The Pike Report on German East Africa

Confidential
REPORT on MEDICAL AND SANITARY MATTERS in GERMAN EAST AFRICA 1917
Nairobi, Printed by the SWIFT PRESS, 1918

CONTENTS

SECTION 1 – INTRODUCTORY
Terms of Reference – Itinerary and order of inspections; Central Railway and Lines of evacuation from the south, namely, Dodoma to Observation Hill via Iringa, Kilossa to Ruaha, Morogoro to Mpangas and Rufiji River via Mikesse and Summit. Preliminary interviews at Dar-es-Salaam. Inspections Dar-es-Salaam. Diary of Inspections.
pp 1 to 6

SECTION 2 – APPRECIATION OF DIFFICULTIES OF CAMPAIGN
Physical features of German East Africa. Paucity of roads and railways. Climatic drawbacks. Prevalence of disease-carrying and noxious insects, also of other pests. Water supply usually impure and often limited. Scarcity of supplies. Heterogenous composition of the force. Medical Officers and personnel usually ignorant of native languages. Number of interpreters deficient. Scarcity of animal transport. Prevalence of trypanosomiasis, horse sickness and East Coast fever. Difficulty of transport by carriers. Shipping difficulties. Nature of harbours. Necessity for frequent transhipment. Prevalence of sickness. High death and invaliding rates. Enemy advantages. Unfortunate and erroneous statement as regards termination of war, its effects.
p 6

SECTION 3 – MEDICAL ADMINISTRATION
Graph showing organisation. List of medical units showing distribution. African Native Medical Corps; strength, assistance rendered by, found very useful, should be continued after the war. Help rendered by Roman Catholic Missions. Scheme of evacuation by stretcher bearers with stretchers and machillas; supply box-cars, trolleys, ambulance train, hospital ships. Number of hospital ships; cases carried by them during 1917. Valuable work rendered by Red Cross Society; provision of launches by the Society at Base ports.
pp 6 to 12

SECTION 4 – PROVISION OF BATERIOLOGICAL LABORATORIES
Bacteriological laboratories and scientific facilities for investigation of disease. Paucity of laboratories. Military bacteriological laboratory, Dar-es-Salaam; clinical and hygienic sections, good work accomplished by. New laboratories at Kilwa and Mingoyo. Necessity for more laboratories and laboratory workers. Requisition by cable to the War Office for laboratories, microscopes, bacteriologists, protozoologists and a consultant in tropical medicine. Need for definite laboratory organisation and consulting bacteriologist. Laboratory supplies and equipment.

MICROSCOPES
Absolutely essential for clinical work. Results of insufficient supply of microscopes. Marked deficiency of. Scheme for supply of microscopes. List of hospitals devoid of microscopes. Efforts made to remedy the situation. Necessity for training medical officers in microscopic work locally. Necessary information of scientific nature not furnished medical authorities in East Africa. Necessity for medical liaison officers both at the War Office and in India. Outline of their duties.

ENTOMOLOGISTS
Temporary appointment of Dr WM Aders; his reports on Dar-es-Salaam and Kilwa. Dr Spurrier’s work in Dar-es-Salaam. Dr Lamborn’s report; neglect of his recommendations by the Veterinary Services. Additional entomologists. Lieut-Colonel Maynard as a scientific adviser. Major Cuthbert Christy, adviser on malaria and other diseases. Director of Medical Services hampered by lack of information.
pp 13 to 17

SECTION 5 – GENERAL PREVALENCE OF DISEASE
Introductory. Statistics. Incidence of malaria and pneumonia amongst East African carriers. Various statistical tables. Data as regards troops, followers and carriers.
pp 17 to 25

SECTION 6 – NOTES ON INDIVIDUAL DISEASES
Malaria
The most prevalent disease. Statistics regarding. Common anophelines in German East Africa. Type of malaria present. Frequency of malaria relapses. Causes of. Reasons for inefficient treatment. Malarial questions not properly handled from the outset. Lack of proper organisation. Need for expert advice and information. Anti-malarial measures carried out at a late period. Malaria in Dar-es-Salaam. Local infection in Dar-es-Salaam. Failure to find suitable places for Concentration Camp and Depot in Pugu hills. Sources of information which should have been available. Lack of immediate survey after occupation of the town. Dr Aders’ survey. Site of Main Detail Camp. Arrangements as regards troops newly landed. Malaria at posts on the Central Railway, at Kilwa Kisiwani, Kilwa Kivinji and in the Lindi area. Diseases mistaken for malaria. Malaria a new disease to many medical officers. Need for tropical consultants. General outlook as regards malaria.

Blackwater Fever
Prevalence. Quinine haemoglobinuria. Bilharzial dysentery. Rarity of liver abscess cases. Water a cause of dysentery. Dysentery amongst natives. The native as a dysentery carrier. Unprotected war supplies in the Kilwa and Lindi areas. Infected food as a cause. Incidence amongst motor transport drivers. Flies apparently little operative. Treatment. Waste of emetine. Anti-dysentery emetine. Anti-dysentery serum. Death rate high amongst followers and carriers.

Diarrhoea
Irritant diarrhoea due to faulty and ill-cooked diet. Influence of chill and ingestion of sand.

Pneumonia
Prevalence of. Malarial pneumonia. Cause of pneumonia amongst Indians and native Africans. Influence of high altitudes.

Cerebro-Spinal Fever
Prevalence of. Chief incidence amongst carriers. Return of admissions and deaths. Segregation and treatment. Preparation of polyvalent serum from local strains of meningococci. Use of Gordon-Flack spray recommended. Pneumococcal meningitis.

Central African Relapsing Fever
Frequently recognised. Confounded with malaria. Mentioned in War Office pamphlet for troops and in Major Christy’s memorandum. Spirillum tick at Morogoro. Treatment.

Sleeping Sickness
Rarity of. Danger of spread. Tsetse areas common. Species of tsetse fly encountered. Danger from influx of porters from Belgian Congo and occupation of Rovuma River districts. Action taken regarding possible introduction of sleeping sickness.

Small-pox
Prevalence of. Almost wholly confined to natives. Outbreaks at Tabora and Morogoro. Preparation and distribution of vaccine lymph.

Measles
Prevalence of. Cause of deaths amongst Seychelles Porters at Kilwa. Apt to be specially severe in ankylostomiasis cases.

Enterica
Prevalence of. Probably often not recognised owing to lack of laboratory facilities. Formerly common amongst natives in German East Africa. Preventative inoculation amongst Imperial units and South African units. Majority of white troops probably protected.

Plague
Nairobi a source of. Outbreak of pneumonic plague on HM Transport Barjora. Methods taken for dealing with outbreak. Facilities for disinfection of ships not available at Dar-es-Salaam. Clayton apparatus at Zanzibar. Use of hydrocyanic acid gas generator suggested.

Effects of sun
A factor in lowering resistance to disease. Sunstroke cases rare. Preventative measures on the whole satisfactory.

Scurvy
Prevalence of. No outbreak has occurred. Its relation to rations. Possible reasons for its rarity.

Beri-beri
Prevalence of. Outbreak amongst Seychelles porters.

Ankylostomiasis
Prevalence of. A factor in lessening resistance to disease. Treatment.

Bilharziasis
Prevalence of. Bilharzial dysentery. Lack of knowledge regarding presence or absence of snail hosts.

Filariasis
Prevalence of. Guinea-worm infection not common.

Sand-fly Fever
Apparently absent. Phlebotomus flies not in evidence.

Myiasis
Chigger flea troublesome, especially amongst Indians. Method of prophylaxis. Maggot infection from larvae of Cordylobia anthropophaga. Congo floor maggot at Tabora and Mpangas.

Skin Diseases
Prevalence of Ulcus tropicum. Treatment of.

Venereal Disease
Rarity of locally acquired cases.

Veterinary
Trypanosomiasis, horse sickness, East Coast fever in cattle.
pp 26 to 35

SECTION 7 – REMARKS IN DETAIL ON INSPECTION DURING TOUR
Dar-es-Salaam – Inspections, Camps, Stores, Hospitals, Dental unit, Red Cross Depot, Hospital Ships, Town, Laboratory. Necessity for ophthalmic centre. Sanitary inspections. Dar-es-Salaam highly malarial. Chief mosquito breeding places. Camps badly placed in relation to mosquito breeding places. Delay in starting mosquito brigade. Work of Dr Spurrier and his brigade. Withdrawal of hospital from Kurasini. Notes on Sanitation. Necessity for separate Medical Officer of Health.

Tabora – Inspections, Hospitals, Camps, Depots, Town, Lulanguru Carrier Camp and Hospital. Now the examining post for porters from Belgian Congo. Sanitation of Tabora.

Itigi – Carrier Rest Post.

Dodoma – Interviews. 14 Casualty Clearing Station. Need for laboratory and bacteriologist. No 1 Stationary Carrier Hospital. Belgian Camp. No 10 Advanced Depot Medical Stores. Motor Transport Details Camp. Station Detail Camp.

From Dodoma to Observation Hill. Makitira Hospital. Termagwe Hospital. No 19 Motor Ambulance Convoy Termagwe. Medical Rest Post. Ho Ho.

Iringa – A Section 22 Indian Clearing Station. Carrier Hospital. Evacuation of sick from Observation Hill.

Kilossa – C Section 4th South African Field Ambulance. And Carrier Stationary Hospital. Carrier Depot. Government Garden.

Kilossa to Ruaha River – 3rd South African Mounted Brigade Field Ambulance at Ruaha and Mfrisi. Motor Transport Camp. Mfrisi. Need for alterations.

Morogoro – Inspections. Hospitals, Camps, Depots, Stores, Dental unit. Need of change for staff and personnel of medical units.

Morogoro to Mpangas on Rufiji River

Mikesse – 3rd South African Field Ambulance. Suggestion to move Carrier Hospital and Carrier Depot from Morogoro to Mikesse not accepted.

Summit – No 3 South African Field Ambulance. Carrier Camp. Work of carriers on this line. No 28 Motor Ambulance Convoy Camp. Water supply well protected.

Mgeta Rest Post – Sickness amongst Rufiji force last spring. Porters incapacitated owing to illness caused by hard work and shortage of food.

Mpangas – Supplies on Rufiji line. Shortage of vegetables. Garden supplies from Kissaki.

Morogoro – Low-lying parts of Morogoro unhealthy. Sanitation unsatisfactory. Lack of sanitary personnel. Need for anti-mosquito operations in neighbourhood of convalescent camp.

Dar-es-Salaam – Conference as regards hutting of troops and hospitals. Suggestions as regards inspection of Carrier Hospitals at out-stations. Military control of sanitary arrangements. Selection of camp sites. Shelters for European sentries.

Zanzibar – Convalescent home. Laboratory and Museum. Inspections Zanzibar Inspection Hospital Ship Neuralia

Kilwa Kisiwani – Faulty sanitation. Prevalence of flies. Inspections. Camps, Hospitals, Stores.

Kilwa Kivinji – Inspections, Hospitals, Depots, Camps. Red Hill a malarial area. Need for protection of water supply.

Mpara

Kilwa Kisiwani – Embarkation arrangements. Inspection HM Transport Barjora.

Lindi – No 1 African Stationary Hospital. Distribution Red Cross comforts.

Mingoyo – No 52 Casualty Clearing Station.

Chirimake – No 4 South African Field Ambulance. D Section West African Field Ambulance. Carrier Hospital.

Mtama – No 29 Motor Ambulance Convoy. No 32 British Stationary Hospital. 3rd Section East African Field Ambulance. C Section Indian Combined Field Ambulance Motor Transport Camp.

Mahiwa – Inspection of Field Ambulances.

Mingoyo – Indian Hospital. Carrier Hospital. Carrier Depot. Detail Camp. Sanitation.

Lindi – Supply Depot. Detail Camp. Carrier Hospital. Advanced Depot Medical Stores. Suggestion regarding drugs sent by ship. Water supply.

Kilwa – Halazone unsuitable for water sterilization in tropics.

Mtandawala – No 4 South African Field Ambulance. No 3 Carrier Clearing Hospital. Faulty arrangements as regards rations and medical comforts for hospitals. Condition remedied. Carrier Camp.

Nahungu – Field Depot Medical Stores. No 2 Carriers Rest Station, condition very unsatisfactory. Supply Depot. Indian Clearing Hospital. Sanitation. Water arrangements of post unsatisfactory.

Mnero – No 2 South African Field Ambulance. No 18 Motor Ambulance Convoy. Porters Camp. Indian and Native Hospital. Water supply requirements. Interview with Commander-in-Chief at Nahungu.

Luale
Lungu
Nanganachi
Mnasi
Kisiwani re-inspected
Dar-es-Salaam. Interviews.

Recommendations as regards water sterilization, lectures to orderlies, reinforcements for Royal Engineers, improved rank for sanitary officers, posting of troops to Dar-es-Salaam. Hospital Ship Vita, inspection of.
Inoculation entries in pay books. Mosquito breeding areas in Dar-es-Salaam. Quinine prophylaxis at Main Detail Camp. Inspection of billets in Dar-es-Salaam. Railway Detail Camp and Hospital.

Motor Transport – Prevalence of Disease amongst motor transport drivers. Causes of. Faulty arrangements for food and sanitation. Recommendations for remedying above conditions.
pp 36 to 47

SECTION 8 – SANITATION
Lack of proper organisation. Sanitation staff inadequate. Difficulties of sanitation in German East Africa. Need for strong sanitation staff. Sanitary sections deficient and inadequately supplied. Sanitary adviser. Absence of literature and information. Delay in sanitary action. Recent changes in sanitary organisation. Co-ordination in sanitary work. Points requiring special attention.

Water Supplies – Sources of. Need for protection of. Equipment deficient. Sterilization of. Danger of bilharziasis. Ablution. Disinfection – Value of railway disinfecting van at Dar-es-Salaam. Collection and disposal of human excreta. Latrines and Incinerators. Urinals. Collection and Disposal of refuse and horse manure. Camps and camp sites. Billets. Cookhouses. Slaughter houses and Butchers’ Shops. Ice and Soda-water. Flies and other insect pests. Sanitary Sections.
pp 47 to 55

SECTION 9 – RATIONS
Conditions governing supply. Difficulties in supply. Need for expert help and scientific advice. Ration scales. European ration, Indian ration, African troops ration, Carrier ration, Cape Boys ration, West African ration, West India Regiment ration. Correspondence regarding rations. Lieut-Colonel Maynard as adviser. Local purchase. Need for more gardens. Recommendations. Scurvy in relation to the ration question. Latest ration scales. Preparation and cooking of food.

SECTION 10 – RECOMMENDATIONS
Table of recommendations and suggestions. Administrative, Sanitary and Clinical.
pp 64 to 66

SECTION 11 – MISCELLANEOUS
Report on embarkation of Union natives on SS Aragon at Kilwa Kisiwani.
Letter from Senior Medical Officer, Kilwa Kivinji.
Letter from Acting Controller, Union Labour.
Telegram from Senior Medical Officer, Kilwa.
Captain Miller’s report on Aragon question.
Captain Douglas’s report on Aragon question.
Memorandum by Deputy Director of Medical Services, Lines of Communication.
Letter from Officer Commanding, No 19 Stationary Hospital to Deputy Director of Medical Services, Lines of Communication.
Letter from Controller, Union Labour.
Copies of wires passing between Surgeon-General Pike and Officer Commanding G Section, Kilwa.
Diary of Controller, Union Labour.

Outbreak of pneumonic plague on HM Transport Barjora. Memoranda from Colonel Clemesha.
Report on proposed camp sites at Kilwa Kivinji, Red Hill, Mpara and Kilwa Kisiwani. Recommendations. Considerations of the water supply. Summary of Dr Aders’ Report on Kilwa area.
pp 66 to 87

SECTION 12 – SUMMARY AND CONCLUSIONS
pp 87 to 89

SECTION 1

Confidential
To The Secretary, War Office

1. On 11 July 1917, Lieut-Colonel A Balfour and I received the following order:-

War Office
Adastral House
Victoria Embankment, EC4
10 July 1917
079/3648 (AMD 1)

Sir,
I am commanded by the Army Council to request that you will proceed to East Africa accompanied by Lieut-Colonel A Balfour, CMG, Royal Army Medical Corps, to examine and report:-
1. Upon all matters affecting the health of the Troops, British and Native, including Followers.
2. On the Hospital provision of such Troops and Followers.
3. On the rations, clothing and comforts supplied.
4. On the provision of bacteriological laboratories and means of scientific investigation of disease problems.
5. Particularly on any recent outbreaks of disease among the Native followers (Union and East Africa) with any special reference to its nature and causation.
6. Every facility will be given to you to carry out this investigation and you will report to the War Office on completion. If considered necessary, interim reports will be submitted together with telegraphic summaries. All reports will be submitted through the General Officer Commanding-in-Chief.
7. You will proceed to the Cape, confer with the Authorities there and obtain such information as may be required. On completion of your work you may, if you consider it desirable, revisit the Cape.
I am, Sir, Your obedient servant,
(Signed) BB Cubitt

Surgeon-General WW Pike, CMG, DSO
Army Medical Service
10 Henrietta Street
Cavendish Square, W

2. We sailed by Union Castle Line RMS Norman from Tilbury on 21 July, arrived at Dar-es-Salaam on 24 August, and reported to General Headquarters East African Expeditionary Force.
3. We then proceeded to carry out an itinerary, the order of which was decided on by the military situation existing at the time. This was roughly as follows. The enemy had been practically driven south of the Central Railway and we were going south after him from (1) Dodoma via Iringa towards Mahenge which he was holding with some strength. (2) Kilossa via Ruaha River also towards Mahenge. (3) Morogoro via Mikesse, The Summit and Rufiji River at Mpangas to head off any force trying to break north. An offensive had also been commenced from Kilwa and Lindi.
4. Before starting we inspected Dar-es-Salaam and had interviews with (1) General Officer Commanding; (2) Deputy-Adjutant and Quartermaster-General; (3) Director of Medical Services; (4) Director of Ordnance Services; (5) Officer Commanding Royal Engineers; (6) Provost Marshal; (7) Naval Transport Officer; (8) Assistant Adjutant-General; (9) Director of Supplies; (10) Director of Supplies; (11) Deputy Director of Medical Services; (12) Assistant Director of Medical Services (Sanitation); (13) Director Spurrier; (14) Senior Medical Officer, (now Assistant Director of Medical Services); Carriers and many other Heads of Departments and Officers Commanding units. We also visited the Admiral on the Flagship and all Hospital Ships and their Commanders. We inspected practically all units in Dar-es-Salaam.
5. The interviews and inspections of units will be dealt with more fully later but the following itinerary will show the places and units inspected and the long and difficult journeys we were obliged to take.

ITINERARY AND DIARY
(see map No 1)

24 August Landed at Dar-es-Salaam ex HMHS Dunluce Castle. Various interviews. General inspection of town.
25 August Inspected Medical Detail Camp, Central premises Base Depot Medical Stores, German Hospital, Dental Unit. Interview.
26 August Rest. Visit to bush country on southern side of harbour. Mosquito breeding pools noted.
27 August Inspected No 2 South African General Hospital (all sections in the town), Isolation Hospital. Military Bacteriological Laboratory, Surgical Section No 2 South African General Hospital (separate building). Ambulance train on Central Railway. Interviews.
28 August Inspected No 3 African Stationary Hospital, Quarantine Island with plague cases. Interviews.
29 August Inspected Mosquito Fish Aquarium, part of area of anti-malarial operations, Main Detail Camp, Kurasini Branch of No 3 African Stationary Hospital, mosquito breeding area, Red Cross Depot, HMHS {His Majesty’s Hospital Ship} Ebani.
30 August Inspected Carrier Depot, Carrier Depot Hospital, African Native Medical Corps Depot, Hygiene Laboratory, HMHS Delta.
31 August Inspected Motor Transport Camp, Prisoners of War Camp, Native Detail Hospital, Slaughter House, part of area of anti-malarial operations, Geresani.
1 September Inspected Medical Detail Camp for second time, Issue Department Base Depot Medical Stores, Bakery. Interviews.
2 September Rest. Office work.
3 September Inspected HMHS Dongola, Ordnance Stores and Workshops, Motor Transport Camp for second time.
4 September Inspected No 9 Sanitary Section. Interviews.
5 September Inspected Geresani Valley, HMHS Wandilla, HMHS Oxfordshire. Interviews.
6 September Left Dar-es-Salaam for Tabora by Central Railway.
9 September Arrived Tabora. Interviews. General inspection.
10 September Inspected Native Hospital, European Hospital, Isolation Hospital, King’s African Rifles’ Depot Hospital, 4th King’s African Rifles’ Camp, Water Supply, Boma, Jail, Town-market, Area of anti-mosquito operations.
11 September Inspected Lalanguru Carrier Camp and Hospital, Railway Workshops, Carrier Camp, Tabora
12 September Interviews. Left Tabora for Itigi.
13 September Inspections at Itigi, Carrier Hospital, Carrier Camp, Railway Camp, Water Supplies. Left for Dodoma.
14 September Dodoma. Interviews.
15 September Inspected No 14 Casualty Clearing Station, various Sections. Interviews.
16 September Rest. Office work.
17 September Inspected Native Section No 14 Casualty Clearing Station, No 10 Advanced Medical Stores, No 19 Motor Ambulance Convoy. Interviews.
18 September Inspected No 1 Stationary Carrier Hospital, Belgian Camp, Headquarters Deputy Assistant Director of Medical Services (Sanitary) Northern Area. Interviews.
19 September Inspection No 1 Stationary Carrier Hospital continued. Inspected Belgian Carrier Hospital, Carrier Depot Camp, Army Service Corps Detail Camp, South African Service Corps Detail Camp. Interviews.
20 September Inspected Motor Transport Camps, Army Service Corps and South African Service Corps, Dental Unit, Station Detail Camp, Water Supply.
21 September Left Dodoma for Iringa. Inspected Makitira Rest Station, Termagwe Rest Post, No 19 Motor Ambulance Convoy. Remained Termagwe over night.
22 September Left Termagwe for Iringa. Inspected Ho Ho Rest Post and Supply Dump, No 22 Indian Clearing Station, Iringa. Interviews.
23 September Iringa to Observation Hill and back. Inspected Rest Post, Observation Hill, Dobarga Rest Post, possible Camp sites on road. Sanitary Inspection Iringa. Sanitation Corps Camp, Mechanical Transport Camp, Western Signallers Camp, Ammunition Column Camp, Belgian Camp, Wireless Camp. Supply Depot in Boma. Barracks of Ruga-Ruga Scouts, Market, Slaughter House. Inspection No 1 Carrier Clearing Hospital.
24 September Inspection No 1 Carrier Clearing Hospital continued. Left for Termagwe. At Termagwe over night.
25 September Left Termagwe for Dodoma. Inspected abandoned ambulances at Kissoga en route.
26 September Office work. Sanitary inspection No 14 Casualty Clearing Station.
27 September Left Dodoma for Kilossa.
28 September Kilossa. Interviews. Inspected C Section No 4 South African Field Ambulance. Left for Ruaha via Mfrisi. At Mfrisi over night.
29 September Left Mfrisi for Ruaha. Inspected Section 3rd South African Mounted Brigade Field Ambulance, Telegraphists Camp, Supplies Camp, Kidatu Isolation Camp. Returned Mfrisi.
30 September Inspected Section 3rd South African Mounted Brigade Field Ambulance, Motor Transport Depot. Left for Kilossa.
1 October Kilossa. Inspected No 2 Carrier Stationary Hospital, Slaughter House, Public Latrines, Motor Transport Camp, Billets, Supply Depot, Sanitation Corps Camp, Bakery, Carrier Depot, Belgian Camp, Vegetable Garden, Belgian Hospital. Interviews. Left for Morogoro.
2 October Morogoro. Rest. Office work.
3 October Inspected No 15 Stationary Hospital, No 37 Stationary Hospital (Nigerian). Interviews.
4 October Inspected No 6 Indian General Hospital, Carrier Corps Hospital, Carrier Depot, Dental Unit, Supplies, Advanced Depot Medical Stores, No 2 Sanitary Section, Government Garden, Jail.
5 October Inspected Convalescent Depot, German African Hospital, Detail Camp, Post Medical Inspection Room, Motor Transport Depot, Advanced Base Ordnance Depot, Machine Gun School, Royal Marine Artillery Camp, Royal Artillery Detail Camp.
6 October Clinical inspection No 15 Stationary Hospital. Visit to anopheles breeding places in Morogoro.
7 October Sanitary inspection of town. Report thereon.
8 October Left Morogoro for Rufiji via Mikesse and Summit. At Mikesse inspected Section No 3 South African Field Ambulance and empty Carrier Depot and Carrier Camp. At Summit inspected part of B Section No 3 South African Field Ambulance, Carrier Depo, 29th Motor Ambulance Convoy, Water Supply of Post.
9 October Left Summit for Mpangas (Rufiji River). Inspected Mgeta Rest Post, Ruga-Ruga Camp, Beho-Beho Rest Post and Camp.
10 October Mpangas. Inspected part of B Section No 3 South African Field Ambulance, Isolation Camp, Carriers Camp, Supply Camp, British West Indies Regiment Camp, Sanitation of Post.
11 October Left Mpangas for Summit.
12 October Left Summit for Morogoro.
13 October Morogoro. Inspected Cape Corps Camp. Water Supply.
14 October Rest. Office work.
15 October Left Morogoro for Dar-es-Salaam.
16 October Rest. Office work. Interviews.
17 October Enquiries re Seychelles Porters. Meeting to consider question of hutting and changes in No 3 African Stationary Hospital. Inspected No 3 African Stationary Hospital – road and approaches.
18 October Office work. Interviews. Inspected Mskara and springs in Geresani Valley – part of anti-mosquito operations area.
19 October Memoranda on Diseases drafted. Office work. Interviews.
20 October Embarked on HM Hospital Ship Neuralia for Zanzibar and Kilwa.
21 October Zanzibar. Interviews. Visit to Biological Museum.
22 October Inspected Officers Convalescent Home. Interviews.
23 October Inspected possible Camp site near Bweleo, Kombrani Bay, Flying Corps Headquarters. Office work.
24 October Inspection town sanitation and water supply.
25 October Revisit to Museum. Sailed for Kilwa Kisiwani. Inspected HM Hospital Ship Neuralia.
26 October Kisiwani. Inspected Supplies Camp, Ordance Camp, Main Detail Camp, Motor Transport Camp, Railway Porters Camp, Mechanical Transport Camp, No 2 African Stationary Hospital, Carrier Hospital. Interviews.
27 October Kilwa Kivinji. Inspected NO 19 Stationary Hospital, Supplies and Transport, Bakery, Public latrines, Ordnance, Carrier Camp, Tractors and trolleys at Lewali Crossing, Motor Transport Camp. Enquiries re Aragon incident.
28 October Kisiwani. Inspected arrangements for embarking sick and wounded. Enquiry re Sanitary Organisation Kilwa Line.
Kivinji. Inspected Red Hill and Water Supply. Interviews.
29 October Kisiwani. Inspected Naval Transport Camp. Interviews. Kivinji. Inspected No 3 Carrier Stationary Hospital. Enquiries re Seychelles Porters and Aragon incident.
30 October Kisiwani. Interviews. Inspected Mpara. Gold Coast Depot, Remount Camp, Inspection Room, Water Supply, Mosquito breeding area. Inspected Camp sites near Kisiwani. Aragon enquiry continued. Office work.
31 October Various enquiries. Office work.
1 November Inspected HM Transport Barjora in Kisiwani Harbour. Eft on HM Hospital Ship Ebani for Lindi. Interview re Aragon incident.
2 November Lindi. Interviews. Inspected No 1 African Stationary Hospital. Interview re Seychelles Porters. Inspected embarkation arrangements. Left for Mingoyo.
3 November Left Mingoyo for Chirimake. Inspected Section No 4 South African Field Ambulance previously seen at Kilossa, D Section West African Field Ambulance. Proceeded to Mtama. Inspected No 29 Motor Ambulance Convoy, C Section 150 Indian Combined Field Ambulance, 3rd Section East African Field Ambulance, No 32 British Stationary Hospital, Motor Transport Camp. At Mtama overnight. Interviews.
4 November N’Jangao. Inspected B Section 300 Nigerian Field Ambulance, A Section 300 Nigerian Field Ambulance, No 3 Column. C Section 120 Indian Field Ambulance, B Section 120 Indian Field Ambulance, No 4 Column. Cape Corps Camp, Mahiwa trenches. Returned Mingoyo, inspecting Field Depot Medical Stores, Chirimake en route.
Mingoyo. Inspection No 52 Casualty Clearing Station, Units No 3 Sanitary Section.
5 November Inspection No 52 Casualty Clearing Station continued. Inspected Section No 16 Indian Clearing Hospital, No 4 Carrier Hospital, Carrier Depot, Railway Camp, Supplies, Bakery, Ordnance, Detail Camp, Slaughter House, Site of water supply, Laboratory. Interviews.
6 November Left Mingoyo for Lindi. At Lindi inspected Supplies, Bakery, Butchery, Detail Camp, Carrier Hospital, Carrier Depot, Advanced Depot Medical Stores, Water Supply. Embarked on HM Hospital Ship Ebani for Kisiwani.
7 November Kisiwani. Office work. Interviews.
8 November Rest. Office work.
9 November Left Kisiwani for Mtandawala. All day journey. At Mtandawala overnight.
10 November Mtandawala. Inspected No 4 South African Field Ambulance. Enquiries re Aragon incident. Left for Nahungu. At Nahungu overnight.
11 November Nahungu. Inspected Field Depot Medical Stores, Indian Clearing Hospital, No 2 Carrier Rest Station, 86th Sanitary Section Camp. 3rd King’s African Rifles Camp, Supply Depot. Left for Mnero. At Mnero inspected B Section No 2 South African Field Ambulance, Motor Transport Camp, Motor Ambulance Convoy, Carriers Camp. D Section 16 Indian Clearing Hospital, A Section 22 Indian Clearing Hospital, Water Supply of Post. At Mnero overnight.
12 November Left Mnero for Nahungu. At Nahungu inspected Motor Ambulance Convoy. Interviews. At Nahungu overnight.
13 November Left Nahungu for Mtandawala. At Luale inspected Post, also Section, No 4 South African Field Ambulance. At Lungu inspected water supplies. At Nanganachi inspected Post and Section No 4 South African Field Ambulance. At Mtandawala inspected tractors and trolleys on railway, No 3 Carrier Clearing Hospital. Interviews. At Mtandawala overnight.
14 November Left Mtandawala for Kisiwani. At Mnasi inspected water supply. At Kilwa Kivinji inspected laboratory. Interviews.
15 November Kisiwani. Interviews. Re-inspected Ordnance, Supplies, Main Detail and Naval Transport Camps. Re-visited camp sites near Kisiwani. Sailed on HM Hospital Ship Dunlance Castle for Dar-es-Salaam.
16 November Dar-es-Salaam. Interviews. Office work.
17 November Interviews. Office work.
18 November Inspected alterations at No 3 African Stationary Hospital, HM Hospital Ship Vita. Office work.
19 November Inspected Sanitary Demonstration Centre. Office work. Interviews.
20 November Interviews. Office work. Inspected mosquito-breeding area – Kurasini.
21 November Inspected inoculation entries in pay books at No 2 South African General Hospital and Medical Detail Camp. Mission Garden at Simbasi and malarial valley. Office work.
22 November Office work.
23 November Inspected Carrier Corps swamps and Bagamoyo pool. General survey mosquito-breeding areas. Office work.
24 November Inspected Main Detail Camp. Enquiries re quinine prophylaxis. Office work. Interviews.
25 November Office work. Interviews.
26 November Office work. Interviews.
27 November Inspected billets in Dar-es-Salaam, also No 1 Railway Detail Camp and Hospital.
27 to 30 November Office work. Interviews.

SECTION 2
APPRECIATION OF DIFFICULTIES OF CAMPAIGN

6. No criticism on the work in German East Africa would be just unless the extraordinary difficulties of the campaign were indicated:-
a) The enormous size of the country, its almost universally dense jungle, its extensive swamps, rivers and creeks with deep water and soft muddy banks (the worst of all to cross), few and indifferent roads and railways.
b) A climate, one of the worst in the world for military operations with the exception of a few months in the dry season. That of the littoral is at all times trying and enervating.
c) The presence of many kinds of disease-carrying and noxious insects, especially during the rainy season, together with an abundance of dangerous creatures, such as the larger carnivores, snakes, scorpions, centipedes and other pests.
d) An almost universally impure and limited water supply.
e) Half rations, on several occasions for long periods, owing to the military situation and hard work while on these half rations.
f) A mixture of a great variety of races requiring 1) different foods; 2) cooking; 3) latrines; 4) transport; 5) camps; 6) washing places; 7) clothing, etc, etc, etc.
g) Medical officers and personnel as a rule totally ignorant of the majority of the languages spoken by their patients and a deficient number of interpreters to meet this difficulty. Further, many medical officers had no previous experience of tropical diseases.
h) Animal transport rarely available owing to tsetse fly, horse sickness, and East Coast fever.
Man carriage by porters was therefore all that was usually procurable and this was constantly interrupted and delayed in the rains by swollen drivers and muddy roads often waist deep. Several men are said to have been seized by crocodiles on the flooded main road near M’geta on the Rufiji Line.
i) Great shipping difficulties owing to the varying size of the harbours and depth of water in them which necessitated ships of special length and draft as at Lindi. Authorities for embarkation or disembarkation owing to the danger arising to lighters which are very secure and cannot be risked. There was also the necessity for transhipment (occasionally several times) of troops, sick and wounded, supplies, and stores of all kinds and this consequently entailed great delay and increased labour.
7. Add to all this a large amount of sickness, very high death and invaliding rates and we think that it is a matter of surprise, not that things were imperfectly done, but that they were done at all in such a manner as to avoid serious disaster in meeting an enemy well up in local information, well taught, well trained and backed up by a country which was far more deadly to a British Force than he was.
8. A public statement made in England early in 1917 that the war was over in East Africa did incalculable harm as it caused a general feeling of ‘Oh! The war is over here, why trouble to increase units, get things out from home for camps and build bandas, etc, etc.’ The war was not over or anything like over, and all precautions against disease were required with greater urgency than ever before; but, in spite of the fact that every thinking man out here knew the statement was not correct, it inevitably led to a curtailing of initiative, for the thought could not but intrude itself when a suggestion was made or a requisition put forward, ‘Is this necessary as the war is said to be practically at an end?’

SECTION 3
MEDICAL ADMINISTRATION

9 a) We attack a graph showing the administration of the various branches of the Medical Services.
Two Mobile Laboratories and an Entomologist asked for have not yet arrived.
10 b) A list shewing the distribution of the Hospitals, Field Ambulances, etc, is also attached, which in addition gives the number and class of patients each unit can normally take giving a grand total of:
4,080 British
1,835 Indian
3,652 African
3,175 Mixed (chiefly Field Ambulances)
12,850 Carriers
The Nursing Services, both regular and volunteer, appear to have been both adequate and satisfactory.
11 c) The African Native Medical Corps has been raised as described in the letter and Standing Orders attached. Its present strength is about 800 and it is hoped to bring it up to 1,000 as soon as possible. Those of its numbers who have been already posted to units in the Field, on Lines of Communication, and at the Base have given almost universal satisfaction, and have been of great assistance in the care of the sick, etc. It is a most useful corps and if possible should be continued after the war as an auxiliary to the King’s African Rifles Medical Scheme.
12 d) Seventeen Fathers and 35 Sisters assist in the nursing, etc, of the patients in the Carrier Hospitals and are invaluable; nothing is too difficult or unpleasant for them to do and everything is done well. They belong to Roman Catholic Missions.
13 e) Evacuation is carried out in the front line by stretcher bearers who bring patients back to waggon head, on stretchers or machillas (hammocks) and at times the carry is for many miles under the most adverse climatic and transport conditions. We would like to mention here a most excellent covered stretcher invented by Lieut-Colonel O’Gorman, Indian Medical Service, which we have tried and consider one of the best seen. It protects the patient from sun and rain and allows easy access to him, should it be necessary on the march. It is far superior to the old and cumbersome Indian dhoolie. At waggon head horsed ambulances (occasionally) and motor ambulance waggons for the severe cases, with empty Supply box cars for the others, continue the evacuation to tram head for collection and transmission by trolley to the coast or to the main broad-gauge line. Several trolleys have been fitted up for two or four lying cases according to construction. These have tarpaulins and various kinds of head cover to protect from the sun and rain during the journey to Mingoyo, Kilwa or the broad gauge line. The journey can be broken on the way down for any ase that requires it which can then be put into one or other of the Lines of Communication medical units for rest and treatment.
14 From the Base Hospitals cases requiring over-seas or inter-port evacuation are taken by Hospital Ships. There are seven permanent Hospital Ships working for the force, viz – Two from Bombay doing one trip each per month. Two running (one every ten days) to the Cape. One stationary on the coast, the Neuralia, at Kisiwani. One, the Dongola for Carriers only. Two smaller hospital ships, the Ebani and Vita, running from Lindi and Kilwa to Dar-es-Salaam, Kilindini and back or at times off-loading on to one of the larger boats which cannot, owing to size, get into Lindi harbour. These ships have carried 59,963 cases since the beginning of this year. There is also an ambulance train for the Central Railway line which runs frequently, and, having been recently altered, does excellent work.
Evacuation to the bases and main line is rendered most difficult and irregular during the rains, which mean bad roads, often combined with half rations.
15 f). The Red Cross Society, British, South African, and, latterly, the Indian Branches, has done an incalculable amount of good work and this has been much appreciated by all troops in hospital. The Society has provided launches at the Base ports which aid in the task of embarking and disembarking the sick and wounded. Lieut-Colonel Montgomery is the local head of the East African Branch and is a very hard-working and capable officer.
NOTE:
16. In attaching the accompanying letter to Section 3 of our Report on East Africa and including the Standing Orders of the African Native Medical Corps as Appendix 1, it gives us the greatest pleasure to state what invaluable aid this unit has given to the sick and wounded troops in hospitals, etc.
The first lot posted were excellently taught and were reliable in every way. The second batch was perhaps not quite so good owing to the fact that they had to be posted before they had been completely trained.
It is hoped and believed that the next batch will be even superior to the first, as they are being excellently trained on Royal Army Medical Corps lines.

To Surgeon-General Pike, AMS, etc, etc No 20/2
General Headquarters, Dar-es-Salaam 29 November 1917
Sir
I have the honour to enclose herewith six copies of the African Native Medical Corps Standing Orders as requested.
2. The present strength of the Corps is 1 Native Officer and 783 rank and file, and recruiting is still proceeding in Uganda to complete the establishment to 1,000.
3. This figure includes 150 absorbed from the original Uganda Native Medical Corps, who have all done three years service in the Field, and also 40 enlisted locally in the Mwanza and Tabora districts towards the end of 1916. Many of the latter had been dressers, ward orderlies, clerks, etc, in the German service.
4. The main sources of recruiting have been the Schools of the CMS, and White Fathers RC Mission, throughout the Uganda Protectorate and the recruits include, in addition to those from the Buganda kingdom, drafts from the neighbouring districts of Bunyoro, Ankoli, Toro, Busoga, Langa and Kavirondo.
5. The men are posted out from this Depot, for duty throughout the EA Force and are at present serving with the following units: – 1) King’s African Rifles (four men with each Battalion in the Field), East African, West African, South African, Indian, British and Combined Field Ambulances, EA Pioneers and Arab Rifles. 2) Large drafts in all Carrier Clearing and Stationary Hospitals. 3) KAR Base Hospitals, African Stationary Hospitals, Casualty Clearing Stations and Indian General Hospitals. Hospital Ships. 4) Special drafts are posted as Vaccinators to the Sanitation Authorities and with Political Officers. Laboratory Attendants at Kilwa, Lindi and Morogoro.
6. The instruction of the ANMC, is being carried out on the lines of the RAMC training, but owing to the pressing need for these men in the Field it has sometimes been impossible to retain them in the Depot long enough for them to undergo a complete course.
I have the honour to be, Sir,
Your obedient servant,
DG Tomblings,
Captain and Adjutant
For Major RAMC, OC, ANMC

Pike Unit Structure

DISTRIBUTION OF UNITS IN OCTOBER 1917
Pike 2 Distribution of Units
Pike 3 Distribution of Units


SECTION 4
PROVISION OF BACTERIOLOGICAL LABORATORIES

17. In the last Boer war the laboratory was regarded as a luxury. It is now known to be an absolute essential if the medical work of a campaign is to be properly performed. No information appears to have been officially furnished East Africa as to the great development in laboratory provision and organisation in other war areas. It was doubtless partly on this account, that on arrival in the country at the end of August, we found only one properly equipped laboratory in the area of operations. This was the Military Bacteriological Laboratory at Dar-es-Salaam under the charge of Captain R Semple, Royal Army Medical Corps.

It is well housed and arranged and has accomplished most useful work including the preparation of small-pox vaccine on a very considerable scale. When first seen, save for laboratory assistants, Captain Semple was working single-handed, but arrangements had been made to supply him with a well-trained bacteriological assistant (a lady) conversant with tropical work. This has since been done and has added much to the efficiency of the laboratory.

There has been but little shortage in supplies, and a good stock of German material was fortunately available from the start.

The laboratory consists of two sections, clinical and hygienic, and for the purposes of administration it comes under the Deputy Director of Medical Services, Lines of Communication.

Captain Semple prior to the war was one of the West Africa Medical Service and so has considerable tropical experience. The hygiene work is carried out by a Staff Sergeant who is a BSC of London and it chiefly consists of chemical water analyses of samples from Dar-es-Salaam. A few from outlying districts have been examined, and a certain amount of food and drug analysis had also been conducted. The equipment is excellent. At the time of our first visit the average of examinations per month in the clinical section was about 600. For October it had risen to about 1,500. Information furnished by Captain Semple will be found incorporated in the section dealing with special diseases.

18. Since our arrival in the country two new laboratories on a smaller scale have been started, one at Kilwa, the other at Mingoyo in the Lindi area. That at Kilwa is under the charge of Captain Garrow, Royal Army Medical Corps, who has had a good deal of experience in Malta and Egypt and is a specialist in enterica examinations. The Officer Commanding, Mingoyo laboratory, is Captain Butler, Royal Army Medical Corps, late West Africa Medical Service, who was until recently microscopist at 15 Stationary Hospital, Morogoro. Both these laboratories are in good hands and are beginning to prove their utility. It is noteworthy that at Kilwa Captain Garrow has already found five cases of true typhoid infection in uninoculated men. As will be seen later there can be little doubt that, owing to the lack of laboratory facilities, a good deal of enterica in this country has escaped notice.

19. As a result of our inspections it was evident that more laboratories and laboratory workers were required. In addition to one mobile laboratory outfit which had been ordered, another was asked for by us in a cable on 13 September 1917. At the same time the War Office was requested to send out three bacteriologists and one protozoologist), a consultant in tropical medicine for the clinical work and six extra microscopes. In addition the Director of Medical Services requisitioned for an entomologist and bacteriologist and indented for six microscopes. Since the above was written we find that the greater part of a field laboratory equipment actually lay unpacked at Nairobi from 1914 till November 1917 (See Section 12, para 187).

20. At the present time a fully equipped laboratory is much needed at Morogoro and another should be forthcoming for at the Dodoma area which is likely to become an important convalescent centre. Indeed every hospital functioning as a large General Hospital should have its own bacteriological laboratory as is now the case in other tropical war areas.

21. A definite laboratory organisation should be established like that in vogue in Mesopotamia and elsewhere. The Dar-es-Salaam laboratory should act as a distributing and co-ordinating centre and it would seem advisable to make Captain Semple Consulting Bacteriologist to the Force. If he were given an experienced assistant who could take his place when necessary he would be able to make much needed tours of inspection both of laboratories and of microscopical outfit at the various hospitals. In this way he could correlate the work, disseminate information and advise regarding supplies, appointments of scientific personnel and the various details with which only the trained laboratory worker is familiar. For this purpose he should certainly be given field rank and its accompanying pay and allowance. In this consulting capacity he would advise the Officer Commanding Base Medical Stores as to the supplies required both from England and India. It would be well if these supplies were on their arrival taken over as a distinct entity by the Base Depot Medical Stores, housed separately, and, though under the charge of the Officer Commanding Base Depot for all office purposes, were actually put under the control of the Officer Commanding Central Laboratory who would be responsible for their distribution. To him also would come directly he indents from bacteriologists throughout the country and he would advise the Officer Commanding Base Depot as to the supplies required. This is a modification of the method which has been adopted in other war areas and has been found satisfactory, namely, placing the Officer Commanding Central Laboratory in sole charge of bacteriological supplies. It is modified because in Dar-es-Salaam the Central Laboratory and the Base Depot are practically alongside each other and, further, it is recognised that it would be very difficult to secure the extra clerical staff which would be necessary.

SCIENTIFIC FACILITIES FOR INVESTIGATION OF DISEASE

22. It is a country like German East Africa the microscope is a much more valuable and essential clinical adjunct that the stethoscope. This will be apparent to anyone with a knowledge of tropical disease when it is stated that by far the most common maladies amongst the troops in East Africa have been malaria and dysentery. Malaria is the most protean of diseases. It may simulate almost any complaint and it can only be accurately diagnosed by the aid of the microscope. This is specially true when, as in German East Africa, the majority of the Medical Officers are men who have had no previous experience of the tropics and little or no training in tropical medicine.

23. In the case of dysentery also, microscopical examination is well-nigh indispensable. Without it there can be no certainty as to whether a case is amoebic, bacillary or bilharzial, and its absence inevitably leads to faulty treatment and waste of an expensive drug like emetine. It is worth noting that the payment price of emetine even in powder form is 8d per grain or £233-6-8 per one lb. The Officer Commanding Base Depot Medical Stores states that the orders for the last six months amount to no less than £1,866-13-4. Yet it is being used extensively, and to a large extent uselessly, in the treatment of cases of bacillary dysentery. The latter is undoubtedly by far the most prevalent form of dysentery in the country. Of the 76 cases examined during the past two months in the Central Laboratory, Dar-es-Salaam, and in which positive findings were recorded, only 10 were due to amoebic infection. A tithe of what has thus been spent usefully uselessly on emetine would have purchased all the microscopes required by the forces in East Africa.

24. There are also other diseases which it is difficult and often impossible to diagnose without having recourse to the lens. These are relapsing or spirillum fever, cerebro-spinal fever, sleeping sickness in its early stages, ankylostomiasis, rectal bilharziasis, and other helminthic disorders, all of which have occurred and some of which, notably spirillum fever, cerebro-spinal fever and ankylostomiasis, have been far from uncommon. Moreover there are skin and other affections amongst native African troops and carriers, the real nature of which can only be determined by the microscope. One of these is Ulcus tropicum which has caused much suffering and loss of efficiency in certain districts.

25. An enquiry into the supply of microscopes at the various hospitals visited revealed a marked deficiency. This is the more to be regretted as there seems good reason for believing that, if the necessary steps had been taken in time, a very considerable number of microscopes belonging to the Germans might have become available.

We were informed by several Medical Officers that they had again and again indented for microscopes but without success. The majority had given up trying to obtain them, regarding the effort as useless.

At the same time it should be noted that in his Circular No 6 of 1 April 1917, the Director of Medical Services, referring to the prevalence of ankylostomiasis and the necessity for examination of the stools for the presence of ankylostome larvae, requests that Lines of Communication hospitals not provided with microscopes should send in a note of their requirements.

Unfortunately only a small proportion of the Medical Officers are capable of recognising ankylostome eggs.

26. The ideal scheme would be for every hospital unit in the country to possess at least one microscope, but it must be admitted that such an arrangements is not possible in the case of Field Ambulances actually in the Field.

27. In order, however, to give the troops in the first line the benefit of prompt and accurate diagnosis there should certainly be a microscopist with a microscope and the necessary re-agents (a small matter) attached to each brigade in the field. As a matter of fact this was asked for by the Assistant Director of Medical Services of the 1st Division, Hanforce, in his 5/19 of 26 November 1916. (Appendix 2). The advantage of such a measure is specifically seen in the case of malaria because it would enable a definite and correct diagnosis to be made before a large therapeutic dos of quinine is given and parasites abolished from the peripheral blood. When this has occurred it is often quite impossible to tell if the patient has or has not had malaria and hence he cannot be properly treated as might otherwise be the case. So much for the field. With the exception of Field Ambulances every other hospital unit should possess a microscope even in places where there is a properly constituted laboratory, for much of the routine clinical microscopic work can and should be performed in the hospital itself, thus freeing the bacteriologists or protozoologists for more important examinations. Field Ambulances more or less stationary on Lines of Communication should also be so provided if only as a temporary measure. They could send back their micrscopes when returning to field duties.

28. As has been said, large General Hospitals should each have, not only a microscope but a properly equipped bacteriological laboratory. The hospitals which require the more simple microscopic outfit are the Casualty Clearing Stations, the so-called Indian Clearing Hospitals, the Carrier Hospitals, Depot and Detail Hospitals, and the Stationary Hospitals whether British, Indian or African.

29. Taking the hospitals of these classes which have been inspected we find that the following, even at this stage of the campaign, do not possess miscroscopes:-
Native Detail Hospital, Dar-es-Salaam
King’s African Rifles Depot Hospital, Tabora
Carrier Hospital, Itigi
No 1 Carrier Stationary Hospital, Dodoma
No 1 Carrier Clearing Station, Iringa
No 2 Carrier Stationary Hospital, Kilossa
Carrier Hospital, Kisiwani
x No 3 Carrier Stationary Hospital, Kilwa
No 32 British Stationary Hospital, Mtama
x No 4 Carrier Hospital, Mingoyo
Indian Clearing Hospital, Nahungu
No 3 Carrier Clearing Hospital, Mtandawala
Note – those marked x are in places where there is now a laboratory.

Many of these are large and important hospitals and it is difficult to see how they can be regarded as performing their duties properly if they lack the assistance of the microscope for the diagnosis of tropical and other diseases.

No 22 Indian Clearing Station at Iringa possesses a good microscope but the latter has no oil immersion and this greatly diminishes its usefulness.

The large No 6 Indian General Hospital at Morogoro is without a microscope of any kind, a deficiency which should be at once remedied.

30. This question of the adequate provision of microscopes is not raised here for the first time. In addition to the SMO Carriers, both Major, now Lieut-Colonel, Maynard, South African Medical Corps, and Major Cuthbert Christy, Royal Army Medical Corps, have in the past drawn attention to its paramount importance and doubtless it is in part due to their efforts that latterly some attempt was made to remedy the situation.

Four microscopes of a poor type arrived from India in April 1917. They have not proved at all satisfactory. Three others were indented for last June and are due to arrive from England in a few days. In September another six were asked for in addition to the six requested in the cable sent by us.

31. There is some excuse to be found for this lack of recognition of the necessity for an ample supply of microscopes. Even if they are got, ‘where are the men to use them?’ is a question not infrequently asked. The answer is that any such shortage must be made good by training a certain number of likely medical officers on the spot. This is by no means difficult, for, with ample material at hand, it does not take long to teach a keen and intelligent officer to recognise the malarial parasites in all their phases, and a good working knowledge of the intestinal protozoa and the ova of helminths can be obtained in three weeks hard work. A month’s training at the Central Laboratory would be quite sufficient for all practical purposes and would be time well spent, even if it accentuated the ever present shortage of medical personnel.

32. Again, one has heard the complaint that microscopes have been issued to Medical Officers who clamoured for them and yet who, after getting them, never need them. This, however, is no argument against the general supply of sufficient microscopes and the remedy is obvious.

33. A much stronger defence is to be found in the fact that this war area had been left very much to itself. Information of vital importance on scientific subjects has been badly needed but has not been forthcoming to any extent. Those responsible for medical work in German East Africa have had no opportunity of learning what has been done elsewhere and the great development in the scientific investigation of disease which the war areas in Salonika, Egypt and Mesopotamia have witnessed. Further reference will be made to this aspect of the case when the treatment of disease and the question of food supplies are discussed but it must be remembered that under the great stress and difficulties of such a campaign as this has been, information on these points would have been invaluable to those who had little time or leisure at their disposal and were constantly engaged in settling endless details and too often trying, in desperation, to make bricks without straw.

34. It would undoubtedly be a great advantage if an expert with the necessary knowledge and facilities for the work were appointed at the War Office to keep constantly in touch with the different tropical or sub-tropical war areas. He would apprise them of any important developments, accumulate information from all sources and distribute it to the best advantage. He would see that Medical Officers proceeding to any area were made fully acquainted with the prevailing conditions there and received instruction in the diseases they would be called upon to treat, and in military tropical hygiene. He would generally act as a kind of liaison officer for all those war areas where the tropical or semi-tropical conditions enormously increase the difficulties of medical administration and urgently call for such special attention and organisation.

So far as East Africa is concerned there should also be a similar officer in India to help and advise as regards the Indian troops and to fulfil the functions above outlined with special reference to Indian conditions.

35. Despite the absence of any such scheme it is gratifying to note that the necessity for obtaining entomological advice and assistance as regards anti-malarial operations was duly recognised. The services of Dr WM Aders, Economic Biologist to the Government of Zanzibar, were requisitioned and on 9 February 1917, he submitted an excellent report (Appendix 3) on the conditions prevailing in Dar-es-Salaam (see Sections 6 and 7), At a later period (22 April) he also reported the result of his mosquito survey in the Kilwa area (See Section 11 and Appendix 3). It is a pity that the Zanzibar Government could not have seen its way to release Dr Aders altogether for work in the war area as his investigations, valuable as they are, would have been still more so had they been prolonged and extended in East Africa.

36. Fortunately the services of Dr Spurrier were offered gratuitously and accepted by the Director of Medical Services. His work, carried out with much energy and thoroughness, has proved most useful and he has succeeded in greatly improving the local conditions in and around Dar-es-Salaam. (see Section 7)*
* Note: Two additional entomologists, Messrs Pomeroy and MacGregor should soon be available.

37. The labours of both these experts have been appreciated and their recommendations largely accepted but unfortunately, to judge from his published report, the same cannot be said in the case of Dr WA Lamborn of the Imperial Bureau of Entomology, who, in 1916, did all he could to warn and advise Officers of the Veterinary Services as to the danger both from filth-breeding flies, tsetses, and also as regards the best means of averting the heavy loss in transport animals and cavalry horses which is sure to follow any carelessness when operating in a ‘fly’ country. It would seem from his report (Appendix 4) that his advice was usually entirely ignored and that thereby the animals suffered greatly with an accompanying loss in efficiency from a medical as well as a military standpoint.

We merely refer to the matter to draw attention to the value of invariably seeking the advice of expert entomologists, and acting upon it as received, when conducing a campaign in a tropical country notorious for its insect pests and ravaged by insect-born disease.

38. On other important scientific questions especially those relating to the food of African natives and the danger of the spread of communicable diseases the Director of Medical Services has had the advantage of Lieutenant Colonel Maynard’s experience and it is clear from various minutes that he at all times was prepared to be guided by this Officer’s opinion and that he did his best, often in the face of opposition, to have his recommendations, which were generally wise and salutary, carried into effect. The same is true in the case of Major Cuthbert Christy, Royal Army Medical Corps, wo for some time acted as Adviser on malaria and kindred subjects and tendered some useful memoranda dealing with the prevention of disease and the general well-being of the troops.

39. It is unfortunate that in several instances the Director of Medical Services, despite earnest endeavour, was not able to carry his point and we feel that had he only been in possession of information as to what had been successfully accomplished in other war areas his hands would have been greatly strengthened.



SECTION 5
GENERAL PREVALENCE OF DISEASE

40. For several reasons it is not easy to obtain anything like accurate statistics of the health of the Forces in East Africa. Such statistics to be of any real value must be expressed as ratios of total strength and the latter has varied enormously and rapidly. Any analysis of the causes of sickness must be taken with great reserve owing to the uncertainty of diagnoses, while, save recently in the case of the Military Labour Bureau, there has been no special medical statistical officer to control and correct the returns. This duty has, however, been performed at General Headquarters, by the Assistant Director of Medical Services, and it is thanks to his labours that we are able to present certain tables of figures which, considered as a whole, furnish some useful information.

41. Table 1 shows the total hospital admissions and deaths per 1,000 strength for troops and followers respectively from 1 January to the end of October 1917. The term ‘followers’ includes carriers as well as Indian followers, African gun bearers, etc.

While the table for troops is probably approximately correct, a comparison of that for followers with the corresponding columns in Tables VIII and IX reveals a marked discrepancy. The latter are almost entirely nearer the mark as they are compiled partly by the statistical officer of the Military Labour Bureau and partly by Captain CP Bligh Wall, Deputy Assistant Director of Medical Services, Military Labour Bureau, while the former are figures furnished by the Assistant Director of Medical Services, General Headquarters, from information supplied by the Adjutant-General’s Department which admittedly was not in close touch with ‘carrier’ affairs. The tables in question are however not quite comparable, as VIII and IX apply only to carriers while, as already stated, the term ‘followers’ in Table 1 has a slightly wider significance. Apart from carriers proper there have been nearly 4,000 other followers on an average computation.

42. Table II speaks for itself. Here again, as regards followers, a similar discrepancy will be found but in this instance it chiefly affects the earlier months of the year.

The comparatively high malaria and pneumonia death rates amongst followers are significant. Enquiry shows that in the earlier stages of the campaign grave errors were made as regards the areas to which carriers from different regions were sent. Thus Kikuyus from the lofty and comparatively cool and healthy regions of British East Africa were sent to the hot, humid and malaria stricken coast belts of the war area, while Kavirondos from the warm districts around Victoria Nyanza found themselves at work on the wet and hilly uplands of Iringa.

The former contracted malaria to which they had not previously been greatly exposed, the latter perished from pneumonia being wholly unaccustomed to the climatic conditions to which they were subjected.

We understand that strong protests were made which eventually resulted in these mistakes being remedied.

The death rate for troops from the diseases mentioned has not as a rule been high.

43. Table III is to some extent an amplification of Table II inasmuch as it divides up the troops into their component parts and thus furnishes some interesting comparative figures. As stated, however, these must be taken with very considerable reserve.

44. Table IV which deals solely with troops is only of value when studied in connection with Table III and as regards the small percentage sub-tables of admissions and deaths from certain diseases.

45. Table V furnished by the Officer Commanding No 14 Casualty Clearing Station, Dodoma, is only given because it embodies the records of a large hospital dealing with all three classes of patients, ie, Europeans, Indians and Africans, and situated at the proximal end of an important line of evacuation. Moreover it furnishes some information regarding blackwater fever showing especially its distribution amongst Europeans, Indians and Africans, all of whom suffered to a certain extent.

46. Tables VI and VII are general tables furnished by the Adjutant-General’s Office. The term ‘followers’ includes all carriers.

47. Tables VIII, IX and X refer to carriers alone but the figures for East Africans are admittedly only approximately correct. The marked variation in monthly strength as between August and September is stated to be due to desertions. The figures for West Africans in Table IX are said to be quite reliable.

48. Table X possesses considerable interest but would have been more valuable if the death rates from the four diseases had been forthcoming and if, so far as least as malaria is concerned, there had been a reasonable certainty as regards diagnosis. The lack of microscopes and microscopists capable of recognising malaria by blood examination greatly detracts from whatever value the figures possess.

Taken all over, however, this table doubtless gives a fair idea of the incidence of the four chief diseases from which the carriers have suffered.

49. For Tables XI and XII we are indebted to Captain Thomas S Dunn, East African Medical Service, Commanding the Native Detail, Dar-es-Salaam, an officer of wide African experience.

In view of the enquiries which had to be made as regards the Aragon incident (Section 11) the figures reating to admissions and deaths amongst South African natives merit special consideration, although Table XII only deals with a limited period.

TABLE 1 – EAST AFRICAN FORCE
Pike 4 Table 1

TABLE 2 – TABLE SHEWING ADMISSIONS AND DEATHS PER 1000 STRENGTH, TROOPS AND FOLLOWERS, JANUARY TO OCTOBER, 1917
Pike 5 Table 2

TABLE 3 – ANALYSIS OF ADMISSIONS FOR PRINCIPAL DISEASES (TROOPS ONLY), AUGUST, SEPTEMBER, OCTOBER 1917
Pike 6 Table 3

TABLE 4 – SUMMARY: ADMISSIONS AND DEATHS – TROOPS
Pike 7 Table 4

TABLE 5 – No 14 Casualty Clearing Station from 28 September 1916 to 14 September 1917
Pike 8 Table 5

TABLE 6 – STATEMENT SHEWING NUMBER OF DEATHS FROM DISEASE OR ACCIDENCE IN THE EAST AFRICAN FORCE FROM THE BEGINNING OF OPERATIONS TO THE END OF OCTOBER 1917
Pike 9 Table 6

TABLE 7 – SUMMARY OF CASUALTIES SUSTAINED IN ACTION BY THE EAST AFRICAN FORCE FROM THE BEGINNING OF OPERATIONS TO THE END OF OCTOBER 1917
Pike 10 Table 7

EAST AFRICANS, TABLE 8
Pike 11 Table 8

WEST AFRICANS, TABLE 9
Pike 12 Table 9

TABLE 10 – RETURN OF DISEASES AMONG CARRIERS
Pike 13 Table 10

TABLE 11 – MORTALITY AMONGST SOUTH AFRICAN NATIVES
Pike 14 Table 11

TABLE 12 – NATIVE DETAILS HOSPITAL, DAR-ES-SALAAM
Pike 15 Table 12

SECTION 6
NOTES ON INDIVIDUAL DISEASES
Malaria
[page 26] 50. This has undoubtedly been the disease responsible for the greatest amount of sickness and invaliding. Major Christy was of opinion that it has accounted for about 80 per cent of the total morbidity.
The Director of Medical Services in his report dealing with the period from 15 January 1917 to 5 May 1917 gives the percentage of total admissions for malaria amongst troops as 60 and amongst followers* as 29. During these 16 weeks the admission rate for troops per 1,000 strength per month is stated to have been 126. Of every 100 cases admitted to hospital 0.7 died. The corresponding figures for followers are given as 20 and 3.
* The term ‘followers’ includes followers in the strict sense of the word, ie Indian followers, African gunbearers etc and also porters (carriers).
In the absence of precise information and the fact that other diseases, especially the entericas and spirillum fever, were frequently taken for malaria it is impossible to present any accurate statistics. Malaria has, however, not only been exceedingly prevalent but has complicated other complaints, both medical and surgical. Happily the mortality has not been high.
51. The common Anophelines of German East Africa are as follows:
Anopheles funestus and its varieties
Anopheles costalis
Anopheles squamous
Anopheles mauritianus

52. The first two are those chiefly concerned in the spread of malaria. A. swuamosus, though probably effective, is not nearly so common. A. mauritianus is a doubtful vector. The most common types of malaria are benign and malignant tertian. Quartan has not been much in evidence. It is not easy to say definitely whether benign or malignant tertian has been the more common, but Captain Semple thinks the former has been more frequent during the dry season and the latter in the rains. This is in accordance with what has been noted in other parts of tropical Africa. There has been a very great number of relapse cases and there can be no doubt that much of this relapsing malaria is due to inefficient treatment of the primary attack. Quinine has not been given in sufficiently large doses at the very onset of the first attack nor has it been continued for sufficiently long periods to free the patient from his parasites. There are several reasons for this inefficient treatment amongst which may be cited the great difficulties of the campaign, the lack of accurate diagnosis, inexperience of the part of medical officers and the fact, only now being fully realised in the various areas of hostilities, that malaria in time of war is a very different thing to malaria under ordinary conditions and requires much more energetic treatment. Whatever precautions were taken there must infallibly have been much malaria amongst the troops in a country like German East Africa but, even so, every effort should have been made from the start to lessen the incidence of the disease by a well considered system of prophylaxis rigidly enforced as far as conditions permitted. If a vicious circle be once established it is exceedingly difficult to set things right. Such evidence as is forthcoming goes to prove that at an early period in the campaign this problem, the most important of all, was not handled in a thorough and capable manner. Neither quinine prophylaxis nor the issue of proper mosquito nets, nor what may be termed ‘malaria discipline’ was enforced as should have been the case. No proper anti-malarial organisation was put in force and apparently we entered lightly on a campaign in one of the most malarious regions of Africa without much idea of the seriousness of the undertaking. That there were many difficulties goes without saying, that it is easy to be wise after the event is granted, but down to the period when the present Director of Medical Services assumed control, there is little to show that his predecessor fully appreciated the position or took adequate steps to protect the troops under his medical charge.

53. Even as late as 29 January 1917, we find Major Christy stating that the mosquito nets issued to the troops were useless, and commenting unfavourably on the organisation for quinine prophylaxis, on the selection of camp sites and the arrangement of camps generally. Enquiry, however, has shown that at the time the position and lay-out of the camps was [page 27] determined by military exigencies. In other respects a most reprehensible carelessness and ignorance as regards malaria seems to have characterised the operations on the Rufiji line about which he is writing. At the same time when dealing with the question of delay in remedying errors it must be remembered that East Africa is a very long way from the original source of supplies.

54. Things improved at a later period and have gone on improving, but those responsible state that they have felt the want of advice both as regards preventive measures and the treatment of acute, relapsing and chronic malaria. The lessons of the war elsewhere did not reach them until lately and they were accordingly hampered and not up to date in their efforts. These efforts, which are entirely praiseworthy, have included the dissemination of information as contained in Major Christy’s pamphlet and in sundry lectures, general orders and instructions; in the issue of prophylactic quinine, of malarial tickets, and a good type of mosquito net; in attention to suitable clothing, in the employment of entomologists and in other directions detailed in the Report in the Report by the Director of Medical Services to the War Office in July 1917.

55. Unfortunately there is evidence to show that some of the regulations were more honoured in the breach than in the observance, that in certain places, such as the Main Detail Camp, the prophylactic issue of quinine was not always properly carried out, that local arrangements made the effective use of nets in the case of Indian troops impossible (ie no beds and bell tents too crowded) and that the strong disciplinary action so necessary for breaches of sanitary regulations was rarely forthcoming.
No prophylactic quinine was issued to carriers but it is evident that this could not have been done in any case. The quantity necessary would have been enormous and though when working in the colder and more elevated regions, such as Iringa, some of the carriers suffered severely from malaria, it is reasonable to suppose that many of them possessed a certain degree of acquired immunity.
The anti-relapse dosage recommended on the malarial ticket, namely, 15 grains on Saturday night and 10 grains on Sunday night, is too small.

56. Of the localities we have visited Dar-es-Salaam is certainly the most malarious throughout the whole year (vide Map 2 attached). The conditions are specially favourable for mosquito life and propagation and it is exceedingly unfortunate that it had to be made the Base. It is but fair to note, however, that in October 1916, efforts were made to find a suitable place for a Concentration Camp and Base Depot in the Pugu Hills, the first high ground inland. The scheme proved impracticable owing to the lack of water and the presence of a dense and impenetrable jungle.

57. Fresh troops arriving from England, South Africa and India had usually to be kept at Dar-es-Salaam for some time and there can be no doubt that much malaria was contracted locally by men who had only been a short time in the country. On page 4 of his Report sent to the War Office in July 1917, the Director of Medical Services remarks:
‘New arrivals are very prone to disease and frequently fall sick within the first fortnight.’
This is a significant statement and if the sickness referred to is, as seems only too probable, in most cases caused by malaria, it proves that many of the new arrivals, who are accommodated at Dar-es-Salaam for varying periods, have become infected locally and that thereby a vicious circle is at least during the rainy season, quickly established which, as stated, it is well-nigh impossible to combat.

58. The Report on Dar-es-Salaam submitted to the late German Governor of East Africa by Dr Orenstein and which should have been available locally after the British occupation of the town (the gist of it appeared in a well-known American Medical Journal in 1914 and was reviewed in the Tropical Diseases Bulletin in March 1915), clearly indicates the unhealthiness of the place from the malarial standpoint and mentions in detail the principal anopheles breeding places. These were specially bad at the time of our occupation for, owing to the war, the Germans had abandoned such anti-malarial measures as had formerly been in progress. The above, and an earlier report by Ollwig, also available, of which an English translation was found in Dar-es-Salaam and an interesting paper on ‘Dar-es-Salaam from a Health point of view’ which appeared in The Medical Journal of South Africa for July 1916 should have served as guides for the placing of camps.

[page 28] 59. A mosquito survey of the town and its environs, made by an expert immediately after our occupation in September 1916 would have served the same purpose but we cannot find that any adequate survey was conducted until Dr Aders appeared on the scene in January 1917. It is true that reports dated 3 November and 2 December 1916 deal with the site of the South African Concentration Camp (now Main Detail Camp) from the point of view of mosquito infestation but from the first it is apparent that the examination made were very local and from the second that the Officer Commanding, Sanitation Corps, at that time had very limited views as to what constitutes a healthy camp site when the danger from malaria is under consideration. His report was made in December (Appendix 5). In the following February before the rains had commenced Dr Spurrier was taking several hundred anophelines of a dangerous species daily in the immediate vicinity of the camp and reports that there were many potential breeding places close to it.
In other respects the site was suitable and well chosen but malaria being what it is in Dar-es-Salaam this position should never have been selected and its choice is much to be regretted.
At that time it should have been possible to secure a safer area on the sea front but this and other questions relating to camps in Dar-es-Salaam are perhaps better considered in the section which treats specially of the Base Area. (Section 7).
The matter is only mentioned here as giving force to the argument that the health of the fighting men of the force is of paramount importance and that every effort should be made to safeguard it from the outset.

60. We have gone into this question fully with the Inspector General of Communications and with several senior Medical Officers and it is clear that, owing to lack of rolling stock and other difficulties, it would have been impossible to transport newly landed troops by the Central Railway to more healthy places a considerable distance inland. A greater effort might, however, have been made invariably to land troops from transports at such times during the day as would have given them an opportunity of settling down comfortably for the night and bringing their mosquito nets at once into use. A single night spent unprotected in a highly malarial locality may be quite sufficient to ensure infection on a large scale especially if there has been, as was often the case, no previous quinine prophylaxis. Occasionally of course military exigencies rendered such a preventive measure impossible but it would appear that the matter was not sufficiently or forcibly pressed.

61. As stated, other areas visited were at the time of our inspection (the dry season) by no means so mosquito infested as Dar-es-Salaam. Tabora has an evil reputation. So has Kilossa, and the low-lying part of Morogoro is also unhealthy. Here we found anophelenes breeding out in October but in no great numbers. Mosquitoes were practically absent from Iringa, not greatly in evidence along the Kilossa-Ruaha road and remarkably few were met with in the Rufiji district which during the rains is notoriously malarious.
Kilwa Kisiwani was practically free, Kilwa Kivinji, known as the white man’s grave owing to its deadliness in the rains, by no means heavily infested in November. At Mpara, between these two posts, anophelines were found breeding but in small numbers. Up country on the Kilwa line mosquitoes were conspicuous by their absence. The same was true of Lindi and the Lindi line though in the rains nearly all the places visited are said to be very malarious. Dr Aders’ report (appendix 3) furnishes useful information about Dar-es-Salaam and the Kilwa area in the rainy season.

62. Malaria has been mistaken for enterica infections, especially perhaps for paratyphoid, for spirillum fever and for the effects of sun. It has also gone undiagnosed which is not to be wondered at as many medical officers encountered it for the first time in their lives. Faulty treatment has already been the subject of comment.
This is where a few good tropical clinicians would have proved their value, but unfortunately none were forthcoming, though here and there an officer with tropical experience helped those less fortunate.
As stated in Section 4 of this Report one of our first duties was to cable home a recommendation that a tropical consultant, preferably with African experience, should be sent out to meet the deficiency.

63. The outlook as regards malaria is better than it has been. Dr Spurrier’s work has reduced anopheline breeding places in Dar-es-Salaam, medical and sanitary officers have gained experience and are better fitted to cope with the disease and its prevention, the establishment of more laboratories and the provision of more microscopes will aid diagnosis [page 29] and make treatment less empirical. Still the troops are so saturated with the disease and there are so many gamete carriers that there cannot fail to be any fresh infections during the coming rains if operations are still being conducted. Every possible care will have to be taken to safeguard those in malarious districts and under Section 10, which contains our recommendations, will be found certain suggestions as to how this may best be accomplished.

Blackwater Fever
64. This concomitant of malaria has been much in evidence at certain times and in certain places. It has caused considerable morbidity and occasioned a good deal of invaliding. Its presence emphasises what has been said about inefficient quinine prophylaxix and the ineffective treatment of malaria. At the same time a certain number of so-called blackwater appear to have been examples of quinine haemoglobinuria in cases with a peculiar idiosyncrasy, and doubtless it has also been confused with bilious remittent fever. Captain Semple states that, using the thick film method, he has frequently succeeded in finding malarial parasites in the peripheral blood during the course of a blackwater attack. The condition seems to have been wrongly treated and blackwater cases were sometimes moved when it was not necessary, but at the present time most medical officers who have been any time in the country are acquainted with the proper line of treatment and realise the danger of sending blackwater patients on a journey by train or motor ambulance when it can possibly be avoided.
Skilled and careful nursing has usually been available for the blackwater cases and this must have greatly aided the recovery rate.

Dysentery
65. Dysentery is second only to malaria as a cause of sickness. For the 16 weeks between 15 January 1917 and 5 May 1917, the Director of Medical Services gives the percentage admissions for troops as 7.5 and for followers as 18. The admission rate for troops per 1,000 of strength per month was 15 and for followers 13. As regards troops, of every 100 cases admitted to hospital, 5.3 died, for followers the corresponding figure is 21.

66. Owing to the lack of laboratory facilities it has been difficult to say accurately wheter it was chiefly amoebic or bacillary but, as a result of our enquiries, a study of the cases and of such laboratory evidence as is available we have come to the conclusion that the great majority of cases both in whites and blacks are due to dysenteric. It is difficult to give any opinion as regards Indian troops but it is possible that amoebic infections have been more common among them. Captain Semple cannot furnish information, as material is very rarely sent him from the Indian Hospital at the Base, and there do not seem to be any reliable observations elsewhere. Captain Semple informs us that in the last two months, ie from the middle of September to the middle of November, out of 70 positive findings in the case of dysenteric stools only ten were due to Entomeoeba histolybica. The cases examined, mostly white troops, came from all parts of the war area. A recent report from Captain Hughes, Indian Medical Service, states that he examined at Bomamaringa the stools of 500 East African natives coming chiefly from the Tabora and Itigi districts. He found 11.2 percent of R histolytica cyst carriers among them. From 8 August to 31 October the number of his dysentery cases proved to be amoebic, apparently averaged 34 per cent. The Director of Medical Services states that amoebic dysentery is more common in the coastal areas but at the time this was written there had been trouble with the agglusnating sera and later work has shown that this is not the case. A considerable amount of bilharzial dysentery has recently been found amongst African natives in the Lindi area.

67. Fortunately the type of dysentery has generally been mild except perhaps amongst the Carriers who have at times suffered very severely. The amoebic dysentery that has occurred does not seem to have been very often followed by liver abscess but some 23 cases of this condition have occurred during the present year.

68. It is difficult, in the absence of definite proof, to be absolutely certain as to the cause of the dysentery but there can be little doubt that water has played an important part especially at the present time on the Kilwa and Lindi lines. Chemical sterilisation of water supplies save in a few places was not adopted in East Africa where, as fuel is plentiful, reliance was placed on boiling. In settled units such as hospitals on Lines of Communication and in base camps this is quite satisfactory, but it is the very reverse in the case of columns on the move and in the case of motor transport on Lines of Communication. There (p30) seems to have been an idea that as the South African white troops were great tea drinkers there was no need to be very particular about water sterilization, but even a South African is not always content with tea under tropical conditions, and there are Indian and African troops to be considered, as well as a host of followers. There appears to be a notion that because a native is used to drinking any water one need not trouble about safeguarding his supply but it must be remembered that he is not usually accustomed to drinking water specifically polluted with dangerous organisms. When he does so he may fall a victim just like the white man and once attacked by dysentery he is probably a more dangerous source of infection than his white comrade. The water supply question is dealt with in the section on Sanitation but it may be said at once that cases of dysentery are likely to continue till the water holes and pools in the Kilwa and Lindi area are adequately protected and till measures have been adopted to render the contents of waterbottles harmless. The problem is by no means easy with native troops and followers but a good deal can be done to remedy things.

69. Dysentery is also doubtless spread by infected food and the cooking and serving of rations are often carried out in a very insanitary manner so that where dysentery carriers are common it is no wonder that infection frequently occurs. Motor transport drivers especially are exposed to risk in this way and the arrangements for the preparation and consumption of their food are very unsatisfactory. Flies are unlikely to have been a potent source of mischief. For one thing those species of fly which are chiefly concerned in the spread of dysentery are, as a rule, not greatly in evidence. This matter will be considered further under the heading Sanitation. (Vide Section 8).

70. The treatment of dysentery in this war area has of necessity been largely empirical. Owing to the lack of protozoologists and bacteriologists and the paucity of laboratories, medical officers too often could not tell which type of dysentery they were dealing with. Accordingly to be on the safe side they administered both salts and emetine. The results have on the whole been good for emetine appears to have a beneficial action on mild cases of bacillary dysentery, a point noted by the Belgian doctors. At the same time there has been a great waste of emetine and a heavy and unnecessary expenditure on this expensive drug. In certain hospitals the bacillary nature of the disease has been recognised and medical officers were treating their cases by salines alone with excellent results. In some cases the dysentery has been of malarial origin and has readily yielded to quinine. Antidysentery serum, though available in many places, has been little used and then in too small doses. It is unlikely to be beneficial as the stocks are usually old and save at Dar es Salaam it cannot be stored on ice. A polyvalent dysentery vaccine was prepared in the laboratory at Nairobi and has been used both prophylactically and as a curative agent. It has not been much employed in German East Africa but it is stated to have given good therapeutic results in British East Africa. The death rate amongst followers and carriers (21 per cent) is high and as this merely applies to hospital cases and as many died outside hospital there can be no doubt that the disease has taken a heavy toll of native life during this campaign.

Diarrhoea
71. There has been much irritant diarrhoea often passing on to dysentery. This has been specially seen in the case of Carriers amongst whom the ration question has been one of the problems of the war. (Vide Section 9)
Most of the diarrhoea has probably been of dietetic origin but a certain amount has doubtless been due to chill and exposure and, in some localities, the ingestion of irritating sand or mica particles.

Pneumonia
72. The Director of Medical Services, dealing with the period above mentioned, states that pneumonia was more fatal than either malaria or dysentery; 28 per cent was the hospital death rate amongst troops, 25 per cent that amongst followers and carriers. The admission rates on total admissions to hospital were 0.8 per cent and 7 per cent respectively and the admission rate per 1,000 of strength per month for followers and carriers was 5. The figure for troops is not stated.
Amongst white troops it is extremely probable that some of the pneumonia was of malarial origin. We saw such a case at Morogoro. The exigencies of war have necessitated sending Indians and native Africans unaccustomed to cold climates across lofty plateaus as at Iringa and this, in addition to the ordinary factors of chill and exposure, has accounted for a good deal of the pneumonia.
(p31)
Cerebro-Spinal Fever
73. The evidence of Captain FC Doble, RAMC late Uganda Medical Service taken in London on 4 July goes to shew that this disease was prevalent from an early period in the campaign. He speaks of it as one of the chief causes of sickness both amongst Europeans and African native carriers in the column which proceeded from Mwanza to Tabora in June and July 1916.
Major, now Lieut-Colonel Maynard, in his report of 1 December 1916, speaks of its occurrence amongst carriers in the Kilwa and Lindi areas and amongst Cape Natives at Kisiwani. The Director of Medical Services in his report above cited devotes considerable attention to this disease, furnishes statistics, and details preventive measures. It appears that in the later stages of the campaign, Europeans have entirely escaped and Indians have only suffered slightly. The chief incidence of the disease has been amongst carriers, there having been 712 cases amongst them out of a total of 883 cases notified during the six months ending 30 June.
The following mortality figures are available:-
Admitted Died
Troops 106 72 or 67.6%
Followers 422 233 or 59.9%

74. We met with a certain number of cases during the curse of our tour more especially in places on the Central Railway. With one exception Medical Officers were doing their best to isolate cases, segregate contacts and treat the condition on sound lines. Unfortunately there was a shortage of anti-meningococcic serum and through some error a large supply of sensitized vaccine had been sent from Johannesburg in reply to a request for polyvalent serum. The former is now being used but information is not yet forthcoming as regards its value. Owing to the want of facilities for cold storage it is to be feared that serum treatment will scarcely have a fair chance up-country but it should be employed at coastal places as soon as fresh supplies are available. In its absence lumbar puncture has been tried with apparently a fair measure of success. At No 1 Stationary Carrier Hospital, Dodoma, atoxyl was being given in addition, and contacts were being energetically treated by throat swabbing with iodine solution.
The segregation measures were on the whole satisfactory though as the Director of Medical Supplies points out ‘the absence of certain knowledge as to the methods of spread, length of incubation, period of infectivity and absence of trained bacteriological personnel to deal with the very large populations scattered over enormous areas, made the control of this disease especially difficult.’
On 24 February 1917, the Director of Medical Services issued special instructions on the method of dealing with porters in view of an outbreak in the Tabora and Mwanza districts. These were in force at the time of our visit but had been modified to ensure a more complete isolation of contacts.

75. Colonel Rodhain, the Principal Medical Officer of the Belgian Forces, suggested that in order to combat the local strains of meningococci it would be well to obtain cultures from cases occurring at Kilossa and elsewhere and transmit them to Kasauli with a view to the preparation of a special polyvalent serum for use in East Africa. We consider this a good suggestion and are endeavouring to see if anything can be done to give effect to it once the bacteriological staff has been augmented.
It is worth noting that, according to the Belgians, there have been several cases of pneumococcal meningitis. With a view to dealing effectively with any outbreak of the disease amongst Europeans in base areas or elsewhere we have suggested that it might be well to obtain a couple of Gordon-Flack sprays for the disinfection of carrier cases.

Central African Relapsing Fever (Spirillum or Tick Fever)
76. This disease, endemic in many parts of German East Africa, may be said as a general rule to have been recognised by medical officers already familiar with it and unrecognised by those with no previous experience of it. As already stated it has been confounded with malaria. Captain Doble reports its presence in the Mwanza-Tabora road in 1916. Information (p32) regarding it and its tick vector was furnished in the pamphlet for troops issued by the War Office and Major Christy deals with it especially as regards Morogoro in several of his reports to the Director of Medical Services early in January 1917. He comments on the difficulties of diagnosing the disease in the absence of microscopes and puts forward preventive measures.
We saw a few cases in the course of our tour and found many Ornihodorus moubata, said to be uninfected, in the Carrier Depot Morogoro.
The treatment of the disease is unsatisfactory and is mainly symptomatic. Some cases seem to have yielded to savarsan or galyl but it is difficult to be certain on this point.

Sleeping Sickness
77. Apparently no cases of this disease have been recognised in the conquered territory but we understand that a few were found in Durban amongst men returning form the front.
Considering the unparralled movement amongst the native populations of this and especially as tsetse areas are common in German East Africa where, however, G morsitans, G brevipalpis, G tachinoides vel austeni and G pallidipes would appear to be the species chiefly in evidence along the routes occupied by troops.
The question of the spread of this disease to our troops is now assuming greater importance owing to the influx of porters from the Belgian Congo and our approach to the Portuguese border where the Rovuma River districts are known to be infected.
Happily a timely minute from Lieut-Colonel Maynard has resulted in immediate action being taken as regards the Belgian porters, and Captain Carpenter, Royal Army Medical Corps, a well-known expert has been posted at Lulanguru with orders to make the necessary examinations.
The matter has also been brought to the notice of senior medical officers with the forces operating south-west from Lindi.
No effort should be spared to keep the disease at bay as, apart from the military aspect of the case, its spread to the non-immune populations of the conquered territory would re-enact the tragedy of Uganda.

Small Pox
78. This, as pointed out by the Director of Medical Services, has occurred but has been almost wholly confined to African carriers and the native civil population. We received information of two such outbreaks during our tour of inspection, one in the Tabora area and one at Morogoro. All porters are vaccinated when recruited and revaccination is carried out in infected areas.
Vaccine lymph is prepared at the Central Laboratory, Dar-es-Salaam. In five months 200,000 doses were prepared. Local calves are employed, tested to exclude East Coast fever, and the strain is enhanced in virulence by passage through monkeys. Great care is taken to avoid infection by anthrax. We satisfied ourselves that the arrangements were in every way satisfactory and consider that Captain Semple deserves great credit for the way he has carried out this work in addition to his other duties and with a very small staff. The lymph is glycerinated and despatched wherever it is required by registered post. The longest time that elapses during transport is 9 days and vaccination with it appears to have been invariably successful.
Captain Semple does not consider transport on ice necessary and from the evidence we have accumulated we believe his conclusion is justified.
The lymph is stored for three or four weeks on ice before issue.

Measles
79. Measles has proved troublesome now and again. It accounted for a good many deaths among the Seychelles porters at Kilwa but they were enfeebled by various other diseases and were also the victims of ankylostomiasis. Recent work in the United States shows that measles is apt to be specially severe in those who suffer from hook-worm infection.

Enterica
80. In his report the Director of Medical Services states that enterica has not been much in evidence. During the six months ending 30 June 1917, only seventy-one cases were (p33) reported. No epidemics have occurred. There can be no doubt that had bacteriological facilities existed throughout the various areas much more enterica would have been brought to light. So far as Dar-es-Salaam is concerned Captain Semple’s evidence on this point is conclusive. Until some four months ago it was not the invariable custom to submit blood samples to the laboratory for bacteriological examination. A good many of the medical officers regarded cases as of malarial origin which in Captain Semple’s opinion were undoubtedly paratyphoid. As a result of his representations of the matter has been remedied and blood culture is now the rule in all cases of doubtful pyrexia. Again Captain Garrow in the short time he has been at work in the Kilwa laboratory has brought to light five case of true typhoid in uninoculated persons. In black and coloured races enterica is very apt to be missed. It was known to be common before the war and, in the absence of reliable information as to its real prevalence, we can only again refer to the necessity for adequate laboratory provision at the start of a campaign.

81. Protective inoculation has been almost universal amongst Imperial units and the necessary enteries have been made in the pay books. Until comparatively recently all white troops coming from South Africa were also inoculated but unfortunately no pay-book records were made. Latterly for reasons stated in our DC/1 of 23 August 1917, inoculation has not been practised but the number of reinforcements from the Union has been insignificant and it is probable that only a small percentage of white troops at present in the country are unprotected.

Plague
82. In his report the Director of Medical Services states that several small outbreaks of plagues had been reported and one of a more extensive nature at Nairobi. He also comments on the paucity of cases amongst persons in military employment. Since then, however, the medical authorities have had to cope with a serious outbreak which occurred on the transport Barjora in August 1917. The infection was clearly traced in Nairobi and the epidemic, so far as the Barjora is concerned, was ably and energetically dealt with, in the first place by Major Hemsted, Royal Army Medical Corps, the Medical Officer of the transport and later by Colonel Clemesha, Indian Medical Service, the Assistant Director of Medical Services (Sanitary). The type was pneumonic but the bacteriological evidence was not entirely satisfactory in all cases. A full report by Colonel Clemesha is attached (see Section 11) and we may merely say that this outbreak was the means of obtaining a useful island outside the harbour at Dar-es-Salaam as a quarantine station and, as the majority of cases recovered, appears to prove the value of preventive inoculation in cases of pneumonic plague.

83. A supply of plague vaccine is available at Dar-es-Salaam. No curative sera are stocked. Facilities for deratisation and disinfection of ships on a large scale are not available at Dar-es-Salaam but there is a Clayton apparatus at Zanzibar only 5 or 6 hours distant. It might be an advantage to have a small hydrocyanic acid gas generator at Dar-es-Salaam similar to that now employed with safety and success at Bombay. Dar-es-Salaam has been attacked by plague in the past and is always liable to infection.

Effects of Sun
84. These have played a great part in lowering the resistance to disease and especially to malarial infection. I German East Africa the sun is by no means so strong as it is in the sandy and desert regions but it is far from being negligible. Actual sunstroke seems to have been rare but, owing partly to the associated humidity, cases of sun-headache and heat-exhaustion have been numerous. Doubtless also there have been cases of what is called for want of a better name “sun fever”.
Care has not always been taken to see that troops marched so far as possible at the best time of the day which is undoubtedly the early morning, and the effects of the sun have been occasionally aggravated by scarcity of water. (Appendix 2). Save in a few instances we do not find that there has been any want of helmets of a good type and, generally speaking, the clothing has not been unsuitable while dark glasses have been available for protection from glare. It is more as a debilitating influence that the sun has made its appearance felt. The constant sweating induced by the heat has also led to skin troubles and predisposed to chill and its attendant evils. Further the heat has deleteriously affected patients in hospital and rendered convalescence tedious.
(p34)

Scurvy
85. During our tour of inspection only one case of genuine scurvy was seen and such evidence as is available does not point to there having been anything like an outbreak of the disease. Indeed in would seem to have been uncommon even in the case of Indian troops. This is somewhat remarkable considering the shortages in food (see Section 9) and the lack of anti-scorbutic substances in the Indian dietary. Doubtless cases have been missed or not reported but, even so, it is strange that in the non-mean eating units at least scurvy did not make its appearance to any extent. The disease has occurred to a slight extent amongst the carriers. The Officer Commanding, Native Detail Hospital, Dar-es-Salaam, informed us that he had seen cases amongst porters coming from the Rufiji line at a time of great privation and suffering and it is possible there were others of which we have no record, for scurvy is not a disease familiar to many medical officers serving in this country.

86. A full and careful enquiry into the matter would be both interesting and instructive, but would occupy much time and would have to be carried out as a special research. The fact that there has usually been a fresh meat ration available probably accounts for the absence of scurvy amongst white troops. An inspection of some Indian troops for the presence of pyorrhoea did not indicate that this condition was common amongst them.

Beri-Beri
87. In the Carrier Hospital, Morogoro, we found some cases of apparently typical wet beri-beri, and instances of peripheral neuritis were encountered in other carrier units.
We know that the Seychelles porters repatriated from Kilwa early in 1917 developed a severe form of the disease between Kilindini and Port Louis and there is evidence to show that they exhibited symptoms of it when proceeding by sea from Kilwa to Kilindini.
The Assistant Director of Medical Services, Military Labour Bureau, informs us that a certain number of cases which appear to be beri-beri has latterly been seen in carrier hospitals but our knowledge of the matter is incomplete.

Ankylostomiasis
88. It has not been possible to form any accurate idea as to the prevalence of this condition but there can be no doubt it has been widespread amongst the native African troops and carriers. Captain Hughes (loc. Cit) reports 10.6 per cent of the 500 carriers he examined as being infected. The Seychelles porters who suffered severely from malaria, dysentery and measles were probably heavily infected. Many of the Indian troops also harbour ankylostomes and the serious effects of the disease are more evident in them than in the African. There is nothing to show that white troops have been infected to any extent but no investigation has been possible. It is probable that in many cases amongst Indians and native Africans ankylostomiasis has played an important part in lessening resistance to other diseases even if it has not itself caused much invaliding. It has been treated by thymol, chloroform, and beta-naphthol. At No 37 Stationary Hospital (Nigerian), Morogoro, which admitted all kinds of African natives and where ankylostomiasis was very common, good results were being obtained with the following:-
Chloroform M 20
Eucalyptus oil M 30
Castor oil to one ounce
Given as one dose in the morning.

Bilharziasis
89. This is known to have been introduced form the Cape and elsewhere but it does not appear to have spread not have we head of any local outbreaks. No information is forthcoming as regards the presence or absence of the snail hosts of either S. haemotobium or S. mansoni. Cases of bilharzial dysentery have recently been found at Mingoyo by Captain Butler. They have probably been much commoner than was supposed. Captain Hughes (loc.cit.) however, found bilharzia ova in two cases only out of the 500 carriers from the Tabora and Itigi districts whose stools he examined at Bomamzinga. (See Water Supplies, Section 8).
(p35)

Filariasis
90. Is known to be wide-spread in German East Africa. There are many cases of elephantiasis amongst the civil population at Kilwa but, despite the great prevalence of mosquitoes there during the rainy season, we did not hear of any case of filaria infection amongst those in military employment. Guinea worm infection (Filaria medinensis)) has occurred but not to such an extent as might have been expected (see Water Supplies, Section 8).

Sand-fly Fever
91. This does not appear to have occurred. A short fever something like it affected troops camped on Red Hill, near Kilwa. Its exact nature does not seem to have been determined. Dr Aders found a small biting Culiocoides (Ceratopogon) to be common on Red Hill. We have not encountered any species of Phlebotomus during our tour.

Myiasis
92. The Chigger {jigger} has in many places proved a source of much trouble but we have nowhere seen evidence of the more serious conditions which result from neglecting invasion of the skin by the flea. The Indians appear to have been great sufferers, at least there was much chigger infection amongst the patients in No 6 Indian General Hospital Morogoro.
A pamphlet is now to be distributed giving information about a method of prophylaxis which is said to have given fairly satisfactory results and which, even if it does not always prevent the entrance of the chigger, is useful, as it kills any which may be already in the skin and renders their extraction more easy and painless. It consists of washing the feet thoroughly and then rubbing in a salve consisting of the five drops of lysol or of cresol soap solution in an ounce of vaseline. The protective action is said to last for three days.

93. Maggot infection from the larvae of the Tumbu fly (Cordylobia anthorpophaga) has been common in some places at certain seasons. Indian troops seem to have been specially attacked.
At Tabora and Mpangas on the Rufiji River we came across the Congo Floor maggot, the larva of Auchmeromyua luteola, which is a nocturnal blood-sucking maggot but does not case true myiasis.
It is much feared by the natives who evacuate the huts in which it is found.
Preventive measures were suggested for the Carrier Camp at Tabora.

Skin Diseases
94. The only skin disease calling for notice is Ulcus tropicum. This has been common in certain districts among the carriers, notably at Itigi, Dodoma and Iringa. In its worst forms it is a very serious condition being a progressive ulceration destroying the skin, tendon and bone, and often necessitating amputation of the infected limb.
The treatment which has met with most success seems to be the application of an iodoform and bismuth paste. In smears from cases at Itigi the typical infection with spirochaetes and fusiform bacilli was found.

Venereal Disease
95. It is gratifying to be able to report that locally acquired venereal disease has been little in evidence even in a comparatively large town like Dar-es-Salaam. This speaks well for the way in which policing is carried out here and elsewhere. It is known that malaria is more difficult to treat in the case of syphilitics and hence, apart from other considerations, it is fortunate that recent syphilis at least has not been prevalent.

Veterinary
96. Three veterinary diseases have caused great loss, hampered military and medical operations, and, owing to the presence of dead animals on the Lines of Communication and the neighbourhood of camps, have been of importance from a sanitary standpoint. These are trypanosomiasis, horse sickness and East Coast fever of cattle. Their mere mention must suffice.
(p36)

SECTION 7
REMARKS IN DETAIL ON INSPECTION DURING TOUR

Dar-es-Salaam
24 August to 5 September 1917

97. Medical Detail Camp – Here all medical units and personnel are put up till their final destination has been decided on and they are made ready for the field. In the early days of the war this camp was in a bad site but now it is in one of the healthiest sites in the Station.
Base Depot Medical Stores – Has large premises in the town for receiving and retaining the bulk of stores arriving here and other premises on the sea front from which all issues to Medical Units are made, and where accounts are kept, etc. Supplies local units and Advanced Depot Medical Stores at Dodoma, Morogoro, Kilwa and Lindi. Officer Commanding asked that cases of 3 ½ cubit feet capacity should be sent from home when possible so as to suit local handling and carriage by porters. Sent a letter to War Office reference this on 28 August 1917. About 20 lbs of quinine have been sent to the Germans for the use of British prisoners by order of the General Officer Commanding. A small box easily carried by a porter has been devised by Major Tilbury Brown, DSO, Assistant Director of Medical Services, and made by the Ordnance for containing Field Ambulance Medical Stores and drugs.
German Hospital – Run by a German doctor for German men who are not interned, women and children, but at the present time not for prisoners of war.
Dental Unit – Works here and has other branches at (1) Dodoma, (2) Morogoro (going to Lindi shortly), (3) Kilwa, with another up the Kilwa line.
A good deal of excellent work is being done.
There is also a dentist right up at the front on the Lindi line, a most excellent arrangement which saves many officers and men for the firing line.
Inspection of 2nd South African General Hospital – On the whole satisfactory but as usual with nearly all South African Hospitals, the discipline is bad and patients are held too long before discharge to duty. It is doing a large amount of work.
3rd African Stationary Hospital – is rather cramped but doing fine work under Lieut-Colonel Rost, Indian Medical Service.
Quarantine Island – Was visited, where we saw all the plague cases from the Barjora. A special report of this outbreak wil be found under Section 11. Saw Dr Spurrier’s “Anti-Mosquito Fish Aquarium” and part of the area in which he is carrying out anti-mosquito measures. Dr Spurrier gives his services free and is a most valuable help in the anti-malarial operations.
Inspected Main Detail Camp – This was being well run but does not appear to be well situated as it has permanent, all the year round, breeding grounds for Anophelinae on two sides of it, one about 300 and one about 600 yards distant.
Red Cross Depot – Has a large stock of things and is being well run by Lieut-Colonel Montgomery who is doing good work.
Hospital Ship Ebani – Very good in every way except officers’ wards which are rather low down and there are no single wards. Received a report from Captain Miller, Royal Army Medical Corps, reference SS Aragon vide full report Section 11.
Carrier Depot – Very well run except urinals which are dirty and not well made. Gave a few instructions reference this to Officer Commanding.
Carrier Hospital – The urinals are the pattern we want put up in the Carrier Camp. This hospital was good except that the infections hospital was not enclosed in any way and the meat for the convalescent enclosure was being chopped up on the ground which was very dirty. A chopping block is required. Cooking for carriers is a difficult problem and Lieut-Colonel Watkins has recently issued a circular on the subject. (Appendix 6) [pencil note in margin: Not SaT] The Camp of the African Native Medical Corps – was very good. The Corps is a body of well educated native boys chiefly from Uganda and they are being trained as superior ward servants by Major Keane, Royal Army Medical Corps, who is very energetic. Full report will be found in Section 3. About one third in hospital.
In the afternoon we had a full description with maps of the military situation from the Brigadier-General, General Staff. Very interesting. We then visited the laboratory (vide Section 4).
(p37)
Hospital Ship Delta – was inspected and found satisfactory.
The Motor Transport Camp – was at Sea View and good except for officers’ latrines which were dirty.
Prisoners of War Camp – Clean and comfortable.
The Native Detail Hospital for Union Natives – Under Captain Dunn was very well run.
The Slaughter House was clean.
Went to Railway Station with the Director of Medical Services and saw a trolley for the use of the sick and wounded cases on the Kilwa and Lindi line. It was satisfactory and took four lying down cases on stretchers.
On 1 September we inspected the 16th Indian Clearing Station which had just arrived with one Medical Officer and one Sub-Assistant Surgeon or four Medical Officers and seven Sub-Assistant Surgeons short of establishment. This seems an absurd method of sending out a totally incomplete unit.
We also saw a batch of Sub-Assistant Surgeons sent as reinforcements for the King’s African Rifles. They are a poor lot and have been sent in a disgracefully slipshod manner from India. Some say they have received their £10 advance, others not. All are irregularly and badly clothed and look slovenly. Their pay-books are not filled up to date and this is a very serious matter for them and entails most unnecessary hardship.
Suggested to Deputy Director of Medical Services that an ophthalmic centre should be started and a stock of glasses and spectacle frames obtained.
Inspected the Bakery in charge of Lieut Skehan, Supply and Transport Corps, an up-to-date, well-run unit. Mechanical mixers working well and very clean.
Hospital Ship Dongola inspected. Generally fair bit not so clean as other Hospital Ships.
We went round The Ordnance Stores with Colonel Hill, Deputy Director of Ordnance Services. They are the best we have ever seen and are doing a marvellous lot of good work.
9th Sanitary Section Officer – Officer Commanding, Captain Stones, who has only just arrived. Generally fair.
Hospital Ship Wandilla inspected. Major W Pemberty, Royal Army Medical Corps (TC) in charge. Skipper, Captain Sunter. An extremely dirty ship all over. Lower wards badly ventilated and impossible to use in this climate. She is only to be loaded to 300 while on this run.
Hospital Ship Oxfordshire inspected. Clean, up-to-date and satisfactory.

98. Dar-es-Salaam – The statement has been made on good authority that Dar-es-Salaam is, next to Tanga, the most malarious settlement in German East Africa and is probably the second worst on the whole of the East Coast. This unenviable reputation is largely due to the ideal mosquito breeding facilities which exist in and about the town as shown in the attached map. (No 2).
There is a large valley called Geresani which runs inland from the harbour and branches off in several directions. At the head of each of these branches there are springs of sub-soil water constantly welling out and in several places forming regular ponds or pools which are often full of weeds or choked by reeds and rushes and other aquatic growth. These springs drain into small streams which all unite to form the Geresani rivulet. In its lower part, this stream courses through an extensive swampy area where formerly anophelines bred in thousands and where they still occur.
To the westward is another valley and another stream called M’Simbasi, and while the lower part of this stream is tidal and hence usually free, the upper portions, being swamp fed, are apt to be heavily infested. In addition there are swamps, now known as the Carrier Corps swamps, right in the middle of the native part of the town and close to them the Bagamoyo Pool and swamp, formerly known as Karavanserai Pond. In the rains low-lying land near Sea View Camp and the Remount Camp becomes the so-called Upanga Road Swamp, while a large pool in the Sultan Strasse forms a favourite anopheline nursery. There are in addition subsidiary breeding places in old borrow pits, chocked drainage channels, etc.
Not very far from the town itself are two other malarial localities requiring notice, namely Kurasini, a place of many surface springs and the new Uganda camp nearly (p38) 2 miles beyond the present Prisoners of War Camp.

99. As stated in Section 8 it was a mistake to place any camps in the vicinity of such pestilential swamps and a glance at a map (No 3) furnished by Dr Spurrier will show that in January last the camps were badly placed with unfortunate results. This is also apparent from a study of Dr Aders’ report (Appendix 3) and further confirmation is obtainable from Lieut-Colonel Maynard’s minute forwarded by the Director of Medical Services to the Deputy Adjutant and Quartermaster General on 6 April 1917. (Appendix 7). It will be seen that, despite Dr Aders’ report of February 1917, some of the camps still remained in dangerous localities although the rains were in progress.
One of the chief difficulties was to find anywhere else to place them, for the questions of water supply, accessibility, type of soil, aeration, bathing facilities and so forth have to be considered.
It seems a pity, however, that from the very start the whole area along the sea front to the norther of the harbour mouth, comprising the grounds of the late Governor’s palace, the German hospital and the land adjacent, was not set aside for incoming troops. This is the least malarious part of Dar-es-Salaam and, had it been chosen, we are confident that the incidence of primary, locally acquired malaria would have been greatly lessened. A step in the right direction was taken when the Motor Transport Camp was placed at Sea View and the Medical Detail Camp was shifted to its present site; see map (No 4) which shows the changes that have been effected.

100. It is to be feared that valuable time was lost after the occupation of the town in September 1916, for it was not till 18 February that a mosquito brigade was approved and formed, and its establishment was not authorised till 14 March.
Thereafter, however, good work was done. Dr Spurrier surveyed the whole district and his brigade, supplemented by extra labour as required, was soon at work oiling, draining, filling up, clearing and training streams, introducing larvivorous fish both from Zanzibar and local sources, training adult anophelines and generally taking those measures which have proved useful in other places. We brought out a couple of the labyrinth traps used in the Panama Canal Zone and one has been tested and has acted fairly well. A scheme for a submerged oiler invented in Cyprus and given us by Sir Ronald Ross was also put in operation and has proved useful.
As a result of Dr Spurrier’s labours conditions have greatly improved but there is still much to be done and the rains will undoubtedly severely test the efficacy of the work accomplished. Some of this is apt to be spoiled by the incursions of men and animals upon areas which have to be drained. This should be stopped as far as possible and every assistance rendered the anti-mosquito campaign. Under present conditions the only feasible thing to do seems to be to continue and extend this work leaving the Main Detail Camp where it is, but enforcing quinine prophylaxis and making better arrangements for protection from mosquitoes. This will be easier when bandas are erected and beds are available for Indian and African troops. It is impossible for men lying crowded together on the ground in bell tents to use their mosquito nets properly.
The hospital which was at Kurasini has been withdrawn and wherever it is possible camps should also be removed from areas which in the words of Dr Spurrier are “girdled by breeding places.”

101. It is scarcely necessary to refer here at any length to the general situation of Dar-es-Salaam. It comes under the Assistant Director of Medical Services (Sanitary) and is specially looked after the Officer Commanding No 9 Sanitary Section who fulfils the neighbourhood of the harbour are constantly being trapped and examined so that early warning as regards plague may be obtained. The drinking water is obtained from several deep bores and the orders are that it be boiled. Such information (chemical and bacteriological) as is available goes to show that these are not deep wells in the strict sense of the word. A good deal of the soda water is prepared from distilled water.
The methods for the disposal of sewage are considered under Section 8.
It would, we believe, be an advantage if a separate Medical Officer of Health appointed to look after the civil population and the civil work generally, thus permitting the Officer Commanding the Sanitary Section to devote himself entirely to the needs of the military section of the community.
(p39)

TABORA
9 to 12 September 1917
102. Inspected Native Hospital and European Hospital. Both satisfactory. Isolation Hospital badly run by Captain de la Touche. No arrangements for disinfection of attendants’ or Medical Officer’s hands; apparently no treatment carried out for cerebro-spinal cases. This Officer seems lacking in initiative and has little knowledge of his duties. He was replaced by another Officer almost at once by order of the Senior Medical Officer, Tabora, Captain O’Donoghue (a very excellent Officer).
King’s African Rifles Depot, Hospital and Camp both good. Water Supply, Boma, Jail and Town Market fair.
Lulanguru Carrier Camp and Hospital satisfactory.
(NB – This is now the place where all Congo natives are specially examined and detailed with a view to preventing sleeping sickness and cerebro-spinal meningitis cases getting in with Belgian porters from the Congo.)

103. Tabora is a very well laid out native town with good and well shaded streets. The anti-mosquito work there requires attention and fortunately both the Kidete Valley and the Railway Valley lend themselves to drainage schemes. Two hundred native labourers acting under a properly trained white non-commissioned officer and controlled by whoever performs the duties of Medical Officer of Health would soon bring about a great improvement.
We explained what was required to the Officer Commanding No 1 Sanitary Section, Lieut Thomson, who took a keen interest in the work.

104. Left for Dodoma and inspected Itigi en route. Well run by Captain Carpenter, Uganda Medical Service (an expert on sleeping sickness and tsetse flies0, now at Lulanguru.

DODOMA
14 to 26 September 1917

105. Various interviews with Deputy Assistant Director of Medical Services, Sanitation (North) reference:-
1) Belgian sanitation, a most difficult subject as the Belgian idea of sanitation is crude in the extreme.
2) Distribution of personnel of the Sanitary Sections, etc.
No 14 Casualty Clearing Station, well run by Lieut-Colonel Benson, Royal Army Medical Corps, in all its sections comprising those for a) European Officers, b) Belgians, c) Convalescents, d) Venereal, e) Indian and Native.
A Laboratory and bacteriologist badly required at Dodoma.
The Carrier Hospital (No 1 Stationary Hospital) is excellently run by Captain Mather with Lieutenants Sergeant and Irvine, all Special Reserve, Royal Army Medical Corps. These three Officers show better scientific attainments than the average Medical Officer and it was a pleasure to inspect their unit.
Inspected Belgian Camp. Physique of troops very good. Sanitation poor. Colonel Thomas, the Officer Commanding, asked us specially to put in a suggestion that his troops should be kept below the 3,000 feet altitude limit if possible as they did not mind heat but died in large numbers if sent to a place like Iringa at a high elevation. This we did verbally to the General Officer Commanding Belgians at Kilossa.
No 10 Advanced Depot Medical Stores and No 19 Motor Ambulance Convoy were very good. Other units seen at Dodoma good except (a) Motor Transport Details Camp which was dirty and apparently uncared for. The Officer Commanding had left for Dar-es-Salaam two days previously, and b) Detail Camp which was only fairly clean and had a slovenly Serjeant-Major.
While at Dodoma we went to Observation Hill, 180 miles on the way to Mahenge.
Makitira, 27 miles out, is at present railhead and has a small Hospital for receiving and entraining cases or putting them on Motor Ambulance Convoy cars.
(p40)
Termagwe 78 miles out, has a Hospital and a large section of No 19 Motor Ambulance Convoy. It is a sort of half-way station between Dodoma and Iringa. Hospital had 136 cases and was well run by Lieut Balmain, Royal Army Medical Corps (Temporary Commission).
Proceeded to Iringa, 144 miles out, via Ho Ho, 119 miles out, where there is a Medical Rest Post or Hospital (125 patients in when visited) for patients on their way to Dodoma.
At Iringa there is an excellent Hospital (A Section of 22 Indian Clearing Station) under Captain Hodge, Indian Medical Service, as well as first-rate and well-run Carriers Hospital under Major Roberts, Royal Army Medical Corps (Special Reserve).
On 23 September we started for Observation Hill, 180 miles from Dodoma, through mountainous country with deep valleys over which it is most difficult to evacuate sick, but this is being done by hand carriage, horse and motor ambulance wagon.
Returned to Dodoma.
Dodoma presents no special problems. It is comparatively cool and healthy and not greatly plagued with mosquitoes, even in the rains. The civil population is small.

106. Left on 27 September 1917 for
KILOSSA
28 September to 2 October 1917
C Section, 4th South African Field Ambulance, not very clean. Major Liebsert, South African Medical Corps had only just taken over. Berkfeld filters in use and dirty. Pack store bad, rifles dirty.
2nd Carrier Hospital well run under Captain Beamish, South African Medical Corps.
Carrier Depot very good. Officer Commanding – Lieut Able, Military Labour Bureau.
The Political Officer (Captain Evans) has a good garden run by prison labour and supplying vegetables to the Hospital.
While at Kilossa we went to the Ruaha River and inspected the section of the 3rd South African Mounted Brigade Field Ambulance there. On the way back we inspected another section of the 3rd South African Mounted Brigade Field Ambulance at M’Frisi which was doing duty there till the Motor Transport Camp, the site for which had been very badly selected by the late Officer Commanding Mechanical Transport, was changed. We suggested to the new Officer Commanding, Lieut Pendray, South African Labour Corps, that improvised shower baths should be put up in the new Camp, showing him a sketch, and that the men should have a banda for dining in and not mess separately in their tents, an extremely bad custom.

107. Left on 2 October for
MOROGORO
3 October to 15 October 1917
No 15 Stationary Hospital was inspected by us and is undoubtedly the best medical unit yet seen. The Officer Commanding Lieut-Colonel McMunn, Royal Army Medical Corps (Regular) is indefatigable and has done an enormous amount of work. As Senior Medical Officer he has also got most of the Camps and Hospitals at Morogoro into a good condition.
No 37 Stationary Hospital (Nigerian), No 6 Indian General Hospital, Supply Depot and Government Garden are well run. The Carrier Depot, No 2 Sanitary Section and the Dental unit (Captain Charles) are only fair and the Carrier Hospital under Captain Cook is bad, latrines not attended to and not much knowledge of individual patients shown by Medical Officers.
The Advanced Depot Medical Stores and the Ordnance Camp and Stores were particularly well done and both Officers Commanding have been commended to their superior Officers.
Many of the staff and personnel of the medical units require change whenever it can be given. Possibly two Sisters, two Officers and two Non-commissioned officers or men could be sent to the Cape and back each trip of the Dunluce Castle and Oxfordshire.
(p41)

108. While at Morogoro we visited the Rufiji line as far as Mpangas via Mikesse, Ruvu River, the Summit, Mgeta, Beho Beho.
The section of 3rd South African Field Ambulance at Mikesse was well run but the cooks were dirty and were working in a not over clean kitchen. The head cook said he could not wear an apron on account of the great danger of catching fire (a novel excuse for being dirty).
A fine Carrier Camp and Hospital with good bandas is lying empty at Mikesse and as the Carrier Hospital at Morogoro is to be moved to another site and the Carrier Depot there is not a large one we suggested to Deputy-Adjutant and Quartermaster General that both be moved to Mikesse which is on the railway line and 20 odd miles nearer where the Carriers have to work. This however was not accepted.
At the Summit we found the section of No 3 South African Field Ambulance satisfactory, the Carriers Camp fair only, as the latrines were badly looked after. The porters are said to work in stages of 35 miles which they do in a day and a half. Health said to be good.
No 29 Motor Ambulance Convoy Camp fair; sanitation poor. Water supply good from a clear pool and well protected. Sanitation only fair. Serjeant in charge not over zealous.
Mgeta Rest Post, Sanitation good. We met the Post Commandant here, Captain Lory, Military Labour Bureau. He was at Rufiji last rains. He states Sheppard’s Brigade left about February and Beve’s Brigade about March. Nigerian Brigade remained (about 4 Battalions and a Battery). They had a good deal of sickness, rations short, averaging under one-half for five months. All food carried by porters amongst whom there was a great deal of sickness owing to hard work and short rations due to the almost impassable state of the road. Nigerians and porters were well housed in bandas. Captain Lory believes that two-thirds of the porters were incapacitated owing to illness due to hard work and short food.
Mpangas Carriers Camp dirty, reported Serjeant Large to Officer Commanding Military Labour Bureau.
Supplies well run but full issue of vegetables cannot be made. With reference to this we wired to the Political Officer, Kissaki, who said he had some pineapples but was nearly out run out of spinach and tomatoes. The Section Commandant it also helping in every way. Hippopotami are sometimes shot by the Officer Commanding British West Indies Regiment to supply his men with fresh meat. Sanitation satisfactory except in Carrier Camp.
Returned Morogoro.
Inspected Cape Corps Depot Camp. 1,050 present as they have just returned from capturing Neumann.

109. Morogoro. The low lying parts of Morogoro are unhealthy. The place has had an evil reputation in the past for enterica and tick fever. There are many anopheline breeding places, one of which we saw and had abolished. The sanitation generally was far from satisfactory and formed the subject of discussion with the Officer Commanding No 2 South African Sanitary Section who was hampered by lack of personnel. As Morogoro is used as a convalescent station it is of the utmost importance that its sanitation received due attention on the lines which have been indicated, for, though the part where most of the camps are situated is fairly satisfactory, men have to pass through the town itself to reach them and moreover there is always a good deal of communication between the hill slopes and the valley. The stream near the Convalescent Camp should be cleared and thorough anti-mosquito measures carried out before the rains.
Returned Dar-es-Salaam.
DAR-ES-SALAAM
16 October to 20 October 1917

110. Attended a conference at Deputy-Adjutant and Quartermaster-General’s Office reference hutting for troops and hospitals during the rains. The general consensus of opinion was:-
1) Hutting could not be provided in the time
2) Bandas would do well
3) Tents with concrete or cement floors or with wooden or canvass bottoms should be provided.
On 18 October we had interviews with Deputy-Adjutant and Quartermaster General and Inspector General of Communications and put up the following suggestions:-
1) Carrier Hospital at out stations should be frequently inspected by local Senior (p42) Medical Officer or Administrative Medical Officer who should, when necessary take local action and inform the Senior Medical Officer, Military Labour Bureau, who cannot watch all out stations at once. Senior Medical Officer, Military Labour Bureau should be graded as Assistant Director of Medical Services on Director of Medical Services staff.
2) All Sanitary arrangements should be under military control at present, Political and Civil Officers to be responsible for their areas.
3) All sites for permanent or semi-permanent camps should be invariably selected and approved by the Medical authorities, preferably the Assistant or Deputy Assistant Director of Medical Services (Sanitation).
We also recommend that European sentries should be protected from sun and rain by proper shelters; at present they have none.
Left on 21 October for Kilwa on Neuralia via Zanzibar.
Visited Convalescent Home, managed by Mrs Turner, for Officers of the Army and Navy and run by the Red Cross and local subscriptions.
Visited Dr Aders’ Laboratory under Dr McHattie the Port Medical Officer.
Inspected the point near Bwelo, Kombrani Bay, for a possible site for a camp or hospital, but we are of opinion it is not a good place or worth while putting a camp there.
Inspected Town sanitation and water supply.

111. Sailed for Kilwa 25 October.
KISIWANI
26 to 31 October 1917
Inspected Neuralia on voyage. It is a very well run ship. Major Hemsted, Royal Army Medical Corps, has only recently taken over and has done much to improve her since doing so. There is want of Thomas’ splints and we wired to Director of Medical Services, who has cabled India for 100.
On arrival at Kilwa Kisiwani Colonel Gunter, Assistant Director of Medical Services, and Captain Jolly, Indian Medical Services, Deputy Assistant Director of Medical Services (Sanitation) came on board. We landed at 9.30 a.m. and called on Naval Transport Officer to ask about next ship for Lindi. He knew nothing about it and we found him singularly lacking in information on all other occasions.
We then went round Kisiwani with Colonel Gunter, Captain Jolly, and the Post Commandant, Captain Wilson. We first visited the Ordnance Camp which was far from clean. The latrines which were shared with the Supply Camp personnel (a very bad arrangements) and putting it into a large receptacle to be subsequently burned in an incinerator a quarter of a mile off.
There were many flies about.
The Supply Camp was the same and the slaughterhouse was not clean. Slaughtering was done in a very cruel manner and steps were taken to remedy this by obtaining a poleaxe.
Motor Transport, latrine dirty.
Sappers and Miners. One latrine very good, the other, 6 feet away, filthy and full of flies.
The Railway Porters had two latrines both badly neglected and foul. One had head cover and was rather dark and protected from the sun and the other one was open. There were no flies in the latrine with head cover and hundreds in the other one exposed to the sun. “Verb sap”.
Railway Motor Transport was quite a good and clean Camp with clean latrines.
No 5 Carriers Hospital clean and well run. Officer Commanding, Lieut Aitken, Royal Army Medical Corps (Special Reserve).
2nd African Stationary Hospital, Major J Anderson, Indian Medical Service, had 1,167 patients at time of visit. Can take about 1,200 but only 100 Europeans. There are 8 Medical Officers and 4 Sisters. We consider more sisters required. Indians 10 a marquee, rather too many.
No 4 Advanced Depot Medical Stores extremely neat, clean, and well run by Lieut F Harvey, Indian Subordinate Medical Department.
(p43)

KILWA KIVINJI
112. 19th Stationary Hospital, Officer Commanding – Lieut-Colonial JA Manifold, Royal Army Medical Corps. 10 Medical Officers and 13 Sisters. A well run unit, with Officers Hospital, sections for Indians, a laundry and a soda water factory. If this hospital is to be kept open in the rains, which is very unlikely, it will require 10 more Sisters.
Supply Depot and Ordnance Depot were both satisfactory.
The Carrier Camp was excellent.
Public latrines good. Corporal Rowe is doing fine work.
Slaughter-house good and a good wire gauze house for hanging meat has been put up.
Lewali Crossing is where the sick and wounded have to detrain from up-country and entrain for Kisiwani and there is a small hospital detachment from the hospital to carry this out and also tents and huts to shelter patients during transfer.
Mechanical Transport Camp, and Lieut Brown, South African Service Corps Mechanical Transport. Kitchen dirty, latrine fair.

113. Visited Red Hill, a good site for troops but rendered untenable in rains by increase in swampy area around it which at all times breeds Anophelinae, and its proximity to Kivinji, a notoriously unhealthy place. The water source here was very badly protected by two strands of barbed wire, wide apart and allowing easy access to anyone. There was a guard tend placed above and near the source of supply but no guard could be seen. Suggested to Assistant Director of World (South) that the source be better protected and he (Lieut-Colonel West) said it would be done at once.

114. We thoroughly examined Mpara and Kisiwani as possible sites for a camp for a Brigade, if necessary, in the rains and a report sent to Deputy-Adjutant and Quartermaster-General and General Staff will be found in Section 11.

115. We inspected No 3 Carrier Hospital at Kilwa Kivinji which is the best run Carriers Hospital we have seen. Officer Commanding – Capt WH Elliott, Royal Army Medical Corps (Special Reserve) who has a good idea of the work. The excellence of the unit is due to his zeal and initiative. He should have increased rank, commanding, as he does, a unit for about 1,500 patients. He had not been supplied with a microscope. One of his best ideas is a special diarrhoea war as diarrhoea is so often a premonitory symptom of other diseases.

116. At Mpara all troops were airing their clothes on the ground. Suggested to Officer Commanding 1) that a short length of wire or rope on a couple of poles for each tent or banda would be an improvement for hanging clothes on, 2) that the following water order on the stream should be enforced:-
a) drinking water
b) Water for horses
c) Washing European
d) Washing Native

117. At Kisiwani there have been few lighters and embarkation of sick and wounded has been often held up. One has now been provided and a second is being prepared. An additional tug is badly needed. Lieut Ross, Royal Army Medical Corps, has been doing the embarking but needs at least two orderlies to assist him. The shed where patients have to wait for embarkation when they arrive from Kilwa Kivinji is not suitable; it should be made rainproof and the floor and walls require attention. Little initiative has been shown by the Senior Medical Oficer, Kiswani, Major Anderson, Indian Medical Service, in this direction or as regards Sanitation.

118. Inspected HM Transport Barjora and left for Lindi in the Hospital Ship Ebani.
LINDI
2 November to 6 November 1917
Inspected No 1 African Stationary Hospital, Officer Commanding – Lieut-Col McGillivray, Indian Medical Service. Not on the whole a good unit. The Admission and Discharge Books are badly kept, Pack Store dirty (especially rifles). African and Indian troops receiving no Red Cross comforts, cigarettes, etc, as Matron (Miss Belcher, Queen Alexandra’s Imperial Military Nursing Service) states she has not enough to go round more (p44) than the Europeans. We think this a wrong attitude on her part. We wired for cigarettes to Red Cross to be sent direct to Officer Commanding for the African section.
The African Section was crowded and the latrines very dirty, the number of pans being deficient. (Lieut-Col Benson and the staff of No 14 Casualty Clearing Station have since been detailed to take over this Hospital which cannot fail to improve it immensely).
We proceeded up the creek by launch to Mingoyo and went to No 52 Casualty Clearing Station. Officer Commanding – Lieut-Col J McKie, Royal Army Medical Corps (Territorial Force). This is an excellent unit and well run in every aspect. There are eight Medical Officers and no sisters, but there is a Lady Superintending Cook who supervises the special invalid and Officers’ cooking, and is invaluable.
Went up the Lindi line to the trenches. Inspected C Section 4th South African Field Ambulance, Carrier Hospital near by being put up, D Section West African Field Ambulance at Chirimake, all satisfactory and on the tramline.
At Mtama we inspected 29th Motor Ambulance Convoy, 32 British Stationary Hospital, 3rd Section East African Field Ambulance and C Section Combined Indian Field Ambulance. All well run except Combined Indian Field Ambulance where the sanitary arrangements were not very good.
The Motor Transport Camp at Mtama was very dirty. Spoke to Officer Commanding for immediate action.
Went on to our fighting line at Mahiwa. Saw a large number of sections of Field Ambulances all acting independently and doing excellent work. The Medical arrangements seem quite good on the Lindi line, (the General Officer Commanding and all Column Commanders are pleased), except those at No 1 African Stationary Hospital which is not satisfactory in many respects and the Carriers Hospital where the evacuation of patients both ‘to and from’ is poor and very slow.
Indian Hospital under Captain Inman, Indian Medical Service, at Mingoyo slightly over-crowded, but otherwise good.
Carrier Hospital good. Latrine pans not washed.
Carrier Depot – Officer Commanding – Lieut PWE Flint. Good. Officer Commanding states a mixture of cowdung and water makes a good flea proof floor.
Detail Camp under the Post Commandant, Captain Richardson, was not clean. Latrines and sanitation bad. Captain Richardson seems to take no interest in the matter. Reported him to the Section Commander. Has since been removed.
Slaughter House at Mingoyo well run and clean. Senior Medical Officer, Lieut-Col McKie, doing excellent work in this station. Water supply good but distribution is not regular, being by pipe which often gets out of order.
November 6 – Left Mingoyo by road and arrived Lindi.
We inspected the following:-
Supply Depot – Fair. The supply of dried fruits is short and the latrines of the native staff were badly neglected.
Detail Camp – Very excellent run by Officer Commanding, Second Lieutenant Haswell. Encouraged and helped in every way by Post Commandant, Captain McLaren. This promises to be a splendid camp for Details.
Carriers Hospital – A good unit but evacuation down the line to it and by sea from it is not free enough. (Since we were there a Carrier Convalescent Camp on the other side of the harbour to take 1,000 or more has been started and this will relieve evacuation).
Advanced Depot Medical Stores – Officer Commanding – Lieut Menead, Indian Subordinate Medical Department. Clean and in good order. Has a poor supply of splints. Suggested to the Director of Medical Services that drugs urgently required when sent by ship should be packed last or kept on deck so as to get them off early and not cause delay.
Water Supply – At present 6,000 gallons per diem are supplied from the Garnet mine. 1,000 gallons per hour will, it is stated, be forthcoming from the new bore when completed and a good supply is always available across the harbour.

119. Left for Kilwa Kisiwani by Hospital Ship Ebani.
KILWA
7 to 15 November 1917
Sent wire to War Office asking if Halazone was considered in every way satisfactory for water-bottle sterilization in the field. Had an answer later saying “Yes but as it deteriorated in hot climates 50% increase in strength should be added to each bottle” and a week later another saying it was very unstable and that bi-sulphate of soda is preferable, so Halazone is not to be used.
Visited following places and units on the way to the Kilwa front:=
Mtandawala – Inspected 4th South African Field Ambulance; short of bandas, but a well run unit.
Railway Station
No 3 Carriers Clearing Hospital – Fairly good show
The Rations and Medical Comforts for the two hospitals at Mtandawala are sent up by train, pass the hospitals and at the station of Mtandawala, 1,000 yards off, they are transferred to another train and sent to Nanganachi, 10 or more miles further, and have to be indented for there and brought back to the hospital. (This whole arrangements was so absurd that we saw the Officer Commanding Supplies Section at Kilwa and he said he would give an order that the hospitals ident on Kilwa and that the rations, etc would then be dropped at Mtandawala for them.)
Carrier Camp fair but not yet completed.

NAHUNGU
Field Depot Medical Stores Clean and well run. In charge of Serjeant Reeves, Royal Army Medical Corps (Regular).
No 2 Carriers Rest Station (a section of No 2 Carriers Clearing Hospital), badly run, latrines dirty, and not properly arranged, the sick man being supposed to get to the latrine pan himself, put in straw, use it and then empty it into the incinerator. The sweepers apparently looked on. In our opinion all this should be done by the sweepers. There was no head cover for the latrines. Dysentery, pneumonia and nearly every other class of case, were lying side by side in the same wards. The young officer in charge had only recently joined, was ignorant of procedure and should not have been sent there so soon if it could have been avoided.
Supply Depot – (Lieutenant Samson, Army Service Corps) clean and well run.
The Post Commandant (Captain JF Kenny-Dillon) appeared keen and up to his work.
The Kilwa Clearing Hospital – Officer Commanding – Major O’Neill, Indian Medical Service, is an excellent unit composed of B Section 22 Indian Clearing Hospital and C Section 16 Indian Clearing Hospital. The water boiling and cooling arrangements were first-rate. The sanitation of the station is above the average but the water arrangements (ie collection and boiling at the river side) were not good.
MNERO
2nd South African Field Ambulance – Major Green, South African Medical Corps. Fairly good unit.
Afterwards went round with Major Green and the Post Commandant.
18th Motor Ambulance Convoy – Captain Walker, Royal Army Medical Corps, (Temporary Commission). A good unit, only 30 cars fit.
Porters Camp – Excellent incineration and a good smoke latrine.
The Indian and Native Hospital was being run by D Section of 16 Indian Clearing Hospital and it will soon be joined by A Section 22 Indian Clearing Hospital. Patients all crowded together between roads thick and with dust and constantly used by traffic. An impossible site which we are informed is to be changed shortly.
Water Supply good, but another hose pipe is required for the pump (arranged with Brigadier-General, General Staff at Nahungu that this should be sent at once).
Returned to Kisiwani and on the way back had an interview with Commander-in-Chief at Nahungu.
Inspected Luale, Lungi (future railhead), Nanganachi (present railhead), Mnasi where there is an excellent water supply from a very deep bore worked by an engine and pump.

120. NOTES
1. All sera and vaccines time expired and held by medical units should be destroyed.
2. All latrines should have head-cover and sweepers should be on duty at all times, especially (p46) during meal hours when the flies probably fly directly from faeces to food.

121. At Kisiwani we inspected the latrines of the Ordnance and Supply Depots. They have been much improved since our first visit.

122. 15 November – Left for Dar-es-Salaam by Hospital Ship Dunluce Castle and arrived early morning 16 November.
16 November – Interviews with:-
1) Deputy Adjutant and Quartermaster-General and Director of Medical Services.
2) Director of Medical Services and Deputy Director of Medical Services when we made the following suggestions:-
a) Bi-sulphate of soda to be used in the fighting line when the boiling of water is impossible or difficult.
b) Sisters should give lectures to orderlies in all their units as regards nursing duties, regularly when possible.
c) That smaller bottles and cases of drugs if issued to Medical Stores would be good economy.
17 November – Interview with General Officer Commanding Lines of Communications and suggested:-
a) Royal Engineers require reinforcing and should have an officer, Royal Engineers, and a water officer in each section.
b) Sanitary Officers should have better rank to emphasise their orders on Sanitary matters.
c) As few troops as possible be kept at Dar-es-Salaam as they are almost sure to contract malaria there.
Inspected Hospital Ship Vita. Officer Commanding – Major Husband, Indian Medical Service. A good Hospital Ship. Admission and Discharge books bad.
19 November – Started preparing report on East Africa for War Office.
Visited Sanitary Demonstration Centre. Good.
20 November – Office work.
Visited Mosquito breeding area – Kurasini.
21 November – Office work.
Inspected Inoculation entries in pay books. The men from home had the books well kept up, but the South African men had no entries at all.
23-26 November – Preparing Report. Interviews and visiting various mosquito breeding areas.
27 November – Inspected several billets in town and reported those of the Base Supply Depot as very bad to the Deputy-Adjutant and Quartermaster-General.
28-30 November – Office work and Interviews.

THE MOTOR TRANSPORT
123. No body of white troops has suffered more, from the hardships of the campaign, than the Motor Transport drivers. These men have nearly always had to be overworked owing to the pressing needs of the force they served, the sickness amongst themselves, and the shortage of reinforcements. They are often on the road by daybreak, and are fortunate if their labours terminate at sunset. They have to drive over roads which are never good, and are often dangerous. They are exposed to the heat by day, and have often to sleep on the road in their cars, a frequent cause of chills. They may not be able to use their nets, and so get malaria at the same time. In certain areas they are constantly bitten by tsetse flies. They get their food where and when they can, and too often drink any water which may be available although warned not to do so.
These things being so, the absolute necessity of doing everything possible to improve the conditions under which these men have to work, and to preserve their health should have been apparent at an early date.
We saw them and travelled with them in the third year of the campaign, and we can only say that we found an absence of any proper system for dealing with the problem.
No attempts had as a general rule been made to provide tents or bandas for messes in these men’s camps, they had no facilities for ablution beyond their individual basins, towels, and soap. Nowhere did we find arrangements whereby they could wash their dirty clothes in a cleanly and agreeable fashion. Their sanitation was as a rule neglected, the (p47) latrines uncomfortable, and the receptacles uncovered. When on their return journeys they carried sick, they could usually manage to get hot food or hot drink at the wayside halts. At other times they had to go without, unless they had time to cook or to make tea themselves.
We do not wish to underrate the difficulties of the situation, but we are of opinion that many of these difficulties might have been obviated, and if the matter had been taken in had from the first a great deal would have been done to safeguard this important branch of the service, provided always that there was adequate supervision and that discipline was enforced.

124. The following letter was sent to the Deputy-Adjutant and Quartermaster-General in November, after our inspection, pointing out what was considered essential to lessen the high sick rate of this class.

DSM/57/17
The DA & QMG, General Headquarters, Dar-es-Salaam
I am of the opinion that the following steps should be taken as soon as possible to remedy, in some measure, the conditions under which the motor transport drivers have to work, and which undoubtedly caused a large amount of unnecessary wastage from sickness.
1. The establishment of rest posts on the lines of communications. These should be about 30 miles apart and before being used should be put into thorough sanitary order by men of the sanitary sections.
2. At these rest posts, hot meals, well cooked and served in a cleanly manner, should be available.
3. At each of these posts there should be a Non-Commissioned officer and 2 men of the Royal Army Medical Corps or South African Medical Corps, one of whom should be taken from a Sanitary Section. In addition there should be a cook and the necessary staff of sweepers and water carriers.
4. A shed cook-house should be built and such provision of basins, soap, towels, aprons, kitchen cloths and washing soda made as will facilitate cleanliness.
5. Boiled water should always be available at these posts so that the men can fill their water-bottles if necessary.
6. Adequate arrangements for washing the hands before eating should be made and men should be encouraged to use soap and water and a nail brush before meals.
In addition to these suggestions for rest posts I would strongly urge that at the main camps themselves, tents or bandas for messing should be the invariable rule and that facilities for ablution, preferably some simple form of field shower bath, be provided, as well as benches for washing clothes. Special attention should be paid to the cooking and serving of food in these camps, and the proper collection and disposal of refuse. All latrines should be covered, fly proof, and provided the toilet paper, and any small mosquito breeding places in the neighbourhood abolished or treated with oil or larvicide.
Both camps and rest houses should be inspected at frequent intervals and any breach of sanitary discipline at once reported and if necessary, severely punished.
WW Pike, Surgeon General, Army Medical Service
Dar-es-Salaam, 30/11/17

SECTION 8
SANITATION

125. From the time the war in East Africa assumed formidable dimensions up to a very recent period in the campaign, sanitation did not receive the attention it merited. There was no proper sanitary organisation. No executive officer of senior rank and with the (p48) necessary knowledge of Army Hygiene in the tropics was appointed to take charge of the numerous and important questions which were consistently arising. The sanitary staff was inadequate to deal with a very difficult situation and in many instances was not fully trained. The necessity for immediate action in all matters affecting sanitation in the tropics and especially as regards anti-mosquito measures, the disposal of excreta and the destruction of the filth-carrying fly, was neither fully appreciated nor enforced.

126. This is not to say that nothing was done. A great deal of useful work was undoubtedly accomplished but when a large force, the greater part of which is devoid of sanitary discipline and any knowledge of local conditions, has to operate over vast areas in a notoriously unhealthy country and when the venue is constantly and unexpectedly being changed, it is obvious that very special measures are required to safeguard its health. When in addition that force is accompanied and followed by hosts of native carriers and followers the problem is still further complicated.

127. Sanitation like other branches also suffered on account of the premature announcement that hostilities were practically at an end.

128. Had it only been possible, it would have been best from the very start to secure a numerous sanitary personnel and to take the responsibility for the sanitary action very largely, if not entirely, out of the hands of units, many of which were quite inexperienced and most of which were so occupied and harassed that it could scarcely be expected that they would pay sufficient attention to sanitary needs. Failing such a desideratum all that could have been done was to indicate the importance of sanitation by giving appropriate rank to those who controlled it and by securing a staff of senior inspecting officers to keep a close eye on those details and minutiae on which so much depends. Instead of this executive sanitary duties were merged with those of the Deputy Director of Medical Services, Lines of Communication, who had more than enough work in other directions. The number of Sanitary Sections was not sufficient to cope with the situation, admittedly one of much difficulty at least when the troops were constantly on the move.
The Sections themselves lacked adequate transport and were practically devoid of sanitary equipment. They had to improvise from whatever material they could scrape together. In some ways this was unavoidable and improvisations are often most useful especially in a country where wood and grass abound, but in certain directions it has had very serious results.

129. It is true that there was from a comparatively early period a Sanitary Adviser but he was attached to General Headquarters and though he frequently tendered good advice there was very often no machinery to carry it into effect. Moreover he dealt chiefly with large questions such as food, clothing, the handling of epidemics, etc,. and in the meantime the practical details suffered from lack of attention. There was an absence of literature, no information was forthcoming as to what was being done in other theatres of war, there was nothing in the way of sanitary demonstration centres; type plans for latrines, cookhouses, ablution places and so on were not prepared.
Even when a sound line of action had been put forward there was too often delay in giving effect to it and, if it was opposed, it was not always pressed with sufficient firmness and tenacity.
Such as least is our impression as a result of careful enquiry coupled with what has been discovered during our inspections.

130. Prior to our arrival, however, considerable changes has been effected as the result of an important memorandum by Major Maynard, dated 8 August 1917. (Appendix 8). Lieut-Colonel Clemesha, Indian Medical Service, arrived from India and after acting for a short time as Senior Medical Officer, Dar-es-Salaam, he took over the duties of Assistant Director of Medical Services (Sanitary) for the whole force with the rank of Colonel. This permitted Major Maynard, South African Medical Corps, who though termed Deputy Assistant Director of Medical Services (Sanitary) had virtually been acting as Sanitary Adviser, General Headquarters, to become Deputy Assistant Director of Medical Services (Sanitary) for the Northern Area while Captain Jolly, Indian Medical Service, was appointed to a similar post in the Southern Area. For five months, however, there was no specialist Sanitary Officer in the important Kilwa area apart from the Officer Commanding, Sanitary Section. Aparently none was available.

131. Steps were taken to co-ordinate the sanitary work and to place it on a better footing. The graph attached to Section 3 shows the sanitary organisation at the present time. Sufficient time had not elapsed at the period of our inspections to enable us to form an opinion as to how the new scheme would work as a whole but it is certainly a step in the right (p49) direction.

132. Four points were, however, apparent:-
1. The need for more Sanitary Sections, preferably from India.
2. The necessity for limiting the duties of the Deputy Assistant Director of Medical Services (Sanitary), Southern Area and giving him higher rank.
3. The desirability of establishing a Sanitary Demonstration Centre at Dar-es-Salaam and instituting courses of instruction there in sanitation and field cooking.
4. The fact that in the area of active operations the water supplies were unprotected and were being badly polluted. In addition to other action it was clearly necessary to supplement the boiling arrangements by chemical sterilization.
The first had already been recognised by Colonel Clemesha and action had been taken. Two Indian Sanitary Sections should arrive ere long. The present establishment is shown in the graph attached to Section 3, page 9.
The second was duly represented and action is being taken.
The third was put forward as a suggestion and has been carried into effect. Captain Stones, Royal Army Medical Corps, the Officer Commanding No 9 Sanitary Section in Dar-es-Salaam, has now constructed a very useful Demonstration Centre. Plans and information for him are being obtained from France and Mesopotamia.
The section for training in field cooking is not yet organised.
The question of protecting water supplies and instituting chemical sterilization of water is now under consideration and action is being taken to carry out our recommendations.

133. It is perhaps best to consider to some detail the chief subjects coming under the head of Sanitation and, as reference has been made to the water supplies to start with them.

WATER SUPPLIES
These vary much in different places but are usually derived from shallow wells, rivers, hill streams, ground water in seepage pools and rain water pools. Very rarely a true deep well supply is available as at Mnasi in the Kilwa area. Sometimes the water is brackish, sometimes it contains much suspended matter or vegetable organic matter. Occasionally, as at Morogoro, an excellent water supply of clear water is obtainable from a mountain stream. The supplies at places like Dar-es-Salaam or Lindi do not require consideration in this part of the report, but, in view of the remarks just made as to the condition of supplies in the present area of active operations, it is interesting to note what was done at Summit where a water pool was adequately protected by a reed fence in which a hole gave access to the pump hose.
A mere armed guard on a water hole or river supply is not sufficient; neither is a single barbed wire fence as was seen at Red Hill and Nagungu. Part of the failure to fence sources of supply properly is to be found in the great shortage of Royal Engineer personnel. Not only is this deficient but there is a lack of pumps, hoses, and water tanks. The trouble is largely due to difficulties of transport, for on such a long Line of Communication as that in the Kilwa area it is difficult enough to get up ordinary supplies and ammunition. At the same time it would pay in the long run to make a special effort to forward sanitary equipment of this kind.
In some places the large rubber canvases used in Mesopotamia might be employed for storage purposes. They are more easily conveyed than metal tanks.

134. As regards sterilization it is noteworthy that in the hospitals on the Lines of Communication where good arrangements for boiling exist the personnel as a general rule did not suffer from dysentery. Boiling, however, is impracticable for troops on the march and for carriers, while motor transport drivers are very careless about it and suffer accordingly. An enquiry as regards Halazone, the new water sterilizer, elicited the information that it was very unstable in the tropics so that recourse was had to the bisulphate of soda tablets for use in water bottles and arrangements are to be made for chlorination at certain places. This chlorination will have to be very carefully done and should be under the charge of a special water officer who will see to the testing of samples of chlorinated lime, the preparation of a proper emulsion and the routine application of tests for free chlorine in the treated water. He should keep a water diary as was done in Mesopotamia.
It is fortunate and, considering the influx of troops from India, in some ways remarkable that there has been no cholera. Had it occurred in the Kilwa-Lindi area a most serious situation would have arisen.

135. At present a scheme for bringing water by pipe from Mpara to Kisiwani is in (p50) process of completion. This will be very advantageous but the water will have to be carefully chlorinated or boiled after it leaves the pipes for the stream at Mpara from which it is to be taken is liable to pollution.

136. In this connection the danger from both urinary and rectal bilharziasis must be borne in mind, and, in view of the condition of the water supplies on the Kilwa and Lindi lines, a survey to determine the presence or absence of snail hosts is required.
We have suggested that when Mr MacGregor arrives his services should be utilized in this direction as he possesses the necessary knowledge on the subject.
Guinea worm infection has not been prevalent. The incubation period is long but if opportunities for invasion had been frequent many cases would have occurred ere now.

ABLUTION
137. In most of the hospitals visited the facilities for ablution were good but the same could not be said of the camps where, as a rule, little attempt was made at anything in the way of showers or tarpaulin tanks for bathing. In many places water was scarce, in many others the camps were of a very temporary nature and nothing very elaborate could be expected. In many of the Motor Transport Camps however much more should have been done to ensure the tired and dirty men getting a good wash. A very little expenditure of ingenuity and energy could often have secured the provision of hot water but failing that there should have been no difficulty in improvising shower-baths from a few pieces of wood, a little wire and a couple of petrol cans. Very rarely did we find anything of the kind attempted and yet it would have been a source of much comfort and would have aided in keeping the men healthy. There is certainly room for development in this direction. (Vide Section VII).

DISINFECTION
138.Taken as a whole the arrangements for disinfection were none too simple. The larger hospitals usually possessed Thresh disinfectors but the Carrier hospitals and depots had to be content with some kind of vessel in which blankets and clothing could be soaked in cresol solution or boiled. Here and there we came across Serbian barrels but they have not been largely employed although there has been a good deal of lousiness amongst Indian and other troops.
Complaints regarding vermin were, however, uncommon and there is no record of lice-born disease. A railway van disinfector of the type employed in Egypt would be useful in Dar-es-Salaam.
The supply of disinfectants was as a rule ample.

COLLECTION AND DISPOSAL OF HUMAN EXCRETA
139. In Dar-es-Salaam we have inherited the German system of water closets and cess-pools. The latter are emptied by a pump cart at frequent intervals and the sewage was, until recently, discharged down drains opening into the harbour, but owing to complaints this practice was stopped. It is now emptied thorugh a man-hole into a large drain which carries it to the sea front where it discharges on the beach. During part of its course this drain is open.
The surgical section of No 2 South African General Hospital and a good many houses have cesspools which discharge directly into the sea or upon the beach.
At the Motor Transport Camp, Sea View, pail contents are emptied directly into the sea at high tide and as the camp is situated on the edge of a low but vertical cliff and as care has been taken to remove crannies, clefts and pockets from the cliff face, and as the tide sweeps the faecal matter right away the system works very well.
Elsewhere in Dar-es-Salaam, as is the general rule throughout the war area, incineration is in vogue. Where for any reason it is undesirable as in our front lines a trenching system is employed and this is also used in other areas where the soil is suitable and sweepers are scarce. The type generally adopted is the so-called smoke latrine first introduced by a German doctor in the Cameroons.
(p51)

140. At the Base, Lindi certain hospitals and camps, and at stations on the Central Railway corrugated iron latrines had been erected. On the Lines of Communication, in carrier hospitals and other places, wood, reeds, grass and matting had been utilized.
The only point to note is that in many instances no head-cover had been provided. Roofs are everywhere essential not only to protect from rain when it comes and to make things more comfortable for the users, but to exclude the sun and thereby discourage the presence of flies. Again and again it was noticed how in an uncovered latrine many flies would be feeding on tin contents while in another alongside but provided with a roof and consequently well shaded, flies were either absent or present in very small numbers. On our representation orders have now been issued that all latrines temporary or permanent are to be roofed. This is an easy matter in a country like East Africa and should have been done long ago.
Latrines for European troops are provided with petrol cans or drums. Even at the Base no proper sanitary pails are available. They are not really necessary though it is true they last longer and are less liable to damage than the improvisations. In many places no effort had been made to render the receptacles absolutely fly-proof tough this was not of such moment where the latrines are dark. Shortage of material and the lack of carpenters were the reasons given for the state of things. We generally found, however, that when a Medical Officer or an Officer Commanding a unit was keen on sanitation he managed to produce fly-proof seats.
We furnished information as regards the very simple and effective sliding petrol can method with falling lid. Specimens of this form of seat and receptacle are now on view at the Sanitary Demonstration Centre and it is gradually being adopted.
The usual Indian double pan system was in use for Indian and African troops and for carriers. In some instances only one tin was employed. In nearly every case a sufficiency of grass for lining the pans was available. It should be noted that at many hospitals and at nearly every large camp it is necessary to have three separate structures, one for Europeans, one for Indians and one for native Africans. This naturally entails a good deal of work both in building and in looking after the latrines.
The custom of placing pans for native use in depressions in the soil is a bad one and should be abandoned.
Where sweeper personnel is scanty an ingenious arrangement for covering used pans until their contents can be dealt with was devised in Mesopotamia. Information regarding it has been circulated with the warning that it should only be used under special circumstances for ‘out of sight out of mind’ is very apt to apply to latrine contents.

141. The types of latrine mentioned are always combined with incinerators. There was a great variety of the latter and a good deal of ingenuity had often been displayed in their manufacture. The chief fault in the case of those with fire bars was that these were placed too far apart so that half incinerated matter attractive to flies fell through them to the ground. Proper fire bars were scarcely ever seen. No stock of them seems to have been provided.
On the whole incineration was being fairly well carried out. This, as is to be expected, was specially true where Indian sweepers were available, but the native African can be trained to make quite a good sweeper as we saw at such a far distant post as Mnero in the Kilwa area where at B Section of No 2 South African Field Ambulance the sweepers were most speedy and alert in carrying the receptacles to the fire the moment after they had been used.
Here and there, however, disposal by incineration was being carried out in a dirty and dangerous manner, the essential of the method, namely ‘from pan to fire direct’ being neglected. Either the used pans were left in the latrines uncovered and exposed to flies, or a pernicious custom of mixing all the latrine contents in one large receptacle before incinerating them was in vogue. In one instance this was due to the fact that the incinerator serving the latrine had been placed several hundred yards away, thus inviting trouble.
The incineration system must be properly carried out otherwise it becomes most dangerous and offensive. It requires careful supervision at all times and everything calculated to make it simpler and safer, such as proximity of incinerators to latrines, sweepers’ quarters in the sanitary area, ample sweeper personnel so that the latrine is attended to at all times during the day, good head cover, grass-lined pans placed by the attendants ready for use, proper arrangement of tins to prevent soakage of urine, etc, should be considered and adopted.
The arrangements for the Indian ‘abdus’ (lavage) were often far from satisfactory. We indicated a simple and cleanly method which has given good results elsewhere.
We were interested in finding at Carrier Hospital, Dodoma, a method in use where, (p52) by the aid of tongs, the excreta receptacles, stout iron cups with their contents, were plunged directly into the fire. Provided the latter is strong enough this appears to be a very sound procedure. The cup-shaped vessels are those used by engineers for carrying earth.
The importance of providing covered sheds for incinerator fuel before the rains begin must be emphasised. We only saw one such shed, ie at Luale in the Kilwa area.

142. Trench latrines were of three types, the shallow open trench only seen at the actual front and a source of great danger, the ordinary deep covered trench having box or petrol drum seats with or without falling lids and the smoke trench latrine.
It is very necessary that at the front, where incineration is inadmissible owing to the danger of the smoke attracting the enemy’s fire, some method of preventing access of flies to the excreta should be at once adopted. The same is true in the case of troops on the march, both European and native, though it is well nigh impossible to control the latter who often straggle along the roads in small detachments without any officer looking after them. In the case of carriers on the move the problem frequently appears to be insurmountable.
Where, however, it is possible, the use of a wooden platform with a falling lid or, better perhaps, considering difficulties in transport, the provision of a series of boards laid closely side by side across the trench should be enforced. A convenient size for these boards which should be of three quarter inch planking is 3 feet 4 inches by 9 inches. A trench 10 feet long can be covered by 14 boards and will serve six men at a time. The user removes one board and straddles across the gap with his feet on the adjoining boards. Each plank should have at its centre a leather or rope handle and be well oiled or creosoted. The whole outfit is easily packed and carried by mule, donkey or porters. The ordinary deep covered trench calls for no notice but the smoke latrine is an interesting development. When properly operated it appears to be quite effective in keeping flies away, but like everything else in sanitation it requires careful supervision. The method is sufficiently indicated by the illustrations. In a good many places special latrines were in use for dysentery patients. These should be provided with facilities for hand washing on leaving the latrine.

URINALS
143. These as a rule conformed to the types with which all have become familiar during the war, but the use of ant-hills and ant-heaps as soakage pits for urine was new to us and evidently answered very well. In one place we saw a large ant-hill used both as an incinerator and a urinal, a remarkable combination.

COLLECTION AND DISPOSAL OF REFUSE AND HORSE MANURE
144. Refuse was generally being satisfactorily burned but certain units were very careless and it was no uncommon sight to find a pit half full of all kinds of objectionable matter and a regular messing spot for flies. The collection of refuse was not always well looked after and suggestions were made as regards weighted covers of sacking for garbage tins.
It is fortunate, at least from the sanitary standpoint, that it has not been necessary except at certain times to deal with horse manure on a large scale, for we understand that when it has been allowed to accumulate flies have been very numerous. One of the reasons for the comparative scarcity of Muscidae in German East Africa is undoubtedly the rarity of horses, mules and donkeys.
In the few places where we found horse camps, the manure was merely being burned in stacks. We explained the value of the ridge methods and also introduced a modified form of open cone incinerator easily constructed from a few petrol cans, milk tins and a little wire and mud.

CAMPS AND CAMP SITES
145. There is no definite scheme in operation whereby units replace each other in camps to which a sanitary area is attached. The outgoing unit very naturally carries off with it everything likely to be useful at its new camp and so, before the incoming unit has got things ready, ground is too often fouled, fly nurseries started and the spread of such a disease as dysentery encouraged.
It must be confessed that in a country like East Africa and a campaign like the present it is very difficult to prevent this kind of thing, but if the Sanitary Sections were strengthened it could be done, at least to some extent.
(p53)
At present all the Sanitary Sections can do in an executive way is to equip sanitary areas for Detail and Depot camps which are very varying quantities and possess no labour. We have suggested that in other cases each unit should tell off several men to be attached temporarily to the Sanitary Section. This would strengthen the latter considerably and tend towards efficiency. Still this cannot make up for the loss of time above mentioned and an effort should certainly be made in the direction indicated.
Another matter of the greatest importance is the necessity for camp sites being chosen only after consultation with a medical and preferably sanitary officer. In a country where malaria is rife this is an absolute necessity and we saw a good example of the evil resulting from ignoring the rule at Mfrisi on the Kilossa-Ruaha road. In addition to sickness resulting there was a lamentable waste of time, energy and money.
As a rule, however, camp sites are good and care is taken to avoid dangerous localities as far as possible. In the past this has not always been the case to judge from Major Christy’s report on conditions at Duthumi in January of this year. These seem, however, to have been quite exceptional.
The troops are housed in tents or bandas. Where EPIP tents are available mosquito nets can be properly used. This is very difficult to accomplish in crowded bell tents. (See note under Malaria as to Main Detail Camp, Section VI).
In several places the tents are protected from the sun by grass or matting and in the case of buildings windows are screened in a somewhat similar way. Bandas if well built and made sufficiently wide are quite good, though it is true they are apt to harbour vermin and special precautions must be taken in localities where the spirillum tick is found, ie Morogoro.
It is in most cases necessary to protect the roof of bandas against rain and this is usually done by utilizing old tend or tarpaulins. Wherever possible messing tents and huts should be provided. The practice of messing in living tents often results in a dirty camp and dirt spells flies.

BILLETS
146. These require very careful supervision. The feeding arrangements especially are apt to be defective in such places and unless there is good sanitary control they too often become foci of disease. Of those inspected at Dar-es-Salaam some were quite satisfactory, others the very reverse and attention was drawn to certain premises which required immediate attention and where, despite representations from the Officer Commanding Sanitary Section, there had been gross carelessness and neglect.
An inspection at Kilossa showed that the billets there were very satisfactory.
It would be an advantage if a short note of sanitary advice paying particular attention to flies, mosquitoes, and their habits were posted in each billet in Dar-es-Salaam and elsewhere.

COOKHOUSES
147. A certain number of travelling kitchens and field cookers such as Sawer’s stoves were seen, but these were chiefly in hospitals which are certainly not the proper places for field kitchens.
In camps the usual range of ‘dixies’ was generally employed. We were glad to note that a regulation had been issued warning cooks against cleaning vessels with unsterilized earth or sand and recommending the use of wood ash or sand which had been through boiling water. On the whole, cookhouses were fairly satisfactory but very often we noted a lack of proper aprons, a deficiency of washing soda, kitchen cloths, and of facilities in the cookhouse itself for cleansing the hands of the cook and his assistants. This is very important with reference to dysentery, and a basin with soap, nailbrush and towel should be provided in each kitchen. The unit Medical Officer should make a point of looking into these matters. Canvas shelters for company cooking in the case of Indian regiments are also important, and the tentage allowance of such regiments in the field should be increased to furnish these.
All cookhouses should be fairly dark and well ventilated. Their doors should face south. It is in the sunny cookhouse that flies are found and it is no use trying to exclude these insects by putting up elaborate erections of wire meshing. This has been found out long ago (p54) on all the other Fronts. Such places serve merely as fly traps. We found a large and otherwise good cookhouse of this type at Lindi. It was a mere waste of money and the wire netting should be used for making meat safes, larders, or out-of-door fly traps.
The cooking places in Indian and African camps and especially those in Carrier Depots were clean and well arranged.
Care should be taken to see that convalescents from dysentery and enterica are not employed in cookhouses or in distributing food by hand. It is the duty of every unit Medical Officer to see to this matter.
Particular attention should be paid to restaurants and pastry shops in such centres as Dar-es-Salaam.

SLAUGHTER HOUSES AND BUTCHERS SHOPS
148. As a rule these were quite satisfactory but, where necessary, we indicated how they might be improved. At Kisiwani we found a large number of hides serving as a fly nursery. They had been placed on the ground instead of being hung up on frames. If this were done and roller sacking passing through arsenite of soda and gur placed near them, they would not only cease to be a nuisance but become useful fly bait. We advised against spraying them with the arsenical solution owing to the danger of handling bales thus treated.

ICE AND SODA-WATER
149. It was only in certain favoured places that these luxuries were available, though here and there we discovered a fortunate field ambulance the possessor of an aerated water plant. The larger hospitals were well off in this respect. Ice is really not a great necessity in this part of East Africa for there is nearly always a cool breeze at some time of the day or night and drinks can be cooled in canvas water vessels. Where ice is not available in hospitals, cloths or sheets can be soaked in spirit and water, the latter serving as an evaporating lotion.

FLIES AND OTHER INSECT PESTS
150. This part of the world compares very favourably with other Fronts as regards the prevalence of flies. It is true that now and again they have constituted themselves a terrible pest as noted by Dr WA Lamborn in his report to the Colonial Office (Appendix 4) but as a rule this has not lasted long. It is also true that there are far too many in certain unsanitary camps and billets and that they have probably played some part in the spread of disease, but on the whole the fly has not lived up to its war reputation in German East Africa. There are probably several factors accounting for this comparative immunity. One appears to be the nature of the country; for the bush with all its drawbacks, is not such a happy hunting ground for the filth-carrying fly as desert lands where sand is plentiful. The climate is also possibly inimical, flies flourishing most under comparatively dry conditions. Again the absence of any large number of horses, mules and donkeys must be taken into consideration while the great prevalence of ants which prey on fly eggs and larvae may have something to do with it. Whatever the cause Musca domestica and its congeners have not been very much to the fore at least during our tour of inspection. In some places, however, there have been great number of Lucilia, Pycnosmoma and Sarcophagidae, associated with the presence of dead animals along the road, more especially in the Kilwa area where, like most other sanitary matters in this locality, little attention was being paid to them.
Good preventive measures are in force for flies and there is plenty of arsenite of soda. It should be coloured to prevent accident, especially in places where alum is used at the same time as a water clarifier.
Tsetese flies – Glossinae swam on many of the roads. They were common on the Kilossa-Ruaha route, in certain portions of the Mikesse-Rufiji line and were worst on parts of the long highway between Kilwa and Nahungu. G morsitans and brevipalpis were those chiefly taken but there has not been time to identify all the speciments captured amongst which G tachinoides and possibly G pallidipes may occur. G palpalis was not seen at any time.
Horse flies – Tabanidae and other Brachycera are common here and there, but can scarcely be described as a great nuisance.
(p55) Bees have caused trouble on several occasions and men have died as a result of their stings.
Mosquitoes – Except at Tabora we were not greatly annoyed by mosquitoes. At Tabora a culex was much in evidence. Anophelines throughout have been rare. The species are mentioned under Malaria (Section VI). Stegomyia are said to be common on the coast. There is evidently a very great difference in the number of mosquitoes during the dry and rainy seasons, even though some of them keep breeding nearly all the year round. According to Dr Spurrier A mauritanus disappears altogether for several months at Dar-es-Salaam.
Other insects do not call for notice here. As stated, sandflies have not been seen and lice, though present, have not been responsible for any outbreaks of disease.
Scabies have been very prevalent amongst Indian units. Measures are now being taken for dealing with it.

SANITARY SECTIONS
151. Something has already been said about them and their work. Like other units they have suffered much from sickness and recently the South African sections were unfortunate in having all their ‘Cape Boys’ returned to the Union. This is a serious matter and the deficiency requires to be remedied. Lieut-Colonel Maynard has represented the danger of thus depleting the sections of some of their best workers.
There are in all five Sanitary Sections.
Numbers 1, 2 and 3 are South African with headquarters at Dodoma, Morogoro and Lindi respectively. No 86 is Imperial with headquarters at Kisiwani. No 9 is Indian with headquarters at Dar-es-Salaam.
A South African Sanitary Section is the same strength as an Imperial (British) Section ie, 26 exclusive of the Officer Commanding, but it is stronger in non-commissioned officers, there being 7 Staff Serjeants, 2 Corporals and 14 privates. No 9 is a full Indian Sanitary Section with additional personnel. In some places the officers and men of the Sections were doing excellent work especially perhaps at Iringa, Mingoyo and Mpangas. In others they did not appear to have a proper grasp of the conditions governing tropical hygiene or to realise that delay is fatal and that sanitation is a question of governing tropical hygiene or to realise that delay is fatal and that sanitation is a question of minutes and hours, not of days, weeks or months. They were hampered by lack of military experience and when they discovered faults they either did not know how to get them remedied or, meeting with a rebuff or inattention, did not carry the matter further. Apparently they had never been given any instruction in this direction. The want of transport was also a great handicap. This is now being remedied in some measure but it should always be borne in mind that in nearly every locality, except the actual firing line, the sanitary section should be amongst the first on the ground in order to have things prepared for the incoming units.
Given more frequent and more detailed supervision by the senior officers, better opportunities for instruction, adequate transport and new blood to replenish their ranks, the sanitary sections, especially when reinforced from India, will continue to render good service and will have their usefulness enhanced.