud McCarthy GBE, prior to attending the coronation of His Majesty King George VI, 1937.

Training

Born in Sydney in 1859, McCarthy was the daughter of a successful solicitor, William Frederick McCarthy and great niece of the Chief Justice of Victoria, Sir William a'Beckett (1806–1869). ² She was educated at the Springfield College in Sydney, a private girls’ boarding school where she passed her senior examinations with honours. In 1891 McCarthy, then aged 30 (her age as recorded in the records from The London Hospital was 28), entered the training school at The London Hospital in Whitechapel. ² By 1894 she had reached the status of Sister in the hospital and was well regarded by her superiors. The Nurse Probationer Register of The London Hospital described McCarthy as ‘conscientious’ and ‘exceptionally nice’. ³ Her skills as a nurse and leader were apparent when, along with six other sisters from The London Hospital, she was chosen to serve in South Africa as Princess Alexandra’s Military Nursing Contingent. ² McCarthy served as military nurse in the South African War from 1899 to 1902, receiving the Royal Red Cross Medal and both the Queen’s Medal and the King’s Medal for service. Due to the use of modern weaponry in the South African War, previously used on such a scale only in the American Civil War, the medical needs of the armies were intense and new precedents in nursing were set. ⁴ Three types of hospitals were established in the South African conflict, the ‘field’ (rarely staffed by nurses), the ‘stationary’ and the ‘general base’. ⁵ Casualties were transported from the initial field hospitals to the marginally better equipped and staffed stationary and general base hospitals, and for the first time nurses worked on the hospital trains that transported casualties to the various hospitals. ⁴ The British Army Nursing Service in the South African War shaped a new model for nursing care during war; developments were made in the use of anaesthetics and drugs; in administration, including the distribution of medical equipment, greater efficiency in evacuation and treatment of casualties; improved standards of hygiene and an emphasis on the use of highly trained nursing staff. ⁶ McCarthy undoubtedly drew much military nursing knowledge from her experience in South Africa. On returning to Britain after the South African War, McCarthy worked as matron in Aldershot, Netley and Millbank military hospitals in England and, in 1910, she was appointed Principal Matron at the British War Office. ² In four years’ time her role as Principal Matron would be one of the most important in army nursing history.

Queen Alexandra’s Imperial Military Nursing Service

In the wake of the South African War, it was deemed necessary to establish a British reserve corps of nurses, able to volunteer in a time of war. In 1902 a committee consisting of military, nursing and medical dignitaries discussed the possibility of an amalgamation of the Army Nursing Service and the Indian Nursing Service. This would not only increase the numbers of trained nurses in reserve but would also create a consistent level of medical care, training and administration.^4,7 On 27 March 1902, with the support of Queen Alexandra and King Edward VII by Royal Warrant, Queen Alexandra’s Imperial Military Nursing Service (QAIMNS) was officially implemented. ⁴ The Queen Consort was an enthusiastic namesake and contributed to the administrative decisions that had to be made in the early days of the service, from issues of nurses’ pay to the design of the badge they would wear. A rigorous selection process determined who would join the service; criteria including appropriate training, experience, education and character were taken into consideration before a nurse was accepted into QAIMNS. Applicants had to have good references from their superior matrons, be unmarried and between the ages of 25 and 35. Due to the strict selection process, QAIMNS began to be regarded as elite, with higher levels of professional knowledge and experience than other nursing groups that were established at the same time. QAIMNS nurses were seen as experts in modern nursing techniques and compassion toward invalided men was a value instilled in the nurses from the highest ranks of the service. By 1912 the QAIMNS had 300 regular army nurses serving in both England and India. ⁷ In 1903 Maud McCarthy was accepted into the QAIMNS as a Matron.

Matron-in-Chief

The beginning of the First World War heralded a need for military nurses. In August 1914 McCarthy and the first contingent of nurses arrived in France. McCarthy had been promoted through the ranks in a complicated and formal process in which merit and routine combined, and war had intervened so that, as McCarthy was the natural candidate for one of the most senior jobs. Her employment as Matron-in-Chief for France and Flanders seemed inevitable. ⁸ Travelling on the first ship to leave England for the battlefields of the Western Front, the task ahead was daunting. From the French port of Le Havre, McCarthy and her nurses travelled by train to Rouen ⁹ and then on to Abbeville which was to be the headquarters of the lines of communication for McCarthy. ⁴ As Matron-in-Chief to the British Expeditionary Force in France, McCarthy was answerable only to Miss Ethel Becher (1867–1948), Matron-in-Chief QAIMNS and to the Director of General Medical Services, ⁴ a reflection of the immense responsibility given to her. Her basic role consisted of the administration of nursing facilities throughout the Somme Campaign and included organisation of pay, leave and promotion, the maintenance of discipline, organisation of reinforcements and decisions as to which nurses would treat which soldiers and under what conditions. This all had to be co-ordinated throughout the various nursing and medical facilities operating on the Western Front, casualty clearing stations (CCS), hospital trains and barges that transported the wounded, ‘stationary’ hospitals (that were essentially mobile), base hospitals where the transported wounded were cared for, and hospital ships on which wounded soldiers requiring rehabilitation would be taken back to England. It was a task fraught with challenges.^6,10 In January 1915, McCarthy simplified the basic tasks required of her nursing staff, ‘The work consists [of] the constant admission of large numbers of patients and the continual evacuation so as to leave sufficient vacant beds always for daily needs’. ¹¹ As Matron-in-Chief, McCarthy had all trained nurses and volunteer medical workers under her co-ordination. These included all QAIMNS nurses, the Territorial Force Nursing Service, the Red Cross and the Voluntary Aid Detachments (VAD). It also included military nursing detachments from Australia, Canada, India, South Africa and, after 1917, the United States of America. On the eve of war there were 2223 QAIMNS reserve nurses and by the end of the war this figure had risen to 10,404. ⁴ Meticulous organisation was required of McCarthy and in this she excelled. In January 1916 she wrote ‘Busy all day, checking names and addresses with category under which every lady is working in France’. ¹² As more nurses arrived in France, more challenges had to be met: ‘The difficulty of meeting large numbers of nurses at one time is very great’. ¹³ As the war escalated and casualty numbers increased, McCarthy was met with the problem of too few trained nurses to staff the nursing units effectively. An example of this can be seen in her Annual Report of the Work of the Nursing Services in France, 1917:

The need for more Trained Nurses was most acutely felt in the Spring of 1917. The total number of beds to which Units were being expanded on March 15th amounted to 19 General Hospitals of 1040 beds each. On the 1st of March the actual shortage of Trained Nurses to complete the establishment of existing units was 283. In order to try and meet these needs and also the needs of the expanded units, a demand was submitted on March 5th for 500 Trained Nurses and 400 V.A.D.’s. The reinforcements of trained nurses were not supplied but the V.A.D.’s were sent out in parties of 50 per week from the 25th March. ¹⁴

McCarthy had to ensure that each unit was receiving sufficient medical stores, rations and equipment, for the staff to work effectively and for the patients to be made as comfortable as possible. ⁹ It was important for morale that the nurses’ quarters in the various hospitals were made comfortable; this was demonstrated in McCarthy’s diary entry from 15 December 1915:

After lunch to Lahore British Hospital. Hospital good. Sisters’ quarters very bare and comfortless – staff apparently saving all they can, sooner than supply themselves with decent homelike surroundings. Told Miss Burkitt the Matron to alter matters, and to make like in all other Hospitals, each member to pay 1 franc a day into the Mess for extra comforts and dainties. ¹⁵

Although her headquarters were at Abbeville, McCarthy constantly visited the various medical units established for the treatment of the wounded on the Western Front. For her this was essential in order to maintain a consistently high level of patient care for the wounded soldiers as well as to ensure the conditions under which the nurses were working were acceptable. McCarthy’s war diary demonstrates the enormous amount of travelling she did to the various medical units. In July 1916 she travelled to 18 different hospitals at as many different locations in France, from Paris and Boulogne to locations closer to the Western Front including Heilly, St Omer and Puchevillers. In several instances, she visited sites more than once in a single month. ¹⁶ She diligently reported all conditions she found in the various medical units, praised those that were run effectively by disciplined staff and criticised units that lacked sufficient discipline and procedural conformity. On 11 December 1916 she wrote

Went to … Gezaincourt where we visited 3 Australian Casualty Clearing Station and saw the OC and Sister in charge. Everything most satisfactory, and the OC spoke in the highest terms of the work both of the Australian and English Sisters during the recent rush – he said he did not think it was possible for women to do the work they had done. ¹⁷

By contrast, on 8 March 1916 McCarthy expressed shame in the lowering of nursing standards in a particular unit:

Official complaint received from WO with reference to the dirty feet of 4 patients from 13 Stationary Hospital, blind and gunshot wound of head who had been in Hospital 19 days and over. Such a thing has never happened before, and I feel we have all been disgraced. ¹⁸

Her diligent inspections of the various medical units ensured the nursing staff retained a high level of professionalism and nursing care. McCarthy experienced the horror of war with her nurses:

… many seriously wounded men and officers continuing to come in during my visit. Many of them had been lying out some days in the trenches and were in a bad condition. The hospital is in good order now and a tremendous amount of good work has been done, the sisters on many occasions having stayed up all night. ¹⁹

Passed thousands of troops marching forward, each battalion with its band, all wearing masks. ²⁰ (Emma Maud McCarthy, 18 July 1916)

The war of attrition that occurred on the Western Front over four long and terrible years from 1914 to 1918 saw an unprecedented number of casualties. Throughout McCarthy’s reports and diaries, the hardships endured by both the soldiers and the medical staff are startlingly clear. The trenches stretched from the English Channel to Switzerland and the stalemate that took place facilitated huge losses. ²¹ Advances in technology meant warfare became increasingly intense and devastating for both the armies. In No-man’s Land, the use of barbed wire, initially manufactured to confine cattle on the American Great Plains, proved to be an effective means of inhibiting the enemy’s progress across the battlefield, as well as a vicious way to entangle the wounded. The use of the newly developed machine gun on such a scale proved devastating as waves of infantry charged into the artillery barrages. On a visit to a CCS outside Heilly, McCarthy reported ‘These units were extremely heavy, crowded with most dreadfully wounded men, many who can never leave’. ²² The introduction of chemical warfare intensified the suffering of the men serving on the front. Poisonous gas, in particular mustard gas, caused horrendous injuries. Introduced by the Germans in 1915 and used by both sides, mustard gas turned an intense yellow when exposed to the air. Once exposed to the noxious agent, the effects did not show immediately but after several hours the chemicals began to destroy the body from within and without. ²³ Skin would blister and eyes were blinded, the gas then stripped the mucous membranes of the bronchi, causing excruciating pain for up to four weeks, until death or recovery. As McCarthy visited the hospital units, she realised the tragic toll that gas attacks had on the soldiers, ‘Unspeakably sad so many hopeless cases, and so many quite blind, mostly very young’. ²⁴

Advances in aviation technology allowed for aircraft to bomb the battlefields. ²⁵ McCarthy first mentioned German Zeppelin air raids over France in August 1916. ²⁶ The front line hospitals were not immune to air raid attacks; throughout McCarthy’s war diary, she writes of nurses killed and wounded in air raids. On 13 August 1918 she wrote

Many bombs were dropped round Boulogne, 2 were actually on 55 General Hospital and the following casualties occurred among members of the Nursing Staff:- Miss Edith Ingram, VAD, was killed. Staff Nurse R. Brain, TFNS and VADs Miss H. Wood, Miss A. C. Larsen, and Miss Pleydell Nott were wounded. ²⁷

In her Annual Report from 1918, she devotes a section to the way in which the air raids had affected the nursing staff. She reported that the most intense shelling occurred through the Summer months of May and June and severely damaged the bases at Dunkirk, Calais, St Omer, Abbeville, Etaples and Boulogne. The safety of the nurses was foremost in McCarthy’s priorities and she reported that many nurses had to sleep in woods and caves to escape the bombardments. In a reminder of the hardships she stated

The raids were the greatest tax on the physical strength of the nurses. They had to go through the day’s work, which was so strenuous … and their rest at night was broken by dreadful experiences of raids … lasting sometimes two hours, sometimes 4 hours … and would fly so low they could make use of their machine guns. ²⁸

McCarthy acknowledged the nurses’ bravery under such frightening conditions:

Great bravery, devotion and presence of mind have been shown by the nursing staff and there have been so many acts of courage and total disregard of self that it is no easy matter to single out any particular case. ²⁹

The nurses working in the hospitals behind the Western Front witnessed firsthand the suffering of the dying and wounded firsthand. The gruesome wounds caused by high explosives and gas attack were often aggravated by the conditions experienced in the trenches. Wounded men from the trenches were riddled with lice, skin diseases, trench foot, malnutrition, dysentery and, commonly, gas gangrene. In the era before the discovery of penicillin, wound infections were difficult to overcome and many limbs were amputated.^5,10,30 Disease was rife in the trenches and the nurses had to deal with typhus, tetanus, tuberculosis, measles, diphtheria, meningitis and, towards the end of the war, influenza. Due to the presence of infectious diseases, the base hospitals established separate infectious wards, a not uncommon practice in medical care in this period. The nurses themselves were not immune; many became ill and some died, for example in McCarthy’s diary she wrote of the death of a nurse, Miss Wilson, from tetanus ³¹ and in February 1916 she wrote of the death of Miss Cole from meningitis. ³²

As a stark reminder of the enormity of the battles fought on the Western Front, it was deemed necessary to separate the wards in the base hospitals by the type of wounds suffered by the patients. The intensity of the weaponry used on the Front caused unimaginable injuries; the nurses confronted with the horror bravely employed all their nursing knowledge and experience. The separate units included ‘abdominal’, ‘jaw’, ‘head injury’, ‘amputation’, ‘respiratory’, ‘skin’, ‘eye’ and ‘moribund’ wards. Writing of her visits to the various hospital units, McCarthy makes reference to the separation of patients and in July 1916, she reported

… the Auxiliary Section of 14 General Hospital, where I have not been for some time, and where all the infectious cases, officers, nurses and men are now nursed, with the exception of Enterics, which are still nursed in the General Section in the Camp. ³³

In April of the same year she received a letter from the matron of 13 Stationary Hospital, giving particulars for Major Valadier’s special ward for jaw cases. ‘Mrs Johnston put in charge, operating theatre attached, all the latest appliances for these special cases have been supplied'. ³⁴ In October 1916 McCarthy made reference to the establishment of a separate skin unit:

Went to inspect the two villas which are being taken with a view to the accommodation of Officers suffering from skin diseases. This Unit is capable of taking in 1500 patients, and it has been decided to take in a large number of patients suffering from skin diseases. Two skin specialists are attached to the staff, and the question is being considered of transferring all officers suffering from skin diseases to this Unit, where they can have specialist’s advice, and all the special conveniences which have been provided for dealing with these trying complaints. ³⁵

Numerous problems arose for McCarthy due to the specialisation of some of the hospitals. As qualified nursing staff were constantly in demand, she deemed their skills to be more valuable in the hospitals caring for more serious cases and the less experienced nurses (often VADs) could nurse the less critical cases such as skin problems. In March 1918 she wrote

The Colonel was loath to part with any of his Sisters and said the treatment of skin cases presented many difficulties in consequence of the baths which were taken first before the treatment could be begun. He also emphasized the fact of the large numbers of cases arriving every day … He was not of opinion that the Sisters were likely to contract skin complaints from the patients and said that if one was short of nurses he would be quite willing to have a proportion of VADs in their place, which I said I did not agree with. ³⁶

McCarthy became an advocate for VADs and their push to be awarded what we today would call ‘advanced prior learning’ towards their training to be registered nurses. Her post-war diaries and reports have several references to the notion of reduced training for VADs who had served in military hospitals. ³⁷ At the end of November 1916 ³⁸ she gave a summary of her meeting at the War Office about the Supply of Nurses Committee and suggested that military service of VADs should be taken into consideration. On 26 October 1918, in the second part of the monthly account ³⁹ she described a discussion with Sir Arthur Lawley (1860–1932), President of the British Red Cross Society in Boulogne, ⁴⁰ about the role of VADs in general and training in civilian hospitals, and on 14 February 1919 in London McCarthy had a meeting with Lady Ampthill (1874–1957) at Devonshire House about the VAD scholarship scheme. ⁴¹ Lady Ampthill was Chairman of the Joint Women’s VAD Department of the Order of St John and the British Red Cross Society. ⁴² )

Cases of mental illness directly related to the man-made horror witnessed by the soldiers were so common that special wards had to be set up for the treatment of these patients. This form of mental illness was termed ‘shell shock’ and it was during this conflict that the condition was first identified as a serious mental illness. ⁴³ Many references are made in McCarthy’s diary to the care of mentally ill soldiers. On 9 November 1916 she reported the need for increased facilities and separate wards specifically for those suffering from shell shock: ‘beds were being supplied for 580 patients and huts were being built to enable patients suffering from shell shock and head injuries to be nursed until it was considered safe to remove them to the Base’. ⁴⁴

McCarthy’s Annual Reports address the treatment of the mentally ill. For example, in 1918 she reported that nurses experienced in caring for the mentally ill were required to serve in specialty wards: ‘these departments have been a great drain on our limited resources, but they have been of the greatest benefit to patients and offered great opportunities of gaining experience to the nurses’. ⁴⁵ McCarthy realised the importance of highly trained nursing care for those with mental illness; she supported the ongoing education of her nurses and the advancement of nursing as a profession.

Another example of nursing advancements throughout McCarthy’s reports and diaries was the use of nurses in administering anaesthetics. The term ‘necessity is the mother of invention’ can be applied to the situation faced on the Western Front by the medical units – there simply were not enough trained medical officers to administer anaesthetics to the wounded. In her official report of 1917, McCarthy wrote ‘At a meeting of Consultants held at General Headquarters in November 1st, it was unanimously agreed that owing to the shortage of Medical Officers, women should be trained as Anaesthetists’. ⁴⁶ The nurses who volunteered were given a three-month training course. They were then quickly deployed to the many CCSs and general hospitals. Although McCarthy realised the importance of well-trained anaesthetists in the hospitals and advancement of her nurses’ knowledge, she had reservations about the effectiveness and timing of the training. She believed that highly trained theatre nurses were able to safely administer anaesthetics and had been doing so throughout the conflict. She also felt there was such a shortage of trained nurses working in the hospitals that to take nurses away for training was a great strain. These concerns were expressed in her Official Report of 1918:

As was inevitable, a good proportion of those trained nurses who volunteered were women with sound operating theatre experience, many of whom had actually been on duty with surgical teams. New Units were opening at the Bases and the nursing staffs had to be provided and anaesthetists meant wastage in the nursing ranks. ⁴⁷

Many of the CCSs and base hospitals included wards dedicated to patients with self-inflicted wounds, another reminder of the horrors experienced by young men in the trenches. The nurses on these wards not only had to care for the physiological wounds suffered by their patients but also the psychological. On 3 August 1916 McCarthy reported ‘Left early for the Reserve Army, arriving at Resmenil Farm near Doullens, where 1/2 South Midland Casualty Clearing Station had opened an Infectious Hospital under canvas, and a certain number of huts for self-inflicted wounds’. ⁴⁸ References to other self-inflicted wound units are common throughout McCarthy’s diary entries and a constant reminder of the need for highly trained and professional nurses to care for these men. McCarthy’s strength, courage, competence and commitment to her nurses and the unrelenting organisation of nursing units in war are clear from her writings.

Conclusion

A wide search for personal information about Dame Maud McCarthy, in both Australia and the United Kingdom revealed little, however, we did find her probationer's record from The London Hospital before the First World War when her superiors described McCarthy as needing ‘more force of character … [and] she needed more moral … courage’. ³ With the benefit of hindsight, this statement could not have been more misplaced. Emma Maud McCarthy’s contribution to military nursing as a profession was profound and, after the First World War, she became Matron-in-Chief of the Territorial Army Nursing Service and retired five years later. She was appointed Dame Grand Cross (GBE) in 1918, was awarded the Royal Red Cross and Bar, Legion of Honour (Chevalier) France; Lady of Grace, St John of Jerusalem; Medaille de la Reine Elizabeth avec Croix Rouge, Belgium; Medaille Epidemies an Vermeille; American Red Cross Medal and the Florence Nightingale Medal. ² While these decorations are recognition of her work, much of her contribution to nursing was her promotion of nursing as a profession, her work to set in place what we would now call ‘advanced prior learning’ for members of the VADs who wished to become qualified nurses after the war, and the education of nurses to take on advanced practice roles such as anaesthetic nurses. She was ahead of her time in her recognition of the need for special care for men who had harmed themselves and in her support for the recognition of mental health as a nursing speciality. We do not know whether Dame Maud McCarthy ever returned to her native Australia. She died in Chelsea in London on 1 April 1949, aged 90. ²