In the 1914–18 War medical examination of recruits was first carried out by the Army Territorial Forces through RMOs of the four military districts. New Zealand Medical Corps officers on the active or reserve list were selected as examiners in the main centres, but in the outlying districts civilian practitioners were utilised, and conditions there were not so satisfactory. When the men entered camp the medical staff there revised the classification and rejected normally from 1 to 2 per cent of the recruits. This naturally caused page 321 trouble and distress, and at one time the standards were lowered, with the natural result that complaints came from overseas and the standard had to be raised again.

Later, full-time recruiting medical boards were formed in each military district, with certain special medical travelling boards to deal with appeals against the decision of the ordinary boards. The rejection rate in the latter part of the war was nearly 60 per cent.

In February 1938 Cabinet approved a report by the Manpower Committee of the Organisation for National Security in which was included the following: 'All medical examinations, whether under voluntary enlistment or under national service will, in general, be carried out under arrangements made by the Medical Committee, the executive control resting with the Health Department.'

Thus the Medical Committee was given full authority to proceed with the work of medical boarding when the need arose. One thousand copies of the Code of Instructions for members of civilian medical boards were printed in 1938. The code covered most of the technicalities that would be involved.

The submission by the Director of Medical Services (Army) to the Medical Committee on 31 March 1939 of a comprehensive medical appreciation of problems associated with mobilisation enabled further details of the organisation for medical boarding to be finalised. Thus, by 31 July 1939 the machinery was ready to swing into action at short notice.

As described in the preceding section, the Medical Committee's organisation consisted of eleven Regional Deputies, outstanding civilian medical practitioners who were responsible directly to the Medical Committee for medical boarding in their regions. There were 253 medical boards, each comprising two doctors and one dentist, chosen to meet the requirements and places of mobilisation of the Army. (In 1940 the dental member was omitted and men were graded without reference to their gums or teeth.) With the number of boards arranged and sessions of four hours each, it was expected to complete the examinations in four days for the 39,900 men the Army proposed to mobilise for home defence. (Note: In actual experience it was found that army mobilisation did not achieve any such intensity as mooted in pre-war proposals. Up to 9 December 1939 nine of the eleven regions had been called upon to examine only 15,796 recruits. Figures were not available for the other two regions but they probably did not exceed 1000 each.)

The respective spheres of control between the Health Department and the Army Department were denned as follows:

Health Department Responsibility

Army Department's Responsibility

Specialists

Each medical board had a system adapted to its own conditions for obtaining consultant advice. Specialists could be engaged to attend at the board room at times arranged in consultation with the chairman, and men whose cases required further investigation would assemble at those times. The shortage of specialists throughout New page 323 Zealand led to much delay in finalising the grading of doubtful cases. Even when consultants could attend there was a lack of properly equipped rooms for their use. In Auckland there was, owing to local conditions, the only complete boarding unit with specialists regularly available. In regard to visual examination, eye specialists were sometimes included on medical boards, or else the system was adopted of referring doubtful cases for specialist opinion to the eye departments of public hospitals. Regional Deputies had the authority to obtain the services of an optician to assist with medical boards if they thought fit. (On 20 November 1940 the National Medical Committee agreed that opticians be attached to all medical boards and this change became effective in 1941.)

Functioning at Commencement of War

At the meeting of the Medical Committee on 24 September 1939 it was stated that reports received and inspections made indicated that the organisation for medical boarding was carried into effect immediately and efficiently following the outbreak of war. The Regional Deputies, who were part-time officers, were asked at that stage to report in regard to the Code of Instructions, the forms in use, and whether there was need to improve the literature or the organisation. The reports were generally satisfactory as regards accommodation and staff, but a number of suggestions were made for the improvement of the Code of Instructions, the Army Instructions for conduct of medical examinations, and Army Form 355 (Record of Medical Board). When the suggested improvements were approved, amendments to instructions were made accordingly. The Code of Instructions was subject to repeated amendments, which led to a revised edition being printed in February 1942.

The introduction of compulsory military service under the National Service Emergency Regulations 1940 (dated 18 June 1940) brought about certain alterations in official policy and imposed additional responsibilities on Regional Deputies and medical boards. It was therefore necessary to supplement the original instructions, prepared as they were primarily for initial examinations under a system of voluntary recruitment.

Under the National Service Emergency Regulations 1940, Regulation 35 et seq, the responsibility for medical boarding was transferred from the National Medical Committee to the Minister of Health. The Regional Deputies were therefore, in fact, deputies for the Minister of Health, to whom the National Medical Committee was, strictly speaking, only an advisory body. In effect, there was little alteration in the administrative control that had previously been exercised.

Medical Grading

In the Code of Instructions for Medical Boards four grades were laid down under which men were to be classified according to their physical and mental condition. These were later (on 2 December 1940) co-ordinated with the Army Department's classification of recruits according to fitness for the various types of military service, as follows:

• Grade I: Men who attain the full normal standard of health and strength and are capable of enduring physical exertion suitable to their age.

  Classification: Fit for active service in any part of the world.

• Grade IA: Men suitable for Grade I, but who have been degraded for minor disabilities easily and quickly remedied.

• Grade II: Those who, while suffering from disabilities disqualifying them for Grade I, do not suffer from progressive organic disease, have fair hearing and vision, are of moderate muscular development, and are able to undergo a considerable amount of physical exertion not involving severe strain.

  Classification: Fit for active service in New Zealand.

• Grade III: Those who present such marked physical disabilities or evidence of past disease that they are not fit for the amount of exertion required for Grade II; those who suffer from any of the diseases or disabilities specifically mentioned in the detailed instructions as indications for classification in Grade III.

  Classification: Fit only for clerical work or other sedentary military occupations in New Zealand.

• Grade IV: Those who suffer from progressive organic disease or are for other reasons permanently incapable of the kind or degree of exertion required for Grade III.

  Classification: Permanently unfit for any military service whatever.

Note: In the revised Code of Instructions published in 1942 slight amendments were made in the classifications, more particularly relating to ability to serve in New Zealand in a state of emergency. In June 1943 2 NZEF in the Middle East found it necessary to alter the terminology for medical grading, as what was originally drawn up for men being received into the Army in New Zealand could not be practically applied to an Expeditionary Force overseas.

Tuberculosis: X-Ray Examinations of Chest

In September 1939 the Director-General of Health and the Director-General of Medical Services (Army and Air), after representations by the latter, took steps towards the elimination of mentally unfit recruits and those suffering from active tuberculosis. In regard to the latter condition, Cabinet approved an X-ray examination of all military recruits and authorised an X-ray unit to be purchased and installed and staffed in each of the three principal military camps.

The X-ray apparatus could not be purchased and set up in the three mobilisation camps in time to make chest X-rays of the First Echelon, and only a few of the Second Echelon were X-rayed before going overseas. Fortunately the men of the Maori Battalion were given chest X-rays at Palmerston North before they left with the Second Echelon, and a number of recruits were rejected, thus eliminating many foci of infection. As a survey by Dr D. Macdonald Wilson has shown, the incidence of pulmonary tuberculosis in the First and Second Echelons later was considerably higher than the average for the Army overseas.

It became obvious that it was desirable that recruits should be X-rayed before they left home, sold up businesses, etc., and entered camp, only perhaps to be rejected at that stage. It was accepted that the X-ray of the chest was really part of the initial medical examination, and a responsibility of the Health Department under the civilian medical board system, which was in fact acknowledged by the stipulation of the Department in December 1939 that the reading and interpretation of the X-ray films be undertaken by the radiologists of the Auckland, Wellington and Christchurch Hospitals.

In April 1940, therefore, it was decided that all recruits should undergo X-ray examination of the chest before they were despatched to camp. Arrangements were made by the Department of Health with the hospital boards concerned, for the X-ray examinations to be carried out at thirty-four hospitals and the interpretation of the films to be made at the eleven largest hospitals. Thenceforth an X-ray examination of the chest was regarded as a routine for all recruits classified fit for active service. Army area officers made the best possible arrangements with the medical superintendents of hospitals for the X-raying, and every endeavour was made to have men who had to travel some distance for medical examination X-rayed immediately after the medical examination, so as to avoid a second journey with consequent expense and loss of time. Shortage of radiologists competent to read X-ray plates was a difficulty, apart from general administrative problems of check and control. Also the centralisation which caused all communications to pass through the Health Department to the hospital boards was an aggravating factor.

If any abnormality was found which the radiologist considered required further examination, the recruit was examined by a specialist chest board comprising a chest specialist and radiologist. In some larger centres the radiologist and chest specialist were too busy to act together. In the circumstances the Regional Deputies had to do the best they could.

Regional Deputies were driven to use on specialist chest boards medical practitioners who were not tuberculosis specialists. It was agreed that Grade I men from outlying districts where X-ray was impossible would be X-rayed on entry into camp. Especially in the peak mobilisation period of 1942–43, these totalled many hundreds and there was often delay in arranging X-rays, or on occasions they were overlooked altogether.

A return compiled by the Director-General of Medical Services for the period January 1941 to 31 October 1942 showed the numbers X-rayed in camp were 2223 at Papakura, 1941 at Waiouru, 2090 at Trentham and 1835 at Burnham. For those who were discovered to be suffering from tuberculosis it was found that the time between the recruit's arrival in camp and his discharge from the forces after X-ray, specialist, and civilian medical board examination had been carried out varied from one month to three months.

A number of men who were in camp for only a few months became eligible for war pensions for 'pulmonary tuberculosis aggravated by service'. An obvious conclusion is that in any circumstances all men should be X-rayed before going into camp. In any future emergency the hospitals would be much more able to cope with the demands, as hospitals everywhere now have adequate apparatus for chest X-ray, with trained technicians and, in many cases, tuberculosis officers.

With the object of preventing the enlistment of men known to have tuberculosis, the army authorities arranged that lists of all enlistments for 2 NZEF be supplied to the Health Department. The names were then checked against the tuberculosis registers kept by the Health Department, and appropriate action taken to exclude from service any who were medically unfit on account of this disease. Throughout the war Medical Officers of Health checked lists of recruits to detect the names of those who were, or had been, on tuberculosis registers. Such recruits were specially examined.

It was the practice to forward to Medical Officers of Health the names of recruits rejected on account of pulmonary tuberculosis, and of the men who were discharged from mobilisation camps for this disability, in order that contact might be kept with them and, where necessary, treatment arranged.

The Elimination of the Mentally Unfit

Although the Director-General of Mental Hospitals had drawn attention to the need in a letter dated 7 September 1939, it was not until some months later that arrangements were made to furnish the Mental Hospitals Department with rolls of those called up for page 327 service so that checks could be made for any known mental defectives. By that time some known defectives had gone overseas, and even after that occasional cases continued to be accepted by the Army. Some defectives, of course, had never been in any mental hospital and were therefore not known to the Department. Psychiatrists were not employed in the selection of recruits in New Zealand. They functioned only in the treatment of cases referred to them from the Army and in the medical boarding of psychotic and psychoneurotic cases arriving in New Zealand from overseas.

During the war repeated observations were made in 2 NZEF on the relatively large numbers of men breaking down overseas, some shortly after their arrival in the Middle East. It was realised that the cause lay in the inherent constitutional instability of the individual and not in any battle strain thrown upon him. The large majority of the cases showed symptoms at the Base with no divisional service at all. The problem is a difficult one and opinions differ as to the best ways of dealing with it. In Great Britain the members of medical boards were required to ask every man a few simple questions designed to bring to light any past or present symptoms of nervous instability. Intelligence tests were also introduced. Psychiatrists were employed in the officers' selection boards but were used to examine only the subnormal group of the ordinary recruits, partly because the large numbers made it impossible for the psychiatrists to examine all recruits.

The utilisation of psychiatrists for the examination of all recruits in New Zealand has been suggested by some, but others have held that this would be a dangerous procedure and might bring in its own train greater evils than we had under the system adopted. The wartime Director-General of Mental Hospitals was against the examination of all recruits by a psychiatrist, stating that this would be wasteful and unnecessary and would tend to make the recruits psychiatry conscious, with undesirable results. Many army medical officers were afraid that if psychiatrists were turned loose amongst the recruits they might decimate the Army. The Director-General of Mental Hospitals considered that academic psychiatry had to be tempered with common sense and experience.

All were agreed that psychiatrists should be readily available for consultation by the medical boards, that the members of the boards should be familiar with psychiatric and psychoneurotic conditions, and that they should pay particular attention to the elimination of the mentally unfit. Perhaps the adoption of the Pulheems system of classification, with special stress on personality weaknesses, might prove to be the best method of selection. Inquiries as to the school and occupational history of the recruit, if carried out intelligently at the time of his medical examination, would be of great assistance.

Special Medical Board

At the meeting of the National Medical Committee on 21 October 1940 the chairman reported that by arrangement with the Director of National Service, and pursuant to Regulation 39 (3) of the National Service Emergency Regulations 1940, a Special Medical Board had been set up by the Minister of Health in Wellington to review the cases of voluntary recruits rejected on initial medical examination, and of volunteers subsequently discharged from the forces as permanently unfit for service prior to the coming into force of the National Service Emergency Regulations.

It was necessary that these cases should be reviewed, and their grading confirmed or amended by a medical board constituted under the National Service Emergency Regulations, before the Director of National Service could transfer the registration cards of permanently unfit men to the Third Division (civil) and exclude their names from subsequent ballots.

This Special Medical Board of three members also dealt with cases of reservists drawn in the ballots who were suffering from, or who were known to have suffered from, pulmonary tuberculosis or mental disease, in order to have their names excluded, where necessary, from subsequent ballots.

Standard of Vision

The visual examinations of recruits for the Army in the early days of the war were in many cases unsatisfactory. This was due to a variety of causes. The taking and recording of visual acuity requires special training and experience not generally possessed by the average general practitioner. Standard test types and a standard illumination of such test types are necessary to ensure that visual standards are the same in all parts of the country. Some medical boards co-opted the services of an optician or oculist, but most carried out the tests themselves. In the great majority of cases recruiting medical officers were overworked, and in some cases the testing of visual acuity was left to medical orderlies. It was doubtful whether there were sufficient opticians to serve all medical boards at the outset had it been decided to use them throughout the country.

In these circumstances it would have been desirable for the Army to carry out its own visual examination once a recruit had entered camp. This was done for those who used or required glasses and had to be supplied with army spectacles, but there was no general rule for the testing of all recruits. As a result of the initial wrong recording of visual acuity a number of men were sent overseas in the wrong grading as far as their visual acuity was concerned.

Following an offer from the Institute of Opticians of New Zealand to make available the service of its members to medical boards for the purpose of assisting in the determination of the visual condition of recruits, the National Medical Committee on 26 November 1940 approved a scheme whereby opticians were attached to medical boards to make more complete visual examinations. This system became effective in February 1941 except as regards certain country districts. The advent of the Army Optician Service in 1942 resulted in a greater check on visual examinations being made in camps.

In actual experience, it was found overseas that men with slightly defective vision could be usefully employed when graded, and it is likely that many cases with vision sufficiently defective to change their grading were never discovered and that such men were not hampered in the course of their normal duty. In any case, eyes could be tested overseas and spectacles supplied for those whose vision was correctable.

Unfit Men Reporting to Mobilisation Camps

As early as October 1939 the Army Department reported cases of men found unfit on admission to camp. The Medical Committee resolved that Regional Deputies in the districts in which the unfit men were examined should be informed that the committee viewed the matter seriously and was perturbed that men with such a degree of unfitness could get into camp. The Regional Deputies were asked to bring the individual cases to the notice of board members concerned and ask for an explanation, if any, and a report.

The problem of unfit men reaching mobilisation camps, and even proceeding overseas, was a perennial one, and, in spite of special measures adopted, was never wholly overcome. At the end of 1940 the DDMS 2 NZEF made a survey of 273 men who had been classified as unfit for service in the field. At the same time a report was received from the Second Echelon in the United Kingdom that between eighty and ninety men had been found unfit for front-line service, mostly because of pre-enlistment disabilities. These reports caused some concern at Army Headquarters in New Zealand. It was realised that the prevention of these men going overseas was largely in the hands of the civilian medical boards that examined and graded them; but medical officers in mobilisation camps were enjoined to make close personal observations and co-ordinate with company and platoon officers to strive to eliminate some of those soldiers likely to break down on active service.

Complaints from overseas still continued to occur, however, as it was repeatedly found that among reinforcements there were a number who fairly obviously should not have been allowed to go page 330 overseas, and a proportion of these were sent back to New Zealand by the first available ship. This was in spite of a measure of elimination in New Zealand, as available figures show that 714 men had been reboarded in mobilisation camps at 30 April 1940, the total reaching 4853 at January 1942.

There was a case for better liaison between camp medical officers, the Army Department, Health Department, and civilian medical boards regarding the types of disabilities so often the cause of rejection. Reports from overseas, however, were widely circulated and had an immediate effect.

It is interesting to note that Australia and Canada had to face the same problem, and the principal causes for rejection of sample groups of 839 men from the Canadian Expeditionary Force, of 900 men from the Australian Imperial Force, and of 1000 men from the New Zealand Expeditionary Force showed a remarkable similarity.

Reboarding of Unfit Enlisted Men

Although it was at first decided (in October 1939) that the boarding of unfit men in mobilisation camps was the responsibility of the Army, a change was made by the Medical Committee on 3 November 1939, at the request of the Army Department. It was agreed that such medical examinations would be carried out by civilian medical boards, which had been responsible for passing them in the first place. The procedure adopted was that when such boards were considered necessary the Senior Medical Officer of the camp notified the Director-General of Medical Services, who in turn sent all relevant papers to the Department of Health, together with a nominal roll showing names of board members responsible for the first boarding. The boards were then constituted by the Health Department and action taken with regard to the final notification to the Army Department. The unfit men were sent from the camps to the medical board centres for examination.

In March 1942 it was decided that, owing to the state of emergency in New Zealand and the demands on the services of medical practitioners by the civilian population and for medical boards, in future all medical boarding of soldiers in camps would be carried out wherever possible by army medical officers. The findings of the army medical boards were subject to the approval of civilian Regional Deputies until July 1942. In the meantime it was pointed out that procedure could be further speeded up by appointing senior army medical officers as Regional Deputies. In July 1942 the Minister of Health approved the appointment as Regional Deputies of the DGMS (Army and Air) and his three page 331 chief assistants at Army Headquarters, the ADMS (Air) and his deputy, and the ADsMS of military districts and divisions.

Specific notes were issued by the DGMS for the guidance of NZMC medical boards, which functioned satisfactorily. This amended system could well have operated from the start of the war, there being no particular advantage in medical boarding being conducted purely through civilian medical boards when the Army Department had a staff of medical officers of standing well able to undertake these responsibilities.

The Employment of Graded Men

The problem of the utilisation of men rejected from the services on account of low physical grading was one of considerable magnitude when it is realised that, in the 355,000 men medically examined during the war for service with the forces, there were approximately 150,000 who were not immediately fit for classification as Grade I.

Remedial treatment was a means of making a small percentage fit for active service, and a proportion of men in Grades II and III were used in home defence and Pacific island garrison duty. Those who remained in civilian life were subject to a measure of manpower direction through which, in spite of their disabilities, they contributed less directly to the war effort. Nevertheless there were many who, because of minor specific disabilities, were exempted from service in the forces, when in actual fact their all-round fitness was undisputably higher than that of many of the less vigorous who were accepted for service.

The liability of the State for pensions payments for aggravation of disabilities in men who were not perfectly fit had doubtless an important influence in the matter. To some extent this was justifiable, but it is felt that with a thorough medical examination of men before attestation, and the ability of the armed forces, especially within New Zealand, to employ efficiently men with specific minor disabilities, a more selective procedure of grading and posting would enable manpower to be utilised to its full strength and provide a greater equality of sacrifice.

In 1943 the National Service Department made a survey of the results of the medical examinations of 105,311 men, aged 18 to 45 years, who constituted the great majority of all men so examined during that period. Of the total number examined, 42,022 were rejected for active overseas service and placed in Grades II, III or IV. The figures showed a marked increase of unfitness with increasing age, especially as regards disorders of the bones and organs of page 332 locomotion and cardio-vascular disease. The causes of rejection were analysed according to particular disabilities as set out in the table in Appendix A.¹

In the British Army a system of categorisation was introduced in 1940 in order that the manpower of the Army might be utilised to the best advantage. Army Council Instructions on the subject were issued in April and November 1940 and again in 1943. The 'category' differed from the 'grade' in that it was based on the army standard as regards physique and capabilities and the locality in which men would normally be employed. For instance a Category B2 man who had defects of locomotion and only a moderate degree of disability was acceptable for lines of communication, base or garrison service at home or overseas.

To conserve manpower for the armed forces the Director-General of Medical Services suggested in February 1941 that all men in Grades II and III be re-examined and placed in the appropriate category, but this was not carried out. Again in July 1943 he recommended that medical classification by category be adopted. For this purpose he had modified some sections of the British scheme to conform to New Zealand requirements and regulations and simplified it to some extent. The matter was given consideration by the Adjutant-General who, in March 1945, asked for a recommendation as to the Pulheems system (British modification) and the system of medical categories for other ranks as issued by the War Office in 1943. It was recommended that the more suitable would be a modified and simpler form of the latter system. However, nothing was done before the end of the war.

The following is a list of disabilities which, under the system of grading operative in New Zealand, placed men in Grades II and III, but which under a system of categorisation would not have precluded them from overseas service: Practically all visual defects; symptom-less flat feet; minor foot disabilities; minor degrees of varicose veins and haemorrhoids; minor hearing defects; minor deformities or disabilities of arms and legs; minor degrees of hernia; post-thyroidectomy cases of a non-toxic nature; minor degrees of nasal obstruction; certain minor skin diseases; and cases of sub-standard general physique.

It was estimated in March 1945 from statistics supplied by the National Service Department that possibly 50 per cent of men then in Grades II and III would, under a categorisation system, become available for overseas service. (Particular care would have been necessary in classifying these men, as was proved by experience in the Pacific islands garrison troops.)

On the same basis, many more less-fit men who were not mobilised could well have been employed in New Zealand in military occupations which were in keeping with their civilian occupation or capacity.

Remedial Treatment

In 1940 it was arranged that remedial treatment would be provided at the expense of the Army for recruits who were likely to be classed fit for active service in any part of the world at the termination of such period of treatment. Only disabilities which could be corrected and would allow the recruit to enter camp within one month after his operation were initially considered. Arrangements were made for such treatment to be carried out at public hospitals, in-patient treatment usually being required.

Types suitable for remedial treatment were set out as follows: Enlarged tonsils; circumcision; minor toe operations (hammer toe and overlapping toe); undescended testicle; varicocele of severe degree; hydrocele; minor degree of varicose veins (not above the knee), where only one, or at the most two, treatments were required for cure.

This provision did not include such conditions as hernia or surgical disabilities requiring a long period of convalescence. Recommendations for remedial treatment were made by the medical boards, but had to be approved by the Regional Deputy.

At first the treatment was restricted to volunteers for overseas service. When compulsory service was adopted the treatment was extended to men called up in the ballot both for the Territorials and for overseas service. The treatment was made compulsory and those refusing treatment were prosecuted and penalties inflicted. Later, compulsion was dropped and no penalties were inflicted, partly because the rules of the hospitals precluded compulsion and required the consent of the patient. In the case of inoculation and vaccination the treatment was compulsory and could be given in spite of refusal, this point being covered in the National Service Emergency Regulations 1940. The regulation read:

Regulation 41 – Medical Treatment of Members of Armed Forces

In August 1941 the liability of hospital boards with regard to remedial treatment became of importance after two unfortunate deaths, one from tetanus, following injections for treatment of varicose veins. Legal action was taken in one case against the hospital. The Auckland Hospital refused operation unless consent had been obtained and other hospitals adopted the same attitude. The question of compulsion arose, and after referring the matter to legal advisers it was finally determined that compulsion could not be enforced, but penalties were inflicted in the case of refusal.

In August 1942 Army Headquarters advised that in future if a man refused to submit to remedial treatment he was not to be prosecuted or charged, nor were any proceedings or other steps to be taken to require him to submit, or to punish him for not submitting. Recommendations were made to place the man in suitable army employment and, if possible, to retain him in the service.

The period of one month laid down as the maximum for remedial treatment was found to be too rigid and Regional Deputies were allowed to use their discretion in some cases in which men would definitely become Grade I, but in the case of varicose veins it was laid down by the DGMS that more than two injections could be given only if the period of four weeks was not exceeded. It had been pointed out that surgeons had been giving more radical treatment, including Trendelenberg's operation.

The question of treating hernia cases arose, but the DGMS expressed strong opinions against treatment being given, asserting that four months' convalescence was necessary and that recurrences might occur if duty was resumed too early.

At the end of August 1941 there were 978 cases on the waiting list for admission to hospital for remedial treatment, 281 of them being in Invercargill. In January 1942 the number had been reduced to 432, only 50 at Invercargill. Because of the delay, suggestions page 335 were made that treatment could be carried out in the camps or in the smaller country hospitals. The DGMS would not agree to treatment in camps, but agreed to the cases being dealt with in the smaller hospitals. Certain smaller hospitals, because of lack of accommodation and staff, objected to treating cases belonging to their district but which were referred to them from military camps outside the district.

In February 1942 reports were furnished from both Auckland and Christchurch giving the results of treatment carried out there. The Regional Deputy in Auckland was unhappy with regard to the treatment of cases of varicose veins and considered that, in general, too much surgery was being carried out.

In October 1942 there was still difficulty at Auckland in getting airmen dealt with. In March 1943 the Regional Deputy at Auckland considered that too much surgery was being done, often with resultant aggravation of the disability and pension liability, and suggested the appointment of a Senior Superintending Medical Officer to supervise and give consent to all surgical procedures suggested. The Director-General of Health referred the matter to the Adjutant-General, who replied that the appointment might lead to friction with the members of the hospital staff, but he advised that the medical boards and the Regional Deputies should adopt a conservative attitude with regard to the recommendation of surgical remedial procedures, both as regards recruits and serving soldiers. All Regional Deputies were circularised to that effect by the Director-General of Health.

Thus it can be seen that results did not realise expectations, though there is a case for remedial treatment for certain conditions, provided there is selection and control by an experienced surgeon.

It would appear in retrospect that too much emphasis was put on the time factor in the treatment, and too little on the efficiency of the surgical treatment. From overseas experience, if any treatment is to be given for varicose veins it should be mainly surgical, and, if surgery is not required, then as a rule no treatment is necessary and is often meddlesome and dangerous. With regard to varicocele no surgical treatment is desirable. The treatment of undescended testis without the inclusion of hernia is illogical both from the point of view of the common association of the two conditions, and also because efficient treatment of an undescended testis is just as prolonged as the treatment of hernia.

There also seems to have been an over-accentuation of ENT procedures where surgery can so easily be overdone.

The results of treatment in the younger group of soldiers has shown that the operative treatment of hernia in this group would page 336 have been more than justified, especially as a long-term policy. Generally there seems to be no evidence that senior experienced surgical opinion was available in determining the policy adopted. Nevertheless, the adoption of remedial treatment did provide many more Grade I men for the Army, though there is much doubt whether the time and trouble given to the cases was warranted.

Territorial Force and National Military Reserve

In May 1940 instructions were issued from Army Headquarters on the medical standard for members of the Territorial Force, which the Government had recently decided to call up for intensive training, and for members of certain units of the National Military Reserve which were being organised and trained.

It was necessary for all ranks to be medically examined. For new recruits the medical examination was in all respects the same as for recruits for 2 NZEF and the standard of fitness was Grade II. For existing members of units the standard was lower. The reason for the two different standards was the desire to retain as many of the serving members of units as possible. It was feared that if the 2 NZEF standard were applied to these men, there would be a risk of units losing too large a number of trained men.

Home Guard

In July 1941 instructions were likewise issued for the medical examination of Home Guard personnel. The conduct of the examinations was in accordance with the regulations for the medical examination of recruits for 2 NZEF and the Territorial Force. The standard of fitness was Grade II. For both the Home Guard and National Military Reserve X-ray examinations of the chest were undertaken only in those cases in which the medical board specially recommended that it was necessary.

Consideration of Full-time Medical Boards

As the war advanced and a stage of mass mobilisation in New Zealand was reached there were indications that the standard of examinations of recruits was deteriorating. To answer this problem the Director-General of Medical Services propounded a system of permanent full-time medical boards. This recommendation of July 1943 was discussed at length by the National Medical Committee on 6 September and 13 October 1943. The desirability of appointing full-time medical boards in place of the established system under Regional Deputy control was open to question and a decision on the matter was postponed. In the meantime the pressure of medical boarding eased considerably. Thus the suggestion was not put into page 337 effect, and it is a moot point whether such permanent boards would have been practicable because of the rush of recruits and the shortage of medical practitioners.

Medical Boarding on Demobilisation

Each serviceman was medically boarded after his return to New Zealand, usually in a centre near his home. The boarding was carried out by the Health Department, acting through Regional Deputies. Arrangements similar to those for the boarding of recruits were made, the boards being identical. Two medical practitioners constituted a board, and in the main centres a senior practitioner approved the findings of the boards on behalf of the Regional Deputy.

The boards were asked to determine:

The personnel of the medical boards varied considerably in different areas and at different periods. There were available some older semi-retired practitioners with long experience, often in the Army, who were well suited to the work. But at times many young house surgeons at the hospitals without the experience or judgment necessary for this work had to be utilised.

The organisation of the boarding was carried out by the Army, which provided the accommodation, the staff and the machinery for calling up the men for all the examinations and making arrangements for any treatment advised by the board, and attended to all the other requirements such as leave and pay. The Sick and Wounded Branch under the Adjutant-General was then responsible for all personnel whilst undergoing treatment before final demobilisation or transfer to the War Pensions Branch of the Social Security Department.

Generally whilst undergoing medical treatment the serviceman was retained in the Army on full pay, but when treatment was page 338 prolonged, especially when a permanent disability was present, he was demobilised, a pension granted, and he came under the control of the War Pensions Branch.

Servicemen were treated liberally with regard to the provision of medical treatment, the main difficulty being delay due to the inability of the hospitals to provide accommodation. Treatment was provided for any disability present at demobilisation which had arisen during service overseas, whether attributable to service or not, and also for disabilities which had been aggravated by service.

As regards service in New Zealand, treatment was granted for disabilities attributable to or aggravated by service. In every case the serviceman was given the benefit of the doubt.

There was an inevitable tendency for some servicemen to prolong treatment, especially in minor cases, when full pay was being provided. Abuses occurred at times; men even resumed civil employment whilst still on full army pay and attending hospital as out-patients. When a medical officer was attached to the Sick and Wounded Branch he was able to check up on these cases and minimise the abuses.

A dental examination on demobilisation was carried out and provision was made for treatment by private dentists so as to render the man dentally fit. The Army paid the dentists' fees.

An X-ray examination of the chest was carried out for all servicemen, generally by miniature radiography; in cases of doubt a specialist examination and report was arranged for. Assessments of the degree of disability of the ex-servicemen, when present, were made by tuberculosis officers for the consideration of the War Pensions Board in its determination of the amount of pension payable. The Pensions Board adopted a very liberal policy, recognising the disease as possibly connected with service life if its onset took place within two years of an individual's discharge. Not always, however, was a discharge X-ray form attached to the soldier's file and this created an added problem for the War Pensions Boards in their assessments of the source of this serious disease.

In the demobilisation medical boarding there were some special problems, generally psychological in nature. There was a tendency in some cases for the serviceman to wish to hurry the process so as to throw off the trammels of service and enter civilian life, and so to ignore some disability not at the time causing any great inconvenience. On the other hand, many servicemen drew attention to trivial matters so as to have evidence or record in case of any subsequent troubles, and also to get the Army's assistance to rectify some page 339 condition not really causing any disability. This was undoubtedly aggravated by the well-intentioned advice given to servicemen by leading politicians. It caused needless trouble and was psychologically harmful.

Invalids from Overseas

Invalids from overseas were brought by hospital ship to Wellington where, except for South Island cot cases, they were disembarked for medical boarding at the Casualty Clearing Hospital, Aotea Quay. Psychotic and pulmonary tuberculosis patients (unless for the South Island) were taken from the ship direct to Wellington Hospital and their subsequent disposal was made on the recommendation of the specialists concerned. The psychotics were seen by doctors from the Porirua Mental Hospital. In the early stages the Superintendent of the Clearing Hospital, Dr D. Macdonald Wilson, picked out the heavy surgical cases and sent them direct from the ship to Wellington Hospital, but this was soon found unnecessary as all the cot cases could usually be accommodated in one of the six wards of the Clearing Hospital. Likewise, all amputees were admitted to one ward where they would be seen by an orthopaedic surgeon and the Supervisor of Artificial Limbs. Anxiety neurosis cases were usually gathered in one ward also.

Medical boarding, X-ray and dental examinations were all done at the Clearing Hospital. X-ray technicians were supplied by the Wellington Hospital, six civilian dentists were employed, and civilian doctors made up the necessary number of medical boards. The invalids were boarded in groups so that they could connect with rail or bus services for their home destinations. On the second day the South Island cases were boarded so that they could be taken to Lyttelton that night by the hospital ship, and by the fourth day after the hospital ship's arrival all medical boarding was completed. Most patients went to their home towns but care was taken that no man left Wellington until he was fit to travel. Instructions were issued to ensure that a man requiring specialist treatment would go in due course to a hospital where such treatment was available. A posting committee consisting of an officer of the Sick and Wounded Branch and a senior civilian medical practitioner appointed by the Regional Deputy reviewed all medical boardings before men left the Clearing Hospital. The medical officer checked to see that grading was in accordance with instructions in the Organisation for National Security booklet, and that recommendations regarding treatment were sound and according to policy; and especially to see that no orthopaedic case went to other than the large hospitals in the four main centres where there were orthopaedic units. The Sick page 340 and Wounded Branch had the oversight of the patients until their final boarding and discharge from the Army.

Work Accomplished by Medical Boards

There can be no doubt that the civilian medical boards under the Regional Deputies carried out a vast amount of work, and most of it very creditably. Detailed figures are not available of the number of medical examinations made by them but the figures for Area 1, Auckland, the biggest of the twelve areas, indicate the magnitude of the task. In six years the medical boards in this area carried out over 140,000 separate medical examinations. (See table below.)

The work of the boards continued throughout the war, and after, until demobilisation had been completed. In fact, one of their busiest phases occurred during 1945 and early 1946, when large numbers of troops returned from overseas and had to be medically examined before resuming civilian life. In cases where there was any degree of unfitness due to war service the pension aspect assumed a particular importance, although the final question of attributability or aggravation was settled by the Pensions Board.

Manpower examinations December 1942 to December 1945 = 5959

Review of Medical Boarding

Butler quotes a letter from General Birdwood in which he makes the following statement in regard to men from Australia found to be unfit for service in the field when they arrived in England: ‘The lack of uniformity is not so much due to the inevitable lack of common and defined bases as to the inevitable lack of unanimity in human judgment as it affects medical authority on the one hand and the psychology of the soldier on the other. It is ‘probably medically correct to say that a man under the exultation of enlistment in Australia might easily be passed by the same medical board which would reject him in England when the exultation has worn off and he has for a period undergone strenuous military training’. Here the basic problem is soundly stated, but this should not of course be used as an excuse for not making the boarding system as complete and accurate as possible, or for not attempting to secure a good measure of uniformity by the various boards conducting medical examinations.

It is interesting to note that in Canada at the beginning of the Second World War the medical examination of recruits was carried out in a similar fashion to our own. This proved unsatisfactory, especially in the smaller and more scattered districts, and full-time travelling boards were instituted. In Australia, also, the boards were under service control. In Britain the boards were composed of civilian practitioners, but categorisation and more particular army posting enabled more men to be accepted.

It would be almost impossible to ensure that none who could be classified as ‘unfit’ by the medical standards actually entered mobilisation camps, but the aim should be to reduce the wastage to a minimum. There are always keen recruits who will not mention their disabilities even if they are aware of them. It would not be possible to have every recruit examined automatically by an eye specialist and an ear, nose and throat specialist, nor could all cases making a statement of injury near a joint be X-rayed. The medical examination could easily be so severe that the forces would get few recruits. Except for serious disabilities, the really important factor is the reaction of the individual to army life. Many render notable service in spite of disabilities that are not discovered. Some of the complaints from overseas followed arduous periods of page 342 training, some of it no doubt monotonous. It is possible that had some of the men been involved in the action of a campaign sooner they might never have reported disabilities.

A reduction of wastage could be achieved if all doctors on medical boards were thoroughly educated in their duties before any emergency arose. Experience in medical examinations for Territorials would, of course, be a valuable background for doctors called upon in emergency. Even then a doctor may be familiar with his instructions, may make a complete and conscientious examination, but then be lacking in judgment because he does not realise the effect of military training and life on the variations from normal that he may find in a recruit. It is here that the experience of doctors with war service is valuable, but the theatre of service or the unknown nature of the campaign again are limiting factors. It would be helpful if medical boarding were staggered and fewer doctors employed, possibly full-time. The making available of the medical files held by the Army or War Pensions Branch for any previous military service by the recruit would be a considerable aid, as also would be any hospital record.

The essential requirements of a medical board are, first, a clear-cut code of instructions so that the requirements of the army authorities as to physical and mental standards under the various categories are clearly understood; second, a team of medical men who are interested and enthusiastic in this class of work; third, a standard of clinical acumen in the board which will ensure the minimum of mistakes being made in evaluating disabilities, real or alleged. The Code of Instructions issued in the Second World War was a reliable and adequate guide, but only if used in conjunction with sound clinical judgment.

As the war went on and fewer practitioners were available, junior men from the hospitals were employed to a great extent on medical boards. Even with a satisfactory code of instructions, the grading of recruits must necessarily be difficult, and it is not surprising that standards varied greatly in the different parts of New Zealand.

The examination of a man took only a few minutes; it was estimated that eight men were examined in an hour, and no adequate tests or no very complete inquiry could be made in that time. The recruit can easily withhold important information, and particularly can deny the presence of any disability even when the examiner may note a possible cause for disability. The psychological make-up of the recruit also can hardly be adequately summed up in the time, or by the ordinary methods of examination utilised. There were marked differences in the proportion of men turned down in different areas, both as regards the number and also as to the disabilities suffered.

The rejection of a man for some minor abnormality which did not prevent him from carrying out a strenuous occupation or indulging in strenuous sport is absurd and brings the medical examination into disrepute. It takes long experience and generally specialised experience in the forces to be able to evaluate the real significance of the numerous small abnormalities to which the body is prone. The medical practitioner is apt to set his standards too high and in his efforts to correct abnormalities is apt to assume that abnormalities have a marked effect on function. He is surprised when he finds a man doing hard manual work without complaint, with some marked abnormality in his physical make-up, which in another man of weaker fibre would give rise to much complaint.

It has always seemed anomalous that such a large percentage of men able to carry on their work in civil life are unfit for service in the forces, especially as only a proportion of those even in overseas service are subjected to the stress of front-line service. During the Second World War it was shown that the main bar to satisfactory overseas, and especially front-line, service was an unstable psychological make-up, and this was not at all a common cause for the rejection of a recruit. The rejection, on the other hand, was generally made on some physical abnormality, which in many instances had never given rise to any appreciable disability and would not have done so in the Army if the mental condition was stable.

The system of medical boarding in New Zealand during the Second World War was generally efficient in the circumstances but it had certain weaknesses. Some of the districts allocated to Regional Deputies did not conform to army areas, and this led to difficulty in the oversight of medical files. The Regional Deputies were part-time officers with busy practices and were unable to supervise boards held in outlying centres. They had no secretarial assistance in the transmission of instructions to the doctors in their areas. The boarding of each balloted group had to be completed in six weeks, which meant inevitable hustle, especially as the medical practitioners were busy and their numbers much reduced. There was a natural tendency to overload the boarding sessions, especially in the smaller and more scattered areas. The shortage of specialists led to delay in obtaining specialist opinions on referred cases. There was no means of allocating men with minor degrees of disability to special occupations in the Army. Standards were laid down for the Territorial and Home Guard service, but the Army altered the conditions of service later without further medical examination for those concerned. The Pulheems system of medical boarding should correct many of these anomalies in the future, and the experience page 344 obtained in the medical boarding of those on Territorial service will help.

Rejection Rates