Medical Services in New Zealand and The Pacific
VI: Special Conditions in Naval War Medicine
VI: Special Conditions in Naval War Medicine
Conditions meriting special comment by reason of their general incidence or their effect on the invaliding rates are:
Neuro-psychiatric and Mental Disorders
Smallpox: Three cases of smallpox, two of them fatal and the other very severe, occurred among New Zealand naval personnel during the war. Two of these cases were contracted in Bombay and the third in Ceylon, and while this disease may be regarded as one of the special risks of service in such areas, the severity of the three cases raises questions as to the efficiency of the protective vaccination.
Naval regulations in force at the outbreak of war required all personnel to be vaccinated on entry and re-vaccinated every five years. On certain stations re-vaccination was required every three years, a period which was later laid down as applicable for all page 186 stations. The scratch method was almost universally employed, and where no reaction was obtained it was obligatory to repeat the process in fourteen days.
As the civil population of New Zealand makes little use of vaccination except in outbreaks of smallpox or for the requirements of travel, it was rare to find recruits who had been previously vaccinated. Despite this lack of immunity, records of the period 1937–41 show a high proportion of failed vaccination and a very low incidence of constitutional reactions. Looking back, it seems probable that these results were due in part to minor errors in technique and in the observation and recording of reactions, and to the use of lymph which had suffered from inadequate stowage.
The first case of smallpox occurred in December 1940 in a rating from HMS Leander at the close of a three-weeks' refit period spent in Bombay, where the ship's company lived in camp ashore and enjoyed a considerable amount of shore leave. This patient, previously vaccinated on entry in 1938 in New Zealand, contracted very severe smallpox but made a good recovery following treatment in the local hospital for infectious diseases. The ship was under sailing orders when this case was first discovered. Fresh lymph was immediately obtained from the Government Laboratory of Bombay, and re-vaccination of the whole ship's company was carried out by her own medical officers without delaying her departure. No further cases developed and the ship remained fully operational, receiving free pratique at her next port. The matter might have been regarded as merely of passing interest but for the fact that the type and intensity of reactions were in such marked contrast to those noted in New Zealand. Again the scratch method had been employed, but there was no single instance of failure even in the case of senior Royal Navy personnel who had been vaccinated many times previously. Out of the 620 men vaccinated, 48 developed severe constitutional reactions necessitating periods of two to six days on the sick list, all of those so affected being New Zealanders.
As a result of this experience, vaccination in the training establishments in New Zealand was subsequently pursued with extreme thoroughness and under careful observation, and it is noteworthy that recorded failures became practically non-existent, though executive officers sometimes complained of the interference with training resulting from the reactions.
Meanwhile in May 1941 the second case, which proved fatal, occurred in a rating on passage from New Zealand to the Mediterranean who was awaiting onward transport in Bombay. He had been vaccinated in New Zealand in October 1940 with a minor reaction only.page 187
The third case, also fatal, occurred in Ceylon in 1944. The victim in this case had been serving on loan to the Royal Navy since November 1939, and his vaccination history subsequent to the original New Zealand vaccination of October 1939 is not known.
Other Major Infectious Diseases: The incidence of other major infectious diseases was confined to a few sporadic cases as under:
Cerebro-spinal meningitis: One fatal case in Auckland in 1941.
Poliomyelitis: Five separate cases, all contracted outside New Zealand from different war areas, and not associated with any common epidemic.
Common Infectious Diseases: Sporadic cases of infectious disease sometimes occurred among new entries in the training establishments, but with the exception of one short outbreak of influenza in the Tamaki in 1942, involving seventy cases, none of these reached epidemic proportions.
In the sea-going ships, risk of infection occurred when crews rejoined after dispersal throughout the country on periods of leave. Where men were known to come from infected homes, prompt isolation could reduce the risk, but most of the outbreaks started in men who were unable to give any very clear history of infection. Despite the difficulties of control and isolation in crowded ships, most of the outbreaks of measles, rubella, and mumps were confined to a few cases. One outbreak of mumps in the Achilles in 1944, immediately after recommissioning in England, reached a total of sixty cases, and one in the Gambia, which broke out at sea after a leave period in New Zealand early in 1945, affected 101 out of her total complement of 820. In this outbreak twenty-three cases developed orchitis, twelve of them with testicular atrophy, and one of the group subsequently developed encephalitis which necessitated invaliding.
During 1942, when mild influenza was prevalent in New Zealand, the Achilles, Leander and Monowai all experienced outbreaks following visits to Auckland. In the Achilles the disease, though of a mild nature, involved 160 of her total complement of 652, the cases occurring in two distinct waves at different periods of that year.
While serving in the East Indies in the latter part of 1944 the Achilles had twenty-four cases of dengue fever, and in the middle of 1945 the Gambia, serving with the British Pacific Fleet, reported sixteen cases of a typical virus pneumonia, which was at that time prevalent in other ships of that force.
As far as the Navy was concerned, malaria was almost entirely limited to shore-based personnel and those engaged in combined operations, though long periods of employment in the Indian Ocean and the South-west Pacific exposed New Zealand ships to the risk of this disease in many of their bases and fuelling ports.
In the cruisers, where control was maintained by the limitation of night leave and by lying well offshore at anchorage, the disease was practically non-existent, only four cases being reported during the whole of the war. All of these occurred in ratings who had been forced to remain ashore with inadequate protection. For example, two cases from the Leander in 1941 occurred in the aircraft's crew who had been compelled to spend a night in a jungle swamp in the interior of Ceylon after a crash landing which destroyed their medical equipment. Somewhat similar circumstances account for the remaining single cases from the Leander and Achilles.
The smaller ships of the 25th AS/MS Flotilla, which had necessarily to make closer and more constant shore contacts, reported thirteen cases in eighteen months, but the majority of the known total of 106 cases occurred in shore-based personnel living under conditions comparable to those of the Army in West Africa, India, Ceylon and the South-west Pacific. This figure does not represent the total incidence of malaria as there were probably other cases occurring during Royal Navy service not recorded in New Zealand.
For some years before the war and prior to the introduction of X-ray examinations at entry, an overall rate of two cases per thousand per annum had been recorded by the Royal Navy, an incidence considerably higher than that of the Army and the Royal Air Force. Rates varied on different stations, being generally higher in the tropical areas served by the East Indies and China Squadrons. From the inception of the New Zealand Division of the Royal Navy, the local incidence had caused no particular concern until just before the war, when between August 1937 and July 1939 seven cases occurred in the Achilles and one in the Leander, equally divided between New Zealand and Imperial personnel. Certain suggestions for the better ventilation of living and working spaces in these ships could not be put into effect owing to the outbreak of hostilities and the employment of the cruisers on active operations with increased complements.
In May 1940 all personnel in the Achilles underwent X-ray examination of the chest, but the exigencies of war service did not permit this to be done in the Leander before November 1941. From the end page 189 of 1940 this examination was part of the standard naval recruiting procedure and was employed to an ever-increasing extent in the investigation of suspects. Unless gross signs of disease were present, a medical officer in a ship was faced with very great difficulties in the detection of pulmonary tuberculosis. Auscultation of a chest is almost impossible at sea and is hardly better in harbour owing to the constant vibration and transmitted sounds from dynamos and other essential machinery. Without facilities for immediate chest X-ray, a careful study of weight records and the closest observation of cases showing otherwise inexplicable decline of health were often the principal means available for the recognition of cases.
The results of the first complete X-ray examination in these two ships is of interest:
HMNZS Achilles. May 1940. Complement 616. (No further cases had been detected clinically since July 1939.) Twenty-seven X-ray suspects were examined by a special medical board including the Tuberculosis Officer of Auckland Hospital. Six of these (3 RN and 3 ratings), classed as active, were admitted to hospital and invalided from the Service. Seven were kept under close observation and subjected to repeated examinations over a lengthy period. Of these, one developed active tuberculosis in 1941, another in 1943, while five remained clear. The other fourteen X-ray suspects were passed as fit by the special board.
HMNZS Leander. November 1941. Complement 628. (Three cases, all New Zealanders, had been detected clinically and invalided since the outbreak of war.) Nineteen X-ray suspects were examined by a similar special Medical Board. Six (2 RN and 4 NZ) were classed as active and invalided. Four were kept under observation, one of them subsequently becoming active. The remaining nine cases were passed as fit.
From 1 September 1939 to 31 December 1946, the total number of cases of pulmonary tuberculosis in male personnel of the RNZN was 117, representing an average annual incidence of 2·7 per thousand. This figure comprises cases of all grades of severity, and includes a number without obvious clinical signs who were picked up radiologically on demobilisation. It covers all New Zealand naval personnel wherever they served, and includes six Royal Navy personnel serving on loan. Thirty cases, including the eighteen already described as detected in the cruisers in the early months of the war, occurred in men who had not been previously X-rayed. Most of these were discovered at comparatively early stages in their war service as X-ray facilities became available in New Zealand and abroad. Forty of the total of 117 were diagnosed or suspected on page 190 symptoms, and confirmed radiologically, while in seventy-seven the X-ray report was the first indication of any abnormality.
The age groups of these cases are as under:
The fact that 87 of 117 cases occurred in men whose X-rays had been clear on entry, and that those cases included some of the most severe and extensive lesions, indicates that too much reliance should not be placed on initial X-ray examination as a means of reducing the naval incidence. The conditions of shipboard life still render it necessary to keep the closest watch for any signs or symptoms which might point to tuberculosis. Early recognition and segregation of suspects is essential and it would seem desirable to repeat the X-ray examination of all personnel at least every two years.
A careful study of the cases occurring in continuous service personnel of the RNZN before and during the war has produced one point which may prove of some value. These cases developed in different ships, in different parts of the world and at different dates and at first sight appear to be unrelated, but in a significantly large number there have been common factors in membership of the same initial training classes. The number of instances in which such grouping can be demonstrated is more than can be explained away as mere coincidence, and bearing in mind that this early training period involved closer common contacts than in any other subsequent period of naval service, it is suggested that some of these groups contained individuals from whom infection was spread. It has not been possible to analyse in the same manner cases occurring in reservists and in personnel entered for hostilities only, but the evidence would seem to justify increased efforts to check the introduction of infection at this likely source.
The return to peace and the resumption of long preliminary training courses before draft to sea afford an opportunity for closer observation of new entries, repeated clinical and radiological examinations and possibly Mantoux testing, which might lead to a marked reduction in the incidence of pulmonary tuberculosis in the Navy.1
The period of the war coincided with an era of improved and simplified treatment, which reduced the medical problem in a remarkable degree but did not diminish the administrative difficulties arising from high rates of incidence in a fighting service. Formerly, treatment involved lengthy periods off duty, a considerable amount of hospitalisation, and a high ratio of invaliding for permanent disabilities. Sulpha drugs had come into use in the Navy for the routine treatment of gonorrhoea shortly before the war and were employed in their various forms until penicillin became available. These chemotherapeutic agents resulted in shortened periods of treatment, a marked diminution in complications, and a reduction in the invaliding ratio to almost negligible proportions. Only nine cases were invalided for the sequelae of syphilis or for gonococcal arthritis, and in all of them the original infection had antedated the modern standard treatments.
In ships carrying medical officers, where the appropriate treatment could be given under proper supervision, most cases could be dealt with while still remaining at duty, but in small ships the occurrence of a case of venereal disease necessitated drafting to shore for treatment and the provision of a relief. Similarly, cases in shore establishments had to be retained under the care of medical officers, and were not available for draft to sea or for employment in outlying stations. Apart from the necessity for making special provision for treatment and the time and cost involved, it may be said that the administrative, disciplinary and drafting problems arising out of venereal disease caused more concern than the actual medical management of the cases.
Records covering the six-year period from 1 October 1939 to 30 September 1945, from shore establishments in New Zealand and all RNZN ships whether employed at home or abroad, but excluding personnel serving with the Royal Navy, show the incidence of venereal disease as follows:
|Number of fresh cases:|
|Average strength of force reported on||4372|
|Average annual cases||156|
|Rate per thousand per annum||35.6|
The rate of incidence showed a steady drop through the six years from an initial figure of 83·9 per thousand to 20·8 per thousand, a gratifying improvement for which a multiplicity of factors is responsible. The rates in sea-going ships naturally varied with the opportunities of shore contact, but it must be admitted that the unenviable reputation of some New Zealand base ports was fully sustained, and that local sources were responsible for almost as much infection as places abroad.
On the one hand, educational campaigns by medical officers in training establishments and in the service afloat probably played some part in reducing the incidence. The frank and open discussion of the problem in the press at various times was of value, and, in Auckland particularly, credit must be given to the efforts of the Health Department and police to control infected women. Another important factor which cannot be over-stressed was the provision of decent recreational facilities for naval ratings in their bases at home and abroad. Without such provision, the extent of which varied considerably in different ports, ratings were compelled to spend their off-duty time roaming the streets in search of amusement and entertainment. The position was particularly bad in Auckland in 1940 and 1941, when the base offered nothing better than a very inadequate canteen, but the subsequent provision of a cinema, recreational huts, library, a good canteen, and the restoration of playing fields which had been lost in the rebuilding of the barracks, left little room for complaint.
On the other hand, it is probable that the improved rates are partly due to better prophylaxis, though there is no means of assessing the proportion of potentially infected persons who adopt precautions or the efficiency with which they are used. In ships, ablution chambers were probably of very limited value owing to the time lag when night leave was given, and for most of the war greater reliance was placed on the issue of condoms. Prophylaxis by the method of Joses, as quoted in the Medical Research Council Memorandum No. 10 (1943), was carried out experimentally in the Gambia from February 1944 to June 1945 with considerable success. In this method a total of 6 grammes of sulphathiazole was administered in three doses on the day following exposure. Of 597 men reporting for this treatment, only one developed gonorrhoea and one a non-specific urethritis. In the same period nineteen cases of gonorrhoea occurred in the same ship in men who had not taken the course. Fears that the method might establish an undesirable resistance to sulpha drugs prevented its general adoption, though it was tried out by other medical officers with variable success; but the later arrival of penicillin with the prospect of rapid and easy cure reduced the demand and necessity for such measures.page 193
Neuro-psychiatric and Mental Disorders
One hundred and eighty-two cases of neuro-psychiatric and mental disturbances, ranging from mild anxiety states and cases of functional dyspepsia to certifiable mental conditions, were invalided from the RNZN during the period September 1939 to December 1946, representing a ratio of 4·2 per thousand per annum.
These cases can be conveniently subdivided into two main groups:
Cases of schizophrenia, melancholia, acute depressive states and psychopathic personality. Total 49, or 1·14 per thousand per annum.
Functional nervous disorders:
|Total||133 or 3·08 per thousand per annum.|
Most of the cases in the first group were detected during training or in early stages of service, when abnormal conduct or failure to respond to instruction and discipline prompted investigation. A number of them had bad personal or family histories which had not been disclosed at entry, but which subsequently came to light either fortuitously or as the result of special inquiry. This is the group which might possibly have been excluded on enlistment had there been time and opportunity for checking personal statements or for the application of special additional tests. As long as such cases can be recognised and withdrawn before draft to sea no great harm is done, but the wartime practice of despatching drafts to the United Kingdom after little or no preliminary training and observation carried the definite risk of the inclusion of some unsuitable types.
The second group, that of the neuroses, presented one of the most difficult problems of service medicine during the war. From the point of view of service efficiency, the prompt discharge of all such individuals has much to commend it, but medical officers had to be constantly on their guard against establishing an easy way out for those who for one reason or other were anxious to avoid their obligations. It would be idle to claim that the number invalided, 133, represents the full incidence of neurosis in the RNZN. Some of the milder cases found suitable employment, temporarily or permanently, in base establishments, and every medical officer at sea encountered cases which responded to the help he was able to give at critical periods.page 194
Much has been written during and since the war on neuroses in service personnel, and there is perhaps a tendency for those outside the services, both lay and medical, to lay too much stress on the hazards and nerve-shattering experiences which all these cases are assumed to have undergone. Careful analysis of the cases occurring in personnel of the RNZN shows that only a very small proportion can be attributed directly to what might be termed the extra hazards of war, such as the mining or torpedoing of their ships, aircraft accidents, exposure to gunfire or bombing and so forth. Furthermore, the greater number did not break down in early stages of service or on the first experience of trying or arduous conditions, but after lengthy periods of service, and it is noteworthy that 98 of the 133 cases were recorded in the years 1944, 1945 and 1946 as compared with 35 in the first four years of the war. Again it is to be noted that of 120 ratings, 9 held leading rates and 13 the rates of petty officer or higher, an indication that they had proved themselves reliable and efficient in their naval service.
Another common tendency at the present time is to discount the importance of discipline, leadership and example in the production of morale, and to ascribe all failures to the inherent weaknesses of the individual. Both of these factors must be considered in any study of service neurosis, and there are few naval medical officers of experience who will not have noted variations in the incidence in different ships in which they have served. There is a great depth of meaning in the old naval term ‘a happy ship’, implying a unit in which there is mutual respect and trust between officers and men, and dependent to a great extent on officers and senior ratings who not only know their jobs but who have a sympathetic understanding of the men under them and can get the best out of them.
Medical officers of sea-going ships on long commissions had exceptional opportunities of studying the reaction of their shipmates to the conditions and the work they were called upon to undertake, and the quarterly journals frequently contained the results of these observations. It was not necessary to go very deeply into psychology to lay bare the factors underlying the majority of cases of neurosis in the New Zealand naval service.
Apart from the actual strain of war experience, domestic and economic problems figured largely. In some men there was a definite feeling of frustration, while at the other extreme some broke down under the strain of promotion and added responsibilities for which they felt themselves inadequate. Reports from home, possibly exaggerated, of the pecuniary and other advantages enjoyed by their fellows who remained in civil occupations led many to think that they would find themselves left out when they returned to civil page 195 life, a feeling which was intensified in the later stages of the war by uncertainty as to the precise meaning of the terms of their enlistment. Men could hardly be blamed for placing their own literal interpretation on such phrases as ‘the period of hostilities’, ‘the period of the present emergency’, or ‘for hostilities and six months thereafter’, and while most of them probably realised that demobilisation must be a gradual process they were unmoved by political and legal quibbles about the official ending of the war.
|Age Groups of Neurosis Cases:|
|Service Groups of Neurosis Cases:|
|Home Service only||53 (includes cases recognised during training)|
The Health of the Women's Royal New Zealand Naval Service
Little comment is required respecting the health of the WRNZNS. This force was employed solely in home establishments in New Zealand, and owing to the lack of suitable accommodation for the treatment of female patients, their care at the hands of naval medical officers was in general restricted to the treatment of minor complaints.
In some centres the initial medical examination before enlistment was carried out by civilian practitioners not fully acquainted with the requirements of the service, but on the whole the physical standard of the force, which reached a total strength of 637, was of a high order.
Most of the sickness recorded was of a minor and general character, but twenty-two cases were invalided for causes as under:
This incidence of pulmonary tuberculosis is disturbing, as all these women had without exception been enlisted after preliminary X-ray examination. They had been employed only in shore establishments and their accommodation and working conditions were page 196 generally of a high standard. None of these cases had presented symptoms during service, all of them being detected by X-ray on demobilisation.
1 In 1949 strenuous efforts were made by the Royal New Zealand Navy to reduce the incidence of tuberculosis in the services. Ratings serving in shore establishments were inoculated to establish a degree of immunity to the disease, and later inoculations were given to men serving afloat in HMS Bellona, etc.