EVACUATION OF THE UNFIT—RELIEVING THE PRESSURE ON THE HOSPITALS AND CONVALESCENT DEPOTS—BACK TO DUTY OR AUSTRALIA—METHODS ADOPTED—TRANSPORT OF INVALIDS BY SEA AND TRAIN.

CHAPTER VI

It became evident, both during the crisis and before the expected attack in August, that Egypt must be cleared of those who were not likely to be fit for service in the immediate future. The necessary effort made to send invalids away for change, and to send the permanently disabled home, involved important questions of policy the determination of which took time. A number of problems at once obtruded themselves. Who was to be permanently invalided, and how was the determination to be reached? Who was to be sent away temporarily, and for how long was he to go? Where was he to be sent to? What was to be done with malingerers, of whom there was a small but sufficiently numerous percentage? As regards the first question: is a man, for example, who has lost an eye permanently invalided? Is he fit for base duty in Egypt, or must he be sent home? It is hardly fair to send him to the front and expose him to the risk of total blindness. In this particular case, in view of the possibilities of the development of ophthalmia in Egypt—which, by the way, did not prove nearly as serious as was anticipated—it was decided that the man who had lost one eye should be sent home as permanently unfit. Men who had lost a limb were put in the same category. It might be argued that such men were quite fit for clerical work, and that one-eyed men were quite fit for ordinary guard work, for which, indeed, the demand was overwhelming. The view already indicated, however, was taken, and these men were sent to their homes to be discharged. But when these definite and obvious cases were disposed of, there remained some thousands of men whose cases were full of difficulty. In each hospital Boards were accordingly appointed to investigate their cases and to fully answer the questions set out in the following Army Form B 179.

MEDICAL REPORT ON AN INVALID

(Taken from Army Form B 179)
8. Disability
STATEMENT OF CASE

Note.—The answers to the following questions are to be filled in by the officer in medical charge of the case. In answering them he will carefully discriminate between the man's unsupported statements and evidence recorded in his military and medical documents. He will also carefully distinguish cases entirely due to venereal disease.

9. Date of origin of disability.

10. Place of origin of disability.

11. Give concisely the essential facts of the history of the disability, noting entries on the Medical History Sheet bearing on the case.

12. (a) Give your opinion as to the causation of the disability.

(b) If you consider it to have been caused by active service, climate, or ordinary military service, explain the specific conditions to which you attribute it. (See Notes on p. 71.)

13. What is his present condition?

Weight should be given in all cases when it is likely to afford evidence of the progress of the disability.

14. If the disability is an injury, was it caused—

(a) In action?
(b) On field service?
(c) On duty?
(d) Off duty?

15. Was a Court of Inquiry held on the injury?

If so—(a) When?
(b) Where?
(c) Opinion?

16. Was an operation performed? If so, what?

17. If not, was an operation advised and declined?

18. In case of loss or decay of teeth. Is the loss of teeth the result of wounds, injury, or disease, directly[6] attributable to active service?

19. Do you recommend—

(a) Discharge as permanently unfit, or
(b) Change to England?

————————————
Officer in medical charge of case.

I have satisfied myself of the general accuracy of this report, and concur therewith, except[7]

Station————————
Officer in charge of Hospital.
Date————————

FOOTNOTES:

[6] Loss of teeth on, or immediately after, active service, should be attributed thereto, unless there is evidence that it is due to some other cause.

[7] Delete this word if no exceptions are to be made.

OPINION OF THE MEDICAL BOARD

Notes.—(i) Clear and decisive answers to the following questions are to be carefully filled in by the Board, as, in the event of the man being invalided, it is essential that the Commissioners of Chelsea Hospital should be in possession of the most reliable information to ENABLE THEM TO DECIDE UPON THE MAN'S CLAIM TO PENSION.

(ii) Expressions such as "may," "might," "probably," etc., should be avoided.

(iii) The rates of pension vary directly according to whether the disability is attributed to (a) active service, (b) climate, or (c) ordinary military service. It is therefore essential when assigning the cause of the disability to differentiate between them (see Articles 1162 and 1165, Pay Warrant, 1913).

(iv) In answering question 20 the Board should be careful to discriminate between disease resulting from military conditions and disease to which the soldier would have been equally liable in civil life.

(v) A disability is to be regarded as due to climate when it is caused by military service abroad in climates where there is a special liability to contract the disease.

20. (a) State whether the disability is the result of (i) active service, (ii) climate, or (iii) ordinary military service.

(b) If due to one of these causes, to what specific conditions do the Board attribute it?

21. Has the disability been aggravated by—

(a) Intemperance?
(b) Misconduct?

22. Is the disability permanent?

23. If not permanent, what is its probable minimum duration?

To be stated in months.

24. To what extent is his capacity for earning a full livelihood in the general labour market lessened at present?

In defining the extent of his inability to earn a livelihood, estimate it at ¼, ½, ¾, or total incapacity.

25. If an operation was advised and declined, was the refusal unreasonable?

26. Do the Board recommend—

(a) Discharge as permanently unfit, or
(b) Change to England?

Signatures:—
——————President.
——————Members.
Station ——————
Date ——————
APPROVED.
Station ——————
——————
Administrative Medical Officer.
Date ——————

It should be remembered that the bulk of the medical officers were civilians, that they were unaware of the broad questions of policy involved, and that they were inclined on principle to give a holiday to a man who had been fighting, and even to believe the stories told them by the malingerer. The reader will therefore not be surprised to learn that a number of men who were certainly not in a very bad way were recommended for two, three, or six months' change, or even for discharge. The proceedings of the Board were reviewed by a responsible officer; for a long time by Lieut.-Col. Barrett when acting as A.D.M.S. on General Ford's staff. It was, however, difficult to persuade any Board which had once expressed their opinion to modify it, and almost impossible to get them to reverse it. If their recommendations had been rejected altogether, the conduct of the Service would have become difficult. Under direction, an attempt was made to modify the practice by appointing a permanent Board in each hospital, presided over by a senior medical officer charged with the duty primarily of attending to Board work, and of acting as a clinician only when he had time.

The Following Draft was made the Basis of the Arrangement

1. Two medical officers are to be detached from other duties at Nos. 1 and 2 Australian General Hospitals respectively, in order to form a majority of a permanent invaliding board at each hospital. They will be known as the senior and junior invaliding officer respectively.

2. The duties of the Board at Nos. 1 and 2 Australian General Hospitals will be to form an Invaliding Board by meeting in each case the medical officer in charge of the case.

3. The Board proceedings when completed will be sent to the A.D.M.S. Australian Force, Headquarters, Cairo, and on being approved will at once be forwarded with nominal roll to the Australian Intermediate Base Depot, Cairo.

4. The Australian Intermediate Base will forward to the O.C. Hospital or Convalescent Home nominal roll of patients who are to be discharged or transferred to Australia or England. These patients will be transferred to the Convalescent Home, Helouan (if they are able to leave hospital), and will remain at the Home till transport is ready for them.

5. The only circumstances in which completed Board cases are to be retained in any hospital, except the Convalescent Home, Helouan, are when patients require a considerable amount of treatment, and are unfit to leave the hospital.

6. The senior invaliding officer will be responsible for the accuracy of the nominal rolls.

7. At Alexandria an invaliding officer will be attached to the Australian Convalescent Home at Ras el Tin. It will be his duty, under direction of the A.D.M.S. Alexandria, to proceed to the various hospitals and camps in Alexandria, arrange for the formation of Boards, of which he will be a member, to deal with all cases in Alexandria. These cases, in like manner, must be forwarded to Convalescent Home, Helouan, except in the cases of those who are unfit to leave hospital.

8. The cases to be dealt with fall into two classes: (a) men unfit for military service, who may be sent by (i) transport to Australia or (ii) by hospital ship to Australia; and (b) men likely to profit by change to England during hot weather, to proceed by (i) transport or (ii) hospital ship.

9. The Board proceedings are to indicate, in the opinion of the Board, the best manner of dealing with patients under the several headings.

June 30, 1915.

Again difficulties arose, since none of the medical officers wanted the job. In fact, medical officers in general never want to do anything except attend to patients. They are unsuited temperamentally for administrative work, and dislike it. Even with this modification, though the system worked somewhat better, evils obtruded themselves. The statements of men who swore they were suffering from rheumatism and severe pains in the back were sometimes taken at face value, and further modification consequently became necessary. Any medical officer could recommend any patient to be boarded. The Board then sat and sent in its report to the A.D.M.S. Under the modified arrangement no patient could be boarded until he had been examined by the senior medical officer of the Australian Force in Egypt, or by the D.D.M.S. Egypt, Col. Manifold. By this means most of the trouble was eliminated and a satisfactory principle was established. It is the old story—the reversion to direction by a limited number of experienced and responsible people.

It was decided not to send Australian patients to Great Britain other than in exceptional cases, that is if they had friends or relatives there, and if they only required a short change, say two months. As the voyage to Australia occupied a month each way, it was absurd to send them back there for two months. For three months or more they were sent to Australia, and in some cases were discharged on arrival. Some men who were no longer fit for service at the front were kept in Egypt for Base Duty.

Only those who have experience of base work become aware of the enormous demands made on a garrison for guard work, for clerical work, orderly work, and the like. At Al Hayat, Helouan, for example, the commandant really required ninety men for sentry work, though he had only forty. The demands for competent clerks were incessant.

As soon as patients were destined for dispatch to Australia they were forwarded to Helouan and kept there until the ship was ready to leave. As a result Helouan was filled with waiting cases. In order then to ease the pressure at Helouan, a waiting camp was established at Suez close to the Government Hospital, to which any patients could be admitted. This establishment of course necessitated further demands for medical officers, orderlies, etc.

Transport of Sick and Wounded by Sea

As soon as it was decided to return patients to Australia in addition to those sent to England, Cyprus, or convalescent hospitals in Egypt, a system was developed in order to provide the necessary staffs and equipment on ships. Surgeon-General Williams had exerted himself to get hospital ships provided, but in the early stages they had not even been promised, and a service was perforce created by utilising empty transports and collecting the staff in Egypt. The first efforts may be described as almost maddening. It was impossible to get adequate notice when a ship was likely to leave for Australia. It had probably been to the Dardanelles and unloaded soldiers and munitions of war. It had returned to Alexandria packed with wounded. It might then be drafted to Australia, at a few days' notice. It was necessary to clean and refit it, to place hammocks, blankets, beds on board, to provide drugs and surgical appliances and Red Cross stores, and to provide a staff in Egypt.

In looking back on the efforts made, the wonder is not that minor defects occurred in the early stages, but that the work was done anything like as well as it was. The difficulties were almost insuperable, and nothing but the devotion of a number of medical officers to the service rendered any decent result possible.

The first ship to leave with wounded on board was the Kyarra on June 7, but previously a number of ships had left containing invalids, venereal cases, undesirables, and oddments. In every case there was a scramble at the last moment to get things ready. The staff for the ships was provided by detailing officers, nurses, and orderlies from the scanty staffs of Nos. 1 and 2 General Hospitals. The Australian Government, under request, then began to provide transport staffs who came with the troopships and returned at later intervals when the troopships went back again as "hospital carriers." Of hospital ships proper there were none. Each ship was inspected in order to ascertain the number of patients she could carry, and to determine the staff requisite—consequently a routine procedure was adopted. Cot cases were seldom taken, as it was thought better where possible to keep cot cases in Egypt. A minimum of two medical officers was allowed for 300 patients, and an additional medical officer for every 150 patients. One trained nurse was allowed for every 50 patients, and one orderly for every 25 patients. These numbers were arbitrary and approximate, but served as a working basis. The supply was probably in excess of real requirements, but it was necessary to contemplate the possibility of an epidemic outbreak in the tropics and the grave results which might ensue. The equipment of drugs and instruments was liberal, and was arranged on a fixed plan worked out by the officer in charge of the base medical store at Heliopolis. The Red Cross stores were supplied in the same way, and the commanding officer was given a sum of money, sometimes as much as £150 to £200, to spend on comforts for the men. A canteen was placed on board in addition. The ship was not allowed to leave the wharf until the commander had given a certificate that he had on board all the medical comforts required by the Admiralty regulations, and until the principal medical officer had given a certificate that he had all that he required in the way of staff, drugs, surgical and medical equipment, and Red Cross stores.

There is no more dangerous branch of medical service than the transport of sick and wounded over the ocean, since there are so many possibilities of disaster.

Base Medical Store

These continual demands on personnel and on medical stores necessitated suitable arrangements, and messages were sent to Australia asking for reinforcements. In addition a large base medical store was established at Heliopolis, and made an independent unit. It became the business of the officer in charge of this store, Captain Johnson, to make up drugs and surgical instruments per 100 patients, and to receive the surplus stores from each of the incoming transports. Two hospital ships were ultimately provided, the Karoola and the Kanowna, and reached Egypt in October.

Transport of Sick and Wounded to Suez

The arrangements for conveying the invalids from Cairo to Suez were interesting. They could not be conveyed to Alexandria or Port Said because one passenger placed on a ship at those ports enormously increased the charges made by the Suez Canal Company, and Suez was consequently fixed upon as the port of departure and the port of equipment. Patients to be conveyed to Suez were at Helouan, or at different hospitals in Cairo, and accordingly two trains were made up—one at Helouan and one at Palais de Koubbeh, Heliopolis. Each train was filled at a specific time, the two trains conveyed to Cairo, a junction effected in the Cairo station, and the whole conveyed to Suez. The journey took about five hours, and the necessary provision was made for feeding the men on the way. One of the difficulties in conveying such patients was to prevent them riding on the platforms of the carriages and falling off. A sentry was placed at each end of the carriage to prevent the continuance of these disasters, which had been too numerous in the case of healthy men in the troop trains. Men had even lost their lives or been mutilated from trying to ride on the buffers À la Blondin.

On arrival at Suez the train proceeded alongside the ship, the patients and their kit were moved on board, and a guard placed in the dockyard. Even then men straggled into Suez, and their recapture gave some trouble. The Australian is essentially a roamer.

The table on page 80 indicates the number of soldiers returned to Australia up to September 25, 1915, and the reason for their transfer.