SICKNESS AND MORTALITY AMONGST AUSTRALIANS—THE DANGERS OF CAMP LIFE—STEPS TAKEN TO PREVENT EPIDEMICS—NATURE OF DISEASES CONTRACTED AND DEATHS RESULTING—DEFECTIVE EXAMINATION OF RECRUITS—OPHTHALMIC AND AURAL WORK—THE FLY PEST—LOW MORTALITY—THE EGYPTIAN CLIMATE AGAIN—SURGICAL WORK AND SEPSIS—CHOLERA—INFECTIOUS DISEASES.

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CHAPTER VII

In civil practice we had long been aware of the fundamental failing of the medical profession. Its members operate in a community as individuals. They seek to cure disease in general; they are conscientious to a degree in the discharge of this duty, and they give valuable personal advice respecting hygiene. But of the prophylaxis of disease they have little trained knowledge, and they are not seriously interested. The prophylaxis of disease really implies organised and co-operative effort, and can only be effectively undertaken by those public-health officials who are charged with it as a definite function. In Australia at all events the inducements to enter the public-health service as a profession are not very great. The influence of the department is not very far-reaching, and the prophylaxis of disease is still in its infancy. One can foresee the time when the number of practitioners per 100,000 of the population will be fewer than at present, and the number of public-health officials will be greater. The transition from the one occupation to the other will only take place when a much higher standard of general intelligence prevails in the community.

What applies to civil life applies to a lesser extent to an army, because the headquarters staff of an army are as a rule excellently informed respecting the risk run by neglect of sanitation. They understand thoroughly that disease may do more harm than battles, and that outbreaks permitted to get out of hand are with difficulty controlled. In the Australian Army, by reason of its necessarily scratch nature, there was practically no instruction in prophylaxis. It was certainly not acutely understood, and the disastrous events which attended the formation of camps in Victoria and elsewhere show that the controlling authorities were either not fully informed of the risks, or if informed, did not understand the best plan of action. What applied in Australia was true to a lesser extent in Egypt, because Surgeon-General Williams and many of the R.A.M.C. officers who controlled medical operations in Egypt, and distinguished members of the Indian Medical Service who were associated with them, had been through a number of campaigns in South Africa and elsewhere, and were aware both of the risks and the difficulties. Consequently some effort was made to avoid, or to minimise the effects of, some of the disastrous outbreaks.

In March and April, before the arrival of wounded, the number of cases in hospital was a source of common comment amongst the medical officers, who could not understand why healthy men under service conditions, camped on the edge of a dry desert, should be suffering from serious disease to such an extent. The diseases were for the most part measles, with its complications, bronchitis, broncho-pneumonia, and a certain amount of lobar pneumonia, infectious pleuro-pneumonia, and tonsillitis. There were a few cases of cerebro-spinal meningitis. The impression made on a physician who had all the cases coming from the Heliopolis camps under his control was that these diseases were inordinately prevalent; but the following figures, obtained from headquarters and forwarded to the Government, show that while disease was more extensive than it should be, it was not excessive. Including venereal disease, the cases certainly did not exceed 6 to 8 per cent. of the force.

First Australian General Hospital

Palace Hotel,
Heliopolis,
May 8, 1915.

(Report begins) "The following figures have been obtained from the office of the D.M.S. Egypt. Owing to the movement of troops out of Egypt, comparisons are apt to be a little difficult to institute with accuracy. Nevertheless the figures given substantially indicate the position.

On February 15 there were 1,329 patients in hospital. The number of sick and off duty in the lines, but not in hospital, is not stated; but as it amounted to 423 on February 1, and to 644 on March 1, it may be assumed to be 500, which will give a total of 1,829 sick and off duty on February 15.

On March 1, 1,737 men were in hospital, 644 off duty and sick in the lines, or a total of 2,361.

On March 15, 1,429 were in hospital, 500 off duty and sick in the lines, or a total of 1,929.

On April 1, 1,217 were in hospital, 495 sick and off duty in the lines, or a total of 1,712.

The totals, therefore, off duty on the dates specified were:

February 15 (approx.)	1,829
March 1	2,381
March 15 (approx.)	1,929
April 1	1,712

It should be stated that the figures quoted above would have been very much larger were it not that a large number of men unfit for duty by reason of venereal and other forms of disease have been returned to Australia, and a considerable number sent to Malta.

There have been returned to Australia by the Kyarra on February 2, the Moloia on March 15, the Suevic on April 28, and the Ceramic on May 4, a total of 337 soldiers who were medically unfit for various reasons, and 341 suffering from venereal disease, or 678 in all. In addition about 450 were sent to Malta. If these soldiers had been added to the list of those reported sick and unfit for duty daily, the number would have considerably exceeded 2,000. The estimate of 2,000 sick and unfit for duty daily was studiously moderate, as pointed out in a private letter to Colonel Fetherston at the time when precise figures could not be immediately obtained.

It is gratifying to find that the amount of sickness is diminishing and that the amount of venereal disease, so far as can be ascertained, is also decreasing.

Strenuous efforts have been made by the A.M.C. to attack both forms of inefficiency by dealing with the causes, and with a view to avoiding future troubles the D.M.S. Egypt has appointed a committee of medical officers to inquire into the causations of the outbreak. It is unlikely that the committee can be very active just at present, because of the prior claims on the time of all concerned owing to the influx of wounded. At a later period it is hoped that an exhaustive report will be furnished for the benefit of future undertakings.

Most strenuous efforts have been made to limit the amount of venereal disease. General Birdwood, Commander-in-Chief of the New Zealand and Australian Army Corps, has personally interested himself in this question, and has through the O.C. First Australian General Hospital arranged for me to visit each troopship on arrival, all leave being stopped from the transport until I have been on board. The practice followed is to interview the commanding officer and the officers of the transports, to explain to them the gravity of the position, and to ask each and all of them to use all the influence he possesses with his men to deter them from exposing themselves to the risk of contagion, to draw their attention to the fact that on the physical fitness of the individual man depends the possibilities of success to the army, and to ask for the loyal and enthusiastic co-operation of every officer in work of such importance from a military point of view, and the point of view of subsequent civil life. The officers immediately parade the men, address them, and convey to each of them a printed message from General Birdwood. General Birdwood's letter to General Bridges, written during the early part of the stay of the Army in Egypt, is handed to the Commanding Officer to be read by him and his staff. There is no doubt that this systematic procedure has drawn attention to the gravity of the problem. It has always been responded to loyally by the officers concerned, and it has certainly limited the action of young and inexperienced men on their first landing in an Eastern country.

Other steps were taken by Surgeon-General Williams, who on arrival in Egypt called a conference of senior medical officers to consider the gravity of the venereal diseases problem.

It is satisfactory to find, notwithstanding the amount of disease which has existed, and which, while not excessive, is still heavy, that the mortality has not been as serious as it might have been. The mortality in No. 1 Australian General Hospital for February and March was seventeen cases out of a total of 3,150 admitted" (Report ends).

The following return shows the total number of casualties in the Australian Force up to July 16, 1915:

The next table shows the average length of stay in hospital of venereal cases at a particular date:

The Enlistment of the Unfit and its Consequences

Prior to the arrival of the wounded the medical service was inconvenienced by another circumstance. Men were continually arriving with hernia, varix, and other ailments which they had suffered from before enlistment, and which had been overlooked during the preliminary examination in Australia. In one case a soldier suffering from aortic aneurism arrived in Egypt, and similar instances might be given. The examination of recruits in Australia had been conducted by practitioners in country towns and elsewhere, often under conditions highly unfair to the practitioner. There is no doubt that the Government would have been well advised to have withdrawn a few men from private practice altogether, paid them adequate salaries, and made them permanent examiners of recruits. Experience of war demonstrates most completely the folly of sending any one to the front who is not physically fit. It is apt to be forgotten that in warfare there can be no holidays, or days off, and that the human being must be at his maximum of physical efficiency, and his digestion of the best. If his soundness is doubtful it is better to keep him for base duty at home, on guard duty at the base, or as an orderly in the hospital. It is simply a waste of money, and tends to the disorganisation of the service, to send such people anywhere near the fighting line. We made an attempt at one stage to roughly calculate what the Australian Government had lost in money by the looseness of official examination. It was impossible to make an accurate estimate, but the sum was great.

Ophthalmic and Aural Work

When one of us joined the hospital as oculist and aurist and registrar (Lieut.-Col. Barrett) he was informed that specialists were not required, but apparently those responsible had formed no conception of the excessive demands which would be made on the ophthalmic and aural departments. The first patient admitted to No. 1 General Hospital was an eye case, and an enormous clinic rapidly made its appearance. It was conducted somewhat differently from an ordinary ophthalmic and aural clinic, in that (by reason of the remoteness of their camps) some patients were admitted for ailments which would have been treated in the out-patient department of a civil hospital. There were usually from 60 to 100 in-patients and there was an out-patient clinic which rose sometimes to nearly 100 a day. It should be remembered that these included few, if any, serious chronic cases, which were at once referred back to Australia. The amount of ophthalmic and aural disease was very great. The figures subjoined show the extent of the work done.

From the opening of the Hospital to September 30, 1915, the patients treated in the Ophthalmic and Aural Department numbered as follows:

The ophthalmic cases may be roughly classified as follows:

The distribution of disease is unusual. In the course of a long and extensive practice one of us (Lieut.-Col. Barrett) had not seen as many cases of adenoids in adults as he examined in Egypt in three months. It seemed that the irritation of the sand containing organic matter caused inflammation and irritation of the naso-pharynx. Of ophthalmia there was a great deal. It was usually of the Koch-Weeks variety, and gave way readily to treatment. There were a few cases of gonorrhoeal ophthalmia, two of which arrived from abroad, and all of which did well. After the arrival of the wounded, however, a new set of problems made their appearance. A limited number of men were totally blind, mostly from bomb explosions, and a large number of others had received wounds in one eye or in the orbit. It soon became evident that an eye punctured by a fragment of a projectile is almost invariably lost. The metal is non-magnetic. It is usually situated deep in the vitreous; it is practically impossible to remove it even if the eye were not infected and degenerate. A still more remarkable phenomenon, however, made its appearance. If a projectile enters the head in the vicinity of the eye, and does not actually touch it, in most cases the eye is destroyed. Whether from the velocity or the rotation of the projectile, the bruising disorganises the coats of the eye and renders it sightless. In all such cases, if the projectile was lodged in the orbit, the eye was removed together with the projectile. The total number of excisions was thirty-six. In no case did a sympathetic ophthalmitis make its appearance. The eyes were not removed unless the projection of light was manifestly defective. A fuller account of the precise ophthalmic conditions will be published elsewhere.

If the general physical examination of recruits was defective, it is difficult to find suitable terms to describe the examination of their vision. Instances were not infrequent where men with glass eyes made their appearance, and there were several recruits who practically possessed only one eye. Spectacle-fitting was the chief work, as many of the recruits required glasses, mostly for near work, but sometimes for the distance. Ultimately the War Office decided to provide the spectacles. In such a war, it is impossible to exclude recruits for fine visual defects, still, men with only one eye can hardly be sent to the front.

One remarkable instance occurred. A man suffering from detachment of the retina had but one effective eye. I gave directions that he should not be sent to the front, but he eluded authority, and reached Gallipoli, where he was hit in the blind eye with a projectile. I subsequently removed the eye.

The work was excessive, but only one life was lost, though on occasion the condition of some of the sufferers was grave to a degree. One of the most remarkable cases of injury was that of a man who was struck below the left eye by a bullet which emerged through the back of his neck, to the side of the median line. The bullet in emerging tore away a large quantity of the substance of the neck, leaving a hole in which a fair-sized wine glass could have been placed. He was a cheerful man, and sat up in bed propped with pillows, because of the weakness of his neck, and observed to a visitor "Ain't I had luck!" He made an excellent recovery.

It is remarkable that there should have been so much refraction work, and there is no doubt that a working optician, i.e. spectacle maker, should accompany every army. Men are often just as dependent for their efficiency on glasses as on artificial teeth, and in a war of this character cannot be rejected.

The acute inflammations of the middle ear were of the most severe type, caused temperatures rising to 103° F. and sometimes left men on convalescence as weak as after a serious general illness. The attacks were so vicious that the pathologist, Captain Watson, sought for special organisms, but found only staphylococcus. Probably the same group of organisms which caused vicious pulmonary attacks also caused these severe aural inflammations.

Before our arrival in Egypt malingerers in the force who, having enjoyed a holiday trip to Egypt, wanted to go home again, suddenly discovered that they were blind or deaf. For a time the department was fairly busy detecting the wiles of these men. When they discovered, however, that they would be subjected to expert examination, sight and hearing soon returned. A number of devices were resorted to in order to detect the fraud—i.e. the use of faradisation, blind-folding, and the like—and it was rarely that the impostor escaped.

Other Diseases: Measles and its Complications; Food Infections

The danger run by an army from measles is very great indeed, and at an early stage the position was surveyed, and an attempt made to limit the trouble. A cable message was sent to Australia, asking that precautions should be taken against shipping measles cases or contacts. At Suez arrangements were made with the Government Infectious Diseases Hospital to admit any patients suffering from measles or infectious diseases who might land with the recruits. In such cases the clothing of the remaining recruits was disinfected before they were allowed to proceed to Cairo. In this way disease was kept out of Egypt as much as possible. In the case of measles it is not simply temporary disablement, but also the complications and sequelÆ which are to be feared. The experience gained has made us converts to the open-air method of treating such cases, at all events in a rainless country like Egypt. Treated on piazzas and in open spaces the cases seem to do better than in hospital wards, and, as far as one can judge without a critical examination, with a lower mortality.

The extent to which the troops suffered from measles and other diseases was the cause of the appointment of a committee to inquire into causation. The committee made some inquiries, but owing to a set of complications never completed its work. There seemed, however, to be a consensus of opinion that the use of the bell tent was objectionable, as it did not ventilate readily, and that the habits of the men contributed to these diseases.

The men were apt to visit Cairo, spend the evenings in the cafÉs or theatres, ride home in the cold nights in a motor car or tram, get to bed at the last moment possible, and then turn out again for a hard day's work. The opinion of the physicians was that the drilling of men suffering from even a moderate cold was a source of considerable danger. If to these causes be added the neglect of the teeth on the part of many of the men, some explanation may be found for the presence of these diseases. Every effort was made to instruct the men through the regimental officers, and there is no doubt that as time went on the quantity of this type of disease somewhat diminished.

Sunstroke was practically unknown. A number of cases occurred during a severe khamsin, but the use of a looser and lighter uniform, and the adoption of sensible hours of work, prevented any recurrence. Of two deaths known to have taken place the cause was only partly due to heat. The men were warned against the risk of bilharzia, and as they were provided with shower baths there was no inducement to bathe in the muddy pools and canals where bilharzia lurks.

With the provision of dentists another risk was removed, at all events in parts. In hospitals, tooth brushes were supplied in thousands, and every effort was made to get the men to use them.

As the summer wore on, however, another type of disease made its appearance—the intestinal infections which, at first unknown, became so frequent in Gallipoli as to be more serious than fighting. In Gallipoli itself it is difficult to see how they could be prevented. In a limited space there were many dead bodies scantily buried, and consequently myriads of flies. The plentiful use of disinfectant, had it been obtainable, might have been useful, but the difficulties were great. Once the dysenteric organisms were introduced, it was practically impossible to stop the spread of disease.

The Fly Pest

At the Island of Lemnos, however, which was not under fire, and where there was room, the conditions appear to have been nearly as bad, and it is somewhat difficult to know why the fly pest could not have been got under at Mudros. At Heliopolis at an early stage the fly problem was seriously tackled. A sanitary officer was appointed, and charged with the duty of dealing with this important matter. The following precautions were adopted. All refuse and soiled dressings were placed in covered bins, which were provided in quantity. These were removed once daily. Any moist ground in the vicinity of these bins was watered with sulphate of iron solution, and sprinkled with chloride of lime. Fly papers in great numbers were distributed throughout the wards. The food in the kitchens, whether cooked or uncooked, was kept under gauze covers or in gauze cupboards. By these means the fly pest was reduced to small proportions. But with the least slackness in administration the flies were again in evidence. It was most instructive to see a floor covered with flies if fluid containing food material had been spilled, and to see dirty clothing covered with masses of flies. A piece of soiled clothing half buried in the desert appears to act as an excellent breeding-place.

It was impracticable in Egypt to cover all the windows and doors with fly-proof netting. The exclusion of the air in the hot weather would have been troublesome, and the best type of netting was not obtainable. Furthermore the precautions already enumerated kept the pest under in Heliopolis.

The fly problem was one of the most serious the army had to face. The passage of a dysenteric stool by a man who is really ill was often followed by the entry into his anus of flies before an attendant had time to intervene. Each of these flies might then become a source of infection and had only to light on a piece of food, cooked or uncooked, to cause further damage.

Outside.

1. No rubbish heaps will be allowed.

2. All manure heaps shall be sprayed twice a week with sulphate of iron—2 lb. to 1 gallon of water.

3. All food in the Arab quarters shall be kept in a closed cupboard.

4. All rubbish boxes and open receptacles shall be removed from the premises and neighbourhood.

5. No receptacles other than iron tins with lids kept closed will be allowed to be used for refuse.

6. Every place on which garbage has been exposed shall be freely sprinkled with chloriated lime.

Wards.

1. All food and receptacles for food shall be kept constantly covered.

2. All spit-cups shall be kept covered.

3. All remains of food shall be removed at once to receptacles which are to be kept covered completely and constantly except when uncovered necessarily to receive waste materials.

4. Sisters-in-Charge shall use a liberal quantity of fly papers. Surgical soiled dressings shall be placed in special bins which shall be kept covered.

Kitchen and Mess Rooms.

1. All food shall be kept locked up or completely covered.

2. All remains of food shall be treated as in the wards. The responsible officer shall use a liberal supply of flat or hanging fly papers.

It need hardly be said that the enforcement of even these simple precautions is more difficult than giving the order.

A good sanitary officer, however, acting on these directions, can and did reduce the fly danger to small proportions. The flies were never exterminated, but were kept well under. The least slackness, however, ended in their rapid reappearance. As they are in all probability the principal cause of the gastro-intestinal infections, the matter is one of the first importance.

Typhoid fever made its appearance, and a proper statistical investigation should be made later on to show the extent of the damage done. The general impression respecting the result of the inoculation to which all the troops were subjected was that the disease was not so frequent and certainly not nearly so fatal as it otherwise would have been. Deaths were few.

The men had not been inoculated against paratyphoid, so that exact conclusions will be difficult to draw even when figures become available.

Many people suffered from Egyptian stomach ache, a form of disease which is as unpleasant as it is exhausting. It manifests itself by repeated attacks of colicky pain, apparently usually associated with the colon. The severity of the pains is remarkable, and the persistent recurrence speedily ends in a considerable degree of exhaustion. It is almost certainly due to food infection.

It is obvious that the business of a sanitary medical officer is not merely to inspect buildings and kitchens, but to spend an hour or two a day in the kitchen quietly watching the preparation of the food and giving the necessary instruction and supervision to those who are preparing it. The inefficiency caused by food infections has probably done more harm than many battles. In the camps similar troubles occurred. By reason of the lack of cold storage and the high temperature, rotten food was not uncommon, and caused outbreaks of incapacitating diarrhoea and ptomaine poisoning.

When, however, the problem is surveyed dispassionately, the remarkable feature of the work at Heliopolis and in Cairo was the low mortality, as the following table will show:

In view of this extraordinarily low mortality, it is interesting to comment on human intellectual frailty. It was said that the hospitals were septic, that operations of election could not be performed with safety, that the climate was particularly dangerous, and so forth. One letter which reached us made reference to hundreds of deaths of brave fellows due to faulty camp and hospital conditions. Yet here is the fact recorded that the total deaths in Cairo amongst Australians from disease and wounds to August 14 were only 155. All men tend to generalise on insufficient instances, and the tendency in this case was aggravated by some physical discomfort experienced by the generalisers throughout an unusually warm summer—a discomfort accentuated by overwork and a conscientious devotion to duty under trying conditions.

The Egyptian Climate again

Dealing with the surgical side of the matter, nothing was commoner at one time than to hear the statement made that owing to the hot weather septic infections were common, that wounds did not heal as they should in Egypt, and that it was not a suitable place to which wounded men should be sent. While quite agreeing with the critics that a cool climate is always preferable to a hot one, it may be remarked that in the first place summer in Egypt, apart from the khamsin, is not excessively hot. The khamsin blows for a certain number of days in April, May, and the first half of June. The temperature may rise to 112° or more. The wind blows with a fiery blast, and there is no doubt it is exceedingly trying. But if buildings are shut up early in the morning and opened at night, even the khamsin may be made tolerable. After the middle of June, however, there is very little wind. One day is very like another. The midday temperature is from 90° to 95° Dry Bulb, and the nights perhaps 65° to 70° Dry Bulb. The Wet Bulb temperatures are set out in the table previously referred to.

For the most part men slept in nothing but pyjamas. No sheet is wanted until towards the end of August. Whilst it is not pleasant to wake in the mornings in a lather, nevertheless, if a practical and cold-blooded examination be made of the facts, the result shows nothing but discomfort.

Grave septic diseases did not occur. The hospitals were perfectly clean, and at Luna Park in particular we have the testimony of Colonel Ryan that the wounds healed by first intention and that the cases did excellently.

As the garrison of Egypt was a very large one, and as Australian troops were continually pouring into it, it was impracticable even if it had been necessary to take the patients anywhere else. The islands of Lemnos and Imbros were far less suitable even for those who had been injured at Gallipoli, and apart from the inconvenience caused by the heat there was no reasonable ground for complaint in Egypt. Furthermore the heat is not tropical. It is subtropical, as the Wet Bulb temperatures indicate.

In the First Australian General Hospital every care was taken to minimise the inconvenience; a very large number of excellent ice chests were purchased, an enormous quantity of ice was used, and the necessary steps thus taken to diminish the amount of food decomposition and prevent ptomaine poisoning. Fans and punkahs were used, and the nights were quite tolerable.

Medical Organisation in Egypt

When the Australian forces pass three miles from Australian shores they cease, at all events technically, to be under Australian control, and pass under the control of the Commander-in-Chief. On arrival in Egypt they passed under the control of General Sir John Maxwell, G.O.C.-in-Chief, Egypt. The medical section passed under the command of the Director of Medical Services, Surgeon-General Ford. The D.M.S. Australian Imperial Force, Surgeon-General Williams, arrived in Egypt in February and was placed on the staff of General Ford to assist in managing these units. He left for London on duty on April 25, and one of us (J. W. B.) was appointed A.D.M.S. for the Australian Force in Egypt on the staff of General Ford. Later, Colonel Manifold, I.M.S., was appointed D.D.M.S. for Australian and other medical units. Thus the Australian medical units were under the same command as New Zealand or British units, but with separate intermediaries.

The Risk of Cholera

In view of the risk of cholera, the following note by Dr. Armand Ruffer, C.M.G., President of the Sanitary, Maritime and Quarantine Council of Egypt, Alexandria, was issued and, later on, inoculation was practised on an extensive scale.

Dr. Ruffer's Views on Cholera

(Report begins) "The first point is that although, in many epidemics, cholera has been a water-borne disease, yet a severe epidemic may occur without any general infection of the water supply. This was clearly the case in the last epidemic in Alexandria. Attention to the water supply, therefore, may not altogether prevent an epidemic. The second point is that the vibrio of cholera may be present in a virulent condition in people showing no, or very slight symptoms of cholera, e.g. people with slight diarrhoea, etc.

The segregation of actual cases of cholera, therefore, is not likely to be followed by any degree of success, because this measure would not touch carriers or mild cases, unless orders were given to consider as contacts all foreign foes, and all soldiers who have been in contact with them. This is clearly impossible.

There cannot be any reasonable doubt, therefore, that if the Turkish army becomes infected with cholera, the British Army will undoubtedly become infected also.

Undoubtedly inoculation is the cheapest and quickest way of protection of the troops, provided this process confers immunity against cholera.

It is very difficult to estimate accurately the protection given by inoculation against cholera. My impression from reading the literature on the subject is that: (1) The inoculations must be done at least twice. (2) The inoculations, if properly made, are harmless as a rule. (3) The inoculations confer a certain protection against cholera. I may add that I arrived at this opinion before the war, when the French editors, Messrs. Masson & Co., asked me to write the article "Cholera" for the French standard textbook on pathology. My opinion was therefore quite unprejudiced by the present circumstances.

The cholera inoculations were harmless as a rule; that is, they were not always harmless. Savas has described certain cases of fulminating cholera amongst people inoculated during the progress of an epidemic. In my opinion, the people so affected were in the period of incubation when they were inoculated, and the operation gave an extra stimulus, so to speak, to the dormant vibrio. One knows that, experimentally, a small dose of toxin, given immediately after or before the inoculation of the microorganism producing the toxin, renders this microorganism more virulent.

The conclusion to be drawn is that inoculations should be carried out before cholera breaks out.

I am afraid I know of no certain facts to guide me in estimating the length of the period of immunity produced by inoculations. Judging by analogy, I should say that it is certainly not less than six months, that it, almost certainly, lasts for one year, and very probably lasts far longer.

I understand that 90,000 doses of cholera vaccine have been sent from London. I take it that the inoculation material has been standardised and its effects investigated, but, in any case, I consider that a few very carefully performed experiments should be undertaken at once in Egypt, in order to make sure of the exact method of administration to be adopted under present conditions.

Probably, a good deal may be done by the timely exhibition of drugs, such as phenacetin, etc., to mitigate the more or less unpleasant effects of preventive inoculation.

As I am on this subject, may I point out the necessity of establishing at the front a laboratory for the early diagnosis of cholera and of dysentery. Cholera has appeared in the last three wars in which Turkey has been engaged, and therefore the chances of the peninsula of Gallipoli becoming infected are great. The early diagnosis of cases of cholera, especially when slight, is extremely difficult and often can be settled by bacteriological examination only.

There never has been a war without dysentery, and almost surely our troops will be infected in time, if they are not already infected. But whereas in previous wars the treatment of dysentery was not specific, the physician is now in possession of rapid methods of treatment, provided he can tell what kind of dysentery (bacillary or amoebic or mixed) he is dealing with.

This differential diagnosis is a hopeless task unless controlled at every step by microscopical and bacteriological examination.

The French are keenly aware of this fact, so much so that they have sent, for that very purpose, three skilled bacteriologists, two of whom are former assistants at the Pasteur Institute, to the Gallipoli Peninsula" (Report ends).

Other Infectious Diseases

The Infectious Diseases Hospitals were filled mostly with cases of measles and its complications, including severe otitis media. Cases of erysipelas, scarlatina, scabies, and diphtheria were met with in small numbers. In the autumn there was a severe epidemic of mumps.

Through the summer and autumn many cases of diarrhoea and of both amoebic and bacillary dysentery made their appearance. There is good ground for believing that many so-called diarrhoeal cases were dysenteric.

There is little doubt short of absolute scientific proof that the greater part of the intestinal diseases are fly borne.

The following table shows the admissions into the hospital, the deaths, and causes of death, to July 31, 1915.

A subsequent table shows the deaths and causes of death in No. 2 Australian General Hospital from May 3 to August 18.

In May and June 5,512 men were admitted, of whom 1,219 were Australians and New Zealanders in camp, 2,967 Australians and New Zealanders from the Mediterranean Expeditionary Force, 1,050 British, and 276 Naval Division from the same force.

This chapter would be incomplete unless proper acknowledgment were made of the most valuable post mortem demonstrations given by Major Watson.

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