NEW ZEALAND EXPEDITIONARY FORCE (REPORT OF DIRECTOR-GENERAL OF MEDICAL SERVICES SHOWING THE STATE OF THE HEALTH OF THE) WHILST IN CAMPS IN NEW ZEALAND, FOR THE YEAR 1916.

Appendix to the Journals of the House of Representatives, 1917 Session I, H-19j

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1917. NEW ZEALAND.

NEW ZEALAND EXPEDITIONARY FORCE (REPORT OF DIRECTOR-GENERAL OF MEDICAL SERVICES SHOWING THE STATE OF THE HEALTH OF THE) WHILST IN CAMPS IN NEW ZEALAND, FOR THE YEAR 1916.

Laid on the, Table of the House of Representatives by Leave.

Memorandum for the Hon. the Minister of Defence. Department of Defence, Wellington, 27' th July, 1917. I have the honour to submit a summarized report on the health of the New Zealand Expeditionary Force whilst in camps in New Zealand for the year 1916. The health statistics have been worked on the estimated average annual strength. R. S. F. Henderson, Surgeon-General, The Hon. Minister of Defence. Director-General of Medical Services.

NEW ZEALAND EXPEDITIONARY FORCE. Health of Reinforcements in New Zealand for the Year 1916, Strength. —The total number of officers and men who have been present in the trainingcamps during the year 1916 equals 42,390. The average strength was 11,772, Admissions to Hospital. —The total number of admissions to hospital was 12,048, giving an admission-rate per thousand of 1,023 and a constantly-sick rate of 19 - 59. Deaths. —There were 92 deaths from disease, of which 85 were in camp hospitals and 7 in civil hospitals elsewhere or at sea, giving a death-rate of 7'B per thousand on the average strength. In addition there were 9 deaths from accidents, of which 7 occurred out, of camp, and 3 suicides, giving a total number of deaths from all causes of 104. This amounts to a death-rate of 24 per thousand on the total numbers and of B'9 on the average strength. The prevailing diseases were influenza and measles. The diseases which caused the chief mortality were pneumonia (39 deaths) and cerebrospinal fever (36 deaths). Health of Camps. —As regards the four camps, the admissions and constantly sick, based on the average strength, with the number of deaths, were as follows : —

Thus Featherston, with a slightly increased constantly-sick rate, had a smaller admission-rate and fewer deaths than Trentham. Narrow Neck had a, smaller admission-rate but a, larger number of constantly sick and a higher death-rate as compared with Awapuni, which had no deaths at all.

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Camp, Average Strength. : Admissions Admissions. 1 per Thousand. ,, ,. Constantly constantly D - i 0 . , J Sick, per Sick. „,, ' r , thousand. Deaths. Disease. Accident Suicide. 37 I 2 45 1 1 3 I ■ I Featherston Trentham .. Narrow Neck Awapuni 6,466 4,737 317 193 6.277 970 5,239 1,105 319 1 .000 211 1,090 125-16 19-35 91-50 19-31 10-66 33-68 3-33 17-25

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That there was undoubtedly a large number of admissions in all the camps as compared with the Imperial Army in peace-time is largely due to the fact that as a precautionary measure Medical Officers admitted most of the men reporting sick, even trivial cases, who in civil life or in the Imperial Army would not have been admitted to hospital. The average number constantly sick is much the same as that of the Imperial Army in England in time of peace, which is 20 per thousand. Venereal Disease. —There were 356 cases admitted for gonorrhoea, 9 for syphilis, and 7 for soft chancre. This shows a total-adraisslon-rate of 877 per thousand on the numbers of men who passed through .camp, and of 3T6 per thousand on the average strength, or about half the amount that occurs in the Imperial Army in peace-time. The, admissions for the various camps were as follows : — Gonorrhoea. Syphilis. Qh ° n^ Trentham ... ... ... ... ... 227 6 3 Featherston ... ... ... ... ... 98 3 4 Narrow Neck ... ... ... ... ... 28 Awapuni ... ... ... ... ... 3 The ratio per cent, on the average strength, of the camps is—Narrow Neck, 8'?; Trentham, 4"9; Featherston, I*6; Awapuni, Is. The admissions for venereal disease show that the proximity of a large town affects the numbers of cases in New Zealand, just as it does elsewhere. Thus in England prior to war-time the, London district showed an admission-rate of 15 per cent., whilst the average admission-rate for the United Kingdom was between 6 and 7 per cent. Influenza. —The chief cause of, sickness in the camps, and accounting for 5,527 admissions, was influenza,. This is a disease which appears periodically in epidemic form, and was reported to be very prevalent in Wellington City last year. As regards the camps, at Trentham it accounted for 3,138 admissions out of a total of 5,241; at Featherston, for 2,234 out of 6,277; at Narrow Neck, for 124 out of 319; at Awapuni, for 31 out of 211. The disease was prevalent all the year at Trentham, but chiefly in January and February, June and July, when it attained its maximum, becoming less in August and September, and increasing in October and November, and almost disappearing in December. In Featherston it persisted from June to the end of the year, and in Narrow Neck the largest number of cases were in June and July. The proximity of Wellington and the large facilities for leave granted from camps, the crowded picture-shows, theatres, and trains, and the tendency to gather together in buildings in the cold months of June, July, and August, were the chief factors in the spread of this disease, reinforcements bringing it into camp with them. The fatigue of training in unwonted exercises rendered fresh recruits more susceptible, the disease being specially prevalent amongst the new arrivals. Free ventilation, fresh air, and segregation are the chief factors to bo observed in preventing its spread, hence the establishment of the camp at Tauherenikau, where new recruits are kept for a month. Measles. —The next most prevalent disease was measles, which is very prevalent in the towns of New Zealand, and is brought into camp by recruits and men on leave. At Trentham there were 572 eases, the largest number of cases occurring in July (100) and September (141). There were no admissions in February or March. At Featherston there were 1,548 admissions, the largest number being in August, September, and October. The reason for this large number in Featherston appeared to be that recruits usually left Trentham for Featherston in the third or fourth week of training, just at the time the three-weeks incubation-period of the disease was being completed, and developed it there. There being no compulsory notification for measles, it is most difficult to ascertain when men arrive from infected houses, and the best that can be done is to keep new and susceptible Reinforcements for a month apart at Tauherenikau, and rigorously to isolate all contacts when the disease occurs. In connection with this disease the trouble of leave occurs, as there is no knowing whether a, man on final leave —or, indeed, any leave —has had an opportunity of contracting the disease or not. Rigorous inspections for measles are conducted twice or thrice a, week, in camp of all troops. Unprotected adults of all ages—of whom there are so many in. the baekbloeks in New Zealand— are very susceptible to infection, and hence the necessity for every precaution being taken and all contacts isolated. in Narrow Neck Camp there were 15 cases, and in Awapuni 20. Cerebrospinal Meningitis was present in the Trentham and Featherston Camps during the year, and although the numbers diagnosed as such were only 51, yet they gave rise to a mortality of 36. The Assistant Director of Medical Services (Sanitary) has written a special note on the disease as it affected the camps, which is attached. The chief point, however, to notice is that the organism which causes the disease has very little capacity for resistance outside the body, tending to die rapidly when dried, or even when cooled down for three or four hours in naso-pharyngeal secretion or cerebro-spinal fluid. This lack of definite resistance of the organism means that it can be transferred only by contact with the fresh secretions of patients and carriers. It is usually freely ejected by coughing or sneezing, and not by ordinary breathing, and it can be carried in the throats of people who are perfectly healthy. Consequently it is not conveyed by clothes or hutments, or food or drink, but by inhaling the breath or cough of a carrier, ft is most prevalent jn cobl and damp weather, when colds and coughs are rife,

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To combat the disease the carriers have to be detected, and it is the custom at Trentham and Featherston, as far as possible, to swab all new recruits on arrival and all reinforcements before embarking for England. These swabs are examined microscopically and bacteriologically, and all carriers are isolated and treated in inhalation-chambers twice a day with sprays of sulphate of zinc or cldoramine T. until their throats are clear. This involves a great deal of labour, but it has been cheerfully and capably carried out, first by the Wellington Bacteriological Laboratory under Major Hurley, and in addition latterly at laboratories established at Trentham and Featherston under Major Leahy, N.Z.M.C, and Lieutenant Ross. Since this system has been established we have had no cases of eerebro-spinal fever on our transports, and the value of the spraying-chambers which have been fixed on all our transports, similar to those in our camps, has again and again been testified to by Medical Officers proceeding with troops, owing to their efficiency in controlling influenza, sore throat, mumps, and measles. Pneumonia. —91 cases, with 39 deaths. At Trentham there were 64 cases, with 21 deaths. The P.M.O. states that of 48 cases which followed upon measles 16 were probably complicated by eerebro-spinal meningitis. At Featherston there were 19 eases, with 17 deaths : these were all eases of measles which developed pneumonia. At Narrow Neck Camp there were 8 cases, with I death. At Awapuni there was none. There are two classes of pneumonia—one of simple lobar pneumonia, to which the cases at Narrow Neck Camp and the bulk of the eases which recovered at Trentham belonged; and the other broncho-pneumonia following on measles, which is a very fatal type of disease, being of a septic character. Some of these cases may have been complicated by the eerebro-spinal meningitis as the P.M.0., Trentham, believes, but I do not think it has been proved that all were so complicated. The A..D.M..5. (S.) has attached a full report on the subject. The indications for prevention by swabbing the throats of all within a ward —doctors, nurses, orderlies, as well as patients—where any of the patients are suffering from measles, influenza, or throat affections, and carefui isolation of all suspects, are carefully carried out. Scarlet Fever. —ls cases: Trentham, 4; Featherston, 4; Narrow Neck, 7; Awapuni, none. No deaths. It is satisfactory to note that in the case of notifiable diseases the camp Medical Officers were able to take prompt action and stop any spreading. All the cases at Trentham and Featherston were imported and promptly dealt with. At Narrow Neck the disease was imported and spread, to some contacts, who were all isolated, and no more cases occurred. The same remarks a])ply to diphtheria (6 cases) : Trentham, 3 cases and 1 death; Featherston, 3 cases, which all recovered. Alcoholism. —91 admissions: Trentham, 39; Featherston, 52. Nervous System. —l 29 cases, of which 41 were eases of epilepsy, with I. death. One death also occurred from convulsions. Mental Cases —l 9 in various forms, of which the largest number were eases of delusional insanity. There was only 1 case of alcoholic insanity. Some of these cases had previouslybeen in asylums, but had eluded the recruiting Medical Officers. Diseases of the Circulatory System. —There were 65 admissions for diseases of the heart and circulatory system, with 5 deaths —one from valvular disease, which occurred at Auckland whilst on leave; 1 of angina pectoris; 1 of heart-failure after an anaesthetic; and 2 from disordered action of the heart and syncope. Digestive System. —There were 966 admissions: Featherston, 654; Trentham, 193; Narrow Neck, 19; Awapuni, 17. The large number of admissions at Featherston was due largely to gastro-enteritis, which occurred chiefly in February and March and accounted for 334 cases. These eases occurred chiefly immediately after the camp was occupied, and have been ascribed to the presence of large numbers of flies, and the dirty condition of parts on the outskirts of the camp occupied by the civilian workmen engaged in building the camp. The water-supply wa.s carefully analysed and found free from contamination. Thanks to the skill and devoted labours of Professor Kirk the fly problem was speedily and effectively dealt with; careful sanitary supervision and cleaning-up was carried out by Major Gunn, the P.M.0., and his officers, and the epidemic, which was mild in character, cleared up. There were 69 admissions for appendicitis, with 2 deaths, one of which died after operation in Christchurch, and the other after a sudden attack at sea. General Injuries. —Effects of heat: 4'to burns and scalds; 10 to effects of sun in January and March whilst training —none serious. Other eases, 9, including 7 deaths out of hospital, 1 from shock, 2 from drowning, 1 from falling down a well, and 3 from falling and being run over by trains. Local Injuries, 610. Sprains and contusions accounted for most. 118 occurred at Trentham and 310 at Featherston, the large number at Featherston being partly accounted for by the rougher ground and the number of mounted troops and Artillery being stationed there. Poisons. —Formalin : 1 admission and I death (accidental). Ptomaine poisoning : 5 admissions; no deaths. Gas, I—carbon monoxide in power-house (accidental; died). Suicides. —At Trentham, 1, by hanging; at Featherston, 2, by cutting their throats. All were temporarily insane : no reason could be assigned otherwise for their acts. Health of the Various Reinforcements. —The Reinforcements which had the largest amount of sickness were the 17ths, with a percentage of 182 admissions and a constantly-sick rate of 49 per cent.; the 21st, with an admission-rate of 176 and a constantly-sick rate of 3'B; the 19ths, an admission-rate of 167 and a constantly-sick rate of 17; and the 18ths, admissionrate of 160, constantly-sick rate 23. The healthiest were the Engineers—admission-rate 12, con-stantly-sick rate 3; the Artillery, 44 and 1 ; the 23rds, 41 and 1. 'fhe mouths which showed the largest and the least numbers of admissions wore as follows :— At Trentham: Largest —July, 876; November, 530; June, 527; October, 523: in all of which influenza was the main factor in causing the admissions. The least numbers were in— l December, 130; April, 222; March, 227.

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At Featherston: Largest—August, 982; September, 696; July, 664: in all of which months influenza and measles were specially prevalent. The least numbers were in—January, 266; December, 315; April, 328. The largest and least numbers in hospital on any one day in Ihe year were: Trentham Largest, 203, on 30th July; least, (i, on 30th December. Featherston —Largest, 279, on 30th August; least, 9, on 29th December. Narrow Neck—Largest, 17, on 12th June and 14th September; least, 1, on Ist January. Awapuni —Largest, 17, on 30th January; least, none on Ist January, sth April, 28th September, Ist October, 29th November, and Ist December. Officers. —The health of the officers has been very good. Out of 103 admitted to hospital in all the camps there was only 1 death —from a bomb accident. At Trentham there were 76 admissions, chiefly influenza, (38), measles (15), injuries (II); at Featherston there were 23 admissions, of which 17 were due to. measles; at Awapuni. 4. of which 1 was due to a paralytic stroke, for which he was invalided; at Narrow Neck, none. Genera! Bemarks. It is satisfactory to notice how very little the troops have suffered from diseases such as enteric, dysentery, diarrhoea, and other complaints such as are conveyed by impure water, bycontaminated milk and food, and by dirt. This is a satisfactory testimony to the efficient drainage and water-supply as well as to the high standard of the quality of the rations All the camps are in every sense of the word clean camps, the latrines, urinals, cookhouses, ablution and bath places, and hutments being kept under constant and careful sanitary supervision. Most of the maladies from which the men have suffered have been inhaled into their throats and lungs. In this way influenza, measles, and eerebro-spinal meningitis have arisen and spread, The indications to prevent these diseases are —first, to have good well-gravelled roads, to allow no water to accumulate in the camps, to sec that spouting is provided to all hutments to prevent the rain from the roofs splashing down on the roads, and to see that water from the spouting is run in proper drains, and that the ground under the floor of the hutments is kept dry; secondly, to see that men make proper use of the drying-rooms; thirdly, to keep men away as much as possible from, towns in winter (the fault of Trentham is that it is much too near Wellington); fourthly, the avoidance of overcrowding in buildings; fifthly, the provision of ample hospital accommodation for isolating the sick; and sixthly, to promptly segregate all contacts in infected cases. With the extra camps at Heretaunga and Tauherenikau there should be provision to meet, the emergencies occasioned by the temporary overcrowding of troops in camps owing to transports not sailing until some days or weeks later than expected, or when the wet weather prevents the men marching over the Rimutakas and brings them a day or two earlier than was anticipated into freshly vacated huts which would have been all the better had they been left empty and been well aired for a day or two before reoecupation. The Tauherenikau Camp is a segregation camp formed for the use, especially during the winter months, of recruits during their first month of service, that being the most susceptible period of their training. Coming in as they do from all parts of the country, and having been possibly in contact with infectious diseases, it has been considered advisable to segregate them in camps under tents —each district by itself —until the longest period of incubation of any infectious disease is over. As the tents contain only six or eight men it is a simple matter, and avoids least dislocation of training, to segregate only the five or seven occupants of a particular tent, should one of its inmates develop infectious disease. Rigid inspection of every man in these camps is made every day by the Medical Officers to ensure that any ease of commencing sickness is promptly dealt with. I have already referred to the great, use of the inhaling-chambers now established at each cam}), about which 1 have received very favourable reports from all the camps, 'there has been a, difficult}' in procuring the most efficacious drug for spraying—chloramine T. — indeed, it is not procurable in a manufactured state, but the ingredients are being imported from America, and, thanks to the co-operation of the Senatus Academicus of the University of and of Professor Inglis, the Professor of Chemistry, this drug is now being manufactured by him and his assistants. With his assistance, and also with the Hacteriological Laboratories established at Featherston and Trentham, we are now in a, much better position to attack the ever-threatening menace of eerebro-spinal fever. I have already alluded to the way the fly plague at Featherston has been overcome by Professor Kirk. I must also allude to the great exertions made by Captain Pettit, N.Z.M.C., in controlling venereal disease, both by his admirable lectures, lantern-slides, and pamphlet; and it is satisfactory to note that the admission-rate for this disease in our camps is much lower than that in the Imperial Army. R. S. F. Henderson, Surgeon-General, Director-General of Medical Services

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STATISTICS (SHOWING THE HEALTH OF TROOPS) FOR THE FOUR MILITARY CAMPS, 1916, Fouu Reinforcement Camps. Average annual strength. 11,722. Admitted into hospital, 12,048. Average number constantly sick, 230-65. Deaths.—ln camp; Disease, 85; accident, I; suicide, 3; poison (accident), 1 : total, 90. Out of camp : Disease, 7 (in hospital); accident, 7: total, 14. Total deaths, 104. Table showing the Admissions into Hospital by Diseases and the Number constantly sick amour/ the Troops of the Expeditionary Force in the Dominion for the Year 1916. Estimated average annual strength, 11,772. Average sick time to each soldier, 2'li days. Average duration of each ease of sickness, 7'ol days.

Disease. Admission to Hospital. L Deaths. Average Number constantly sick. I I General Diseases. Group A. — Cerebro-spinal fever ., Cow-pox Chicken-pox. . Diphtheria . . . . Influenza Enteric fever Enteritis, infective German measles Measles Scarlet fever Whooping-cough Paratyphoid Mumps 51 9 7 6 5.527 5 2 36 I 2 3-77 0-07 0-26 0-31 06-07 0-08 0 02 447 86-83 0-91 0-01 o-o.", 0-06 117 2,155 15 1 I I 2 Group 11— ■ Dengue Dysentery .. 2 - 6 0-02 0-05 ( rl'OUp ('■ Malaria ■ 0-01 ((roup I) Pyrexia of uncertain origin 5 0-09 (Iroup E- - Erysipelas Ostca myelitis Periostitis .. Pyapmia Septicemia Inflammation of lymphatic glands Inflammation of connective tissue Abscess of connective tissue Boils Carbuncle Onychia Dicer Whitlow 4 2 4 2 3 I I 27 30 56 7 12 29 8 0-18 0-01 (HI 0-1,1 0-18 0-14 0-36 0-51 1-00 0-14 0-15 0-48 0-10 Group FTetanus I 0-05 Group G — Pneumonia Rheumatic fever Sore throat Tonsilitis 91 97 103 115 39 4 -72 I -74 1-16 1-31 Group H— Tubercle of lung Other tubercular diseases 15 3 2 0-57 0-09 Group I- —• Gonorrhoea Syphilis Soft chancre 356 9 7. 13-17 043 0-09

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Table showing the Admissions into Hospital by Diseases and the Number constantly sick among the Troops of the Expeditionary Force in the Dominion for the Year 1916 —continued.

Featherston Military Camp, Average annual strength, 6,466. Admitted into hospital, 6,277. Average number constantly sick, 125-16. Deaths.—ln camp: Disease, 37; accident, I; suicide, 2: total, 40. Out of camp; Disease, 5 (in hospital); accident, 2: total, 7. Total deaths, 47. Table showing the Average Strength, Admissions into Hospital, Deaths, and, Numbers constantly sick among the Troops stationed at Featherston Military Gamp daring the Year 1916. Average strength, 6,466. Average sick time to each soldier, 9*7 days. Average duration of each case of sickness, 729 days.

■ lv Admission to .. ,, Disease. tt ,, , Deaths. Hospital. Average Number constantly sick, General Diseases- continued. Alcoholism .. . . . . . . 91 Other intoxications .. .. .. .. 7 Scabies . . .. . . . . . . . . 56 Other parasitic diseases .. . . . . . . ; 22 Debility .. .. .. .. .. 15 Other general diseases .. .. .. .. 61 0-86 0-04 1-09 0-20 ()-l(i 0-78 Local Diseases. Nervous .. .. .. .. .. 129 3 Mental . . .. .. . . . . .. 19 Diseases of the eye .. . . . . .. j 75 Other organs of special sense .. .. .. 18 Valvular disease of the heart .. .. 10 1 Other diseases of the circulatory system . . . . 55 4 Diseases of the respiratory system . . .. .. 409 Hernia .. .. ".. .. .. .. j 9 Other digestive diseases .. .. .. .. j 966 2 Lymphatic system* .. .. .. .. 3 Urinary system .. .. .. .. .. 67 Generative system (except-soft chancre) .. .. ! 45 Myalgia . . . . .. . . L19 Other diseases of organs of locomotion . . . . j 83 Connective tissue* . . . . ,. . . 12 Skin* .. .. .. .. .. .. ! 171 1-80 0-20 0-89 0-18 0-09 0-72 7-05 0-13 10-18 0-05 1-00 0-76 2-24 1-32 0-18 2-26 Injuries— Sunstroke .. .. .. .. .. 10 Other general . . . . . . .. 12 1 Local .. .. .. .. 613 3 In action .. .. . . .. .. I Poisons. . .. . . . . . • 7 I Effects of antityphoid .. .. .. .. 51 Suicide .. .. .. .. • • • • ■ ■ 3 No appreciable disease . . .. . . 3 0-1 I 0-31 7-82 0-02 0-08 0-2 S 0-03 Totals 12,(MS 10! 230-65 j * Except those included under the heading of "Minor septic diseases."

Disease. Admission to Hospital. Deaths. Average Number constantly sick. General Diseases. Group A-Cerebro-spinal fever Cow-pox Diphtheria Influenza Measles Scarlet fever Whooping-cough Paratyphoid 21 9 3 2,234 1,548 4 I 1 15 1 1-84 0-07 0-18 27-19 61-92 0-1 7 0-01 0-03 Group B — Dengue Dysentery 1 2 0-01 0-03

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Table showing the Average Strength, Admissions into Hospital, Deaths, and Numbers constantly sick among the Troops stationed at Featherston Military Camp during the Year 1916 —continued.

., ,, Admission lo .. ,. Average Number Deaths. „ .. . Deaths. ,° ., . . Hospital constantly sick. Deaths. _ '< . n ,,„ r\ General Diseases- -continued. Iriottp (j — Malaria. . . . . . . . . . . I . . 0-01 Group EErysipelas .. .. .. .. .. 2 ,.. 0-09 Periostitis . . .. . . .. . . 4 . . 0-11 Pysemia .. .. .. ..... 2 .. 0-11 Septicaemia .. .. .. .. .. 3 I 0-18 Inflammation of the lymphatic glands . . . . 3 . . 0-02 Inflammation of connective tissue . . . . 23 .. 0-31 Abscess connective tissue .. .. .. 11 .. 0-21 Boils .. .. .. .. .. 12 .. 0-18 Carbuncle . . . . .. . . . . 5 . . 0-08 Onychia .. .. .. .. .. 10 .. 0-13 ITlcer ... .. .. .. ,. 13 .. 0-21 Whitlow . . . . .. . . .. I .. 0-01 Group G— Pneumonia .. . . . . .. . . 19 17 0-73 Rheumatic fever .. .. .. .. 97 .. I -74 Sore throat . . . . .. . . .. 21 . . 0-28 Tonsilitis .. .. .. .. .. 71 .. 0-75 Group II — Tubercle of lung . . . . . . . . 2 2 . , 0-04 Group I— Gonorrhoea .. .. .. .. .. 98 .. 4-31 Syphilis .. .. .. .. .. 3 .. 0-16 Soft chancre .. . . .. . . 4 . . 0-03 Alcoholism .. . . . . . . ..- 52 . . 0-55 Other intoxications .. . . . . . . 2 .. 0-01 Scabies.. .. .. .. .. .. 12 .. 0-11 Other parasitic diseases . . .. . . . . 9 . . 0-08 Other genera] diseases .. . . . . . 53 .. 0-68 Local Diseases. Nervous .. . . . . . . . . 79 I 0-99 Nervous svstem .. . . . . . . 7 .. 0-08 Eye .." .. .. .. .. ,, 31 .. 0-37 Other organs of special sense .. .. .. 7 I 0-08 Valvular disease of heart . . .. . . . . I I 0-01 Other diseases of the circulatory system .. 36 3 0-56 Respiratory system .. .. .. .. 293 .. 3-91 Hernia . . . . .. . . . . . . 5 . . 0-08 Other digestive diseases .. . . . . . . 736 2 8-00 Lymphatic diseases* . . . . . . I . . 0-02 Urinary diseases . . . . . . . . . . 42. . . m 0-68 Generative (except soft chancre) .. . . . . 24 .. 0-37 Myalgia. . .. . . . . . . . . 47 . . 0-78 Other diseases of organs of locomotion . . . . 51 . . 1-00 Skin* .. .. .. .. .. .. 87 .. I-II Injuries — Sunstroke .. .. .. .. .. 1 .. 0-02 Other general . . . . .. . . 8 2 0-23 Local .. .. .. .. .. 310 .. 3-95 Elects of anti-typhoid .. .. .. .. 51 .. 0-28 Poisons .. .. .. .. .. 3 0-03 Suicide .. . . . . . . . . . . . . 2 Totals .. .. .. .. 6.277 47 125-16 _ ' _ J_ * Except those included under the heading of "Minor septic diseases." Officers. The health of the officers was good. Admissions to hospital, 23; ratio per thousand, 14*3 j deaths, nil.

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Trentham Military Cami\ Average annual strength, 4,737. Admitted into hospital, 5,241. Average number constantly sick, 91-5. Deaths. —In camp: Disease, -15; suicide, 1; poison (accidental), 1; total, 47. Out of camp: . Disease, 2 (in hospital); accident, 5 : total, 7. Total deaths, 54. Tattle showing the Average Strength, Admissions into Hospital, Deaths, and Numbers constantly sick among the Troops stationed at Trentham Military Camp during the Year 1916. Average strength, 4,737. Average sick period for cacb soldier, 835 days. Average duration of each case of sickness, 639 days.

Disoase. Admitted to Hospital. Deaths. ! Average Number constantly sick General Diseases. Group A— Cerebro-spinal fever Chicken-pox. . Diphtheria Enteric fever Enteritis, infective German measles Influenza Measles .. Scarlet fever 30 7 3 3 2 117 3,138 572 4 21 1 -93 0-26 0-13 0-01 0-02 4-47 35-58 23-34 0-15 1 Group B— Dengue Dysentery 1 3 0-01 0-02 Group E — Major septic diseases Minor septic diseases 4 51 0-10 0-63 Group F Tetanus 1 0-05 Group G- — Pneumonia . . Sore throat, Tonsilitis . . .. . . . . • 64 55 27 21 3-52 0-61 0-36 Group H— Tubercle of lung Other tubercular diseases 30 3 0-53 0-09 Group I— Gonorrhoea Syphilis Soft chancre. . . . . . .. 227 6 3 6-86 0-27 0-06 Alcoholism Other intoxications Scabies Other parasitic diseases Debility Other general diseases 39 5 31 30 15 4 0-31 0-02 0-51 0-12 0-16 0-02 Local Diseases. Nervous system : Nervous Mental.. 43 12 42 II 9 16 85 3 193 2 23 17 51 20 12 82 2 0-60 0-15 0-49 0-10 0-08 0-15 1-24 0-02 2-58 0-03 0-29 EyeOther organs of special sense Valvular disease of the heart Other diseases of the circulatory system Respiratory system .. .. .. Hernia .. .. .. .. .. Other digestive diseases .. .. ,. Lymphatic* .. .. .. ,. Urinary .. .. .. . • Generative (except, soft chancre) .. . . Myalgia . . . . . . . . .'. Other diseases of organs of locomotion . , Connective tissues* .. .. .. Skin* .. .. .. .. .. .. i 1 0-31 0-72 0-31 0-18 1.04 * Except those under the heading "Minor septic disi igtses."

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Table showing the Average Strength, Admissions into Hospital, Deaths, and Numbers constantly sick among the Troops stationed at Trentham Military Camp during the Year 1916 —continued.

Officers. The health of the officers was good. Admission to hospital, 76; ratio per thousand, 503*81. Death, 1, Ratio per thousand, 662. The death was the result of a, bomb accident. Narrow Neck Military Camp. Average annual strength, 370. Admitted into hospital, 319. Average number constantly sick. 10-66. * Deaths.—ln camp : Disease, 3. Out of camp : Nil. Total deaths, 3. Table showing the Average. Strength, Admissions into Hospital, and Numbers constantly sick among the Troops stationed at Narrow Neck Military Camp during the Year 1916. Average strength, 370. Average sick period to each soldier, 1231 days. Average duration of each case of sickness, 1223 days.

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Disoase. Admitted to Hospital. Deaths. Average Number constantly sick. ■ . ■ Local Diseases —continued, njuries— Sunstroke . . Other general Local In action Poisons No appreciable disease Suicide 8 3 158 1 4 3 3 0-08 0-04 2-83 0-02 0-05 0-03 i i Totals 5,239 54 91 -50

Disease. Admitted to Hospital. Deaths. Average' Number constantly sick. General Diseases. Group A— Enteric fever Influenza Measles Scarlet fever 2 124 15 7 2 0-06 2-69 1-04 0-59 Group D— Pyrexia of uncertain origin 3 0-07 Group E-— Inflammation of lymphatic glands Inflammation of connective tissue Abscess of connective tissue Boils 3 1 5 24 0-08 0-02 0-11 0-60 Group G— Pneumonia Sore, throat 8 4 1 0-46 0-06 Group I — Gonorrhoea 28 1-92 Scabies 12 045 Local Diseases. 3 2 I 19 1 3 18 11 1 0-14 0-03 0-01 0-34 0-12 0-04 0-71 0-30 0-01 Nervous Bye Circulatory system Digestive system Respiratory system Generative system Myalgia Other diseases : Organs of locomotion Skin .. Injuries — General Local 1 23 0-04 0-77 Totals 319 10-66

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Officers. The health of the officers was good. There were no admissions to hospital and no deaths. Awapuni Military Camp. Average annual strength, 199. Admitted into hospital, 211. Average number constantly sick, 333. Deaths: Nil. Table showing the Average Strength, Admissions into Hospital, Deaths, and Numbers constantly sick among the Troops stationed at Awapuni Military Gamp during the Year 1916. Average strength, 199. Average sick time to each soldier, 6\36 days. Average duration of each case of sickness, 5*78 days.

Officers. The health of the officers was good. Admissions to hospital, o'4; ratio per thousand, 34. There were no deaths. Rejection of Recruits after Arrival in Camps. The number rejected was 2,440, out of 42,390 who were in and passed through camps during the year, giving a rate of 57 per thousand. These only represent men who had already been previously passed as fit by Medical Officers. Full statistics as regards rejected in the districts by Medical Boards will be furnished separately.

Disease. Admitted to Hospital. i Deaths. ! Average Number constantly sick. General Diseases. Group A- — Influenza Measles Mumps 31 20 4 0-06 0-55 0-06 Group B-— Dysentery Pyrexia of uncertain origin I 2 0-01 0-02 Group E— Minor septic diseases . . . , . . .. , 18 0-29 Group G— Sore throat Tonsilitis 23 17 0-21 0-19 Group I— Gonorrhoea 3 0-08 Scabies Other general diseases 1 4 0-02 0-07 Local Diseases. 4 30 1 18 2 1 3 I 4 0-07 042 0-04 0-25 0-03 0-04 0-03 0-01 0-07 Nervous system Respiratory system Hernia Other digestive diseases Urinary system Generative system Myalgia Other diseases of organs of locomotion Skin-diseases* . . . . InjuriesSunstroke Local injuries I 22 0-01 0-27 Totals 211 3-33 * Except those included tinder the headin, ig of "Minor septic e diseases."

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It will be noticed that myalgia (226) and rheumatism (188) constituted by far the largest number of rejections, although defects of the lower extremities account also for a large proportion. Diseases of the nervous system and weakness of intellect are also important causes. The whole subject of physical defects will be noted more fully in another paper. Causes of Rejection. Syphilis . . . . . . . . 13 Diseases of the. thyroid glands . . . . 16 Tubercle of lung . . . . . . 45 Diseases of the urinary system .. .. 11 Rheumatism . . . . .. . . 188 Varicocele .. . . . . . . 85 Debility .. .. . . .. 124 Other diseases of the generative system .. 29 Other general diseases . . .. .. 213 Flat feet .. .. .. .. 58 Diseases of the nervous system .. .. 211 Myalgia .. . . . . . . 226 Diseases of the eye . . . . . . 107 Deformed feet . . . . . . 61 Diseases of the ear . . . . . . 1.14 Other diseases of the. organs of locomotion 88 Diseases of the nose .. .. .. 11 Diseases of the skin .. .. .. 19 Valvular disease of the heart . . . . 32 Defects of the upper and lower extremities 304 Disordered action of the heart . . .. 56 Sunstroke . . . . .. . . 1 Diseases of the veins (varix) . . .. 80 Poison (narcotic) .. .. . . 1 Diseases of the respiratory system .. 89 —— Hernia .. .. .. .. 96 Total .. .. .. 2,440 Other diseases of the digestive system . . 162

CHAMBERS FOR INHALATION TREATMENT, MILITARY BASK HOSPITAL. On the 12th September the treatment by a steam vaporizer for sore throats and meningococcus and diphtheria carriers was instituted. At first the only machine available, an old-fashioned Lister spray, was used, and cases treated with this machine showed conclusively that the treatment was almost a real specific, and warranted a more efficient apparatus. On the 22nd September a new machine, capacity 80 oz., was procured, and the results since obtained show that it has been of great value in dealing with the epidemics of sore throats and clearing up carriers of the meningococcus and bacillus diphtherias. Up to the 31st December, 1916, in all, 1,879 cases were treated in the iuhalatorium at Trentham; of these, 1,613 were sore throats and colds, 261 were suspected carriers of meningococcus in Classes I and 11, and 5 were diphtheria-carriers. In addition to this all (he hospital wards were visited with the machine, but the difficulty of securing a properly saturated atmosphere in a ward probably interfered with the efficacy of the treatment; at the same time, all carriers who were discovered in the wards were effectually cleared up.

Sore Throats. —Of 1,613 eases treated, 1,401 were discharged from sick-parade as cured, 104 were improved, while no change was observed in 108 cases. All of the men shown as improved in return were afterwards discharged as cured at the completion of treatment, whereas of the 108 men shown as "no change " many were afterwards sent to hospital with influenza. The zinc sulph. treatment did not seem to be particularly effective in eases of influenza, anil towards the latter part of the year' these cases were not put through the chamber. Cerebrospinal Meningitis and Diphtheria, Carriers. —In order to cope with the increase of eerebro-spinal fever a system of parades for throat-inspection was adopted in September, and swabs were taken from the naso-pharynx of every man in camp. The camp Permanent Staff were swabbed once and each Reinforcement twice —once on entering camp as recruits and again just prior to embarkation. On bacteriological examination all carriers in Classes I and II were immediately placed m an isolation camp set aside for the purpose, and while there were treated twice daily in the inhalatorium until further examination proved them to be free. No man was released from isolation until he had two clear swabs, taken at an interval of two days. Many cultures were sown for the Bacteriological Department. At first, in September, in the experimental stages, a solution of zinc sulph. was used, giving a 1-per-cent. vapour in the atmosphere. This was found to be efficacious, but the treatment was necessarily slow, and the small machine was unable to provide a properly saturated atmosphere. Later, using a larger machine, the solution was increased to 2 per cent, and even 5 per cent, in the atmosphere. It was proved that the saturated atmosphere of a 5-per-cent. solution can be tolerated without much discomfort for a period of from ten to twenty minutes. No injurious

Cases treated. Cured. Improved. No Change. Sore throats and colds . . . . • • • Suspected cerebro-spinal fever carriers Diphtheria-carriers 1,613 261 5 1,879 shargcd as cured. 1,401 261 5 1,667 104* 108 104 108 Totals * Since disc

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after-effects were at any time observed, but it became evident that without a respirator the operator of the machine could not remain in the atmosphere for more than an hour without discomfort and without epitaxis appearing. An interesting fact discovered during October was that a man who had eighteen months previously been a patient in this hospital with eerebro-spinal fever, and had been discharged from the Forces for at least a year, on re-enlistment was examined carefully and a swab taken and he was found to be a first-class carrier. He was treated, special care being taken in his case, and after the usual period of isolation and treatment the meningococcus was found to be entirely absent. This was confirmed later, but it was considered inadvisable to allow him to embark, and he was discharged. Diphtheria-carriers. —Five only appeared, and these were treated with a Eusol spray, which proved effective in three days, producing a negative result in each case. General. —On the whole the results obtained from the installation of these machines show that the system is a valuable adjunct, and worthy of fostering. Lieut.-Colonel Andrew, G.M.O.

MENINGOCOCCAL INFECTION IN MILITARY CAMPS DURING 1916. The Director-General, Medical Services, Headquarters. The following report summarizes the facts connected with the appearance of meningococcal infection in the camps in New Zealand during the year 1916. Seasonal Distribution. Cerebro-spinal Fever. —Save for 1 case remaining under treatment in Trentham Hospital, no case of cerebro-spinal meningitis was reported from the camps during January and February. The first case occurred on the 20th March, at Featherston, when a fatal case in the 12th Mounted Rifles was reported. No case was reported at Trentham until the 20th July, when 2 fatal eases occurred in the 18th Reinforcement, followed by 3 other eases in that unit. Thereafter at Trentham the disease became epidemic during August, when 14 eases arose, lessening in September (5 cases) and October (7 eases), dying out in November (2 cases) and December (1 case). At Featherston, on the other hand, only I case was reported in July and only lin August. The disease did not become more general till September, when 8 cases arose. Thereafter it diminished to 3 cases in October, 2 in November, and 2 in December. The seasonal distribution therefore differed considerably in the two camps. Pneumonia following Measles. —This disease was present in Trentham in January, when 1 nonfatal case occurred, reappearing in May with 2 non-fatal cases. In June 2 out of 5 cases died. A very fatal type of the disease became prevalent in the latter half of July. During July and August 14 cases occurred, with 12 deaths. In September there were 4 cases, with 2 deaths; in October and November 2 cases, both fatal; and in December 3 cases, 1 fatal. A.t Featherston the severe type of pneumonia appeared in March, when 2 fatal cases occurred, but it was absent in April. During each of the months May, June, and July I case was reported, all being fatal; and in August 3 eases arose, also all fatal. In October it fell to I case, but rose to 4in November, 3of them dying. In December it fell to 2 cases, 1 being fatal. It will be noticed that in each camp the fatal type of pneumonia followed fairly closely the distribution of cerebro-spinal fever. The attached table indicates the monthly distribution of each disease: —

Monthly Distribution of each Disease.

Trent ;h am Feathi srston. Month. Cerebrc Menii i-spinal lgitis. Pneui nonia. a. Cerebro-spinal Meningitis. Pneumonia. Cases. Deaths. Cases. Deaths. >aths. i. Cases. | Deaths. Cases. I Deaths. l_ January February March April May June July .. August. September October November December 1 1 1 2 2 2 2 5 14 5 7 2 1 5 8 2 5 8.. 6 4 1 1 3 2 6 6 2 1 1 1 3 2 2 I 1 1 1 I 8 4 3 2 2 2 2 1 1 I 3 4 1 4 2 1 I 1 3 3 1 3 1 5 1 1

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Incidence and Mortality. Cerebrospinal Fever. —ln all 59 eases of this disease have been dealt with during the year 1916 among the troops. Of these, 4 cases were treated in hospitals outside the camps—one in Auckland, one in Masterton, one at Otaki, and one in Tiinaru—these patients being men on leave from Trentham or Featherston. Certain cases given in the returns as " measles " and "influenza " are included, as subsequent results revealed meningococcal infection. In 5 eases soldiers on leave were notified from outside the camp as probably suffering from cerebro-spinal meningitis. The diagnosis lacked confirmation, and they are not included in the 59 given above. ■ Of the 59 cases 36 died, giving a ease mortality of 61 per cent. Thirty-five of the cases came from Trentham Camp, of whom 21 died, yielding a case mortality of 60 per cent.; 24 cases came from Featherston Camp, of whom 15 died, a ease mortality of 62-5 per cent. The mortality in the two camps, therefore, is much the same. No cases were reported from Awapuni or Narrow Neck Camps. The mortality shows a marked seasonal variation. Thus from January to the end of July 14 cases occurred, with 12 deaths—a mortality of 80 per cent.; from the lst August to the 31st December 44 cases, with 24 deaths, occurred—a mortality of 545 per cent. It is shown in the following table :—

Seasonal Mortality.

The difference in the mortality between July and September is very marked, especially at Trentham. It rises again very noticeably in October, and though the figures for November and December are too small to yield a reliable percentage it is evident that the mortality was again tending to decrease. The drop in mortality in September has been attributed to the use of autogenous vaccines; but, as the same methods of preparing vaccine were followed in October, when the mortality rose, this explanation does not seem sufficient. In most epidemics of infectious disease there is a tendency for the virulence to decrease towards the end of the outbreak, and as nearly all the cases in September occurred in the first two weeks one can regard them as the final cases of a first outbreak, and the October cases as being the beginning of a second epidemic with renewed virulence. Pneumonia. —A total of 50 eases of pneumonia following measles occurred in men from the two main camps during 1916. Of these 35 were fatal, yielding a case mortality of 70 per cent. Thirty-one cases were reported from Trentham, with 19 deaths—a case mortality of 61*3 per cent. Of these 31 cases I was reported from Dunedin Hospital. Of the 19 cases which occurred at Featherston 16 died—a case mortality of 84 per cent. The high mortality at Featherston probably is due to the presence of a special type of infection throughout the year, whereas at Trentham this type did not appear till July, as will be noticed when we consider the seasonal variation. The seasonal variation in mortality wholly differs from that of cerebro-spinal meningitis. Thus at Trentham up to the middle of July, out of 10 cases only 2 deaths had occurred. From the 16th July to the 31st December out of 21 cases only 3 recovered, which closely corresponds with the figures for- the whole year at Featherston. The appearance of the fatal type of pneumonia at Trentham corresponds with the appearance of cerebro-spinal meningitis at that camp, the first ease of which occurred on the 20th July. It was subsequent to that date that the pneumonia cases following measles became so virulent. At Featherston, on the other hand, cerebro-spinal meningitis had been present since March, and the pneumonias (which first appeared in that month) were all of a virulent type. Of pneumonias not connected with measles, 12 cases occurred at Trentham, with 5 deaths. Some of these may have been cases of the specific infection accompanying the cerebro-spinal meningitis outbreak. Certainly one which occurred in November and followed influenza had all the features of the virulent post-measles type, and proved fatal. Two others which occurred in the latter half of July after the cerebro-spinal meningitis outbreak began also were fatal. It is probable these 3 deaths were cases of specific infection. Of the remaining 9 pneumonias not following measles the majority occurred before the cerebro-spinal meningitis outbreak, and it is possible that they were—like the earlier post-measles cases—simple pneumococcal infections. Assuming that this is the case, we find the mortality at Trentham from

Month. Trentham. Featherston. Totals. ' p eroenta[ , 0 I— of Cases. Deaths. Oases. Deaths. Cases. Deaths. i ; January February March April May June July August September October November December 1 5 14 5 7 2 I 1 5 8 0 5 1 1 '2 3 2 1 1 8 3 2 2 '2 2 I I I 4 2 0 2 I 2 3 2 (i 15 13 10 4 3 I r 2 .. 2 IJ 6 9 4 7 1-1 3)' 75 100 60 30 70 57

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such eases is 21 per cent., in marked contrast to the 85-per-eent. mortality of the other class of pneumonia associated with cerebro-spinal meningitis. At Featherston 3 cases of pneumonia unconnected with measles occurred, with 2 deaths. From the high mortality it is possible that they too may have been infections of the specific type. • Age Incidence. The following tables show the distribution of cases in the various age-groups: —

Cerebro-spinal Meningitis.

Cerebrospinal Meningitis. —The influence of age on the prevalence of this disease is very marked, 32 out of 59 cases, or more than half, occurring in men under twenty-two. We have no statistics for age distribution among the troops, but it is very improbable that half the men are under twenty-two years, so we cannot attribute the high distribution amongst the youngest men to a preponderance of men of those ages. Of the 22 cases (if twenty years it is probable that some were among lads under twenty, but allowing for this there is a very marked drop from twenty to twenty-one. From twenty-two to thirty we find a fairly even distribution of eases to each year, and a marked decline after thirty. Only I case was notified in a man over forty. As regards variation in mortality according to age-grouping we find the following: — Under twenty-two years: Cases, 32: deaths, 18; case mortality, 56 per cent. Twenty-two years and over : Cases, 27 ; deaths. 18 ; case mortality, 66 per cent. The disease, then, though much more prevalent among the youngest men, was markedly less fatal than to the more mature patients. On examining the mortality at each age-period it appears to be most fatal to those between twenty-live and thirty, the ratio being as follows: Under twenty-one years, 56 per cent.; twentytwo to twenty-four years, 66 per cent. ; twenty-eight to twenty-nine years, 75 per cent. ; thirty years and upwards, 55 per cent. Pneumonia following Measles. —This disease was also more prevalent among the younger men, 26 out of 50 being under twenty-three years of age. The prevalence among men under twentyone was less marked than with cerebro-spinal meningitis, for although 31 of the cases occur in the first quinquennial age-group as against 10 in I he next, the distribution is more even in the first three years of military life. The case mortality increased among the older men thus: Under twenty-two years: Cases, 20; deaths, 12; case mortality, 60 per cent. Above twenty-two years : Cases, 30; deaths, 23; case mortality, 76 per cent. The highest mortality was among men in the quinquennial period thirty to thirty-four, and was lighter in the previous group, thus differing somewhat from meningitis. This is not perhaps surprising, as measles has always been recognized as proving a formidable disease—if a rare one— among older patients.

Age. Under 20. i i I" 20 to 24. 25 to 29. 30 to 34. ' 35 to 39. ! , 40 and over. 20. 21. 22. 23. 24. ' I l ~ l '""{ 'totals. Cases Deaths Case mortality r I r .. ,| .. 100% 22 9 2 2 2 "I > ., i I 12 6 2 1 37 J 13 4 1 1 2 ] > r . 9 4 1 21 j 57% 75% 66% 50% 59 36 61% • I I . Pneumonia following Measles. Age. 20 to 24. Totals. Under 20. 25 to 29. 20. 21. 22. 23. 24. 80 to 34. 35 to 40. t Cases Deaths Case mortality i ! f II 9 6 2 3 ] .. <| > -v ' y io 31 f 8 4 5 2 2 II ... | -- (', I 21 j 67% 60% 7 7 2 I 50 35 100% 50% 70%

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Association op Meningococcal Infectiom with other Diseases. Influeiua. —In the Public Health Report it was stated that up to September the prevalence of influenza did not have a very marked effect on the incidence of meningitis in either camp. The attached table shows the monthly incidence of meningococcal infection, and the number of influenza, and measles cases reported: —

At Trentham influenza became very prevalent in June, when 5 cases of pneumonia following measles occurred—none, however, definitely meningococcal in origin—and no cases of meningitis. In July influenza rose to its height, and 5 cases of meningitis occurred. But influenza fell to one-half in August, and now 14 cases of meningitis arose. There was another rise in influenza in November, but only 2 eases of meningitis resulted. Similarly at Featherston, when influenza was at its height in July and August only 1 case of meningitis occurred in each month. There was not then any close connection between the prevalence of influenza and the spread of meningococcus. Measles. —With measles there is much closer union, since we must accept the pneumonic complication as being in the majority of cases a meningococcal infection. Even so there is lack of co-ordination between the prevalence of the two diseases. Thus at Trentham measles was most prevalent in March, when there were no eases of meningococcal infection : but when that infection was at its height in August measles had dropped to a total of 47 for the month —a comparatively low figure. At Featherston there was a closer connection, measles being most prevalent from August to October, when there was also most meningococcal trouble, yet when the former dropped in November the pneumonic infection increased. Taking the histories of 46 cases of meningitis in both camps we find that in 27 of these cerebrospinal meningitis appeared without preliminary infection by influenza) or measles; in 10 it was preceded by measles; in 9 it was preceded by an influenzal attack. Of the pneumonia cases some 8 of the earlier ones at Trentham are dubiously of meningococcal origin, but we can regard 22 cases at Trentham and 19 at Featherston as meningococcal infection following measles. In addition, some 4 cases of pneumonia following influenza were probably meningococcal, so that in all 45 eases of pneumonic infection occurred as a sequel to these two diseases. It must be admitted, then, that measles markedly, and influenza to a lesser extent, were strong factors in the spread of meningococcal infections. As we have seen, however, that the prevalence of such infections did not vary according to the prevalence of measles or influenza, it is apparent that meningococcal complications were a, result of chance secondary infections rattier than a direct outcome of these two diseases. This affords evidence adverse to the, theory lately propounded that the meingococcus may be the cause of certain influenza, like epidemics, in the course of which it becomes worked up in virulence till it can produce infections of the cerebro-spinal type. If this were so we should expect meningitis and pneumonia to have varied directly with the intensity of the influenzal outbreaks. It seems more probable that measles and influenza act by making the individual more susceptible to the attack of the meningococcus, which may thereby be given the opportunity to change from a saprophytic existence in the naso-pharynx to a virulent infective agent. Doubtless, too, its virulence would be increased by passing through a series of individuals thus made receptive by the preliminary catarrhal diseases. The role played by the carrier would be explained by this theory. We know that carriers exist fairly commonly without producing any manifestations of meningococcal activity. But if such a carrier were to come in close contact with a group of persons made susceptible by catarrh-producing diseases the chances are that some of these persons would afford a suitable nidus for the meningococcus to develop its pathogenic properties. Three factors are required for an outbreak of meningococcal infection —a carrier, a susceptible person, and a close contact between the two. An epidemic of measles or influenza means an increased number of susceptible persons. The extent to which the existence of this prepared soil will lead to encouragement of the meningococcus depends on the chance of the presence of a carrier, and on what opportunity is permitted for contact close enough to enable the organism to lie transferred from the throat of the carrier to those of the receptive individuals, Probably also opportunity

Month. Trentham. Pneumonic and Meningococcal Influenza. Cases. Measles. Featherston. Pneumonic and Meningococcal Influenza. Oases. Measles. I January . . February March ' .. April May June July August . . September October . . November December 1 207 218 71 94 2(?) 164 5 (?) 368 13 618 20 291 9 236 8 348 4 395 4 59 58 70 163 21 38 54 95 47 141 71 54 24 I • 56 91 4 68 88 4 108 3 247 2 422 4 416 12 224 4 139 6 236 4 141 31 113 71 40 57 32 77 355 283 238 148 76

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of transference from one susceptible person to another is necessary to raise the pathogenicity of the organism to its full pitch. A simple and direct influence which the existence of coughs and colds in a community must exert is the increased scattering of organisms from the throat during the act of coughing, and doubtless this is no small factor in the spread of the meningococcus as a sequel to catarrh-producing diseases. It is possible then to reconcile the obvious influence exerted by measles and pneumonia on the meningococcal epidemic with the absence of co-ordina-tion as regards prevalence of these diseases. Association between Cerebro-spinal Infection anh Pneumonia. In the report of the Public Health Committee it is pointed out that there was a very close relationship between the pneumonia which proved such a fatal complication of measles in both camps and the presence of cerebro-spinal meningitis. The two agree as to the distribution in the camps and show the same variations in incidence. At Trentham the cases of pneumonia which occurred in May and June prior to the appearance of meningitis were simple, and yielded a comparatively low mortality. AVith the appearance of meningitis the pneumonia became very virulent, with a high mortality for the rest of the year. At Featherston the cerebro-spinal meningitis appeared early in the year, and there was a corresponding incidence throughout of a very fatal pneumonic complication in the measles cases. There is a similarity between the two diseases as to age-incidence and as regards the influence of occupation. Both were most prevalent amongst newly arrived recruits. There is evidence also of personal association between individuals suffering from pneumonia and those affected by cerebro-spinal meningitis. Bacteriological confirmation of the supposition that this pneumonia was a manifestation of the meningococcus has been given by Major Hurley, who found the organism frequently in the sputum. This observation has also been confirmed in the Dunedin Laboratory by Professor Champtaloup, who detected it in the sputum of a man suffering from pneumonia, who was taken to the Dunedin Hospital while on leave from Trentham Camp. In some cases the use of meningococcal vaccine in these pneumonias was followed by beneficial results. Finally, we have clinical evidence that cerebro-spinal meningitis can result from contact with the pneumonia form of infection, and vice versa, in the following cases : — (1.) Private M. entered hospital with measles in the middle of November. About the lst December he developed acute pneumonia, and died on the 10th December. His mother, who was admitted to see him when his illness became acute, developed cerebro-spinal meningitis, and died on the sth December, after two days' illness. It is worthy of mention that a child in the house in which Mrs. M. stayed shortly afterwards developed measles. (2.) Private H., N.Z.M.C., was an. orderly in charge of the ward at Featherston in which several severe cases of pneumonia were under treatment a,t the beginning of December. He was not in contact with the cerebro-spinal meningitis eases, which were treated at the racecourse buildings; yet, on the 12th December he developed symptoms of meningitis, and died in six days. There is, then, sufficient evidence of the identity of the infective agent in the two diseases to warrant their classification together under the general term "meningococcal infections." Distribution by Reinforcements. The infection was widely spread throughout the Reinforcements, although in only a few did the disease affect more than one or two individuals. The infection was present but did not spread, indicating that the conditions were for the greater part of the year adverse to the disease becoming epidemic, probably due both to the satisfactory sanitary condition of the camps and to the well-known infrequency of persons susceptible to meningococcal infection. Three units— the 10th, 13th, and 24th —escaped entirely. The latter unit, however, did not mobilize till January, so that it was only the officers and non-commissioned officers who so escaped. The noncommissioned officers mobilizing prior to the unit were not, however, wholly immune to infection, as 2 cases of meningitis and 1 of pneumonia, were recorded amongst them. No instance of infection of an officer occurred. One case was reported from the Engineering units at Trentham. In the Permanent Staffs 2 cases occurred in each camp. Infection appeared in six of the units whose whole training is carried out at Featherston—the Mounted Rifles and Artillery. That these units were affected is strong evidence against a, somewhat widely held belief that the infection originates only in Trentham. The units which suffered most were naturally those mobilizing in the wet, cold, winter months, when predisposing catarrhal diseases are prevalent and climatic conditions induce men to crowd together inside buildings. At first there was little evidence of the infection being carried from one camp to the other. Thus the 17th Reinforcements had 10 eases of infection at Trentham and but 2 at Featherston. The 18th Reinforcement, which suffered most severely at Trentham with 18 cases, only yielded 1 case while at Featherston. With the I 9th and 22nd Reinforcements, however, there seems some evidence of transference of infection from camp to camp. On examination of the details of movements of these cases it is often difficult to judge at which camp the infection was contracted. In a few cases it is evident that a man contracting the disease while at one camp developed it on arrival in the other. These, however, are the exception, and taking it all round the occurrence of disease in the one camp appears not to have affected the other to any extent. Both types of infection were, roughly, 20 per cent, more prevalent in Trentham. However, in the case of the 20th Reinforcement, which mobilized in the middle of August at, Featherston,

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the proportion is reversed, 8 cases occurring in this camp as against ,'! in Trentham. 'the next succeeding Reinforcement—the 21st—affords an interesting comparison, for it mobilized at Trentham, and here 9 cases occurred, with only 3 at Featherston. That the only Reinforcement which mobilized at featherston should also he the only one to show I he highest proportion id' infection in that camp well illustrates the contention in the report of the Sanitary Committee of the Public Health Department, that it was the new recruits who suffered, and that the prevalence at Trentham was consequent on this being the mobilization camp, and not a result of any insanitary conditions. Distribution ht Companies. An examination of the eases classified according to the company from which they came shows that rarely was there any marked prevalence in one company, and frequently with the transference of the unit from one camp to another the infection would at once disappear from a company in which several eases had been reported. In only two instances did more- than 4 eases occur in one company, even if we group the pneumonic type of infection with the meningeal. In these two companies the distribution was as follows: — C Company, 18th Reinforcements: In this company—from which 6 cases came—the dates of infection show two distinct groups. The first three were of the pneumonic type and followed measles, the patients entering hospital with this disease on the 14th. 16th. and 18th July. It is evident here that one did not infect the other with measles, and from the rapidity with which pneumonic symptoms followed it is unlikely they received the meningococcal infection in the wards. Two of them came from the Nelson District and lived in the same hut. The second group followed three weeks later. These were of the meningeal type. They all came from the Canterbury District, but lived in separate huts. There was no evidence connecting the one group with the other, and the most noticeable feature is the grouping according tn the district from which the patients came. X Company, 19th Reinforcements: The other company yielded 7 cases; all but one being of the meningeal type. Five occurred between the 3rd and 15th August, and suggest a, sequence of infection. All 7 were from the Auckland Province, and 4 from one small district near To Aroha. Yet only 2 came from the same hut; and, as men from the Auckland District were showing infection at this time in four other units, the conclusion seems to be that the transmission was taking place not so much by contact in huts or companies as through the association together of men coming from the same area. This association must have taken place outside their official duties, and will be referred to later. Another ease requiring comment is one in which four men in one company were afieeted. Three came from one hut, and all were from the same district- -Taranaki. As will be shown later, a man from the same district but in another Reinforcement was affected about the same time; so that this group of cases, like the others, affords little evidence that the infection was spread through contact resulting from association as a military unit. In 7 other cases 3 men of one company were affected. Tn some of these there was evidence of association outside tho camp, in others there was a possibility of contact in the hut. It is evident, however, that the disease did not spread much in any of (he companies; and while contact in (he huts may, and social companionship certainly did, play a part:, in no case is there evidence that association during military duty resulted in transmission of infect ion. i Distribution bt Huts. At, Trentham there was one hut in which 3 cases of meningococcal infection (2 meningitis, I pneumonia) occurred, and seven huts in which were 2 eases. In Featherston no instance is recorded of more than one case in a hut. As regards tents, 4 cases were reported from Canvas Camp, Heretaunga ; 3 from men in tents at Papawai; 2 from tents at Tauherenikau; and 6 from Canvas Camp, featherston. There is no evidence then that men in tents were more immune from infection than men in huts, nor is there much evidence of spread in huts. Of the 8 cases at Trentham in which two or more persons in one hut suffered from infection, in throe instances the dates of infection are SO far apart that there is little probability of any cross-infection. In the ease of the hut in which 3 eases arose, (he interval between the first case (pneumonia following measles) and the second (meningitis) was three weeks, and between the second and the third nine days, so that there is much uncertainty as to whether the contact in the hut had any effect. In one ease 2 men entered hospital with meningitic. infection within twentyfour hours of each other, so that the infection was obviously not transmitted from one to the other, but: contracted probably simultaneously elsewhere. In only 3 id' the 8 cases do the dates of development of the illness make it likely that the infection was transmitted from one to the other in the hut, and in each case there is evidence, equally strong, of association outside the camp with other men who developed symptoms of infection about the same time. It is apparent from the above facts that the huts had very little influence in spreading the disease, and that the contacts in the huts rarely if ever developed symptoms of infection. Influence of Stay in Camp. The report of the Public Health Committee showed a general improvement in the health of the troops who had been over two months in the camps as compared with the more recent arrivals. II was also found that the majority of the meningococcal infections arose during the first six weeks of camp life. The subsequent observations fully bear this out. Among 43 cases occurring since the beginning of September the infection arose within the first six weeks in 33 cases and within the first month in 21 cases,

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It is scarcely justifiable to draw the conclusion that the freedom of the men in the later weeks of camp life was a, result of either a rapidly acquired immunity to the meningococcus or because the susceptible persons had been eliminated by infection. Either argument would depend on a very widespread dissemination of the meningococcus. More probably the immunity acquired is to the preliminary catarrhs, which would disappear as the men settled down to their new environment. Influence by Travelling. The Public Health Committee's report mentions the possibility that travelling in trains and trams affords an opportunity for the dissemination of infection, the crowding-together of men being perhaps greater then than at any other time in their camp life. It is difficult to trace the significance of the influence of travelling, since between movements of troops and journeys while on leave the men are very constantly travelling, and evidence that, the outbreaks had any definite relationship to railway journeys is certainly not strong. There is, however, one instance in which contact during travelling is probable. Two men of the 21st Reinforcement went South on leave from Trentham on the 21st December. One became ill on the 24th December, and was admitted to Dunedin Hospital with meningococcal pneumonia on the 31st December. The other entered Invercargill Hospital with cerebro-spinal meningitis on the lst January. There is a suggestion here that the first was a carrier of the meningococcus from the camp and infected the other on the journey to Dunedin. Doubtless other cases exist, but without evidence by cross-examination of the patients themselves —and they 7 are generally too ill to question closely—if is not possible to confirm or deny the spread of infection while travelling. Influence of Contact in Hospital. It is obvious that the introduction of a meningococcus-carrier into a ward filled with men made receptive by a preliminary infection with catarrh-producing diseases such as measles and influenza makes the dissemination of menigococcal complications a probable consequence. In the majority of cases, however, the period of illness in the wards before meningococcal infection set in was too brief to enable one to say with any confidence that.the disease was contracted in the hospital, although it may be admitted to be not unlikely in one or two cases, as, for instance, that of the orderly who developed meningitis while attending on cases of the pneumonic type of infection. In some cases there is a previous history of influenza, but, there is a possibility that the so-called influenza was really an early stage in the meningococcal attack. It lias been shown in the report of the Special Committee for investigating Meningococcal Infection in England that. a, person can carry the organism for weeks before he develops the disease. A patient therefore may carry the meningococcus in a dormant state with him into the ward, and the subsequent condition of his health—the occurrence of measles or influenza—may awaken the organism to active virulence and so to an invasion of the body. He may in this way also be a source of infection to others who are lying near him in the ward. The more crowded the wards the severer would become the type of the preliminary catarrhal invasion and the less the resistance to the meningococcus, whether brought in by the patient himself or conveyed to him in the ward. It is therefore very necessary that all cases suffering from catarrhal affections should have their throats swabbed periodically, and so also should orderlies, nurses, and medical men in attendance. It is essential that there should be ample room between the beds in the wards to avoid as far as possible contact between patients in the adjacent beds. Influence of Occupation. That meningococcal infections are more prevalent among men from the country has been mentioned by several observers, and the Public Health Report shows that it was so also in our camps in New Zealand. Of the cerebro-spinal infections the occupations of the patient is known in 42 cases, and the proportion and mortality was as follows : — Cases. Deaths. ... ( !" m , Death-rate. Indoor occupations ... ... ... 13 4 30 per cent. Outdoor occupations ... ... ... 29 21 72 per cent. 42 25 60 per cent, average. Of the pulmonary infections, the occupations were- known in 9 oases, 8 of which were fanners or farm labourers and I a bank clerk. A further analysis in regard to the place of residence of flic menigeal infection gives the following result :— Employed in large towns : 12 cases (21 per cent, of the total), 5 deaths (41 per cent. case death-rate). Employed in small towns : 7 cases (12 per cent, of the total), 2 deaths (28 per cent, case death-rate). Employed in the country: 37 cases (66 per cent, of the total), 28 deaths (75 per cent, case death-rate). The disease was not only twice as common among country dwellers than among town dwellers, but if was also twice as fatal (75 per cent, as against 37 per cent.). We cannot explain how the town dweller acquires this comparative immunity until we know mote about (he life of the meingoooecus under non-epidemic conditions. It suggests the possi-

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bility that the organism acquires a phase which results in mild infections, and that such infections arc fairly common under urban conditions. On the other hand, the immunity of the town dweller may lie through the nasopharyngeal catarrhs which arc commonly antecedent to the meningococcal infections. A country-bred lad has not been exposed so much to influenza, measles, anil allied troubles, and has not acquired immunity to them to the extent attained by the town dwellers. When suddenly transported to conditions in which he is exposed to these catarrh-producing organisms he falls an easy victim, and thus the door is opened to invasion by the meningococcus. It is quite possible that both suppositions are correct. It is reasonable to attribute lo the same causes the comparative freedom to infection of older persons who have bad more years in which to acquire immunity by repealed attacks of catarrhal or modified meningococcal infections. Inflckxce of Localitt from which Recruits came. The following represents the distribution of cases according to locality from which the patient came : — Cerebro- ~ Auckland Province— spinal , (;asos. Auckland City ... ... ... ... ... ... 4 1 Auckland Hospital District other than city ... ... ... 4 1 North Auckland ... ... ... ... ... ... 4 2 Waikato ... ... ... ... ... ...» 6 Thames- Te Aroha ... ... ... ... ... 5 2 Hay of Plenty ... ... ... ... ... 2 Tauin a run vi ... ... • ... ... ... I 23 9 Total meningococcal infections ... ... ... 32 Wellington Province— Wellington City ... ... ... ... ... 1 Wellington Hospital District other than city ... ... ... 2 Palnici-ston district ... ... ... ... 2 Wanganui district ... ... ... ... ... I 4 Taranaki district ... ... ... ... ... ... 5 1 Wairarapa district ... ... ... ... ... I 2 Hawke's Ray ... ... ... ... ... ... I 2 10 12 > V > Total meningococcal infections ... ... ... 22 Canterbury Province— Christchurch City ■ ... ... ... ... ... 3 2 North Canterbury ... ... ... ... ... 2 South Canterbury ... ... ... ... ... •"> 6 8 8 Total meningococcal infections ... ... ... 16 Otago and Southland — Dunedin City ... ... ... ... ... ... 3 I Otago ... ... ... ... ... ... ... 3 2 Invereai-gill ... ... ... ... ... 1 Southland ... ... ... ... ... ... 3 9 4 Total meningococcal infections ... ... ... 13 Nelson District, — City ... ... ... ... ... ... ... 2 Country ... ... ... ... ... ... ... I 5 3 5 Total meningococcal infections ... ... ... 8 Marlborough District (no meningococcal infections). Westland District ... ... ... ... ... ... 3 Total meningococcal infections ... ... ... 3 There at*' some apparently contradictory results shown in these figures. Auckland, fur example, leads with 32 cases of infection, or about one-third of the total, Yet this province suffered lightly in regard to pulmonary complications, being considerably lower than Wellington,

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and about equalled by the much smaller Canterbury District. Nelson suffered quite out of proportion lo its size as regards the pneumonic infection, yet among men from the neighbouring Marlborough District not one ease of either type occurred. The men from the district round Tc Aroha ami Waihi suffered very heavily, with 7 cases, while the Bay of Plenty adjoining it contributed but 2. Wanganui district contributed 5 eases and Palmerston only 2; North Canterbury 2 cases and South Canterbury 9, and so on. The climatic differences between these con l tasted districts is negligible, and throughout there is no obvious connection between climate and Ihe susceptibility of Ihe recruits to infection. Thus from the mild climate of the Auckland Hospital District we-find hut 2 cases of pneumonia, while from the almost equally mild climate of Nelson 5 pneumonic cases came. It was suggested in the Public Health Report that the immunity of the men from the Wellington Hospital District was due to their being inured to the boisterous climate and so did not suffer from preliminary catarrhal troubles. Yet while only •"> cases arose from that district, 13 came from the much more rigorous climate of Otago and Southland. It is useless, then, to look for any climatic influence governing the distribution of the disease. We have seen, too, that by far the majority of the patients followed the same occupation—namely, farming—and lived in rural districts irrespective of what part of New Zealand they came from. The true explanation of this distribution probably can be found by a close examination of Ihe grouping of the cases, when it will be seen that the disease prevailed more among men from a particular locality at, definite periods, irrespective to some extent of the unit to which they belonged. We have already seen the influence of locality in examining the grouping by company. Thus in the case of one Reinforcement in July the disease affected men belonging to a company who oame from Nelson, while in August the patients in that company were all men from Canterbury. In the case of another company, 4 out of the 7 patients came from the WaihiTe Aroha district, and so on. This distribution by district, however, does not confine itself to one company or one Reinforcement, otherwise one might regard the grouping as dependent on the fact that the companies arc largely made-up from men from one particular area. The following table shows the distribution by month and by locality from which the patients were recruited. Prior to July the cases are too scattered to be of much interest as regards the prevalence in any one district, so that the table only shows the cases as from July, when the disease became epidemic. Auckland. Wellington. Canterbury. Otago. Southland. Nelson. Westland, July ... 4 2 2 I 1 1 August ... 9 3 6 1 1 2 2 September ... 5 5 2 4 1 3 October ... I 5 1 I ... I November ... 3 1 2 1 1 ... I December ... 2 I 2 1 ... 1 (Note. —Meningeal and pneumonic cases are grouped together.) 'Phis table shows how unevenly the incidence fell on each province. Auckland throughout contributed a high proportion, but in September and October a higher percentage came front Wellington, and in November and December Canterbury contributed almost as many as Auckland. The proportions for the large provincial districts are as follows :— Auckland. Wellington. Canterbury, and •' Sou till and. Per Cent. Per Cent. Per Cent. Per Cent. July and August ... ... ... 36 14 22 11 September and October ... ... 28 32 9 19 November and December ... ... 31 10 25 19 In September Nelson contributed 15 per cent, of the cases. If we now reconsider the distribution of infection in Reinforcements and companies it becomes evident that the locality from which the patient was recruited exerted the greatest influence on the outbreaks. Taking each province in torn we find outbreaks arc distributed thus:— Auckland. —During July 3 out of 4 cases came from Auckland City or its neighbourhood. These cases were drawn from two Reinforcements—the 17th and 18th. After the first week in August, although infection was common among the men from Auckland Province, practically none came from the city or suburbs. During August 4 out of 9 cases came from the neighbourhood of Te Aroha and Waihi. They were drawn from the 18th and 19th Reinforcements. In September 2 mote came from the same neighbourhood—the 19th and 20th Reinforcements contributing I ease each. Thereafter there was only I mote case from this district—a man in the 22nd Reinforcement, in November. The group is of interest since the district is not a populous one and docs not contribute a large number of men to the Forces, and there were no cases in the civil population ai this time. It is a district somewhat noted for its freedom from all forms of infectious disease, anil it is unlikely the men came into camp already infected. The fact that the patients did not develop the disease till they had been three to four weeks ill camp supports this conclusion. The patients were drawn from four Reinforcements and no two Jived in the same hut, so that there was little chance for contact in the ordinary round of camp life. Similarly I here was no evidence of infection in. the hospital wards. It seems probable, then, that these men. being from the same neighbour! I. associated together while on leave and in places of amusement, and that this group of companions included, or came in contact, with, a carrier, and probably thereafter the infection continued to spread from one to another of the coterie. Wellington.—During the sharp outbreaks of meningococcal infection in July and August Wellington Province suffered little; but during September and October more patients came from

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that province than any other. This was due chiefly to an outbreak among men from the Taranaki District which hitherto had not yielded any cases. The type of infection was very virulent, for of the five men affected all died. The first of this series was a man in the Mounted Rifles at Featherston, who had no official association with the 21st Reinforcement at Trentham, to which all the rest, belonged. lie had. in fact, died a fortnight before the others had mobilized; yet it seems more than a coincidence that this man's illness should be followed by an outbreak among men from the same district hitherto free from infection. It should be added also that this group was the first to show infection in the 21st Reinforcement. All belonged to B Company, and three lived in one hut, though the fourth did, not. No further cases came from the Taranaki District, so that the outbreak was much circumscribed, yet it must have been of a, virulent type, as all the men affected died. It certainly suggests that a carrier was at, this time associating specially with men from Taranaki. Possibly there was also a spread of infection by .contact in the hut, but the dates on which the symptoms began make this uncertain. Canterbury. —During the first twelve days in August: men from this district suffered most heavily, 6 being then infected. Three belonged to C Company, 18th Reinforcement, and have already been mentioned; another came from J Company of that Reinforcement, and 2 were noncommissioned officers in the 20th and 21st Reinforcements, which had not then been mobilized. The. inclusion of these 2 non-commissioned officers, who would not be in contact with the others officially, certainly suggests contact, outside cam]) among a group of men associating, because they came from the Canterbury District. After this group of eases in August: no more came from Canterbury District, for a month, and the succeeding cases appear rather to form part of other groups not connected with the main outbreak. Otago. —The Otago men escaped lightly during the heavy outbreak of July and August, but in September we find that of 5 eases of cerebro-spinal meningitis at Trentham 4 were from Otago. All arose within six days of each other, anil all had a mild type of infection, since none of the cases were fatal. Three came from the 17th Reinforcement, which had been free from infection for over a, month. They were from separate companies, and one was in the Engineers, and thus had no official association with the other. Probably associated with this group was a man in the 17th Reinforcement Specialists, who was at Papawai Camp and got ill at the same time. He came from the same military district as the others, but unless he met them while on leave had no apparent opportunity for contact. This Otago group, then, was drawn from four separate units, and is an outstanding example of a definite outbreak among men whose only association was that all came from one district. Several other instances could be given in which men from one neighbourhood—Wanganui and Nelson among others—sickened about the same time, although not associated in huts or companies. It appears, then, that at different seasons the epidemic prevailed among men coming from one particular district—in July, from Auckland City; in August, from near Te Aroha; in September, from Otago; in October, from Taranaki; and so on. It is of importance to note that these groups were not confined to men from one hut or one company, but involved several wholly separate units between which there was no contact in camp or while on duty. The conclusion therefore seems to be that the infection was spread as a result of association while on leave or in the various places of recreation attached to the camps, the only opportunity for contact between men from various Reinforcements. At such times it is natural that men coming from the same neighbourhood would tend to group together; thus the spread of infection would tend to show the geographical distribution which has been demonstrated. Concluson. The reports of the Public Health Department show that during July, August, and September, when the epidemic was at its height in the camps, there was very little infection among the civil population. The total number of eases of cerebro-spinal meningitis notified in the Dominion during 1916 was 134. This includes all the cases connected with camps, so that the civilian cases for the whole Dominion total only 75, and in many of these the diagnosis was very doubtful. So small a prevalence is not likely to have greatly influenced the distribution in camp, and certainly would not account for the prevalence among men from one particular district. The cases in camp have to some extent affected the civil population in a fair number of instances, as shown in the report of the Deputy Chief Health Officer dealing with the period October, IDI6, to January. 1917, when out of 33 cases a history of contact with troops from the camps was found in 14; but we do not find in the civil population of a district any evidence of an epidemic antecedent to the outbreak in camp among men from that district. Again, if the infection were spread among men from one district while mobilizing and journeying to the camp, the histories would show a preponderance of attacks within the first week of camp life. This is not the case, as generally from three to six weeks elapsed before tindisease showed itself. Carriers of the meningococcal doubtless may arrive in camp from outside, but these are known to exist in civil life without producing harmful results. The question arises then, what is there in camp life to stir up the organism so carried to virulent activity or to lower the resistance of the individuals exposed to its influence? The general sanitary surroundings of the men in camp are without doubt much better than their surr6undings in civil life. The seasonal effect of wet and cold on the epidemic has been shown, as also the influence exerted by the epidemics of measles and influenza. But these influences are also present in civil life without inducing an epidemic of meningococcal infection. Fatigue is frequently mentioned as a predisposing cause, but this would affect men who have followed sedentary occupations in towns more than men from the country, whereas the opposite is the case. What is lacking in civilian life, however, is the essential crowding-together of men while these influences

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ate at work. Cases of measles or acute catarrh in a country .district do not affect many persons, but it is otherwise in a camp; for here there are opportunities for cross-infection which do not exist in civil life, especially in the country. The miningococcus introduced by a carrier into groups of catarrh-infected persons is likely to find conditions favourable to the development of its virulent attributes, and this doubtless is what often may happen in camp life. Men from the country are perhaps more likely to form small coteries associating closely together, and the individuals forming the coteries are not: protected against measles and other catarrhal infectious by preliminary attacks as are men from the towns. A meningoeoccus-catrier in such a group becomes, therefore, a very serious danger. We see then a reasonable explanation for the various features of the epidemic—the tendency for meningococcal infection to appear in camps; the greater prevalence among men from the country; the infection of small territorial groups; and the appearance after some weeks in camp, during which period the preliminary catarrhs are being contracted and spread. The prevalence in the winter months is a sequel to the epidemics of these preliminary catarrhs, and to the colder weather driving the men into crowded overheated buildings. The absence of disease among men from Wellington City and neighbourhood is probably a result of these men having their homes and friends to go to while on leave. There is less temptation for them to form those social groupings during which opportunities for close contact arise. We see clearly also that the elimination of the carrier is only one of the precautions to aim at. We must also seek to prevent the crowding-together of recruits, more especially during their moments of leisure, till they have obtained in a measure the immunity enjoyed by town dwellers. But perhaps most important of all must be the efforts to minimize the preliminary infections, both as to spread and as to virulence. We have had in the first four months of the present year but 42 eases of measles, as against 55!) in the same time last year. Influenza has also been conspicuously less—l3s cases as against 928 last year. How fat this is due to systematic gargling and inhalation, which is now enforced in the camps, it is not possible to say with certainty, but it probably has played a large part. In any case the results so far have been that we have had but I case of meningococcal infection in the two camps, as against 5 in 1916. which is encouraging. The full value of the recent precautions, however, will not be put to the test till the camps have been subjected to the influence of the wot, cold months of June and July, Yet with the increased knowledge we have gained of this disease, with the segregation at Tauherenikau of newly arrived Reinforcements for a month apart from the rest of the troops, with the increased facilities for bacteriological examination and for spraying and isolating contacts, and with the new hospital wards wherein patients can be carefully classified, we may hope to find a lessening in the number and severity of the attacks during the coming winter. R. H. Makgill, Lieut.-Colonel, Assistant Director Medical Services (Sanitary).

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