Each battalion at the front has a headquarters, usually in a dug-out or a sheltered farm house close to the lines: each brigade, consisting of four infantry battalions has a headquarters farther to the rear: each division, consisting of three infantry brigades, artillery, etc. has a divisional headquarters in some town, still farther to the rear, out of shell range: each corps comprising two to four divisions has its headquarters in a town back of this again: each army, composed of two to four corps, has its headquarters still farther to the rear, and the popular idea of the Tommy is that since the respective headquarters occupy bigger and bigger chateaux the farther back they go, away back somewhere in a town all by himself, living in a big castle from which he operates everything, is the commander-in-chief of the whole British Army.
General headquarters is usually a very busy place, for there are the heads of the various services of the army, and all the orders affecting the army as a whole are issued through it. The offices of the chiefs of the services are business offices and are operated in a most business-like way. The system is so perfect that it is difficult to escape from it should an order be neglected or a duty left undone.
Among these chiefs is the Director-General of Medical Services of the British Army in the field, General Sir Arthur Sloggett. Through him and his deputy, General Macpherson, went all the general orders affecting the health of the army.
At the head of each army medical service is a Surgeon-General (D.M.S., or Director of Medical Services), and at the head of each corps a full colonel (D.D.M.S. or Deputy Director of Medical Service). The chief medical man of each division is also a full colonel (the A.D.M.S. or Assistant Director of Medical Services), and he is responsible for the operation of the field ambulances and the evacuation of the wounded to the casualty clearing station while his division is in the firing line. The medical officers of battalions and the sanitary squad are also under him.
The casualty clearing stations and the mobile laboratories, are under the D.M.S. of the army, who is responsible for the clearing of the hospitals by motor ambulance convoys and by hospital train.
There are normally three field ambulances to each division and one casualty clearing station. The number of base hospitals to each division is normally two, but as many of these are utilized as are needed. They are scores of miles from the fighting zone, and do not particularly concern us here.
When a battalion medical officer or sanitary officer wishes to make a report or suggestion he does so through the A.D.M.S. of the division. In the same way the A.D.M.S. of the division communicates with the D.D.M.S. of the corps; the D.D.M.S. of the corps with the D.M.S. of the army, and the D.M.S. of the army with the D.G.M.S. at G.H.Q. A battalion medical officer cannot go over the head of his A.D.M.S., nor could the latter pass his D.D.M.S. to make a report or suggestion. Everything must go up or down the system through the various heads, and no side stepping is permitted.
The front line trenches were about seven miles from our laboratory which was located in a town with three casualty clearing stations, a railroad and canal. This made it possible to evacuate the wounded rapidly to the base by means of hospital trains and barges during an engagement.
The system which enables a sick or wounded man to be removed from the front is simple enough. Each day the medical officer of a battalion, who himself may be located in a dug-out in the trenches themselves or in a cellar of a house not far behind the trenches, holds a "sick parade" at his "regimental aid post." During a battle the wounded are collected by the regimental stretcher bearers and brought to the aid post.
Any soldier who is feeling unwell reports to the M.O. of the battalion who, if the trouble is a minor one, may give him some suitable medicine. It is one of the difficulties of the M.O. to distinguish between a case of genuine illness and a fakir or "scrimshanker," and a good supply of common sense and a knowledge of human nature is a great asset in making correct diagnoses. It is almost impossible, for example, to distinguish between a genuine case of rheumatism and a clever imitation of it, because the only symptoms are pains, the effects of which can easily be simulated by a soldier. If the man shows serious symptoms he is sent back to the "advanced dressing station" which will probably be a mile or so behind the front line trenches, if possible in a house and on a road accessible to motor ambulances.
If the man can walk he goes through the nearest communication trench; if wounded he is given first aid, and if unable to walk he is helped or carried back by stretcher bearers from the ambulance—to the dressing station.
Some of these dressing stations taking in wounded under shell fire were located in shell-proof dugouts. At many points light narrow gauge railroads had been built which ran from the dressing stations right up to the trenches. On these railways little cars pushed by hand were used both for bringing out the wounded during a battle and for taking in food, water and other supplies. It is, of course, impossible to lay such railways in many parts of the lines where they would be exposed to direct observation by the enemy, but they are becoming more and more numerous as their value in saving time and labour in the "man handling" of food and trench supplies has been proved. At one of these dressing stations where the railway came right up to the shell proof dugouts fresh shell holes in the neighborhood testified to the fact that the work of the field ambulances is at times not unmixed with excitement.
The cases which accumulate at the advanced dressing station are given further treatment if required, and are evacuated by motor ambulance, usually at night, as the road to the station is frequently under the enemy's observation, to the field ambulance proper where they are given further treatment or dressings as the necessity may be.
From the field ambulance the sick and wounded are cleared by motor ambulance convoy to the casualty clearing station, or possibly in cases of tired or slightly shell-shocked officers and men, to the rest stations or convalescent hospitals, of which there are a number well behind the firing line.
At the casualty clearing station the men are checked over, their wounds redressed, operations performed, and all the work done necessary to enable the men to be passed on to the base hospital by hospital train or barge. These clearing stations, of which there are usually three in a town, may keep certain serious cases for days until it is deemed advisable to send them on.
While one clearing station is filling up and treating the patients, the other will be sending all possible treated cases down the line. From the base hospitals, which are near the sea, the men are forwarded as soon as advisable by hospital ships for distribution among the hospitals of England.
While a battle is in progress the men pass through this system so rapidly that they may be wounded one morning and be in a hospital in England the next.
The medical officer, of course, is attached to the battalion, and goes everywhere with it, and under him are a number of stretcher bearers who gather up the wounded. The advanced dressing station is merely an advanced party from the field ambulance which itself is divided into three sections, each of which may operate independently according to the nature of the country. Each ambulance is self-contained, having its own transport, and by using tents can work in an area which has no houses or other shelter.
The casualty clearing station, on the other hand, having an established capacity of nearly 600 beds, has much heavier equipment and is not supposed to be a mobile unit, though it is capable of moving with the aid of its two lorries by making repeated trips. Many of the casualty clearing stations are located in huts which can be torn down and moved forward and rebuilt by the engineers and construction units.
There is also in each division a sanitary section composed of one officer and 25 men, whose function it is to keep an eye on the sanitation of the divisional area, report failure on the part of units to observe the established sanitary regulations, see that the incinerators are operated, have new sources of drinking water tested, look after the bath houses on occasion, search for cases of typhoid fever, etc., among the civilian population, and, in general, make itself as useful as possible.
The British army regulations are such that each officer and man must be a sanitarian and must not only observe the regulations but see that others do the same; the principle underlying this system being that "if each before his doorstep swept the village would be clean." Consequently it is not left to the sanitary section to clean up a divisional area, but rather to report those responsible for not keeping it clean. In this way every man is made a responsible party, and if the officers of any unit see that the regulations are enforced by each man, the unit will be a sanitary one.
Naturally as the battalion M.O. is directly connected with the field ambulance to which he sends his cases, he is most interested in the efficiency of that unit. Since the field ambulances are under the direct supervision of the A.D.M.S. of the division, you will find the latter during a battle visiting these to see that they are operating smoothly and whether more motor ambulances, stretchers, supplies or other necessities are being provided.
At the same time you will find the D.M.S. of the army visiting his special pets, the casualty clearing stations, and seeing that the evacuation of the wounded by train is working smoothly.
The hospital trains are specially fitted up with beds, kitchens and dispensaries, and with nurses and a medical officer in charge.
The hospital barges make the finest little hospitals that you could desire. They are the ordinary flat-bottomed square-ended Dutch barges, roofed in, and when the interior has been cleared out they form elongated covered floating boxes. Skylights in the roof give a splendid light, and the barges are wide enough to allow of two rows of beds with an aisle down the middle. The medical officer's surgery and bedroom are at one end of the barge, while the nurses' quarters are at the other.
The barge is entered through the roof by a stairway, and the first impression one gets on descending these is one of cosiness and restfulness that is never forgotten. Whether the barge is moving or at rest cannot be determined while one is inside, because the motion is so easy through these sleepy placid canals. Usually only serious cases that cannot stand the vibration and jar of a train journey are taken by the water route.
In the British Army there are specialists of renown in medicine and surgery who are supposed to supervise the medical and surgical work of a certain given area. They travel about, find anything new that occurs of interest, act as advisers, and hand on to other units the special information or "stunts" that have been worked out or discovered at home or in the field. The consulting surgeons are usually to be found during a battle operating where there is the greatest need of skilled surgery.
Besides the sanitary officer of each division there is a sanitary officer for each army, and a chief sanitary officer for the whole expeditionary force. These are all in touch with the sanitary adviser at the base and the authorities in England. Since, under war conditions, new developments are always taking place in this work, the knowledge gained of practical value filters through to the army by these channels as well as through the scientific journals.
Each army is provided in the field with one or more "advanced depots of medical stores" which keep on hand and give out the drugs and medical materials demanded by the various hospitals and medical units. If, for example, a field ambulance wants a lot of iodine, absorbent cotton, etc., the officer commanding sends an ambulance with an indent signed by himself, and the officer in charge of the depot hands over the material required.
There are other branches of the service, like the gas schools and inland water service, which, though strictly not medical, are closely akin to it.
It would be of little avail to speak of all the minute detail, of which there is a tremendous amount in each and every one of these offices and sections of the medical service. The methods of filing correspondence and records alone is wonderful when one thinks of the conditions and number of men involved, and comparatively few mistakes are made. This appears the more remarkable when one has had numerous experiences with the mistakes made in the offices in England where one would think the systems would have been systematized long ago.
The medical service of the British Army in France is a marvel of efficiency and one that the nation can well afford to be proud of.
The history of war has always been a history of epidemics. The fact that in an army men are crowded together makes it easy for all communicable diseases, once introduced, to spread with great rapidity. And because soldiers are always associated with the civilian population, it means that such diseases are readily communicated from the army to the civilians, and from the civilians to the army. It is therefore apparent that during a war, disease, unless quickly checked, may run like wild fire through a country, and be disseminated far and wide by soldiers returning to and from their own homes, or other distant places while on leave.
Advances made in our knowledge of how diseases are spread and controlled, particularly through recent studies in bacteriology and immunity, have made it possible to keep communicable diseases in absolute subjection. The marvel of the age is the lack of epidemic disease in the army to-day. This is particularly striking in view of our experiences in other recent wars. In the Franco-Prussian war of 1870, for instance, smallpox was fanned into a great flame, and there resulted the largest smallpox epidemic in 80 years. It is interesting to note that the medical authorities in Paris, in the first year and a half of the present war, vaccinated over 25,000 strangers passing through Paris; they are taking no chances with another outbreak of smallpox.
In the Boer War the British losses through typhoid fever alone were 8,000 against 7,700 killed by bullets, shells and other agencies.
The British army of nearly five million men in France and England to-day, has so little typhoid that it is practically a negligible quantity, and this holds with other communicable diseases. There must be some basic reason for this freedom from contagious diseases, for we know that such freedom does not come by accident.
No attempt will be made to deal with those auxiliary forces employed to keep the men physically and mentally fit. Such things as the provision of an adequate and wholesome food supply; proper clothing; amusements, such as games, competitions, horse shows, cinemas, variety shows; and Y.M.C.A.'s are all an integral part of the machinery necessary to keep an army in the field well and happy.
Only an attempt will be made to discuss the principles underlying the prevention of disease in use in the British army in France,—principles with which the average layman is comparatively unacquainted.
In the first place, it is well to realize that in the temperate climate of Europe, the vast majority of communicable diseases of importance from the military standpoint are contracted largely from three sources:
Group 1. From throat and nose secretions; e.g., diphtheria, measles, etc.
Group 2. From biting insects; e.g., malaria, typhus fever, plague, etc.
Group 3. Through intestinal secretions; e.g., typhoid fever, cholera, dysentery, etc.
The first group, which includes practically all the ordinary diseases like measles, mumps, whooping cough, influenza, colds, pneumonia, scarlet fever, diphtheria, etc., is conveyed in most cases by one infected person transmitting directly to another person,—through coughing, spitting or sneezing,—germs present in the nose and mouth secretions.
The second group is conveyed by insects biting people or animals infected with the disease, and subsequently biting people who are healthy. In this way the disease-producing organism is introduced into the body of the healthy person, and beginning to multiply, brings about the symptoms of the disease. Malaria is transmitted in this way by the anopheles mosquito; typhus fever by lice, and plague by the rat flea. These are all diseases greatly to be dreaded in the army.
The third group, including typhoid and paratyphoid fevers, cholera, and dysentery, all of which are intestinal diseases, is largely conveyed from the sick to the well indirectly through contaminated water and food. To develop one of these diseases means that the excreta of somebody who has the disease or who has had it, has been taken into the mouth and swallowed, and the germs finding a favorable medium in the intestines have multiplied and produced the typical symptoms. One of the chief ways in which this type of infection occurs is through drinking sewage-contaminated water or milk; another is through contamination of food by the hands of the person excreting the germs; and the third is through the contamination of the food or eating utensils by flies and other insects which carry filth germs from place to place on their feet and bodies.
With these facts in mind and with some knowledge of sanitation and medicine it is easy to see how most epidemic diseases can be held in check. Put briefly, it means that the sanitary organization must be such that the germs from one infected soldier are prevented from reaching another, or as is sometimes said, some link in the chain of circumstances whereby disease germs can pass from one to another, must be broken.
The methods employed to break these links are simple; the carrying out of the methods is oftentimes very difficult.
It is obviously essential in the first place to remove from the army, at the earliest possible moment after it has been diagnosed, every case of communicable disease. This means the adoption of measures for picking out soldiers who show symptoms of disease, which really comes down to the fact that the medical officers must always be on the alert and carry out the instructions of the director of medical services of the army with despatch. In the British Army this is one of the most important features in the control of epidemics. If a man is suspected of having any communicable disease he is instantly placed under quarantine until the diagnosis has been confirmed, after which he is removed from the army area altogether as a possible focus of infection. The British Army takes no chances, and its wonderful record of freedom from contagious disease proves that it has been absolutely sound in its technique.
This is practically the only way of eliminating diseases, such as measles and scarlet fever which cannot be diagnosed by bacteriological methods, but of course the procedure is employed in all other kinds of epidemic disease as well.
Great Britain has been fortunate above all other nations in this respect that she sent over at first a small army of regular troops, perfectly equipped from the medical standpoint as well as in every other way. Efforts had been made for years to remove typhoid carriers from the regular army, and naturally no soldier was sent into the field who was known to have typhoid, or to be a carrier of typhoid or any other contagious disease germs. Furthermore, the soldiers had practically all been vaccinated against smallpox and inoculated against typhoid fever.
As division after division was sent out to the army in France, they too were completely equipped with sanitary squads, casualty clearing stations, field ambulances, water carts, and other necessary medical equipment. Consequently as the army grew and expanded into a huge force it was thoroughly equipped not only with the necessary apparatus for caring for sick and wounded, but also with the experience acquired by those already in the field. In this way the British Army differed from all of our European Allies who had been compelled to mobilize everything at once and found themselves woefully lacking in medical equipment and personnel, so much so in fact that they had been in the beginning unable to handle all epidemics successfully.
With a realization that the medical equipment of the British Army was complete; that it had been sent into the field free of communicable diseases; that it had been vaccinated and inoculated against two of the most dreaded diseases, smallpox and typhoid fever, and that every reinforcement subsequently sent out had been carefully freed from suspicious cases of disease, it can be readily understood that the British Army began under auspicious circumstances, and that thereafter its freedom from contagious disease depended to a great extent on the preventive measures adopted.
It is impossible, however, to prevent our soldiers billeted in France from occasionally contracting communicable diseases from the French civilian population, and it is obvious that as there were from 3 to 5 per cent. of the soldiers uninoculated against typhoid fever, we would get some cases of typhoid fever.
Besides this, unless further precautions were taken, the army would be susceptible to disease such as cholera, dysentery and the like should there be cases of these in the war zone.
We therefore arrive at the conclusion that, as there might be some "carriers" and undiagnosed cases of disease among soldiers and civilians excreting disease germs, additional means must be adopted to destroy such germs before they could reach other soldiers. This is the place where sanitation and hygiene steps in, and it is in these matters that the army of Great Britain is unexcelled by any army in the field to-day.
Since the group of intestinal diseases can originate only from the excretions of people who are giving off the specific germs, it would be logical to endeavour to destroy such excreta or render it incapable of contaminating water or food. This is done. All excreta behind the front line and reserve trenches is destroyed in numerous incinerators, which are kept burning night and day. The British Army is the only army which has succeeded in doing this. All excreta which cannot be burned is buried so that it cannot be reached by flies.
As it may happen through accident or carelessness that water supplies have been contaminated, it is the rule to sterilize all water used for drinking purposes, either by boiling, by the use of bisulphate of soda, or by chlorine. The chlorine method is the one in general use in the British Army, as it is in all of the other allied armies.
The possibility of using chlorine in the field was brought to the attention of the British Army authorities by the publication of a method evolved by the writer in 1909. According to this method a stock solution of hypochlorite of lime was added to the water, the amount necessary for any given water being determined by a solution of potassium iodide and starch. This was particularly useful in the trenches where it was possible to accurately sterilize a pail or a barrel of water if necessary. Small tablets of hypochlorite of lime, each one sufficient to sterilize a pail of water, were also ordered and issued to the first Canadian division, and proved useful.
The great bulk of the water supply, however, is sterilized directly in the water carts by adding one or two spoonfuls of the dry chloride of lime to the partly filled water cart, the mixing being done by the addition of the rest of the water and by agitation during the trip back to the place where the cart is stationed.
In addition to this, large mobile filter units, after a plan draughted in September, 1914, and officially suggested by the writer in 1915 after experience in the field, were built and issued to all the British armies. These mobile filters are capable of filtering and sterilizing large quantities of water and delivering it to water carts or into stand pipes, ready to drink. A check is kept on the efficiency of the filtration and sterilization by mobile field laboratories.
Standing orders forbid the use of unboiled milk in the army as well as fresh uncooked vegetables, so that there is little danger from these sources. When ones sees the peasants watering their vegetables with sewage, the reason for such regulations are apparent.
As it is possible for flies to carry typhoid bacilli and other disease germs from excreta to food, a constant war is waged against these filthy insects. Flies breed chiefly in manure, and one fly will produce many millions of flies in the course of one summer. The obvious method of keeping down flies is to destroy their breeding places, and therefore it is the duty of everybody concerned to see that all manure piles in the army area are gotten rid of. Some of it is burned, some spread on the fields, some buried, and so forth. On the other hand food is screened from flies whenever possible, and privy pits made inaccessible to them by the same means. On the whole the house fly has not yet, in so far as we know, played any great part in causing epidemic disease in the British Army in France, because so many of the precautions outlined have been carried out.
By getting rid of cases of intestinal disease, and "carriers" of intestinal disease, destruction of excreta and garbage, screening of food, destruction of breeding places of flies, sterilization of drinking water, boiling of milk and vegetables, and in the case of typhoid and paratyphoid fevers, inoculation, the chances of intestinal disease germs getting through from one person to another are comparatively small, as the results would indicate.
To show that these results are not due to accident an example will demonstrate: Early in the war when the British took over from the French a section of the line in the Ypres salient, the Belgian population in the little village of Vlamertinge and neighborhood was being devastated with typhoid fever, and the French troops also had a great many cases. When the British troops took over the line they not only escaped getting typhoid fever themselves, but they succeeded in absolutely stamping it out among the civilian population, and in getting rid of any "carriers" of the disease.
The cases were discovered by a house-to-house investigation by "The Friends' Search Party"—a group of Quakers who had conscientious scruples against bloodshed. This search party notified the medical authorities, particularly the laboratory in the area, of any doubtful cases, and the diagnosis was then made by laboratory methods. In the last six months of my stay in France, near the Belgian border, I do not think that the Friends' search party unearthed a single case of typhoid, and as a matter of fact few cases of the ordinary epidemic diseases such as measles or diphtheria were discovered, although they continued to make house to house investigations and report to us regularly.
The insect-borne diseases in the Western Europe war zone are, as far as we know, carried by flies, lice and mosquitoes. Flies carry disease germs more or less mechanically, and are controlled by the methods outlined above.
Mosquitoes are responsible for transmitting malaria and yellow fever, though the latter never occurs in Europe. Malaria in France is also comparatively unknown, though we found the Anopheles mosquito which is responsible for transmitting the disease elsewhere.
There were also numerous cases of malaria recurring in soldiers from India, Egypt, and other hot countries, so that we had both the infected individual with the malaria parasites in his blood, and the mosquito which was capable of carrying the organisms. Yet in 1915 we had only a dozen cases of malaria develop in men who had never been out of England, and were therefore, presumably, infected in France.
Possibly the chief reason for this was due to the fact that after the mosquito has sucked the blood of an individual infected with malaria, and been infected with the malaria parasite, the weather was not warm enough for the parasite to undergo its necessary transformation in the blood of the mosquito. A continuous warm period of several days' duration is necessary for this purpose, and in France these time periods never occurred of sufficient duration. Here was a climatic feature which proved to be of very great importance in preventing the spread of a disease most inimical to the health of any army.
Here again, any cases of malaria developing were removed as rapidly as diagnosed, so that mosquitoes did not have much opportunity of becoming infected.
Typhus fever is one of the most dreaded diseases in the army, for it is highly fatal, and both in former wars and in the recent Serbian campaign has proved a terrible scourge. It is quite a different disease from typhoid fever, and is conveyed from man to man solely through lice. In other words, the phrase "No lice, no typhus" is scientifically true.
Every army in the field is a lousy army, and every soldier in a fighting unit is more or less lousy. The louse commonly present is the body louse, and it lays its eggs in the seams of the uniforms and on the underclothes. The eggs hatch out quickly so that when a man once becomes infected the lice multiply with great rapidity.
For typhus to get a grip on an army means that there must be at least one case of the disease, and there must be lice on the case. Some of these lice will fall off, wander away, or be left on the bedding, in the straw, or in the patient's discarded clothes. If these lice have bitten the typhus patient and thereby been infected, it seems to be necessary for a certain length of time to elapse for the organism to develop in the body of the lice before they are able to introduce the virus into uninfected individuals by biting them.
As yet there have been no cases of typhus fever in the British Army in France, though it has occurred to a greater or less extent in Germany, Austria, Russia and Serbia. The quarantine services at the ports of the countries bordering on the Mediterranean have prevented it spreading to any other country.
Typhus fever is known as a dirt disease, and its control is possible through the plentiful use of soap and water. The most difficult thing for a soldier to obtain in the field is a bath. Normally he is in the front line trenches for a week, in the reserve trenches for a week, and in rest for a week. This means that he cannot get a bath for at least two weeks, and he doesn't. So that though a soldier goes back into the trenches clean and free from vermin he is sure to become reinfected from lice left in the dugouts; or some lice eggs on his clothes perhaps have escaped destruction, and he may be as lousy as ever when he comes out of the trenches again. The old straw in the barns and the billets is sure to be infected with lice, and it is very difficult to sterilize the men's blankets. Consequently a persistent continuous fight against this variety of vermin must be kept up, for lice are not only a potential source of danger in transmitting typhus fever and relapsing fever, but they are a great source of irritation to the men and responsible for much loss of sleep.
The greatest luxury at the front is a hot bath, and these are provided in every divisional area on the British front. Three or four miles behind the trenches in the rest areas, in places where a plentiful supply of water can be obtained, the army has established bath houses. Sometimes a brewery, or part of it, has been taken over for this purpose, because the breweries all have deep wells from which a plentiful supply of water can be obtained. If the bath house is in a brewery they may utilize the large beer barrels cut in two for baths. These are filled with cold water and live steam turned into the water to warm it. After the bath the men dump the barrels, which are immediately refilled by attendants, for the next group.
Most of the bath houses, however, are in improvised shacks built upon the edge of creeks or ponds. The water is pumped into an elevated reservoir and heated frequently by means of a threshing machine boiler, rented or purchased from some neighboring farmer. One section of the shack is divided off for a bathroom with a number of showers and the other rooms devoted to the receiving of dirty clothing, storing the clean clothing, washing, drying and sterilizing.
As you pass along the road you will see perhaps a platoon or a section of a platoon marching to the bath house, without belt or equipment, and carrying towels. At the bath house a certain number, say twenty men, pass into the first room where they undress. Their underclothes and shirts are thrown to one side to be washed; their caps and boots are not treated in any way. The uniforms are hung on numbered racks and placed in the disinfection chamber where they are immediately treated with live steam, or they are taken into an adjoining room where the seams are ironed with hot irons to destroy lice and eggs.
The men then pass on into the bathroom where they are given about ten minutes to luxuriate with plenty of soap and hot water. As they pass out of the bath through another room they are given clean socks, underclothes and shirts, and by the time they are dressed their own uniforms, disinfected, are handed back to them. The whole operation takes from twenty-five to thirty minutes, and from a thousand to fifteen hundred men can be put through each bath house in a day.
The discarded clothes are washed by local peasant women paid by the army; in one of these establishments in our area there were 160 Belgian peasant women engaged in this work. Mending is also done by them, while socks and clothes too far gone to be mended are packed in bundles and sent away to be sold.
The waste wash water from the baths and laundries entering the creeks naturally causes trouble from troops down stream who may have to use it. Horses will not touch soapy water, and the brewers object to making beer with it; they say it spoils the beer.
Consequently the sanitary officers have in many cases been compelled to put in tanks to treat this dirty water and purify it. This is usually done by adding an excess of chloride of lime, which precipitates the soap as a curd and carries the dirt down with it. By sedimentation, and filtration through canvas, cinders and sand, the water is clarified and turned into the creeks again clean. So completely can this be accomplished that the experience at one bath house is worth narrating.
This bath house was built on a little pond which accumulated in winter and was not fed by springs or any other auxiliary source of supply; consequently with the advent of warm weather it would have dried up unless the water had been conserved in some way.
The sanitary officer in charge was equal to the task. With the advice of engineers and the laboratory he built a plant which subsequently worked to perfection. The water used to bath at least a thousand men a day, as well as the wash water from the laundry attached to the bath house, was collected and treated with acid to remove the soap; the scum formed carried to the top all of the dirt, which was then filtered off by means of sacking, cinders, and sand. The excess of acid was treated with lime which neutralized it, and the excess of lime was removed by soda. The water was all filtered before it was returned to the pond into which it flowed just as clear as it had been before, and with enough hardness present to give it a lather with soap.
The system was operated during the whole summer and gave complete satisfaction. It really did what nature would have done in a much longer time and with a much bigger plant. Had the pond been used to bathe in direct it would have been unfit for use in the course of a few days, whereas by the method employed it was always perfectly sweet and clean.
The common sense and resourcefulness of the British sanitary officer is well shown by this solution of a difficult and apparently hopeless problem. It is indeed a difficult problem which a British officer will acknowledge to be hopeless, and it is this very British quality that the Hun should always keep in mind in thinking of the end of the war and the reckoning afterwards.
As far as we know there has been no plague among the warring armies in Europe. Plague is conveyed from rats having this disease to human beings by means of rat fleas. These fleas become infected by biting the infected rats and subsequently infect human beings by biting them. There are plenty of rats in the trenches and dugouts, particularly in winter; in the summer they breed along the water courses, and in the autumn are attracted to the trenches where there is plenty of waste food to be had.
Numerous devices are used to destroy them, and it is a common thing to see a soldier sitting patiently in the trenches with his rifle between his knees and a piece of toasted cheese on the end of his bayonet. As Mr. Rat, attracted by the savoury odour, approaches and takes the first sniff, the trigger is pulled and there is one living rat less. Prizes are sometimes given to the man who can kill the largest number in a week, and bags of 25 and 30 are not uncommon. Sometimes poison is used, and even ferrets have been employed with, however, little success.
In connection with the rat problem, we had an illustration of how impossible it is even for a rat to escape the British army system. Army routine, the result of many years of experience, once put into operation is as sure and certain as death and taxation.
The regulations are that if any considerable number of rats have been noticed around the trenches sick or dying, some of them shall be sent to the field laboratories for examination. Bubonic plague is a rat disease; consequently if rats are dying in any great numbers, we would conclude that some disease, possibly plague, must be the cause.
In this case the Director of Medical Services of the army had been notified that a rat had been despatched to a laboratory for examination. Consequently he was anxious to know the result of the examination, and when a report was not forthcoming he sent a telegram to the officer commanding the Canadian laboratory asking that a report on the rat be forwarded at once. As we had not received the rat we reported the same to the D.M.S. who put the matter up to the D.D.M.S. of the corps who had forwarded the rat. The rat had gone to another laboratory, and "the system" to locate the rat was put into operation.
The following is the correspondence upon the subject:
1. To D.D.M.S. J. Corps.
In accordance with your 1w/ER, 16 of 1/2/3, a rat is being sent from trench x.y.z. to No. 1 mobile laboratory at ——.
(Signed) A.D.M.S. K. Div.
2. To O.C. No. 1 Mobile Laboratory.
Please let me know the result of your examination of this rat.
(Signed) D.M.S. Z Army.
3. D.M.S. Z Army.
I have not received this rat.
(Signed) O.C. No. 1 Mobile Lab'y.
With reference to attached, will you please say what has become of this rat.
(Signed) D.M.S. Z Army.
5. To D.M.S. Z Army.
It has been sent to Canadian laboratory and report has been called for.
(Signed) D.D.M.S. J. Corps.
6. To O.C. (Canadian) Mobile Laboratory.
Will you please let me know the result of your examination of this rat.
(Signed) D.M.S. Z Army.
7. To D.M.S. Z Army.
This rat was quite normal and had evidently been killed by a blow. The report was forwarded to A.D.M.S. K. Div.
(Signed) O.C. No. 5 (Can.) Mobile Lab.
Even a partly decomposed rat was unable to escape the army system.
With the medical organization of the army in mind it may be seen that a small mobile laboratory might be of great practical service to the army in the field. Under the conditions which exist in the present war, the army itself is not very mobile, nor is it necessary for the laboratory to be, but it is of great importance to have a car which will permit of the area being covered quickly should a specimen, sample or investigation be required. The car is the really essential mobile part of the unit.
Our laboratory had charge of both the bacteriological and hygiene work of a given area; it was the only laboratory that did both types of work. When our apparatus had been unpacked and set up in the old ball room of the Hotel de Ville it made quite an imposing show, and after we saw what equipment the other laboratories had we were decidedly proud of ours.
Our first bit of work proved to be the examination of a number of soldiers who had been in contact with a case of cerebro-spinal meningitis, to detect "carriers" of the specific germ. Then material of all sorts began to come in for examination from the casualty clearing stations, field ambulances, sanitary and medical officers, rest stations and other places. Most of the routine bacteriological work proved to be of much the same nature as that done in a health laboratory at home, and consisted of examinations to detect some of the ordinary communicable diseases such as diphtheria, cerebro-spinal meningitis, typhoid fever, malaria, dysentery, tuberculosis, and venereal diseases.
Should a case of diphtheria, for example, be found in a soldier, all his immediate friends and companions with whom he had been in contact, would be swabbed to see whether they were infected. Those found to be infected would be removed from the army at once.
In a case of suspected typhoid fever the examination of serum, blood and excreta would be necessary to determine whether the case were really typhoid or not. If found to be typhoid the laboratory would be called upon to try to discover the source of the infection. The same general methods hold good in other epidemic diseases where the laboratory is capable of making the diagnosis, to see whether any danger lurks in "contacts" or "carriers" and to find the source of the infection where possible.
Very frequently material from wounds is sent in by the hospital surgeons to see whether wounds are infected. The soil of Flanders has been liberally manured for hundreds of years, and in every cubic yard of this manured soil are millions of the germs which cause gas gangrene and tetanus (lock-jaw) when introduced beneath the skin. If a wound is infected with gas gangrene or other dangerous organisms, the knowledge that they are present may materially modify the treatment used by the surgeon, and the laboratory is of value to him sometimes in determining that point.
The usual routine work of a hospital clinical laboratory was also carried on by us for the casualty clearing stations in the area, and all kinds of work from the making of a vaccine for the treatment of bronchitis in a British General to the inoculation of a civilian child with anti-meningitis serum came within our scope.
The hygiene work of the laboratory is also of a varied character: It consists of the examination of water supplies, milk and foods; the detection of poisons in water, and, occasionally, in human beings; the evolving of methods to purify effluents discharged into streams; work on poison gases and methods used to combat these, and many other things.
In each division there are some sixty water carts, each of which holds about 110 gallons. We attempted to get samples from all of these in turn, to see whether the water had been disinfected. As all the sources of water supply in Flanders, with few exceptions, contain large numbers of bacteria, and as a properly chlorinated water contains very few bacteria, it is easy to tell from a couple of simple tests whether or not the water in the carts has been chlorinated.
As we sometimes had eight divisions in our area at one time, this water control meant a good deal of work. The water carts were usually to be found at the headquarters of the unit to which they belonged, and we quickly discovered that the way to get the largest number of water samples in the shortest time was to travel by the map up and down the twisting narrow roads which intersected each other as though following the trails of the original inhabitants.
It must be remembered that four or five miles behind the front line every farm house and barn is in use most of the time for billeting soldiers, and that these farm houses are infinitely more numerous than they are in America. Little villages and towns are very frequent and many of them bear the same name as other towns and villages a few miles apart. Thus there are at least two Bailleuls, two Givenchys, two Neuve Eglises and so on. In our quest of these water carts we had to search the countryside diligently and we averaged a great many miles a day; we soon got to know every road and almost every farm house in our area.
When a cart was found it was necessary to get the man in charge of it—the water detail—in order to obtain information as to the source of supply, the amount of chlorine used, whether there had been complaints of taste and so forth. While the information was being obtained, officers of the unit would often come out to see what the trouble was and would ask questions; possibly some non-coms and men would also gather about, and the first thing we knew would be giving, to a very interested audience, a little lecture on the dangers of drinking untreated water; their interest would be greatly increased if a bottle filled with the water, to which a couple of drops of solution had been added, turned bright blue, thus showing the presence of the free chlorine. By such means a good deal of practical educational work was done, and the danger of men drinking raw water thereby reduced.
Reports of all samples were sent to the A.D.M.S. of the division concerned, who forwarded them to the medical officers of the units, with more or less caustic remarks should the samples be bad. The M.O. in turn would get after the man in charge of the water cart, who usually had some more or less plausible excuse.
The water details of the first Canadian Division were the best trained lot of men we ever ran across. The very first day we took samples from their water carts they were all sterile, and there were no complaints about taste. It was an excellent example of what training could accomplish, for they had all been carefully trained in their duties in Canada and England.
As the water details of any division were constantly changing, the efficiency of the treatment depended to a great extent on the constant supervision of the problem by the A.D.M.S., medical and sanitary officers.
We have found divisions coming into our area for the first time with only 25 per cent. of their water carts chlorinated, whereas before they left they would have 90 per cent. or more chlorinated, and the division thoroughly educated as to the necessity for sterilizing their drinking water properly.
Wells, springs, creeks, and ponds used as sources of supply were also examined, and not infrequently samples from "springs," encountered while digging new trenches, were sent in to be tested. The tremendous number of bacteria found in some of these "spring" samples we on several occasions reported as indicating the presence of buried animal matter in the immediate vicinity of the springs, and resulted in finding this to be correct. In one case in which a badly polluted water was so reported upon, the burial place of some fifty Germans was found only a few feet away.
One suspected epidemic of dysentery was a typically water borne infection which did not prove to be the real thing. Half of one company was in a front line trench and half in support. Part of the one section took their drinking water from a shallow well near at hand without treating it, and practically every one who drank it, thirty-one in all, came down with typical symptoms of dysentery, while all the others who did not drink it raw escaped. The well water was found to be badly polluted. The sick were all quite well in four or five days, and able to return to the front line, but it proved to be an excellent lesson in hygiene to that Division.
A curious phenomenon in connection with the army water supply was noted that first spring in Flanders. The flat surface of the country in our area consisted of a very tenacious clay, and the farm wells were usually sunk ten to twelve feet in that clay. In the months of March and April, though the fields were water logged and the ditches brimming over, the wells which were being used by the troops were going dry. In other words the soil was almost impervious so that once a well had been emptied it would not fill up again for days.
For this and several other reasons we reported the necessity for large mobile water purification units, which could take the water from larger bodies of water such as ponds, creeks, canals or rivers, purify it, and deliver it filtered and sterilized into the water carts or tanks. Such a system was subsequently adopted by the war office and is now in general use in the British Armies.
One hot morning in mid June we received a telegram from the Surgeon General to investigate a water supply complained of in the Festubert region. A premonition seized me that I was going to be killed, for the battery to be visited was in a very "unhealthy" spot. So I made a new will, and wrote a letter of farewell, to be posted in case of accident.
The battery was found nestling in the midst of an orchard, but the M.O. who knew all about the water supply, was not to be found. Reluctantly I accepted from the Colonel an invitation to dinner, for the feeling was still strong in me that some danger was impending. Half-way through dinner there came the well-known scream of an approaching shell, which burst at the other end of the orchard. A second shell burst a little closer; a third came closer still, and a fourth rained shrapnel on the roof; all the others, with one exception, fell short, and the shelling was over for the time. It was just another one of those "intuitions."
While the shells were flying we all kept on eating as if this were a usual everyday accompaniment to lunch, though I noticed that they watched me with as much interest as I eyed them during the process, each curious to know how the other took it.
The varied nature of laboratory work in the army and its practical applications may be seen from the following examples:—
One day the O.C. of a hospital sent over a pint of tea suspected of poisoning 28 out of 29 men who drank it. From the history of the affair we did not believe that this could possibly be the cause, and after making a few rapid tests to exclude metals, we proved that the tea was not poisonous by the simple, practical test of drinking it, Major Rankin being the official tester. This method of making a practical physiological test rather astonished the British authorities.
A German gas mask found on the battle field was submitted to us to find what chemicals were present. That mistakes were sometimes made by the Germans was evident when we found that the mask had not been treated with chemicals at all; some of the Huns at least had been unprepared for a gas attack.
The clarifying apparatus on the British water carts was mechanically defective and usually broke at certain definite places. Recommendations were made by us after we had experimented with rubber instead of rigid connections, which resulted in all the water carts in the British army being equipped with rubber connections, the results being entirely satisfactory.
A great deal of experimental laboratory and field work was done with chlorine gas and the efficiency of gas masks and helmets. Experimental physiological and pathological work was done on animals with chlorine and other gases, and on the drying out and deterioration of gas helmets and the chemicals used in them. Subsequently a Gas Service was inaugurated and all work of this sort carried out in special laboratories at G.H.Q.
Quite a number of cases of nephritis occurred among soldiers, and arsenic was suggested as a possible cause. The laboratory was asked to examine a considerable number of samples of wine and beer to see whether traces of arsenic were present or not. None was found. A large quantity of wine found to be diluted with ditch water, and sold to our soldiers, was destroyed, and the vendors fined.
One day a young medical officer, so excited that he could hardly speak, rushed into the laboratory with a lot of dead fish. After some questioning we found that there were tens of thousands of dead fish in the Aire-La Bassee canal and, as this ran into the German lines, he suspected that the canal water had been poisoned by the enemy. We told him that we thought the fish had probably died from asphyxiation as a result of organic matter from a starch works being emptied into the stream. He went away unconvinced, to make a further enquiry and returned later in the day to report that the fish in the canal died every year in the spring when a certain distillery dumped its waste into the canal. Thus did former experience with starch mills pouring their effluents into Ontario streams and killing fish prove of unexpected use.
The laboratory was used a great deal by the highly trained officers of the Indian Medical service, who were always wanting some unusual parasite or insect identified, and made a good deal of use of our library.
A German high explosive percussion bomb was brought in one day for us to identify the explosive present. We did not allow the messenger even to lay it down but besought him to hold it tight and to keep moving towards the explosives laboratory seven miles away while we escorted him quickly and safely from the premises. The way some of those chaps handled bombs and shells made you tired. It would have been a great pity if that two hundred year old building had been blown up and the British Army compelled to pay for it.
A poor soldier up and died one day without warning or preliminary sickness. They thought it might be poison, and his wife would have been deprived of her pension if the man had committed suicide. We were asked to examine the stomach contents to decide whether poison was present. No poison was found.
We were sent a little vial containing a small amount of material and asked to determine the nature of the contents. The bottle had been found beside a dead German. It proved to be opium, and the owner had evidently been prepared for a painless passage across the Styx when such necessity arose.
Occasionally we had to investigate possible cases of cholera among troops coming from India. One day we received a telegram to proceed to a certain place about ten miles away and report on the sanitary surroundings and particularly on the water supply of a place where an old Frenchman had died with "choleric dysentery." We found the place after some search, and discovered that the old man had died a month before, and that the suspected water supply, unboiled, had been used ever since by a certain headquarter staff without ill effects. Needless to say that was the best proof obtainable that the water supply was safe.
The use of raw milk was forbidden in the army, and condensed milk was issued instead. Sometimes "blown" cans of this were sent in for examination and found to be infected with gas producing organisms. Whenever such occurred, the report would be forwarded back through the system to England and the manufacturer would be apprised of the fact and checked up on his methods. Canned foods of various sorts were also brought in for examination, but nothing of a harmful character ever discovered. The food supply of the British Army, as a matter of fact, was of the highest quality and had been subjected to rigid examination by the Government inspectors during its preparation; practically none of it was ever found to be bad.
Another unusual problem arose out of the fact that several soldiers had contracted anthrax, both in England and in France, and the shaving brushes issued were suspected of being the cause. We undertook to search them for anthrax spores, but found it was too long and tedious a job for a field laboratory, for the brushes were full of spores of all kinds. Later on in England anthrax was actually found by other bacteriologists in some of these brushes, according to reports published.
These few examples taken at random will serve to demonstrate the varied character of the work of a field laboratory, and to show that a certain amount of experience is necessary in order to handle some of the problems affectively. We were peculiarly fortunate in our combined experience. Major Rankin, a first rate pathologist and bacteriologist of the government of Alberta, had been in charge of the government laboratory at Siam for five years previous to the war, and knew tropical medicine like a book, while Captain Ellis had carried on research work for three years in the Rockefeller hospital laboratories in New York and was thoroughly conversant with all the most recent work in vaccine and serum therapy. Consequently there was practically nothing that we could not tackle between the three of us, either in bacteriology, pathology, sanitation or treatment of epidemic disease.
Wherever an action was about to occur on the front the hospitals were evacuated of all sick and wounded in order to obtain the maximum number of empty beds. Consequently when fighting was going on the hospitals were very busy but the laboratory routine greatly decreased except in hygienic work. We therefore undertook scientific investigations of various kinds to keep busy and be of the maximum use.
At the suggestion of the D.M.S. of the army, Major Rankin made a survey of the army area for anopheles mosquitoes. The Indian corps was in our area at the time and he obtained the co-operation of the officers of the Indian Medical Service, who being particularly keen on biting insects collected many specimens for him. This variety of mosquito transmits malaria, and, as we were getting a few cases of malaria in troops who had been in tropical climates, it was important to determine accurately the varieties of mosquitoes present, particularly since the numerous ditches, canals and ponds of the country were ideal places for their multiplication. In spite of the anopheles mosquito being found everywhere, Major Rankin reported that he did not believe that there would be many new cases of malaria, develop in France and such proved to be the case.
Captain Ellis began an investigation into the grouping of the various strains of "meningococci"—the organism causing cerebro-spinal meningitis, with the ultimate object of obtaining a more efficient anti-serum for the treatment of this disease.
Apparatus designed to purify wash water from baths before turning it into the streams; designs for the building of small chlorinating plants near the trenches, and the construction of field incinerators for consuming garbage, were constantly being referred to us for consideration and suggestions; we thus had a variety of sanitary work of an interesting and useful kind, which helped to keep us busy.
The nature of our activities carried us through the area of shell fire, among the batteries and sometimes quite close to the trenches. We were free lances to all intents and purposes and frequently had to hunt out new problems to work upon. In travelling about in the course of our work we saw things more or less from the spectator's standpoint, and there were few things going on that escaped us.
Many sad and depressing sights were witnessed, and one received many vivid impressions of what war means to an invaded country,—impressions which can only be attained by actual experience.
Accompanied by the sanitary officer of the 19th division one morning I saw a very sad example of what ignorance of the essentials of hygiene can bring about. Down in a swampy spot on a branch of the canal was a little hamlet, and one of the tiny houses was occupied by a family of refugees from La Bassee.
When we entered the house swarms of flies flew up from the table and buzzed about while we did our best to prevent them from settling upon us. The father of the family was in bed unconscious, with typhoid fever. The mother, dead from the disease, had been buried the day before.
During the funeral the eldest daughter, a pretty girl of sixteen, sat up in a chair trying to look after the visitors. When we called she also was in bed delirious with the disease in the same room as her father.
The baby in the carriage had had typhoid. A little two year old boy was just recovering, and was thought to have been the original case. Two other boys of seven and nine years of age were getting some bread and milk for their dinner, one of them being probably a mild case; and a girl of eleven, evidently coming down with the disease, was going about looking after the household.
With that swarm of disease-carrying flies in the house there was no possibility of any of the children escaping the infection. It was with the greatest difficulty that the sanitary officer of the division succeeded in getting the French civilian authorities to move in the matter and remove the cases to the French civilian hospital. The father died a week later, and the sanitary officer himself was subsequently killed during the battle of the Somme.
The French refugees do not complain; they are not that kind. They told their stories simply and invariably finished with a shrug of the shoulders and the phrase "c'est la guerre n'est ce pas?" (That is war, is it not?) But if the French army ever gets on German soil I would hate to be a German.
One night we found that our first Canadian brigade was going into the trenches at Festubert without the chemical necessary to saturate their gas masks, which had just been issued to the soldiers; we succeeded in borrowing 500 pounds from a wide-awake army corps and took it down in the car to an advanced dressing station which the brigade would have to pass. The Germans were particularly jumpy that night as we felt our way along that very rough road with no light to guide us except the electric green light of the numerous German flares, the occasional flashes of a powerful German search light sweeping the sky and ground, and the angry red spurts from the guns which lit up the sky like summer lightning.
Once we had occasion to make a trip from one shelled village to another, the driver had been given the direction and no further attention was paid to him until we came across a reserve trench manned by Ghurkas. This drew our attention to the fact that the country was quite unfamiliar. However, the next French sign post showed us that we were on a road leading to the desired village and we kept on.
The day was very quiet and hazy and it was impossible to see very far. We suddenly came upon the remains of a little village which had been literally levelled to the ground; not two feet of brick wall could be seen anywhere. At the cross roads in the centre of the village two military policemen seemed to be surprised at our appearance with a large motor car but said nothing, evidently thinking that we knew our own business best, and we made the correct turn according to the sign board and kept on. About two hundred yards farther on we ran into a veritable maze of trenches, barbed wire entanglements and dug-outs, without doubt part of the front line trench system. Needless to say we made a rapid right-about face and speedily retraced our steps by the road we had come.
We found later on that the road we had taken did go to the village that we wanted to visit but that it went through the German trenches en route. At the point where we had turned, which was only four hundred yards from the German trenches, thirty men had been killed by snipers during that month while getting water at one of the wells in the neighborhood. The haze in the atmosphere saved us from observation for we would have been a fine target for rifles, machine guns and even whiz bangs.
We met officers in every branch of the service,—infantry, cavalry, artillery, flying corps, ordnance, army service, medical, engineers, construction, water transport, etc., and thereby obtained a splendid idea of what was going on, and how the various branches of the service worked together and viewed any given problem.
Some of these views were quite at variance with one another. For instance the artillery man looked upon the infantryman as the man who protected his guns and kept off the enemy while he killed them. The infantryman naturally looked upon the artillery as the arm to support him in time of trouble and prepare the ground while he did the dirty work. The aviator called them all "ground soldiers" in a more or less lofty manner.
The medical and other services looked upon the fighting man as the one who gave them a great deal of work, and they all usually forgot that they existed for the express purpose of keeping Tommy in the trenches clothed, fed, healthy and protected from the assaults of the enemy; for Tommy is the man, say what you will, without him everything else goes smash; it is the human being who still counts in war; it is the man power which will win.