The New Zealand Medical Service in the Great War 1914-1918
Chapter XIV. After Messines
Chapter XIV. After Messines.
After a brief period of rest the New Zealand Division came back to the line on the 12th of June taking over the trenches south of the Douve, previously held by the 3rd Australian Division. North of the Douve the 4th Australians were replaced by the 25th Division. Divisional headquarters again established its offices in Steenwerck. The enemy was cautiously withdrawing to a prepared position about a mile and a quarter in rear of his outposts; it was the Corps intention to keep close touch with this local withdrawal and to seize any outlying strong points still held in the slowly crumbling defences. The medical dispositions included the taking over of the A.D.S. at Charing Cross by the No. 2 New Zealand Field Ambulance and the opening of an M.D.S. at Nieppe by the 3rd New Zealand Field Ambulance while the 1st Field Ambulance remained at Ravelsberg. The 4th New Zealand Brigade and its ambulance passed to the command of the New Zealand Division; no changes were made on the sector held by the 4th Brigade.
A limited advance under barrage was carried out on the whole Second Army front on the 14th commencing at 7.30 p.m. In all about 145 wounded were brought in, all R.A.P.'s being reported clear by 9 a.m. on the 15th. The trench tramways through the wood and beyond were extensively used in these evaenations. A readjustment of medical positions followed this operation. No. 2 and No. 3 Field Ambulances established headquarters at the C.M.D.S. at Pont D'Achelles with Charing Cross and Underhill Farm as A.D.S.'s and the 4th Field Ambulance, shelled out of Pont de Nieppe, withdrew its M.D.S. to Nieppe with advanced dressing station at the Brewery.
During the second half of June the Division maintained an aggressive policy, treading heavily on the heels of the retiring Bavarians who were grudgingly giving up minor strong points in their forward defences. There was much artillery activity on both sides, our trench areas were subject to very heavy bombardments, and the back areas, including Baillieul, were receiving an increased page 318volume of enemy fire. Even about the A.D.S. at Charing Cross, on account of the close proximity of our batteries, there was severe shelling at times, making the work of this post a very trying service. Our daily losses in consequence, were much above the average. During the period from the 15th to the 30th of June our casualties were reported to be: 106 killed; 801 wounded; 27 missing. There was an increasing casualty list due to gas poisoning and there were clear signs of nervous exhaustion in many of the sick admitted to D.R.S. Of 414 soldiers admitted to Ravelsberg, by sickness, no less than 151 were diagnosed exhaustion; 32 neurasthenia; and 62 N.Y.D.N., the new army designation for "shell shock" which demands some explanation.
About this time medical opinion had undergone important modification in regard to the nomenclature and early diagnosis of those nervous diseases which we now know as the psychoneuroses of war. According to Lieut.-Col. Aldren Turner (B.M.J. June 10th, 1916), soldiers suffering from nervous and mental shock began to arrive in England as early as September, 1914. The cases were stated to be of three types: (1) those suffering from the effects of shell concussion; (2) men suffering from neurasthenia; (3) cases exhibiting one or other of the severe psychoses.
Early in 1915, Sir Alfred Keogh, acting on the reports of specialists, arranged that all this category of casualties should be sorted out by neurologists and pshychiatrists at base hospitals in France. Amongst the specialists, were Lieut.-Col. Aldren Turner, Physician to the National Hospital for Paralysed and Epileptics, and Lieut.-Col. Chas. Myers, Psychologist of Cambridge University. As early as February, 1915, Lieut.-Col Myers who was working at the Duchess of "Westminster's Hospital at Le Touquet, described in the Lancet (February, 1915) under the heading "Shell-Shock," certain nervous conditions in soldiers associated with loss of special senses, e.g., deaf-mutism, and narrowing of visual fields, indistinguishable from hysteria. Whereas Lieut.-Col. Aldren Turner, in detailing his three months experiences at a Base Hospital, (B.M.J., May, 1915) differentiates those suffering from shell concussion from others showing extreme neurasthenic states. Neurological centres had been established in most of the large military hospitals in England for the treatment of similar cases. Of the neurological divisions, that of No. 4 London General Hospital, known as the Maudsley Hospital, became very prominent; it was commanded by Lieut.-Col. Mott, R.A.M.C., the distinguished pathologist of the London County page 319Council Asylums' Board. The three Lettsonian lectures on the "Effects of high explosives on the central nervous system." delivered in February, 1916, before the Royal Society of Medicine by Mott, in which the lecturer demonstrated hystological changes in the brain and spinal cord in fatal cases, did much to influence army practice in nomenclature and disposal during 1916. There was, as is evidenced by the definition of shell shock given by Colonel Begg during the Somme operations, a strong bias in favour of an organic traumatic condition as the chief if not the only cause of shell shock. But, in 1917, these views were materially changed. Both French and German neurologists had attacked the problem from different angles, but in the main united in discrediting the organic traumatic basis of shell shock and in emphasising the fact that the true condition was a functional nervous disorder, hysteria, "pithiatism," arising in a premorbid personality and in every way similar to like conditions of traumatic neurasthenia, or hysteria, already recognised in civilian practice. But there was a wide divergence in methods of treatment and much confusion in nomenclature. A list of the various modes of therapy, then in vogue, reads like a page from Rabelais. There was treatment by cerebrospinal galvanism; treatment by disciplinary measures; by "Torpillage": painstaking, indefatigable, masterful, relentless pertinacity on the part of the operator, fortified by a powerful sinsusoidal current a treatment condemned by the Germans as "inhuman." There was treatment by suggestion, in hypnosis, or during light ether anesthesia. Treatment by massage and Faradism; by the administration of leicethin; treatment by lumbar puncture; treatment by psychoanalysis.
In March, 1917, Major Carmalt Jones, R.A.M.C., now Professor of Medicine at Dunedin University, read a paper at a meeting of the Second Army Medical Society at Remy Siding which was attended by officers of the N.Z.M.C. and of which the notes have been preserved by one of them. The notes succinctly outline the opinions then held by neurologists attached to the Second Army, in as much as "shell-shock" is stated to be caused by an explosion in the immediate vicinity of the patient "sufficient to knock him down." The lecturer went on to show that external or recognisable lesions were rarely demonstrable and that lesions of the nervous system probably minute, microscopic, led to exhaustion states or functional disease. Tremor, insomnia and sensory-motor changes were the symptoms most frequently met with, paresis or tics were not so common; the worst cases page 320were seen in the younger soldiers, there appeared to be a high immunity after the age of 32. The treatment advised was by encouragement and persuasion coupled with physical and workshop training. As a rule some 60 per cent were dischargable to duty. Admittedly an optimistic estimate as compared with the 40 per cent. given by contemporary German writers. We may conclude then, that the central idea of physical trauma still dominated the army concept of shell-shock. And, at Messines, cases were labelled as N.Y.D. "Shell-shock." Under the influence of the psychiatrists and psychologists changes in army opinion were taking place, and there was a growing body of opinion, both French and English, that the terminology was bad as many cases classed as shell-shock would have been better described as concussion neurasthenia, psychasthenia, hysteria or neurasthenia. That there was much confusion owing to the rapid change in the patient's condition from front to base, was evident. The fact that those wounded by high explosive were immune from shell-shock, led many to believe that the condition—whatever it was—was not related to explosion concussion in any way but that fear with gradual psychic exhaustion acting on a neuropathic individual was the predisposing cause, whereas any circumstances, quite apart from shell explosion, might determine the onset of the disorder.
Two very important monographs issued in the "Horizon" Series under the auspices of the French Service de Santé did much to remodel current views and emphasised the great importance of scrupulously avoiding any diagnostic "suggestions" inherent in the terms "commotioné" or "shell-shock." The attitude of Roussy and L'Hermite was somewhat opposed to that of Babinski; the former based their opinions on the observation of cases seen close to the firing line, the latter was strongly impressed by experiences gained at the base hospitals at a longer interval from the original "shock," "commotio," "traumatism," or "suggestion." But the divergencies of opinion in the French workers although very acute and causing many ripples in English neurological circles, were in the main unimportant to the front line surgeons, who chiefly desired to be relieved of the onus of making any expert diagnosis in these ambiguous conundrums. G.R.O., dated June 17th, 1917, introduced a new method of classification and disposal of soldiers who, "without any visible wound became non-effective from the effects of British or enemy weapons in action." The R.M.O. or the ambulance officer was not to record any diagnosis. He was to page 321enter on the field medical card the letters N.Y.D.N. (not yet diagnosed, non-efficient), and to note any known facts as to the true origin of the condition. The term "shell-shock" was on no account to be used. The responsibility for further medical examination was to rest with the A.D.M.S. concerned. If it seemed clear that the case was of such a nature as to require treatment for more than a week, transfer to a special C.C.S. was indicated; but if the soldier could be returned to duty after rest and attention in the D.R.S. the diagnosis was to be altered to some such term as "exhaustion." In July the D.M.S. Second Army directed that all cases of N.Y.D.N. should be sent to a special receiving centre, a C.C.S. where final agreement as to hospital treatment was to be decided.
The month of June ended in very hot oppressive weather with frequent thunderstorms. The enemy artillery was exceptionally active, much gas was used especially against Ploegsteert Wood; night bombing aeroplanes and long range guns raked our back areas at intervals; our balloons were frequently shelled or attacked by fighting aeroplanes. On the 28th, the Nieppe balloon which had been shelled unsuccessfully for nearly 3 hours was at last brought down in flames by a flash of lightning during a violent thunderstorm, which ended the day. A cynical Frenchman who witnessed the event from Nieppe said to one of our medical officers, "vous voyez qu'ils ont raison les Boches—le Bon Dieu est avec eux—Gott Mit una!" A welcome relief of the Division came at the end of the month, leave reopened on the 1st of July. The medical posts were taken over by the ambulances of the 4th Australian Division. Our headquarters retired to Vieux Berguin, about five miles south west of Baillieul where the tired troops were billetted in pleasant country places. The 4th Brigade Group remained under the command of the 4th Australian Division and did not leave its sector just north of the Lys.
Early in July the 3rd (N.Z.R.) Brigade and the Pioneer Battalion attended by one section of No. 3 New Zealand Field Ambulance went north to assist General Anthoine's Second French Army in digging gun positions. Many untoward delays had hampered the launching of the British coastwise offensive. Even now there was much to be done, especially in the Northern sector. The Germans wondered why we did not come on; and in the middle of July, made a stroke against the 4th Army at Lombartzyde, whereby a bridge head was lost to us. In this operation an unexpected gas shell attack caused very serious casualties because of our unpreparedness for a new and very page 322potent type of volatilised oil, called later "mustard" gas, with which the New Zealanders were to make acquaintance very shortly.
All the plans for the British Flanders Campaign were now complete: on a fifteen mile front the Second French Army, the Fifth and the Second British Armies were to attack from the Lys northwards to Steenstrate; the main thrust was to come from the Fifth Army on a front of seven and a half miles in the north of the Ypres salient; General Anthoine was to advance step by step northward of this; and to the south, our Second Army was to strike between Hollebeke and Warneton, feinting a flanking movement to the north of Lille. The IInd Anzac Corps on the right of the Second Army with the New Zealand Division on its right was to push in a south-easterly direction towards Warneton so as to make the enemy believe that a crossing of the Lys was intended. The special work of our division was to take La Basse Ville, a cluster of factories and a sugar refinery, about three-quarters of a mile south-east of Warneton on the main road from Armentières.
By the 19th of July, the New Zealand Brigades, well rested and in good fettle, were coming back to their old position in front of Ploegsteert Wood. The medical arrangements of the A.D.M.S., Colonel McGavin, D.S.O., were not markedly modified from previous dispositions. A special fortified R.A.P. was constructed in the captured German trenches about the centre of our Northern sector near the site of the cabaret "Au Chasseur," which at one time stood on the Messines-La Basse Ville road and about 1000 yards north of the last named village. The R.A.P. was called "Ultimo" from a trench name given by us to a German avenue connecting their front and supporting lines and in which the R.A.P. was situated. The avenue had been restored by us and was operable by stretcher parties. Ambulance bearers taking over wounded at "Ultimo" could carry down the avenue about one mile to the bearer relay post at Dead Horse Corner at the northern angle of the wood, which connected with the Charing Cross A.D.S. by trench tramways. The M.D.S. at Pont D Achelles, similar in all respects to that of Westhoff, provided ample accommodation and was in telephonic communication with divisional headquarters. The A.D.S. at Underhill Farm was at present little used except for local casualties. The dispositions of the 4th Field Ambulance were not altered, their M.D.S. at Nieppe in the Communal School provided accommodation for 60 stretcher cases. The car post at Motor Car Corner was still held serving Surrey page 323Farm R.A.P. about half a mile away. At the Brewery, in spite of damages to motor ambulance cars and occasional casualties to M.T.A.S.C., a large car was always on duty. The Brewery, although much exposed to observation and frequently participating in the "hate" intended for all too proximate batteries, was a convenient A.D.S. which it was usually possible to evacuate both by day and by night. With the exception of the two R.A.P.'s on the 4th Brigade front and Ultimo all the other R.A.P.'s were situated a considerable distance from the front line, which was, possibly, a disadvantage in the forthcoming operations. By this time all RA.P.'s were provided with Thomas hip splints and a much more extensive use of the Dayfield Body shields had been recommended for regimental stretcher bearers whose losses had generally been very severe in previous actions.
The allocation of medical units was as follows:—No. 1 Field Ambulance, at the D.R.S. at L'Estrade near Steenwerck which had been occupied by us in early 1916. The 2nd and 3rd Field Ambulances divided between the M.D.S. Pont D'Achelles and the A.D.S.'s at Charing Cross and Underhill Farm, supplying all R.A.P.'s with field ambulance bearers. The Dental Hospital was at de Seule not far from the Reinforcement Camp; the usual allotment of dental sections: 1 per field ambulance was adhered to. The New Zealand Dental Sections had been remodelled and had now reached their perfected organisation. The Dental Section which had been, formed in the United Kingdom to accompany the 4th Field Ambulance was a very mobile unit, all cumbersome equipment had been eliminated, with the result that two small panniers, one pack-mule load, now contained sufficient instruments and material for all operations, surgical or prosthetic. The actual space taken up in transport was only half of a half limbered G.S. cart. The Dental Hospital had also been made mobile by allotting one three-ton lorry to the purpose of its transport as required. There was no difficulty in maintaining a constant supply of expendable material as, in accordance with a contract made between the New Zealand Government and the War Office, all necessary dental equipment could be obtained from Advanced Supply Depots of medical stores. In this way all difficulties had been overcome by experience in the field and the New Zealand Dental Corps may justly claim to be the pioneers of a movement which resulted in an efficient and practical dental service for the front line troops.
At 2 a.m. on the 27th, the first attack on La Basse Villa was made, a company of 2nd Wellington entered and hold the village page 324capturing prisoners at the Moulin Carlin, the sugar refinery at the southern end, and at the Tissage at the northern end nearest to Warneton. The company withdrew before 5 a.m. leaving posts to hold the position, but shortly after that hour our posts were overwhelmed by a company of the 16th Bavarian Division who retook the village. Our casualties were 4 killed, 25 wounded, 9 missing. The wounded admitted to M.D.S. up to 1.30 p.m. were 40, and 13 gassed.
On the night of the 28th Armentières was subjected to an extraordinarily heavy bombardment with the new "Yellow Cross" gas. Shells seemed to rain into the town for many hours. A very large number of civilians were gassed in their cellars: of these unfortunates the New Zealand Stationary Hospital admitted a convoy of over 100 men, women and children. Armentières was cleared of its remaining civilians and became a city of the dead.
The final attack on La Basse Ville was timed for 3.50 a.m. on the 1st, and was to coincide with the opening of the great Flanders Campaign of 1917, whose first objectives were the ridges about Ypres as far out as Passchendaele. The task of retaking the lost village was given to the 1st New Zealand Brigade. Under the cover of a well planned and skilfully executed barrage, 1st Auckand and 2nd Wellington advanced to the attack on the extreme right of a 15 mile battle front. Two companys of 2nd Wellington penetrated the ruins, cleared the cellars and in a stiff fight lasting 50 minutes completed the capture of the village, killing most of the garrison. All the New Zealand objectives were reported by our contact planes to be secure by 5.40 a.m. and a local attack easily beaten off by rifle and machine gun fire. By 6 a.m. the wounded, mostly by passing through "Ultimo," had reached Charing Cross A.D.S. and at noon, the the tally of our wounded cleared by M.D.S. was, 29 lying and 54 sitting. The German counter attack took place in the afternoon and was accompanied by extremely heavy shelling which gave us more casualties; but, the enemy parties were easily held off by our barrages and infantry fire, although they advanced with much determination. At 5 p.m. there was a downpour of rain which continued all night. About 6 p.m. the wounded were coming in freely, carrying parties organised from Bavarian prisoners assisting. The total at this time was 149, of which 58 lying and 91 sitting. During the night the wounded continued to come down in an unbroken stream; by midnight, the total treated at Pont D'Achelles was 7 officers, 171 O.R. and 9 wounded prisoners. Information obtained from the prisoners showed that page 325La Basse Ville had been held by one company of the 29th Bavarian Regiment; there was a garrison of over 40 at the Sugar Refinery, all of whom were presumably killed in the cellars. At the north west corner of the village in a cellar under the Tissage was a forward R.A.P. The battalion medical officer was not there—he lived farther back at battalion headquarters—but a Bavarian Medical N.C.O. and some stretcher bearers had an aid post there. The regimental dressing station was in fortified cellars at Warneton and was cleared by motor ambulances to a Feld Lazaret six miles away at Bousbecque near Commines. The Bavarian medical orderly was attending to two wounded men in the cellar when our stormers arrived, several Bavarian soldiers rushed into the aid post but a New Zealander threw two bombs in at the doorway; the men inside took cover behind some boxes, the bombs did no damage. Later, one of the soldiers crept up the steps to reconnoitre, but was promptly bayoneted; the remainder wisely determined to stay below and were ultimately taken prisoner. From the prisoners we also had news of some of the missing of the 27th. One of these, seriously wounded, was carried back to the regimental dressing station at Warneton and from thence went by car to Bousbecque where in the field hospital he had his leg amputated and remained for some six days receiving all necessary attention and good treatment.
The casualties reported to the A.A. and Q.M.Q, by units of the division for the two operations at La Basse Villa were: killed, 111; wounded, 312; missing, 21: total 444. The 1st Brigade had 61 killed, 183 wounded, 5 missing. The arrangements for the evacuation of wounded worked smoothly, there was no delay at any point. Captain Goldstein, M.C., R.M.O. to 2nd Wellington had his hands full at "Ultimo", but all his wounded were safely in when he was relieved.
The first casualties caused by the new "Yellow Cross" gas were observed on the New Zealand front during the later part of July. Shells containing the so called "mustard" gas were first used in the Ypres salient on the 12th of July 1917; some 2000 casualties resulted. Ignorance as to the nature of the gas and its effects was the cause of the initial losses which were heavy: the incidence of serious cases amounting to over 12 per cent. during the July bombardments, the mortality stated to be in excess of four per cent. On the 31st July some 20 gassed cases were admitted to No. 3 New Zealand Field Ambulance. They complained chiefly of smarting of the eyes and occasionally page 326blistering of the skin where the gas had made contact. The eyelids, in severe cases, were swollen and œdematous, the conjunctiva markedly inflamed. Chemosis was frequently present; all had severe irritation and photophobia. A case admitted to No. 4 Field Ambulance gave the following history: he was a company cook, during the night a gas shell entered his kitchen; in the morning be picked up a fragment of the shell and put it in his trousers pocket as a "souvenir" of the event; some hours later, on his admission to the ambulance, he was found 10 be suffering from a severe burn of the groin, for which he had to be treated for several days. He had no other symptoms. Warnings had been issued to the division a week previously as to the nature of the new gas and its symptoms. After the bombardment at Ypres two blind shells had been collected and sent to the central laboratory for examination. They were painted blue with a yellow head and were marked near the shoulder with a yellow maltese cross. The so called "mustard" oil, di-chlor-ethyl sulphide, a heavy liquid with a boiling point above that of water, was enclosed within the shell case and atomised at the moment of contact by a small charge of high explosive. The liquid, being heavy, clung to the ground giving off vapour slowly and for some considerable time; even the small quantities which remained in shell holes and on fragments of the shells caused blistering if handled. The gas being very heavy filtered into dugouts and permeated the air for much longer periods than any other gas used. Although weak concentrations caused no immediate discomfort, yet prolonged contact produced in time serious disabling conditions. The absence of visible gas and the comparatively inoffensive odour prevented early recognition. The late onset of symptoms permitted the inhalation of the gas for long periods without noticeable effects at first; the severe respiratory complications were often delayed for from 36 to 48 hours. All these conditions combined to make "mustard" gas the most effective poisonous substance employed by the Germans in producing material casualties. Information was promptly circularised to all medical officers by the Army authorities whose experiences were now based on the investigation of bombardments in the Fifth Army area. The hypodermic injection of calcium chloride 10 per cent. was reported by Colonel Herringham to be effective in reducing the swelling of the conjunctiva and eyelids and a spray of menthol in oil for the protection of the throat and larynx was suggested. The tracheitis followed by bronchitis coming on about the second or third day soon led to pneumonia, page 327frequently with fatal results. Special instructions were issued as to the disposal of cases. The clothes of those exposed to the oil were to be removed and the whole body sponged with sodium bicarbonate solution, with which the eyes and naso-pharynx were also to be treated. The alkaline solution had a markedly sedative and neutralising effect on the gas burns and relieved irritation.
Exceptional weather conditions prevailed during the month of August. Heavy rains, cold winds and thunderstorms marked an unusual season; the low-lying forefield south of the Douve became a swamp, the trenches filled with water. All the hardships of the muddy battlefields of the Somme were reproduced, even trench foot broke out amongst the drenched trench workers. Winter precautions, including the use of rubber boots, became a necessity and solidified alcohol for fuel, and pea soup tablets were isued for use by the outposts. Everywhere there was a considerable weight of enemy bombardment, most severely felt in the front positions and attended by heavy casualties. During the first 14 days of this wretched month we had 211 killed, 941 wounded and 10 missing. Sickness claimed 1130 casualties. The divisional sick wastage rate crept up to over 10 per 1000 per week. If we add to the battle casualties our losses from disease this fortnight claims no less than 2292 soldiers lost to the division, a wastage equivalent to 20 per cent per month, or about double that recorded for the whole of the first year in France, which did not exceed 10 per cent. per month for infantry, 5.4 per cent. pioneers, engineers or artillery and 2 per cent for medical troops. The Anzac Corps was holding the flank of the salient and was taking the heaviest fire which the enemy could concentrate on what seemed to them the most dangerous point in their defences. Amongst other evidences of their activity our baths at Pont de Nieppe were rendered useless by heavy shells. The neighbourhood of the A.D.S. at Charing Cross was feverishly searched by 21 cm. howitzers. Baillieul was shelled by day and bad its share of the night bombing raids which killed many of our horses in artillery and field ambulance lines. Even Hazebrouck was subject to occasional bombardment by a naval gun firing at the phenomenal range of over 20 miles. This necessitated the hurried evacuation of the New Zealand Stationary Hospital, a step decided upon by the D.M.S. All patients were removed to hospitals in the St. Omer area. By the 10th most of the staff with the exception of 5 officers and 60 O.R. was detached for service with other medical units of the Second Army. The work of dismantling the hospital was proceeded with, all equipment was packed and ready for transport by the 14th. A new site at Wisques, near St Omer was page 328chosen for the hospital towards the end of the month, and by the first of September work had commenced in the new quarters. The New Zealand Stationary Hospital was now to become the N.Y.D.N. centre for the Second Army.
The last week in August saw a welcome relief for the division. On the 23rd the 4th Australian Division was taking over a part of our line and on the 27th the relief was completed by the 8th Division. The sorely tried troops marched to various entraining points about Baillieul, ultimately detraining in the Lumbres area, where pleasant billets in a beautiful fertile country provided a sheltered retreat for well earned rest.page break page break