VENEREAL DISEASES—THE GREATEST PROBLEM OF CAMP LIFE IN EGYPT—CONDITIONS IN CAIRO—METHODS TAKEN TO LIMIT INFECTION—MILITARY AND MEDICAL PRECAUTIONS—SOLDIERS' CLUBS.

CHAPTER VIII

The venereal-disease problem has given a great deal of trouble in Egypt as elsewhere. The problem in Egypt does not differ materially from the problem anywhere else, but a number of fine soldiers have been disabled more or less permanently.

When the First Australian Division landed in Egypt and camped at Mena, the novelty of the surroundings and the lack of intuitive discipline resulted in somewhat of an outbreak, both with regard to conduct and to sexual matters. Both of these phases have been greatly exaggerated, but nevertheless there was substantial ground for apprehension, and the following letter from General Birdwood, Commander-in-Chief of the Australian Army Corps, to the officers commanding units was sufficient evidence of the necessity for action.

"For Private Circulation only

"Divisional Headquarters, Mena,
"December 18, 1914.

"The following letter written by Major-General W. R. Birdwood, C.B., C.S.I., C.I.E., D.S.O., Commanding the Australian and New Zealand Army Corps, to Major-General W. T. Bridges, C.M.G., Commanding the First Australian Division, has been printed for private circulation.

"V. C. M. SELLHEIM,
"Colonel, A.A. and Q.M.G."

"HEADQUARTERS: AUSTRALIAN AND NEW ZEALAND ARMY CORPS,
"SHEPHEARD'S HOTEL, CAIRO,

"December 27, 1914.

"MY DEAR GENERAL,

"You will, I know, not misunderstand me if I write to you about the behaviour of a very small proportion of our contingents in Cairo, as I know well that not only you, but all your officers and non-commissioned officers and nearly all the men must be of one mind in wishing only for the good name of our contingents.

"Sir John Maxwell had to write recently complaining of the drunkenness of some of our men in the Cairo streets. During Christmas time some small licence might perhaps have been anticipated, but that time is now over, and I still hear of many cases of drunkenness, and this the men must stop.

"I advisedly say 'the men must stop,' because I feel it is up to the men themselves to put a stop to it by their own good feeling. I wonder if they fully realise that only a few days' sailing from us our fellow-countrymen are fighting for their lives, and fighting as we have never had to do before, simply because they know the very existence of their country is at stake as the result of their efforts.

"We have been given some breathing time here by Lord Kitchener for one object, and one object only—to do our best to fit ourselves to join in the struggle to the best advantage of our country. I honestly do not think that all of our men realise that this is the case. Cairo is full of temptations, and a few of the men seem to think they have come here for a huge picnic; they have money and wish to get rid of it. The worst of it is that Cairo is full of some, probably, of the most unscrupulous people in the world, who are only too anxious to do all they can to entice our boys into the worst of places, and possibly drug them there, only to turn them out again in a short time to bring disgrace on the rest of us.

"Surely the good feeling of the men as a whole must be sufficient to stop this when they realise it. The breathing time we have left us is but a short one and we want every single minute of it to try and make ourselves efficient. We have to remember too that our Governments of the Commonwealth and Dominion have sent us here at a great sacrifice to themselves, and they fully rely on us upholding their good name, and indeed doing much more than that, for I know they look to us to prove that these two contingents contain the finest troops in the British Empire (whose deeds are going down in history), whom they look forward to welcome with all honours when we have done our share, and I hope even more than our share, in ensuring victory over a people who would take all we hold dear from us if we do not crush them now.

"But there is no possibility whatever of our doing ourselves full justice unless we are every one of us absolutely physically fit, and this no man can possibly be if he allows his body to become sodden with drink or rotten from women, and unless he is doing his best to keep himself efficient he is swindling the Government which has sent him to represent it and fight for it. From perhaps a selfish point of view, too, but in the interests of our children and children's children, it is as necessary to keep a 'clean Australia' as a 'White Australia.'

"A very few men can take away our good name. Will you appeal to all to realise what is before us, and from now onwards to keep before them one thought and only one thought until this war is finished with honour—that is, a fixed determination to think of nothing and to work for nothing but their individual efficiency to meet the enemy.

"If the men themselves will let any who do not stick to this know what curs they think them in shirking the work for which it has been their privilege to be selected, then, I know well, any backslidings will stop at once—not from thoughts of punishments, but from good feeling, which is what we want.

"I have just been writing to Lord Kitchener telling him how intensely proud and well-nigh overwhelmed I feel at finding myself in command of such a magnificent body of men as we have here; no man could feel otherwise. He will, I know, follow every movement of ours with unfailing interest, and surely we will never risk disappointing him by allowing a few of our men to give us a bad name. This applies equally to every one of us, from General down to the last-joined Drummer.

"Will you and your men see to it?

"Yours very sincerely,
"W. R. Birdwood."

Those who possessed any experience of life could not but realise that 18,000 particularly vigorous fine men, brought up in a country where discipline is conspicuous by its absence, and landed for the first time in a semi-eastern city such as Cairo, were likely to behave in such a manner that a small minority would get into trouble. Active steps were taken to meet the difficulties, and to prevent recurrence of the outbreaks when the Second Division and other reinforcements arrived.

General Birdwood accordingly issued the following circular:

"Warning to Soldiers respecting Venereal Disease

"Venereal diseases are very prevalent in Egypt. They are already responsible for a material lessening of the efficiency of the Australasian Imperial Forces, since those who are severely infected are no longer fit to serve. A considerable number of soldiers so infected are now being returned to Australia invalided, and in disgrace. One death from syphilis has already occurred.

"Intercourse with public women is almost certain to be followed by disaster. The soldier is therefore asked to consider the matter from several points of view. In the first place if he is infected he will not be efficient and he may be discharged. But the evil does not cease even with the termination of his military career, for he is liable to infect his future wife and children.

"Soldiers are also urged to abstain from the consumption of any native alcoholic beverage offered to them for sale.

"These beverages are nearly always adulterated, and it is said that the mixture offered for sale is often composed of pure alcohol and other ingredients, including urine, and certainly produces serious consequences to those who consume it. As these drinks are drugged, a very small amount is sufficient to make a man absolutely irresponsible for his actions.

"The General Commanding the Australasian Forces, therefore, asks each soldier to realise that on him rests the reputation of the Australasian Force, and he is urged at all costs and hazards to avoid the risk of contracting venereal disease or disgracing himself by drink."

This leaflet was entrusted to Lieut.-Col. Barrett to deliver to troops on arrival, and he accordingly visited Port Said and Suez, interviewed the officers on the transports, and fully explained the position to them. They were requested to use their influence with the men in the direction of restraint. Subsequently after the destruction of the Konigsberg the transports began to arrive at irregular intervals and it became impossible to meet the officers at the ports. They were then interviewed at Abbassia or Heliopolis, and later still by order of General Spens, G.O.C. Training Depot, the men themselves were addressed on the day of their arrival. The form of address was simple. The dangers of infection were pointed out to them—particularly as regards typhoid fever, dysentery, bilharzia, and venereal disease. They were shown how the first three diseases could be avoided. So far as venereal disease was concerned they were informed that the matter was in their own hands. They were asked to imitate the Japanese, and by their own efforts preserve their health with the same care that they bestowed on their rifles or their ammunition, the preservation of health and arms being equally important. Passages from the famous rescript of the Emperor of Japan before the Russian war were quoted in which it was stated in substance that if the normal proportion of sick existed in the Japanese army defeat was a practical certainty; but that if they followed the direction of their medical officers and took the same care of their bodies as they took of their equipment, the number of troops saved thereby would make all the difference in the ensuing conflict.

General Birdwood asked for the whole-hearted and enthusiastic co-operation of all officers in doing their best to control their men, and to prevent them from exposing themselves to the risk of venereal disease. Some little time before the issue of the circular 3 per cent. of the Force were affected by venereal disease on any one day. Fortunately, as a result of the efforts made, the tendency was to diminution, but the amount of venereal disease was still sufficiently great to give concern and anxiety.

There is no doubt that the action of General Birdwood prevented outbreaks and limited the amount of disease. It is also equally true that in spite of his efforts the amount of disease was too large to be contemplated with equanimity.

The Venereal Diseases Hospital, Abbassia, was nearly always full, but from time to time drafts of men were sent back to Australia. One draft of 450 soldiers was sent to Malta early in the campaign. The principle involved in the policy of returning them to Australia was as follows. In Egypt they were useless as soldiers, whether suffering from gonorrhoea or syphilis. They required a large number of medical men and attendants to take care of them. They knew they had disgraced themselves and were a source of trouble to every one concerned. On shipboard they could not get into trouble. They were more likely to be cured, and could then be returned to Egypt, and if not cured could be treated in Australia at leisure. Against this policy the argument was used that diseases were being introduced into Australia, but as a matter of fact a minority of the men suffering from venereal disease brought it from Australia to Egypt. They arrived at Suez suffering from gonorrhoea contracted in some cases at Fremantle. Furthermore the business of those conducting the campaign was to wage a successful war, and to keep the base as free from encumbrance as possible. The total number returned to Australia in this way was as follows:

From February to September 14, 1,344, and in addition 450 were sent to Malta.

At first they were sent in ships with other cases and sometimes segregated on board, but difficulties arose at the Australian ports. The people who welcomed the returned soldiers were sometimes enthusiastic in greeting venereal cases by mistake, and sometimes non-venereal cases were regarded with suspicion because they came from a ship known to convey venereal patients. It was finally decided by the Australian Government that venereal cases should be conveyed in ships by themselves, the first consignment of 369 being sent in the Port Lincoln.

A certain number of the gonorrhoeal cases recovered and became fit for service, but too often they relapsed.

The authorities were fully alive to the damage which was being done, and persistent and earnest attempts were made to deal with it from many different points of view. General Maxwell issued an order prohibiting the sale of drink after an early hour (10 p.m.) in the evening, and also prohibiting soldiers from being found in Cairo after an early hour. There is no doubt that both of these directions proved to be of considerable value.

Moral Conditions in Cairo

Something must be said, however, about the moral conditions in Cairo, about which exaggerated and perverse notions seem to be entertained. Cairo, like all large cities in the world, possesses its quota of prostitutes, who differ only from prostitutes elsewhere in that the quarters are dirtier and that the women are practically of all nationalities, except English. The quarter in which they live is evil-smelling, and is provided with narrow streets and objectionable places of entertainment. It contains a considerable infusion of Eastern musicians and the like, and is plentifully supplied with pimps of the worst class. These men were promptly dealt with by the police, the authorities giving the most sympathetic assistance to the military.

As in other countries, there were graduations in the class of women employed, and the personal impression gained by the authorities was that the danger of infection was greatest from those at the top and the bottom of the social scale. Prostitutes who were registered were examined by a New Zealand gynecologist, who did the work very thoroughly, and conscientiously, and with kindness. Women who were free from disease were furnished with a ticket indicating that they were healthy. At the beginning of the war there were 800 of these women in Cairo, but as the war progressed the number grew to 1,600. The arrangement then differed in no way from the arrangements in Melbourne or Sydney except that the surveillance of the police was direct, and medical examination was insisted upon. It further had this advantage over those of Melbourne and Sydney, that the women were confined to one particular part of the city, and no one need come in contact with them unless they wanted to. Consequently for those who went to this quarter there is no excuse, since they acted deliberately.

Prophylaxis

At the same time, when all these measures were weighed in the balance—plain speaking to the men on arrival, police surveillance, medical examination, etc.—it was felt that more might be done. A number of medical officers accordingly gave instruction to their men in the means of effecting prophylaxis and of preventing infection in the event of association with these women. The medical officers acted entirely on their own responsibility. They advised the men to avoid the risk, but as they knew a certain number would not take their advice in any circumstances—in fact the men said as much—they showed them how to avoid infection if they would take the necessary trouble.

Result of Prophylaxis

In the case of our own unit, the First Australian General Hospital, trouble was taken to explain in detail the consequences of venereal diseases to the men, and to those with whom they would be associated in later life. They were asked to refrain from taking the risk, but for those who would not take the advice—and there was bound to be a percentage—the necessary directions and material were provided for preventing infection. The result was challenged by a medical officer, and an immediate examination of all the men made, when it was found that in the whole of the unit only one man was infected. In other words, the precautions taken had practically stamped the disease out of the unit, and shortly after arrival in Cairo.

Once the disease was acquired the treatment was troublesome to a degree. The men knew they were disgraced; they would probably be sent back to Australia; and in some cases, those of the finer men, the consequences were serious. Mostly, however, they developed an attitude of sullenness and indifference, a tendency to lack of discipline, and they rendered the management of camps difficult. These troubles to a large extent disappeared when a suitable hospital was established.

Soldiers' Clubs

But another and constructive side of the matter appealed forcibly to those concerned. Why not supply for the benefit of the men places of entertainment with music, refreshments, and the like, similar to and better than those which the prostitutes supplied, but minus the prostitute. In other words, why not give a healthy and reasonable alternative? After consultation with His Excellency Sir Henry MacMahon, with the G.O.C.-in-Chief, General Sir John Maxwell, and with the D.M.S. Egypt, General Ford, the Australian Red Cross Society determined to combine with the Y.M.C.A. and establish clubs for the soldiers in central positions where these requirements would be met. They accordingly established a club at the quay in Alexandria, and a magnificent open-air club in the Esbekieh Gardens, Cairo. They were both immediately successful, and have played a most important part in the further limitation of the amount of venereal disease. It is difficult to give statistical evidence, but there is no doubt that by these various means a sensible difference has been produced in the incidence of disease amongst the troops.

The Duty of the Medical Officer

We have never wavered from the conviction that any one suffering from venereal disease should be treated by a medical practitioner exactly like any other sick person. In military service, however, an added element makes its appearance in that the soldier by his act has rendered himself unfit, and consequently must suffer some pains and penalties. It is no answer to say that other men have exposed themselves and have not become infected. The fact remains that he has by a deliberate and avoidable act deprived his country of the value of his services. And whilst the doctrine of punishment should not be pushed too far, he certainly should not receive the same general treatment as other soldiers, and the policy of his prompt return to Australia and deprivation of pay was in the circumstances the best one.

In the Venereal Diseases Hospital, Abbassia, the men were well treated. They were well fed, and a certain amount of Red Cross help was given to them.

Many proposals were made which were not carried into effect: for example, placing of the prostitute quarter "out of bounds" and the posting of sentries. It was realised that the immediate effect of this action would have been to drive women to the vicinity of the camps, and that it was impracticable. Another practicable proposal was made, which, however, was not carried into effect—the creation of dispensaries in the vicinity of the prostitute quarter, so that immediate treatment could be obtained. In many camps such dispensaries were established by the medical officers.

The essence of the problem was learnt by a Brigadier-General who visited a number of young educated men in one of the camps, and asked them for their viewpoint on the subject. Their answer was that which every medical officer knows full well: that many men were influenced by the appeals which had been made to them, but that a percentage have indulged in this way throughout their adult life, and intend to continue to do so irrespective of anything medical officers, chaplains, or generals may say to them. It is this fundamental position which every reformer must face. So long as a sufficient number of men determine to adopt this policy, and so long as there is a sufficient number of women prepared to cater for them, the problem of venereal disease will continue to be acute in every country.

The opinion has been expressed elsewhere that the world will not be rendered more or less moral by the abolition of venereal disease, and instruction in the mode of preventing infection should be an essential part of education. Because people are immoral there is no reason why they should acquire gonorrhoea or syphilis. If the lex talionis is to be enforced, the logical way to deal with the matter is to refuse treatment to all the infected, and to let them die or become disabled. But the most thorough-going Puritan shrinks from adopting so terrible a policy. One method or the other, however, must be adopted—there can be no half-way house. And if the decision be in favour of eradicating the disease, it is essential to firmly face and grapple with the problem.

Wassermann Tests

The examination of the cases showed that gonorrhoea was far more common than syphilis, and a series of Wassermann determinations showed that the cases of soft sores did not give a syphilitic reaction in the early stages. Captain Watson of the First General Hospital made a number of determinations in order to try to settle this important point.

The Policy to be Adopted

In spite of all that was done, 1,344 men were returned to Australia disabled, and 450 were sent to Malta. If a calculation be made of the cost of sending these men to Egypt and back, and of their pay before they were infected, some idea may be formed of the enormous sum of money the Australian Commonwealth wasted on men who were a drag and hindrance to the army machine.

The Government should, on the raising and equipping of a volunteer army, treat it as older countries treat a standing army by issuing instructions to the men.

When the Hospitals left Australia neither officers nor men received instructions, and not until the arrival of Surgeon-General Williams in Egypt was any serious collective action taken. He at once called a conference of medical officers and did what he could to limit the extent of disease.

The governmental action—or lack of action—is unsound, since the man who contracts disease is severely punished, but adequate attempts are not made to prevent him acquiring it. The notable departure made in the case of Cairo was the effort to make the men understand clearly what these diseases meant to them as soldiers and as citizens; to remove temptation from them as far as possible, and with the aid of the Australian Red Cross to give them a reasonable, healthy, and decent alternative. Nothing the Australian Red Cross has done (or is likely to do) is more important than the establishment of the Soldiers' Clubs. Nothing has been more successful or is likely so to redound to the credit of that great institution. And yet, under the new Constitution of the Australian Red Cross, not a shilling can be devoted in the future to such purposes.

Venereal Diseases Conference

The following are brief notes of a Conference of senior medical officers convened by Surgeon-General Williams.

Reference was made to the gravity of the problem with which the force was faced. It was estimated that about 1,000 men of the First and Second Australian Divisions are suffering from venereal disease on any one day, and of these a large number are incapacitated from work. The proportions seemed to be much greater than those of other forces, such as the Territorials, in Egypt. The displacement of so large a proportion of men and the ultimate consequence of numerous infections, rendered it necessary to take a comprehensive view of the position, and to endeavour to take some action to minimise the damage done. It was proposed to ask each officer present to furnish the secretary with a general statement of the number of cases treated under their command, specifying them under three headings—syphilis, soft chancre, and gonorrhoea. The information so obtained would form the basis of a report to headquarters. The problem was considered under five headings:

1. Military assistance.

2. Use of prophylaxis.

3. Treatment—general and special.

4. Establishment of convalescent depots—accommodation and position.

5. Ultimate destination of affected men.

1. In what way can the military authorities give assistance?—There are three ways in which they can approach the problem:

(a) They may decide that all areas known to contain brothels are out of bounds.

(b) They can provide adequate military control by military police organised under a competent officer, with one or more junior medical officers to assist him.

(c) That punishment can be inflicted on those men who break bounds and expose themselves to the risk of venereal infection. It might be desirable to reduce the pay of men found in those areas whether suffering from venereal disease or not.

2. Prophylaxis.—Officers were invited to discuss the question whether it would not be advisable to establish prophylactic depots in various parts of Cairo. Men to report immediately after exposing themselves to infection, and by cleanliness and the use of medicaments prevent infection. Circulars couched in plain and sensible language might be issued to the troops, conveying to them a knowledge of the risk they run, and the fact that if infected they will take back to Australia a disease which would reduce their value as citizens.

3. General and Special Treatment.—Suggestions from officers present were invited.

4. Convalescent Depots.—Was it right that the hospital should be crowded out with venereal cases, which demanded very much time and attention from the staffs? If the hospital was placed near the scene of military action the wounded might suffer from the amount of attention required for venereal cases. Most venereal cases required rest in the main, and this could be obtained in convalescent depots.

5. The ultimate destination of the affected men.—Two courses are open: The men may be treated in Egypt, or sent back to Australia.

(a) If they are kept in Egypt and the Australian Expeditionary Force is moved to the front its medical services would be depleted, and medical men of great ability and experience would be left behind to take charge of venereal cases when their services were required at the front.

(b) If on the other hand the Australian and Imperial Government could utilise some ships for the accommodation of these men, those who were cured could be sent to the front, and those who could not be cured could be sent back to Australia at once. But such ships would require special staffing so that the existing units should not be depleted in order to provide staffs.

In the discussion which ensued it was represented that there was a difficulty in placing areas out of bounds, as the brothels would be moved to other areas. Prophylaxis was regarded as most important. Isolation tents could be set apart in the regimental lines where men could be treated on return from leave. Cases of syphilis should be sent to Australia.

The reduction of pay is forbidden by King's Regulations, and although the Minister for Defence in the Commonwealth of Australia authorised such reduction, it is only for such period as the troops are in Egypt.

It was agreed that cases of syphilis should be returned to Australia, as there is no chance in Egypt of treating them efficiently, and even if such treatment were available the men would not be fit for duty for from four to six months.

It was pointed out that at least 100 men left Australia with the First Division suffering from venereal disease.

The chief difficulty seemed to be what venereal cases would ultimately be of service to a fighting line, and to properly arrange for them during convalescence; in other words, when and how men considered unfit for further service should be returned to Australia. Officers were asked to recollect that the future of these soldiers was to be considered and the part they would play in civil life. In the American Navy unbounded shore leave had been given, and had some effect in checking the disease. In the British Navy it was an offence not to report "exposure."

The Soldiers' Clubs are fully described in the chapter on the Red Cross. They were rendered possible by an alliance between the Y.M.C.A. and the Australian Branch British Red Cross. To the Y.M.C.A., who managed them, the best thanks of Australia should be given, for Australians will never fully know what they owe to Mr. Jessop and his assistants. Unfortunately, the Australian Branch British Red Cross subsequently decided that help should be given only to sick and wounded. Although convalescents frequent these clubs, the view was taken—we think wrongly—that Red Cross funds could not be used for their support. We feel sure that when Australians fully understand the matter the decision will be reversed.