SUGGESTED REFORMS—DEFECTS WHICH BECAME OBVIOUS IN WAR-TIME—RECOMMENDATIONS TO PROMOTE EFFICIENCY—DANGERS TO BE AVOIDED—CONCLUSION.

CHAPTER X

The experience gained in connection with the establishment and extension of the First Australian General Hospital suggests modifications which should immensely increase efficiency. A base hospital modelled on the R.A.M.C. pattern may work exceedingly well in times of peace, or when staffed by R.A.M.C. or I.M.S. officers who have devoted their whole lives to the work. But base hospitals constructed during a great war, and staffed almost entirely with civilian elements the majority of whom are untrained in administration of any kind, do not work in all cases with the necessary degree of smoothness. It certainly does appear that changes in the base hospital establishment might be introduced with advantage.

In the first place there arises the question whether it is necessary for the Commanding Officer to be a medical practitioner, or whether, as in the case of the convalescent hospitals, he might be a combatant officer, or at all events a non-medical officer. The general consensus of opinion is that he should be a medical officer, though there is a great deal to be said on the other side. Almost the whole of his work is administrative, though he necessarily must have a good knowledge of clinical methods. But unless such an officer be selected not simply with regard to seniority, but with regard to experience in administrative methods, and unless he be tactful and watchful, troubles are very likely to ensue. His task is beset with difficulties if he possesses character and insists on efficiency. Whatever doubt there may be, however, about the Commanding Officer, there need be none about many of the other positions. A noteworthy feature of the First Australian General Hospital was the continual complaint from the medical officers that they had not come away to do administrative work. This distaste for administrative work was a constant source of trouble.

The Registrar, as the principal executive officer of the hospital, whose business it is to carry out the decisions of the Commanding Officer, is at present invariably a medical officer. The greater part of his work does not need medical knowledge, and the difficulty might be obviated by the adoption of one of two methods. Either the Registrar might be an educated business man or he might have such a one as his immediate understudy. In the latter event a very small portion of his day would be taken up with the duties of the Registrar's office.

Similarly the orderly officer, whose business it is to deal with details concerning the rank and file, is usually a medical officer, and in some hospitals it is the practice to change this officer from day to day. At No. 1 General Hospital, however, his functions were so important that one medical officer was permanently told off to do this work. There is no doubt that the orderly officer need not be a medical officer, and might well be an invalided combatant officer, transferred to the army medical service.

Owing to modern developments another officer has made his appearance who is not provided for in any establishment—that is, the transport officer. Motor transport has become so large a portion of the work of the base hospital that a special officer is requisite for the purpose. There is no reason whatever why such an officer should be a medical man.

If these changes were made it would result in releasing at least three officers for clinical purposes.

The amount of clerical work that was necessitated by the returns furnished to the War Office, the Australian Government, Headquarters Egypt, and other departments was so great that a large staff of very competent clerks was required. The future establishment should certainly include not only a number of trained stenographers, but some one versed in statistical work. The lessons to be learned are so numerous and so important that something of the kind should be done. Furthermore, in the Quartermaster's department there was a demand not only for stenographers, but for men who had been accustomed to the methodical ways of a large warehouse.

Were all these changes made there is no doubt that the efficiency of the administration would be increased and the burden of the work lightened.

As regards clinical work other desirable changes might be made. Senior men who have been in full practice, and who come to a base hospital as physicians or surgeons with the rank of lieutenant-colonel, are apt to be entrusted with the detailed administration of medical or surgical wards. They are often unfitted by training for such administration and are frequently disinclined to undertake the work. It would be far better to leave the actual detailed administration of the wards in the hands of a comparatively junior man with the rank of major, and to retain these senior officers as consultants only. Consultants of course possess great powers, since their authority as regards the clinical work itself is absolute. They can do as much or as little as they like, but they are in complete control and are absolutely responsible for the treatment of the cases. Our own feeling is that in such a position they would be far more comfortable and would be more efficient.

On the subject of specialists there is much to be said. It is almost incredible that a base hospital should have been formed without being provided with an ophthalmic and aural specialist. The change has been made since war began, but it seems inconceivable that any one should have contemplated the efficient handling of wounds and diseases without such aid. At the First General Hospital the ophthalmic and aural department was the largest and most heavily worked department in the hospital, partly owing to the fact that one of us had been appointed Consulting Oculist to the Forces in Egypt, and that much of the work consequently centred at Heliopolis.

Similarly the failure of the Australian Government to provide dentists in the first instance is difficult to understand. The day has gone by when it is possible to exclude from the force a man who possesses dentures or defective teeth, and it is practically impossible to complete the work for the recruits before they leave. So it became necessary at No. 1 General Hospital to borrow two dentists from the New Zealand Government, to fit them out with Red Cross money and goods, and in this way to meet informally the difficulty. Subsequently the Australian Government appointed a corps of dentists, and the problem was to some extent solved, though even now the demand far exceeds the supply. There is no doubt that dentists are wanted not only at the base hospitals, but also near the firing line, as the dispatch of a man from the firing line to the base hospital to obtain dental treatment represents a waste of time and money.

It is further desirable to attach one or more anÆsthetists to every hospital.

It must, however, be said that the constant changes of staff which took place at No. 1 Hospital owing to the various exigencies of the military situation rendered it extremely difficult to keep a physician or surgeon in any fixed position for any length of time. Consequently a certain amount of pliability and adaptability was absolutely necessary. At the same time, if the organisation were sketched in the manner indicated, the problem would have been more simple, and good results easier to obtain.

There is no doubt that one medical officer (who could be attached to the Pathological Laboratory in addition to the Clinical Pathologist) should devote himself entirely to sanitary work. This duty is not taken too seriously, and should be emphasised. It would really be better to rename this officer the "Prophylactic Officer," unless a better term can be found, and it should be his aim and duty, not simply to enforce cleanliness, but to actively exert himself to ward off disease.

Stress may be laid on the usefulness of a sensible chaplain, whose value depends on his own interpretation of his duties. The chaplain (Colonel Kendrew) at No. 1 General Hospital not only attended to the religious needs of men, but earned their affection and respect by managing the extensive post office and library, the canteen, and by helping with Red Cross work. It is just these badly defined functions in a base hospital which a chaplain can discharge so well.

We think also that women might be used in base hospitals as stenographers, ward maids, telephone operators, and the like. Base hospitals in the future are not likely to be housed in tents, and under rough conditions. At present, trained nurses are sent to the Stationary Hospitals. It seems a pity to waste fine young men, who could be combatants, as orderlies in a base hospital.

Masseurs are certainly badly wanted in a base hospital, and it is difficult to understand the objection to their incorporation. The difficulty was removed in Egypt by employing Egyptians.

Electricians, i.e. orderlies who in civil life are electricians, are required in every base hospital, and at Heliopolis they were invaluable for general purposes, and as aids to the radiographer. They should, however, form part of the establishment, and should number two or three.

Is it not clear that chefs, laundrymen, skilled carpenters, and other tradesmen are also required?

The table which follows represents the establishment of the ordinary 520-bed hospital, R.A.M.C. It has been adopted by Australia, but the Australian establishment allows for 93 nurses instead of 43. If the foregoing suggestions are adopted, as we think they should be, this table would require material alteration.

With reference to the duties of N.C.O.s and men, nothing gave more trouble than the fact that men recruited in Australia were made N.C.O.s before their special qualifications were known. There is no officer in the Army whose position is so thoroughly safeguarded as the N.C.O., and nothing but the adverse decision of a court martial can effect his removal. Yet an unsuitable and even dangerous man, from the point of view of the sick, may do nothing to warrant a court martial (which no one enjoys). These appointments should be made therefore with great care. Such considerations, of course, lead to but one conclusion, viz. the necessity for sketching out these hospitals in time of peace. Scratch enlistments are too dangerous.

The "grouser" is always with us, and sometimes gives trouble. The particular Australian "grouse" was that the Australian hospitals should have been nearer the front than Cairo, and at last No. 3 Australian General Hospital was placed at Mudros.

Now we have always understood that a large base hospital cannot be placed far from a great city. A city grows in a particular place for natural reasons—water supply, lighting, transit, etc. The hospital gets the benefit of all these agencies, whereas it was necessary at Lemnos to create them. The result was somewhat disastrous as regards supplies, and might have been foreseen.

"Grousers" should stay at home, and exercise their privileges there.

The difficulties of obtaining supplies by requisition were easily surmounted at Heliopolis because of the broad policy adopted by the Officer Commanding the Australian Intermediate Base, Colonel Sellheim, C.B.

Ordnance cannot supply the varied requirements of a group of expert medical officers during a great war, and delays cause untold annoyance to active men. On the other hand, it would never do to give the staff a free hand to purchase when and how it pleased.

The institution of "local purchase orders" met the difficulty. The O.C. of the hospital sent in a requisition for something which could not be obtained from Ordnance, marking it "urgently required." The A.D.M.S. endorsed it, or, if it were an entirely new line, asked the D.M.S. to endorse it. The Ordnance officer then issued a local purchase order to the medical officer, who made the purchase. The method combined a measure of control with reasonable speed in execution.

We have no sympathy with the usual references to military red-tape. If the administration is competent, the military system is thoroughly sound from the business point of view, and from the standpoint of record difficult to improve on. It may be at times a little cumbersome, but it is much easier to fall in with it than to attempt to effect alteration during war. We never had any real difficulty with requisitions, although supplies were sometimes withheld from us on grounds of policy not disclosed at the moment.

There is no doubt that the erratic changes of staff were injurious. Some medical officers preferred the front, others the base, and an attempt was made to effect an orderly system of periodical exchange. Orders, however, were continually arriving to send so many medical officers, so many nurses, and so many orderlies, here and there, with the result that at the end of ten months the original medical staff had disappeared, many of the nurses were new, and so were most of the orderlies. Whenever there was a shortage of staff near the front, the base hospitals were depleted. These changes were inevitable in the circumstances, but they emphasised the value of the advice given by Colonel Manifold, that there cannot be too many unattached junior medical officers in a campaign.

The following report from Major Brown, Officer Commanding Luna Park No. 1 Auxiliary Hospital, shows what he experienced owing to these oscillations:

April 30	Opened with 296
	patients
May 2	790 patients	Staff: 4 sisters, 4 orderlies,
		and myself. With
		Captains Bentley, McDonald,
		and White
		from Light Horse
		Regiments.
May 6		Sisters increased to 13.
May 14	1,171 patients	13 sisters, 4 medicos, and
		40 orderlies (mostly
		untrained).
May 18	1,244 patients
June 7	1,099 patients	41 sisters (new).
	(also 65 Casino)
June 9	1,370 patients	"""
	(also 65 Casino)
June 11	1,620 patients	"""
	(also 65 Casino)
June 16	1,520 patients	Still 4 medical officers,
		Capt. Brown, Capt.
		Single, Capt. Lovegrove,
		and Capt. Craig.
June 17		Medical officers now increased;
		sisters also
		increased.

Palace of Prince Ibrahim Khalim (Nurses' Home).
To face page 198

With reference to orderlies, the work from May 3 has been done with 10 A.M.C. men and 30 men drawn from the patients.

On June 17, 40 reinforcement A.M.C. men were detailed for duty. Up to June 16 over 1,600 patients have been discharged. On May 23 the Operating Theatre was opened.

For the 1,600 patients we had six cooks with six natives to assist.

T. F. BROWN, Captain,
Officer in Charge, Luna Park.

Heliopolis,
June 17, 1915.

Of the 93 nurses belonging to the hospital, within a week of landing no fewer than 47 were taken away and dispatched to various parts of Egypt, viz.:

No. 1 Australian General Hospital was much inspected by keen and curious, as well as sympathetic, eyes. His Highness the Sultan, Their Excellencies Sir Henry and Lady MacMahon, the General Officer Commanding-in-Chief, Egypt, the General Officer Commanding Australian and New Zealand Army Corps, and many other distinguished people honoured the hospital by an inspection.

The following letters were written by three distinguished visitors. Two Corps Orders are also attached.

"Shepheard's Hotel, Cairo,
"May 20, 1915.

"Dear Colonel Ramsay Smith,

"Allow me to congratulate you upon the admirable medical arrangements at Heliopolis, and upon the excellent hospital you have established there. One is at first disposed to say, 'How well the building adapts itself to a hospital!' until the true fact becomes revealed of the genius displayed in converting a decidedly refractory building into a place for the sick. You and your staff have done wonders and have once more shown that in the land of Egypt 'it is possible to make bricks without straw.'

"Australia may well be proud of the part she has played in this war, and I can pay no higher compliment than by saying that the medical arrangements of the Australian Army are as splendid as are the fighting qualities of its men.

"Above all I was impressed with the energy and enthusiasm with which the work at Heliopolis is being carried on, with the ingenuity and resource displayed at every turn, and with the thoroughness that was manifest in every department of the vast hospital.

"The generosity with which Australia has provided motor ambulances for the whole country and Red Cross stores for every one, British or French, who has been in want of same is beyond all words.

"I only hope that the people of Australia will come to know of the splendid manner in which their wounded have been cared for, and of the noble and generous work which the great colony has done under the banner of the Red Cross.

"Yours sincerely,
"(Signed) Frederick Treves."

"St. Mark's Buildings, Alexandria,
"June 5, 1915.

"Dear Major Barrett,

"I have been away at the front or I should have written to you sooner to thank you for the interesting visit which you enabled Sir Frederick Treves and myself to pay to your hospital and stores. I enclose an extract of a report which I made on May 25 to the Hon. Arthur Stanley, Chairman of the British Red Cross Society and Order of St. John in London.

"You may have noticed a minute published in the press with the approval of the G.O.C., Sir John Maxwell, in which it was laid down that all Red Cross work, except the Australian Red Cross work, should be under the control of the British Red Cross and Order of St. John. I hope you will not think that in drafting this minute in this way I wished to convey that we were not working in perfect harmony with your Red Cross, but I feel that we could hardly suggest to you that you should be in any way under our control. At the same time, I hope that when you either come here, or when I come back to Cairo, that we may have an opportunity of conferring together so that we may so co-ordinate as far as possible our mutual work.

"May I add that I went to the Dardanelles in a transport with over a thousand of your brave soldiers, many of whom were returning to the Peninsula after having already been wounded. It is impossible to speak too highly of their gallantry, and of the splendid spirit they displayed. I need not tell you that I heard of their fighting qualities at the front, since their heroic deeds in this campaign have already become a matter of history.

"Yours sincerely,
"(Signed) Courtauld Thomson,
"Chief Commissioner for British Red
Cross and Order of St. John, Malta,
Egypt, and Near East Commission."

[Copy]

Extract from a Report from Lieut.-Colonel Sir Courtauld Thomson, Chief Commissioner of the British Red Cross and Order of St. John, to the Hon. Arthur Stanley, dated May 25, 1915.

"A striking feature in Cairo is the remarkable work which is being done by the Australian Red Cross. They have not only two exceptionally large hospitals and the large convalescent home, but they supply the motor transport for the wounded for the whole of Egypt. They have also very large Red Cross stores which they have brought with them. With these articles they have been more than generous, and I am informed that they have given away to the hospitals for our own troops something like 75 per cent. of whatever they had."

Extract from Corps Orders, March 28, 1915

"Appreciation.—The D.M.S. Egypt, who visited the Hospital yesterday afternoon, has requested the Officer Commanding to convey to the officers, nurses, N.C.O.s, and men in the Hospital his appreciation of the work done and the thorough character of the organisation."

Extract from Corps Orders, May 1, 1915

"Appreciation.—The D.M.S. Egypt, Surgeon-General Ford, witnessed the detraining of the invalids who arrived here Wednesday evening. He asked Major Barrett to convey to the Officer Commanding his great appreciation of the excellence of the arrangements and the efficient and quiet manner in which the work was done.

"He congratulates officers and men on the splendid work they are doing and requests that it shall be communicated to them in Corps Orders."

Looking back, does it not seem essential that these hospitals should have been formed, at all events in outline, in time of peace? That their commanding officers and essential staff should have been marked out beforehand, so that on the declaration of war the gaps could have been filled in from the reserve without difficulty? Satisfactory appointments are much less likely to be made in the turmoil which follows the declaration of war than in the atmosphere of deliberate calm which prevails in time of peace. Had such an arrangement prevailed, the First Australian General Hospital would certainly never have been recruited from three States distant from one another hundreds of miles.

Finally, Australian hospitals in time of war should either be regarded as responsible solely to the Australian military authorities and Government, or handed over without reserve to the R.A.M.C., and placed entirely under the control of the British authorities. Where two different authorities exist, as in the case of the First General Hospital, a large amount of trouble and delay is almost certain to ensue. The adoption of the latter course is in our judgment absolutely essential if efficiency is to be secured.

As is invariably the case, weaknesses in any system are only revealed by costly experience. But while in the Australian Medical Service the experience need not have been so costly, we can at least profit by what has occurred, and frame a stronger and a better policy for the future.

On the whole, the record of work done in most trying circumstances is, we think, satisfactory. It is true that the universal democratic fault was evidenced in the lack of preparation for conditions which were fairly obvious. Nevertheless the adaptability and growth of the hospitals in time of great emergency were achievements of the highest order.

Yet it would be unwise to leave the subject with the usual Anglo-Saxon expression of satisfaction that the crisis was passed. The history reviewed has too deep a significance. It must be regarded not merely as an individual incident, but as an indication of the inefficiency evidenced by too many departments of the Empire.

The causes which found the medical services unprepared, which forced them to expand to the breaking-point, and which led to the criticism of the hospital authorities, are not departmental or sectional—they are national. If attacks on individuals are permitted, initiative will be stifled; if on the other hand we are content to follow the time-worn policy of "muddling through," the virile people who skirt the border lines of our Empire will sooner or later bid us make way for stronger men.

Our policy for the future must be one of scientific organisation and calculated preparation in every department. We must not only appoint capable administrators, but also trust them. We can again, if we like, obtain that temporary mental tranquillity which comes to a democracy—and to an ostrich—which does not or will not see the calamity which threatens it, but temporary beatitude will be purchased at the price of an Empire. Never was it more certainly true that the price of liberty is eternal vigilance.