The New Zealand Medical Service in the Great War 1914-1918
Chapter XVI. New Zealand L.O.C. in. 1917
Chapter XVI. New Zealand L.O.C. in. 1917.
After a few weeks rest, during which very large numbers of sick were evacuated daily to the New Zealand Stationary Hospital, the Division received orders to relieve the 21st Division and to take over ground recently held by Ist Anzac south of Passehendaele. The Divisions forming IInd Anzac Corps remained the same: the 49th, the 66th, and the New Zealand Division. By 13th November the 4th Brigade battalions were taking over the line, the remaining brigades entraining in the rest area. Command of the sector passed to the New Zealand Division on 16th November, divisional headquarters being at Chateau Ségard in a hutted camp south of Ypres; the bulk of the troops in camps situated in the neighbourhood of Poperinghe and Dickebusch. The sector of defence of 2500 yards comprising two subsectors, each held by a brigade, extended from a small stream, the Reutelbeke, some 1200 yards north of Gheluvert on the Menin road, to a road junction to Reutel a mile south of Broodseinde on the main road Passchendaele-Becelaere. On our front three spurs projected into the valley in front of Becelaere. Our posts lay across these spurs separated by valleys in which small streams ran in a south easterly direction. The southernmost spur was the most elevated, and at its eastern extremity still afforded a slender footing to German troops in the ruins of the Polderhoeck chateau. Our front line consisted of a series of shell-hole outposts, with machine guns covering the undefended intervals; the support line comprised a chain of organised localities linked up by a continuous travel trench; the reserve line, the main position, some 1200 yards from the outposts was held as a continuous line of defence. No Mans' Land was very wide; a condition of semi-open warfare existed. The weather was fine, the ground very muddy, but the sandy subsoil of the new sector was advantageous, as the mud was not so tenacious as that in the heavy clay lands about Passchendaele. In rear of the divisional front was the Polygon de Zillebeke, Polygon Wood, now a muddy pock-marked space jagged with broken tree stumps; within the wood there had been a racing track and, at the northern extremity, the Butte de Polygon, a rifle butt of unusual height—of all this the wood, the track, the Butte—only the latter remained dis-page 359tinguishable, a prominent feature in the battle landscape and a nesting place for enemy shells. Galleries driven into the Butte gave shelter to brigade headquarters of the northern sector. The approach was by a plank road which branched north from the Menin road at Burr crossroads. At Hooge on the main road, the southern brigade had its headquarters in dugouts in a large mine crater.
The evacuation of wounded from this sector hinged upon the A.D.S. at the École de Bienfaisence near the Menin gate of Ypres, an historic medical post. It was a M.D.S. during the first battle of Ypres, then an imposing quadrangle of brick buildings of handsome design and solid structure, previously used as an Industrial or Reformatory School for boys, but ever since September, 1914, as a dressing station. Lopped, maimed, and battered by three years of intermittent bombardments it still preserved a trace of its original structure and the stout cellars, now fortified and protected, continued to give shelter to the wounded and their attendants. The 3rd Field Ambulance in charge of wounded evacuations for the divisional front, took over the École, and Lieut.-Col. Hardie Neil assumed command of the bearers detached from the other ambulances. As the building was still subject to artillery fire, work was put in hand by parties of N.Z.E. assisted by N.Z.M.C. bearers in order to improve shelter, to drain the cellars which were liable to flooding, and to strengthen the vaults and dugouts. In the main cellar a well planned dressing room was furnished with every necessary for the comfort and immediate treatment of the wounded, including a liberal supply of oxygen cylinders, and it may be said that this A.D.S. realised all the ideals of perfected organisation which had been evolved during three years of position warfare. The A.D.S. served 4 R.A.P.'s each approached by duckboard walks and as a rule situated in or adjacent to the support line. The bearer relay posts were four in number; one in the southern sector, at Clapham Junction, a point of convergence of many plank walks, on the Menin road about a mile east of Hooge, where there was a detail of two medical officers and 41 O.R. N.Z.M.C.; the second bearer relay was at Hooge Tunnel half a mile ahead of the village site; a third, in the large crater at Hooge. The wounded were carried down by hand along the duckboard tracks to Hooge crater or to Westhoeck where the fourth bearer relay post was stationed at a car post, where there was a loading point for motor ambulance waggons. The route lay along the Menin pavé past Burr Cross road and Hell Fire page 360corner, to the École. The longest carry was about two miles; reserves of bearers, blankets, stretchers, dressings and comforts were kept at the bearer relay posts, of which the most important were those at Hooge Crater, and at the Westhoek Car Collecting Post. From Ypres an improvised ambulance train ran daily for the evacuation of sick and lightly wounded; the M.A.C. took the stretcher cases to M.D.S.'s about Vlamertinghe. The divisional rest station was at Wippenhoeck, a hutted camp, and was in charge of the 2nd Field Ambulance while the 4th Field Ambulance had a M.D.S. and a corps recording bureau at Dickebusch. The 1st Field Ambulance had charge of a corps scabies hospital near Remy Siding, where most of the casualty clearing stations were congregated.
Medical and surgical matters of first importance were under consideration at the close of 1917. The year had been notable for a great advance in the surgical treatment of the wounded in front line units. During the Flanders Campaign the staff and equipment of the C.C.S.'s had been doubled, each now had 24 medical officers and manned eight operating tables; the added personnel was derived from the United States Medical Service, comprising many of America's best known surgeons, and surgeons drawn from the Colonial Forces. During the rest periods of the Division, officers from our ambulances were attached to surgical teams with which they worked until recalled at the resumption of operations. In the three and a half months of fighting that followed the 31st July, the total wounded numbered 196,000; of which 60,000, or 30 per cent., were operated on under anaesthetics at the C.C.S.'s where, now, all that was necessary in decisive surgical treatment could be accomplished. The advance of military surgery during the war was an epitome of modern surgical progress since the days of Lister. First, antiseptics to combat the long forgotten suppurations of war wounds that confronted the surgeon in the early battlefields; next physiological methods of wound treatment; lastly, the surgical removal of all damaged tissues with the use of antiseptic pastes, aiming at primarily suture—all efforts at first directed to combatting infection. The next step was the improvement of methods of splinting and fixation in which the Thomas splint was pre-eminent. Lastly came the fight against shock. A study of traumatic or wound shock had been carried out during the past four months by a body of British and American workers in the First Army area; the deductions and working recommendations of this committee were rapidly disseminated throughout the Armies, and page 361the preventive provisions recommended put into immediate effect. As it had been shown that during the transport of the wounded man to A.D.S. secondary shock was prone to originate through loss of heat, certain preventive measures were adopted: a special blanket parcel, containing a waterproof sheet and blanket, was attached to each stretcher used in forward areas so that extra coverings should always be available; at the R.A.P.'s every care was to be taken that the patient was well wrapped in the blankets, having several folds disposed under him; the provision of hot drinks was enjoined wherever possible; the R.M.O. was required to ensure that adequate splinting and the greatest care in hand transportation were duly afforded; a small dose of ¼-gr. morphia was recommended as a further measure in avoiding shock by pain. The bearers of the ambulances and the regimental stretcher bearers received special instruction as to the danger of shock and as to the best means of prevention with the simple apparatus at their disposal. The first stage of treatment at the A.D.S. was to be the application of heat to the body by means of an improvised hot air bath made by conducting heated air through a tin pipe from a primus stove into a special folding of blankets; hot bottles and an abundance of hot sweetened liquids were to be used as adjuvants; sodium bicarbonate by the mouth, or 1 per cent intravenously, was to be administered with a view to checking "acidosis," then considered to be a prime factor in shock causation. Large doses of morphia were said to increase "acidosis" but a small dose of ¼-gr. was recommended, as was the intravenous transfusion of 6 per cent. gum acacia in normal saline with the object of raising the blood pressure. On all these matters special instructions were issued and the recommendations became Army Orders.
Another matter of medical importance was the increase in gas casualties. Mixtures of phosgene and mustard gas—some said a new type of gas smelling of sulphuretted hydrogen—were frequently used by the enemy artillery. On the night of the 16/17th November there was a heavy bombardment of our back areas with mixed gases, the "shoot" opened at 11 p.m. and continued until 2 a.m., not without casualties. This type of gas attack, in which there was concentration on limited areas, was now much used by the Germans and realised very material results. Special instructions were issued, the intention of which was to secure earlier evacuation of all slightly gassed men and a greater care in handling this class of casualty and their clothing, so as to minimise ill effects to the attendants.page 362
Trench foot was frequently seen in the later part of November. During the year ending 31st October, 1917, some 147 New Zealand soldiers were evacuated from the Division for trench foot. The precautions adopted during this period had comprised the use of whale oil frictions to the feet, a daily supply of dry socks and the issue of rubber boots when in the trenches; dry standings were provided as far as possible in forward positions, and hot drinks and food were regularly supplied to front line troops at night. During the coming winter Colonel Begg had determined to enforce the camphor method of prophylaxis, in use in the French army, and already very favourably commented on by the New Zealand Stationary Hospital. The new method included the issue of camphor soap for foot washing, and a camphor borax dusting powder to be used daily with the dry socks provided. The application of whale oil was to be discontinued. In order that the new method of prophylaxis—which is highly efficient against ordinary chilblains—should be well understood by all, a chiropodist from one of the ambulances was, at this time, attached to each bathing establishment, his duties being to supervise the application of the camphor soft soap and the dusting powder and, generally, to attend to any faulty conditions in the bathers' feet. At a time when regular foot inspections could not be carried out with any degree of thoroughness in the battalions, such inspection by a skilled N.Z.M.C. chiropodist was very valuable, especially so for the large detached parties in the camps away from their battalions, who were deprived of the services of the chiropodists, now permanently with the troops in front line and made responsible for the prophylaxis of trench foot. At the baths all must pass the inspection of the N.Z.M.C. chiropodist in attendance, and all had the benefit of his services. The experience of trench foot which the Division had at Passchendaele showed that the puttee was a contributing factor in causation. A contemporary divisional report on the "Lessons to be learnt from recent operations," has the following pertinent paragraph:—"Under conditions such as those prevailing on October 12th and subsequent days, it is a question whether puttees should not be left off before troops go into the line. There appears to be little doubt that the constriction of the leg caused by the contraction of the puttee contributed largely to the occurrence of trench foot, as the average puttee contracts 3½ inches in length when wet. It was frequently observed in advanced medical posts that the puttees of the wounded were very tight and that the feet were visibly swollen, even with the page 363boots on, but the men often made no complaint of pain in the legs and feet, nor had they any sense of constriction of the limbs." In spite of all precautions trench foot was much more prevalent during this winter of 1917: conditions in the outpost zone of organised shell holes were such that the nice arrangements of 1916-17 could not be ensured; nor were dry standings possible as in the well drained trenches of the Sailly sector. The number of cases of trench foot admitted during the month of December was 108, so considerable as to cause disquiet in the present sickly state of the Division.
About the time of taking over in the new sector it was noted that the divisional wastage by sickness was extraordinarily high; the mean strength was about 18,700, the sickness wastage averaged 12.8 per 1000 per week evacuated out of army area, whereas the average Second Army rate was 9.1 per 1000 per week: a very unusual rate of wastage. The other two divisions of the corps showed equally high wastage which must be attributed to hardships endured during the Passchendaele operations. Other causes operating in the New Zealand Division were:—an outbreak of rose measles traceable to reinforcements who acquired the infection at Etaples where it was endemic. A few cases had been reported in September and October, but during the rest period, in consequence of crowding in close billets and inclement weather, the disease became general, and the height of the epidemic was reached about the middle of December. Another source of wastage was scabies and the various skin diseases complicating it. Trench fever was disabling an ever increasing number, and trench foot as we have seen, helped to swell the list. The principal sources of sickness wastage on the Western Front could now be attributed to faulty personal hygiene. Of the intestinal disorders, hitherto so fruitful a source of disability in previous wars, there was little left save an occasional sporadic outbreak of dysentery during the late summer months, easily controlled and never very important as a menace to the efficiency of the armies. Far otherwise was it with P.U.O. or trench fever: always prevalent, easily contracted, and difficult to eradicate, where so many men habitually harboured the intermediate host now proved to be the louse. A most powerful waster of armies was trench fever, as it often resulted in prolonged unfitness for active service and as it could be fought only by means of the divisional cleansing stations. But the perfected ritual of personal disinfestation and the efficient cleansing of the clothing were not as yet fully elaborated, the fact that the body louse page 364frequently laid eggs on the pubic and axillary hairs was as yet not clearly apprehended by medical officers. Without complete sterilisation of all clothing, inner and outer, of all men of a unit, including their blankets and the thorough application of an ovicide to the body hairs, there could be no reasonable anticipation of total prophylaxis. The treated men mingled with and possibly shared the blankets of untreated; the onset of fever in one made the infection of the other a biological necessity as the louse abandons the infected man shortly after pyrexia develops.
Scabies, with its crippling skin infections, was another disease rife in the Division and added a considerable volume to the flow of invalids from the army area. The disease could be easily detected and the skin complications observed in the bathing establishments, but the treatment was difficult and the complications most refractory. Impetigo, furunculosis, and local abscesses or glandular infections, caused serious gaps in the fighting line; a source of wastage needing control by early segregation, efficient treatment and, again, sterilization of clothing and blankets, in this instance best carried out by means of the Clayton S.O.2 disinfectors now attached to the baths. The Army Cleansing Station had now become a key position in the conflict against parasitic invasions: Colonel Soltau is of opinion that no less than 50 per cent. of the total admissions of sick were due to diseases caused by dirt or body parasites, and were preventable by enforcing hygiene of the person and clothing, he writes: "What was wanted was more baths, more laundries, more vermin destroyers, and more adequate provisions to ensure that the soldier had the opportunity of using them."*
In spite of all preventive efforts, except in the periods of heavy fighting, the sick of the New Zealand Division and of the British armies, always outnumbered the wounded. A return of officers and O.R. pensioned in England for disabilities from the outbreak of the war to the 30th November, 1917, showed that while 43 per cent, of the total were pensioned by wounds or other injuries received while on service, 55 per cent. were discharged on pension because of disease. Preventable disease in warfare, not only does it increase the total of human sufferings and prejudice the conduct of war, but what is of greater consequence, it is productive of moral and material effects on the welfare of the race much more detrimental than those attributable to wounds honourably won in the battlefield.
* Official History of the War. Hygiene, p. 9.
General Plumer and the Second Army Headquarters went to Italy on the 20th the New Zealand Division passing into the command of the Fourth Army. Our second Christmas Day in France was exceptionally cold, snow fell in the evening. The day passed quietly except for an affair of patrols: a small party of 20 attempted to raid one of our posts, but was driven back, leaving in our hands a prisoner—a lad of 20—batman to the platoon commander. Turkeys and plum puddings were provided for the men out of the line, and there was a grand dinner followed by a concert at the divisional rest station. For the German troops there was no Christmas cheer—so our Intelligence informed us—their bread ration had been recently augmented; page 366they had to make shift with a handful of cigarettes. At midnight on the last day of the year the two Anzac Corps ceased to exist. Ist Anzac became the Australian Corps, to which all the Australian Divisions were now joined; IInd Anzac became the XXIInd Corps, General Godley still commanding, so the name coined and made famous on Gallipoli, was to die out officially in France; but the spirit that it conjured was to live on, immortal, and unconquerable.
We must now leave the Division in their winter trenches in order to glance down the New Zealand lines of communication; the longest, surely, of any British force operating on the Western Front. Our point of departure will be the travelling Medical Board which had been provided by the Division for the purpose of classifying the large numbers of category men accumulated in France during our two year's campaigning and who were employed on a variety of duties in rear of the front line: some at divisional headquarters, others at corps headquarters, some at the stationary hospital and the remainder at the base at Étaples. The Board held monthly sittings at each of these places. The usual procedure was that "C" class men were evacuated to England for repatriation to New Zealand, no "B" class were permitted to leave France, but were detailed for employment at the various points enumerated. The members of the Board, appointed in June. 1917, were: Lieut.-Col. Murray, D.S.O., N.Z.M.C., with Major Guthrie, M.C., N.Z.M.C. and Capt. W. Aitken, M.C., N.Z.M.C. The supervision of the Board was in the hands of Colonel Begg, D.D.M.S., to whom all reports were furnished. An abridged form, N.Z.M. 6 had been devised by N.Z.E.F. Headquarters in London, with the approval of the War Office, it furnished all the necessary information required and was now in use by the Board. In this way co-ordination in the important matter of classification and invaliding Boards and Pensions assessment was attempted.
The fact that the Commander-in-Chief of the N.Z.E.F. was. at the same time a British Corps Commander in France, even though dissociated from the so-called Anzac Group, did not prejudice co-ordination of administration; although seemingly an inconvenient arrangement, yet, through the capacity for work of General Godley and the harmonious cooperation of the G.O.C. in Charge Administration it proved workable and efficient. But it may be said, generally, that coordination of the medical services in France and in England, was to a certain extent prejudiced by the administrative situation. The N.Z.M.C. in England being under the direct control of the page 367D.M.S., Colonel Parkes, whereas the same force in France was under a dual control; that of the D.G.M.S., B.E.F., and the D.D.M.S., IInd Anzac, who happened to be a New Zealand officer, in close touch with the supreme command of the N.Z.E.F. and was, at the same time D.D.M.S. of the corps to which the New Zealand Division was attached and who therefore acted as the channel of communication between the A.D.M.S. Division and the D.M.S. in London.
Interchange of medical officers between the field and the United Kingdom base units, was desirable in many ways, more especially in the case of some junior officers who were hastily qualified at the outbreak of war in order to Join the Main Body and on whose behalf the University authorities in New Zealand were pressing for post graduate training in the base hospitals. Such interchange was difficult to arrange satisfactorily because of the not unnatural disinclination of the N.Z.M.C. higher staff in France to part with experienced officers, or to accept in exchange from the base senior officers who had no previous experience of field work. Promotions, at the U.K. Base were perforce influenced by professional attainments, which were of less value with the Division than war wise knowledge. The difficulties of the problem were not made any easier by the medical administrative conditions already outlined.
The New Zealand Stationary Hospital, at Wisques fully staffed, by the energy of their personnel had considerably improved the establishment by the erection of huts and an elaborate roading and drainage scheme. There were 700 beds available and a further expansion to 1000 beds was in course of completion. The class of patient admitted, now in greater numbers than ever before in the history of the unit, consisted largely of the N.Y.D.N. type, but there was also a considerable volume of admissions for P.U.O. and respiratory infections. Pending the completion of the operating theatre and X-ray room no large number of surgical cases could be admitted, but there was every prospect of completing this necessary work early in 1918. At the end of the year Lieut-Col. O'Neil, D.S.O., relinquished command of the unit, proceeding to England on duty; he was replaced by Lieut.-Col. Hand Newton, N.Z.M.C., late commanding the New Zealand Mounted Brigade Field Ambulance in Palestine.
At the base at Étaples, there were in September some 6650 New Zealand reinforcements, but in November many were temporarily held up by quarantine on account of measles; the N.Z.M.C. reinforcements, of which the divisional medical units page 368required over 50 to complete strength, were also detained for the same reason. The Stationary Hospital was able to supply 25 "A" class N.Z.M.C. for the immediate wants of the Division, and the break up of the 4th Field Ambulance, now in prospect, would provide ample personnel to meet all requirements. Major Gordon, N.Z.M.C., had replaced Lieut.-Col. Pearless, N.Z.M.C., at the French base, as S.M.O. and had on his staff two or three reinforcement medical officers.
In England the year 1917 had witnessed a great improvement in the administration of our medical services and a notable expansion and perfection of the arrangements for handling the very large numbers of our sick and wounded arriving from France. The medical headquarters in Bloomsbury Square now comprised:—the D.M.S., Colonel Parkes, C.M.G., N.Z.M.C; the A.D.M.S., Lieut.-Col. B. Myers, C.M.G., N.Z.M.C.; the D.A.D.M.S., Major McKibbin, N.Z.M.C; two junior medical officers in charge of Boards and orderly duties, and a clerical staff of 14. Miss M. Thurston, R.R.C., N.Z.A.N.S., Matron in Chief of the N.Z.E.F. had by now completely staffed all the New Zealand Hospitals with N.Z.A.N.S. and had a small reserve of nursing staffs both in England and in Egypt, some of which was employed in British units. The total strength of female staff employed with the United Kingdom medical units had been greatly increased by the substitution of V.A.D.'s and female cooks for "A" class N.Z.M.C., other ranks drafted to the ambulances in France. The changes in the hospital kitchen staffs so effected were stated to have been highly satisfactory, more especially with regard to cleanliness and economy.
A most important rectification in the methods of boarding temporarily and permanently unfit men of the N.Z.E.F. had been brought about by establishing uniformity of the procedure of Invaliding Boards, and by bringing the classifications of the Travelling Board in France into harmony with the categories in use in England. A standing Medical Board was established under the presidency of Lieut.-Col. Acland, N.Z.M.C., the consulting surgeon, who making his headquarters at No. 2 N.Z.G.H. had handed over the surgical division of No. 1 N.Z.G.H. to Major T. M. D. Stout, D.S.O., N.Z.M.C., Lieut.-Col. Acland also presided over the standing invaliding boards which were constituted at the Depots by the addition of the Commandant and the S.M.O.: the inclusion of a combatant officer as a member of the Board being considered an advantage. By these means uniformity in boarding, classification and invaliding was attained.page 369
A Discharge Depot had been established at Torquay, to which all those found to be permanently unfit, were drafted, but owing to the dearth of overseas transport, this unit, although relieving the pressure in the hospitals, was itself usually much overcrowded. During the quarter ending July 31st, 1917, no less than 599 officers and men were repatriated to New Zealand from this unit. There were two medical officers stationed at the depot, of which Captain H. A. Davies, N.Z.M.C., was S.M.O.
But it was chiefly in the general hospitals that the most important changes were evolving: with the increase in knowledge of military surgery, and the final triumph over the problem of the infected wound, attention was now being directed more particularly to specialisation. Orthopœdics, physiotherapy, plastic surgery, and psycho-therapy were becoming more widely practised and demanded an increase of medical staff with specialised training. During the first six months of the year there had been a chronic shortage of medical officers and trained N.Z.M.C. orderlies, made necessary by the demands of the 4th Field Ambulance in part, and partly by the increase in the number of medical units in England. Expansion of hospital accommodation in order to meet the greatly increased flow of casualties expected during the Flanders Campaign was the first necessity, and as the summer and autumn yielded its thousands of patients, the accommodation steadily increased, but was not, in October and November, sufficient for all New Zealand casualties, as 1500 patients had to overflow to British hospitals. On 30th November, 1917, the New Zealand hospitals accommodated 141 officers, 4441 other ranks, and there was a total of near 6000 New Zealand wounded and sick in the hospitals in England including our own; yet during that month no less than 2799 unfit men had been evacuated to New Zealand by hospital ships and by ordinary transports or direct liner. The numbers to be handled were considerable then: the total for the year exceeded 14,000 sick and wounded evacuated from France, of which 44 per cent. were invalided as permanently unfit for service, while the remainder required at least six months hospital treatment, convalescence, and training before rejoining the Division.
No. 2 New Zealand General Hospital at Walton-on-Thames had now expanded to 1530 beds, huts had taken the place of tents, the Mt. Felix Mansion had been appropriated for wards, and a new operating theatre an X-ray room and a laboratory had been erected in the grounds. A special "jaw" department under Major Pickerell, N.Z.M.C., Professor of Dental Surgery at the page 370Otago University, had been opened and was not transferred to the Queen's Hospital, Sidcup, until 1918. At Oatlands Park the limbless had been congregated and, as Roehampton Hospital for limbless was not far away, this arrangement was agreeable to the British authorities. Some attempts at reconstruction were already succeeding. Vocational workshops established by the generosity of the Red Cross Society at Oatlands Park were providing a healthy and educative occupation for the limbless, who by now were estimated to exceed 500, of whom many already repatriated to New Zealand. At the end of the year Colonel O'Neil, D.S.O., took over command at Walton from Colonel Mills, while Major G. Home, late of Brockenhurst, relieved Major Unwin, as Chief of the Surgical Division.
At No. 1 New Zealand General Hospital, Brockenhurst, under the able administration of Colonel Wylie, C.M.G., N.Z.M.C., many beneficial changes had taken place and the accommodation was much increased. A neurological centre was established at Balmer Lawn under the direction of Major Marshal McDonald, N.Z.M.C., who had acquired a wide experience of the psycho-neuroses of war and neurological conditions generally during his service with the French Army in 1916 and 1917. To this centre all "functional" cases were transferred and the results attained were attracting appreciative attention. More arresting from the surgeon's point of view, however, was the first institution of an orthopœdic department at Brockenhurst. With the great advances made in the after treatment of injuries, in which Sir Robert Jones was a pioneer, and the provision of special military orthopœdic hospitals in London, Liverpool and elsewhere, the New Zealand Hospitals were keeping step. Provision had been made by the D.M.S. for the special training in British units of New Zealand surgeons, and at Brockenhurst already there were the elements of a military orthopœdic hospital with its physio-therapy and plaster departments, splint shops and curative workshops, all of which were much perfected in 1918. But Brockenhurst had now become the orthopœdic centre of the New Zealand Medical Service in the United Kingdom. Already representations had been made to the D.G.M.S. in New Zealand to make similar provisions for the after care of the wounded, as certain medical officers returning to the Home Base were to be available for the formation of orthopœdic departments.
Consequent upon the submarine warfare and the frequent interruptions of the Havre-Southampton Ferry Service, the inward flow of patients to Brockenhurst was, at times, very irregular.page 371
Up to December, 1917, some 7862 patients had been admitted and discharged during the year, and of these, no less than 1303 came in June during the Messines rush, and 1451 during October following Passchendaele. It is stated on good authority that the wounded from Messines were being admitted at Walton within a few hours of the assault; the maximum of 1491 beds was filled within a few days and the excessive work thus entailed in both hospitals caused severe strain on the staff. Owing to the exclusion of British wounded from our two large general hospitals and the fact that they served one division only, at times in a quiet sector, at times engaged in costly fighting, the admissions were so irregular as to necessitate breathless spells of work during active operations and comparative inactivity at other times. But the policy of having our own hospitals justified itself for administrative reasons as well as for the added comforts it provided for our men, to whom a New Zealand Hospital seemed more like home.
At the Convalescent Hospital, at Hornchurch, which now had a capacity of 1,900 beds a very complete Physio-Therapy Department had been established under the direction of two medical officers and a staff of 18 masseuses and masseurs. No less than 30 massage couches were available, with whirlpool baths, mechanotherapy apparatus, radiant heat and light baths, all accommodated in suitable quarters where 400 cases could receive treatment daily. The Y.M.C.A. had also fitted up vocational workshops, wherein a variety of useful crafts were taught. Owing to the growing shortage of foodstuffs in England a small area of land about Hornchurch was put under intensive cultivation for vegetable growing and some attempt was made both here and at the other hospitals to rear domestic animals, pigs, fowls and rabbits, whereby to increase the daily rations.
In the Salisbury Plain group of units No. 3 New Zealand General Hospital, at Codford, was so remote from the ordinary routes of evacuations from France and had so few beds—which hardly sufficed for our own and the British sick of the immediate district—that it had no admissions by convoy. Much representation to Southern Command had so far failed in increasing the hutted accommodation so as to make the complement of beds up to 500. Attached to this hospital was the Venereal Disease Section, a very important department which, as it was a Detention Hospital, enclosed in barbed wire and supplied with a guard, had been at first attached to the Command Depot for rations and discipline. Admissions varied between 30 and 50 a week, the page 372proportion of infection being 77 per cent. gonorrhoea, and 22 per cent syphillis. Major Falconer Brown, N.Z.M.C. still in charge, was visited early in the Summer by Colonel Harrison, R.A.M.C. of Rochester Row, and by this officer's recommendations, certain necessary improvements were effectuated; the section was attached to No. 3 New Zealand General Hospital, the staff and accommodation were increased, and the Syphilis Case Sheet, A.F.I. 1238 was introduced into general use in the N.Z.E.F. Colonel Harrison had expressed his entire satisfaction with the methods of treatment in use—which were based on the Rochester Row technique—and with the prophylactic measures which we had adopted in England. For the first six months of the year 1138 cases of venereal disease had been admitted, of which only 223 came from France—50 per cent. of the infection, acquired in England originated in London. Prophylactics were on sale at all New Zealand canteens at a nominal cost, and ablution rooms were provided in each unit; men were warned, as far as possible, of the dangers of infection and the methods of prevention; but practically all cases admitted with disease had failed to use either preventatives or the ablution rooms. At the end of the year there were 400 patients in the venereal section with 200 convalescents attached. Approximately 3600 men per annum of the N.Z.E.F. were infected and required treatment, and about two per cent. of the strength in England and a less proportion in France were constantly sick by venereal disease. This was not a very high percentage, but sufficient to warrant strong efforts directed to reduction. The estimated loss to the State by this wastage was stated to be £70,000 a year.
At the Command Depot, numbering some 2000 men on the strength, Major Bernau, N.Z.M.C. had replaced Lieut.-Col. Pearless, N.Z.M.C. as S.M.O. Additional medical officers were now attached and under Major Bernau's direction classification was brought to a closer discrimination. By means of a card system, each man's status and an epitome of his history was recorded, which simplified the sorting process considerably. The opening of the Discharge Depot had relieved this unit of a congestion of "C" class men, which was very desirable. Physical training was now energised and having in view a possible shortage in man power, a vigorous campaign of combing out was initiated.
At the Infantry Base Training Depot at Sling, there was usually over a brigade strength in four battalions corresponding to the territorial regiments in France. The Rifle Brigade section, 2000 strong was moving towards the end of 1917 into a separate camp page 373at Brocton near Rugeley. At Sling the medical staff comprised the S.M.O., Major Hoskins, N.Z.M.C., and four junior officers, each attached to a battalion as R.M.O. As the N.Z.M.C. reinforcement medical officers reported here on landing there was no shortage of medical officers as a rule. The health of the troops in this, a model camp, was always satisfactory; the site was well chosen, the disposition of the hutments and the roading excellent, while all modern sanitary requirements were provided for. The Dental Clinic was fully staffed, and busy, but found that they were less overworked as the year went on, and a higher grade of dental efficiency became noticeable amongst the recruits. But some deterioration in the standard of fitness and the training of reinforcements was already manifest. Certain classes of undesirable recruits were only too frequently arriving with each draft that came from New Zealand: those presenting pre-enlistment disabilities, such as defects of the feet or hernia, and others whose eye defects were such that they could not satisfy the Army Council requirements of visual acuity, more especially men who had lost the use of one eye. Both these types of recruit were, perforce, repatriated to New Zealand as they could not be sent on active service, and the number of unfit available for light duties at the base was already over great. The dangers of over recruiting, now thoroughly appreciated in France and England, were not as yet fully realised in New Zealand. Serious economic loss was incurred by displacing this type of man from his employment and by drafting him overseas at great expense, only to have him returned, unfit, pensionable, and for a time cut of employment.
Reinforcements for the N.Z.M.C. had heretofore been concentrated at Sling where there were few facilities for training, but in October it was decided to transfer them to a special depot established at Eweshot in part of the hutted camp occupied by the N.Z.F.A. Reserves. At its inception, the N.Z.M.C. Depot had a strength of 2 officers, 77 O.R. Major A. V. Short, M.C., N.Z.M.C., late D.A.DM.S of the Division was the first commandant; an admirable choice, as this distinguished young officer had gained a very wide and varied experience during his three years continuous service in the field His syllabus of training and his methods of instruction, more especially his insistence on hospital training and concentration on gas defensive measures, and the best methods of protecting medical aid posts against artillery fire, made the course both novel and eminently practical. To the Cambridge Hospital at Aldershot, nearby, he sent his orderlies in rotation page 374for instruction for a period of two months, while the remainder were trained in such operations as were of most importance in the ambulances. The work of the depot attracted considerable attention and much favourable comment. At the end of the year, Major Izard, N.Z.M.C. replaced Major Short, who returned to New Zealand on duty, only to perish during the great influenza epidemic of 1918. By his untimely death, we lost one of the best and most highly trained young officer of our Corps.
Through the generosity of Mr. and Mrs. C. A. Knight, a New Zealand Officers' Convalescent Home had been established at the end of 1915, which was at first controlled by Matron Reynolds, N.Z.A.N.S., but with increasing needs, the establishment was so enlarged in 1917, as to accommodate 40 officers. A medical officer, Major Bernau, was placed in charge of the home, and was succeeded, later, by Captain Chisholm, N.Z.M.C.
In all our hospitals and depots, luxurious recreation halls, clubs and canteens provided with billiard tables, cinemas, and a variety of other means of amusement had been provided by the New Zealand Y.M.C.A. and the New Zealand War Contingent Association, whose staffs of voluntary workers, both ladies and gentlemen, bent every kindly effort towards the task of comforting and helping the sick and wounded with unfailing energy and sympathy. Of special worth was the venture of the War Contingent Association in establishing a hostel in London where men on leave from France could find a home and live under agreeable conditions at a nominal cost. In this work, the administrative capacity and energising activities of a New Zealand gentleman, Mr. Robert Nolan, C.B.E., were always manifest and bore excellent fruits.*
* The late Sir Robert Nolan. K.B.E.
The Maheno. the first to be commissioned, had accommodation for over 400 patients, the Marama the larger of the two, carried as many as 565 patients in July and August, 1917, through the Panama Canal. As this hospital ship was the last to arrive in New Zealand in 1917, we may recall briefly the salient events of this her 5th commission, as the voyage and her operations were typical of other commissions of the New Zealand hospital ships. Under the command of Lieut.-Col. Percy Cook, N.Z.M.C.—the master being Captain McLean—the Marama sailed from New Zealand on 22nd September, 1917, reaching Albany on 3rd October and called at Capetown on the 20th where 18 officers, 2 Q.U.A.I.M.N.S. and 480 O.R., British sick and wounded, were embarked for English ports. The medical staff on board consisted of 6 officers; 1 adjutant and quartermaster; a dental officer; and 76 O.R., N.Z.M.C. To this complement eight R.A.M.C. orderlies were added to assist with a draft of 50 mental cases embarked and who required close attention. Leaving the Cape on the 24th October, Avonmouth was reached without mishap on the 11th of November. Disembarkation was completed in some four and a half hours which was considered to be slow. Ten days later the New Zealand patients were coming aboard: 23 officers, 2 N.Z.A.N.S., and 522 O.R.; the ship sailing at 10 p.m. on the same day. Colon was sighted on the 5th of December; here representatives of the American Red Cross Society, officers of the Civil and Military Departments and sympathetic friends visited the ship and made arrangements for the entertainment of such of the patients as were fit to go ashore. Many gifts were distributed to the cot cases remaining and the most generous and enthusiastic hospitality was dispensed by the U.S. colony. At Balboa the British Ambassador, Sir Claude Mallet and Lady Mallet, with officials of the Panamanian Republic and the Canal Zone, visited the ship; the up patients were motored to the Soldiers' Club at Panama and much goodwill and expressions of practical sympathy were everywhere manifest. Laden with gifts of all kinds the Marama steamed out into the Pacific and, calling at lonely Pitcairn Island, finally reached Auckland Harbour on December 28th. 1917. It was at this time customary for hospital ships and transports to anchor off Rangitoto for some hours prior to disembarkation at the wharf at Auckland. During this interval important adminis-page 376trative arrangements were completed. A medical board, including a representative of the Director of Military Hospitals, examined all the patients, the process taking some six hours to complete, during which time the Base Records, Pay Department, and the Returned Soldiers Information Department dealt with each patient in turn. Representatives of the local civil and military authoriites were also present, with a certain number of voluntary workers: in all some 50 to 100 officials and workers boarded the ship at the anchorage. Berthed at the wharf the ship had a civic reception, following which the patients for Auckland, numbering 185, were disembarked. The Director of Military Hospitals, duly warned beforehand, had made all necessary arrangements for the reception of those soldiers who required hospital treatment. The next-of-kin of the more serious cases had, in every instance, received railway passes from their homes to the port and were in attendance to welcome their relatives on arrival. A fleet of motor ambulances and cars owned by private citizens, conveyed the disembarking patients to their homes, the hospital or the ambulance train in waiting. At the other ports of call, disembarkation arrangements were similar: at Wellington; at Lyttelton, where the Marama was visited by His Excellency the Governor, Lord Liverpool; and at the final port, namely, Port Chalmers, which the Marama reached on January 1st 1918, the voyage having lasted 100 days, during which the ship had transported over 1000 patients. The Maheno commanded by the Hon. Colonel Collins, C.M.G., leaving England in December, and carrying 410 patients, was due to arrive in New Zealand just one month later. Over her long lines of communication New Zealand was transporting her soldiers at a net average cost of 14/1 per ton, including hospital ships whereas the B.E.F. rate paid by Australia was 15/2 and the rate paid by the United States 'under her charters was £1 12s. 2d. per ton; and again the liability of the New Zealand Government, in the event of loss of a vessel, was less by 16 per cent. than under Imperial charters, so that the Dominion could claim not only the longest lines of communication of any British force engaged in the Great War, but could also boast of the cheapest rates of transportation.
By the end of the year, 1917, New Zealand had despatched to overseas forces in all, 88,221 soldiers, of whom 11,487 had been killed or had died as the result of sickness or accidental injuries and 14,141 had returned to New Zealand. Of the returned soldiers, 11,675 had been discharged from the service and of this number 1,167 had been found unfit on arrival at overseas bases page 377and had not reached the firing line; while 62,692 remained with the Expeditionary Force. Recruiting was now on a compulsory basis. The Reserve constituted in 1916 by the Military Service Act comprised two divisions of which the first included men of military age from 20 to 46 who were:—(1) unmarried; (2) widowers or married men whose marriage had been dissolved by separation order or otherwise and who had no children under 16 years of age; and (3) married men whose marriage took place subsequently to 1st May, 1915, except such as had children under 16 years by a previous marriage. The 1st Division was to be called up prior to the summoning of the 2nd Division. For the purpose of examining the recruits called up in regulated quota, by ballot, recruiting medical boards were formed in each military district with certain special medical travelling boards whose duties were to examine those recruits who had appealed against the decision of the recruiting boards. The appointments to the recruiting boards were wholetime and for the duration of the war, with the rank and pay—at Expeditionary Force rates,—of a lieut.-col. in the N.Z.M.C. Medical officers were posted to military districts remote from their normal place of abode and practice so that the public might be assured of complete impartiality. A Board consisted of 2 medical officers with a dental officer, an attesting officer of combatant rank, a senior N.C.O., two clerks and an orderly. The Boards sat in various area groups in rotation and were expected to examine from 40 to 50 recruits per working day. The categories of classification were as follows:—"A": fit for active service overseas; "B": fit for active service overseas after prescribed medical, surgical, or dental treatment to be carried out in camp; "B2.": as for "Bl"' except that the treatment required to make such men fit was to be carried out in their own homes or district hospitals; 'C1": likely to be fit for active service overseas after special' training; "C2.": unfit for service overseas but fit for home service; "D": permanently unfit for military service. Classes "A" and "B," or "B2." were considered acceptable for service and were recruited; "C1." class had special treatment as will be seen later. The 1st Division ballots were completed on November 18th, 1917; the Division—now exhausted—comprised 82,974 men at the time of the first ballot held at the end of 1916, but the number of reservists actually called up in 1917 was 76,567. Many had voluntarily enlisted. From the 1st of July, 1917, until the exhaustion of the 1st Division, 30,404 were medically examined with the result that 12,556 were accepted—of which 9,806 "A"page 378 class; the remainder "B" or "Cl"; and 17,184 were rejected. The chief causes of rejection in order of frequency being: diseases of the heart, defects of the lower extremity, defects of vision, varicosity of veins, hernia, defects of the upper extremity, impaired constitution, diseases of the ears, flat foot. The proportion of recruits, accepted for service was 41.4 per cent. the rejected were 58.6 per cent. Apart from the general concern expressed at the low rate of acceptability of the recruits, the working of the permanent medical boards appeared to give satisfaction in spite of the fact that appeals were numerous. The proportion of unfit amongst the recruits is easily accounted for by the fact that this class of the male population had already contributed many of its best men by voluntary enlistment.
The environment of the two large reinforcement camps was vastly improved: the new camp at Featherston was well planned and gave hutted accommodation to 7000 troops under the most favourable conditions, while Trentham had restricted its population to 3000, and in both camps, which now represented a capital value of half a million pounds, good roading, drainage, and cheerful Institutes made for greater comfort: while a certain attractiveness had been added by the cultivation of gardens and ornamental grounds, mainly about the vicinity of the camp hospitals. In marked contrast to previous years, the health of the reinforcements in training during 1917, had been excellent: in all, some 36,191 men had passed through the camps—the average population being about 10,000—and there had been 4,104 admissions to hospitals, giving a constantly sick rate of 12.49 per 1000 per annum, as against 19.59 in 1916; a rate comparing very favourably with that of the British army in 1913, which was 23.53 per 1000. The deaths from all causes numbered 30. A mortality rate of 1.2 per 1000 for the total reinforcements, or, more closely computed, as far as is possible with a floating population, 3.8 per thousand of the mean strength, a rate considerably lower than that of civilian adults of a like age. A most gratifying success had attended the persevering efforts of the sanitary officers: epidemic diseases had been wiped out of the camps; only 14 admissions for pneumonia had been recorded as against 91 in the previous year; and 13 cases of cerebro-spinal meningitis as compared with 107 in 1916, when the total admissions by infectious diseases numbered 1,574, whereas in 1917, they had fallen to 62. The chief difficulties encountered in previous years had been the susceptibility of the incoming recruits, and the rapid spread of catarrhal infections amongst page 379what was, to a great extent, a country population with low immunities. The proneness of the newly arrived to acquire nasopharyngeal infection, measles, pneumonia, and cerebro-spinal meningitis, during the early weeks of camp life had been noted, and formed the special crux of the problem of prevention.
The preventive measures adopted to meet the danger were no less thorough and drastic than they were ultimately successful. The most important precaution was the segregation of all new recruits in special encampments for a full month of quarantine prior to admission to the training section. A Spartan simplicity and rigour was enforced in the segregation camps where the men were sheltered in I.P. tents with floor boards and boarded sides—a type of tent much more familiar to the bushman than the circular tent—and the number of inmates in each tent was jealously limited. The canteens and institutes were "open air" in type, and as the A.D.M.S. Sanitary, Lieut.-Col. McGill, N.Z.M.C. says in his report, "there were no snug retreats." The camp site was roaded and drained and divided into quarters; drying rooms were provided; but there was little protection against high winds save such as was afforded by fences built of manuka scrub. Above all, the absence of closed canteens and institutes, where infections could be disseminated in crowded overheated rooms, and the refusal of all leave to the isolates were measures deemed to be the key notes of the scheme of prevention. During the four weeks of probation—a period sufficient to cover all possible incubations—the new arrival was subjected to a careful bacteriological investigation of his naso-pharynx by throat swabbing and cultural examination. All carriers were, in this way, detected on arrival. The regular use of zinc chloride spray inhalation chambers by all, with special care for those who showed any disorder of the naso-pharynx, and prompt segregation of the carriers of any suspicious or abnormal organism, was the second step taken to rid the camp of the winter plagues. Further, the period of quarantine was put to good use for the purposes of vaccination against small pox, immunisation by T.A.B. and dental treatment, so that by the time the recruit passed from this purgatory into training he was free from the pupillary cares of the medical officer.
In the camps a very efficient sanitary service existed; an area of one mile radius from the camp centre was under military sanitary control, which included visits of inspection to the civilian houses and farms in the prescribed area. All civilians working in camp were subject to throat swabbings page 380and frequent medical inspection. The outgoing drafts were examined by swabs for carriers and passed through the inhalation chambers prior to embarkation, the average time consumed being five hours for 1000 men. All patients admitted to the camp hospitals had a prophylactic injection of antimeningococcal serum which, associated with the fact that none of the patients developed the disease as a complication, as was very frequently the case in 1916, seemed to warrant the satisfaction expressed by medical officers in this procedure. So that, in every way possible, all that had been learnt during the previous years of camp epidemics, was now applied in the form of preventive measures in which the medical staff had reason to place full confidence. The V.D. rate in the camps in New Zealand was not high: for 1917 it averaged 3.4 per cent. per annum, whereas the average in peace for the British army in England had been about 50 per thousand per annum and double that rate in Egypt. No prophylactics were on sale or issue, but ablution rooms were provided in the camps.
It has been noted that men in category "Cl" were accepted for military service in New Zealand. In order to fit these men for general training, a special "C1." camp was established at Tauherenikau near Featherston. The course of graduated training lasted for from four to six weeks, and was conducted by a special staff of P.T. instructors under the supervision of the medical officers. The results of this graduated training were fairly satisfactory; at the end of the course some 46 per cent. of the men were improved to "A" class and passed to the reinforcement camps, the remainder discharged to lower categories.*
* But many were rejected for service in France after arrival in the United Kingdom.
The system of dual control shared by the Public Health Department and the Defence Department in the case of sick and wounded although still in operation, was not satisfactory; it led to duplication of work, some confusion, and above all, to a serious lack of discipline amongst the military patients of civilian institutions. But already the Minister of Defence, Sir James Allen, was moving to have this anomaly remedied as he realised that the care of the sick and wounded of the Expeditionary Force was essentially a function of the Defence Department alone.