The Australian Army Medical Corps in Egypt Part 10

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 a.s.sociated 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 dispa.s.sionately, the remarkable feature of the work at Heliopolis and in Cairo was the low mortality, as the following table will show:

BURIALS IN OLD CEMETERY, CAIRO

_From Arrival of Australians in Egypt, December 5, 1914, to August 14, 1915_

British Imperial Force 77 Australian Imperial Force 155 New Zealand Force 50

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 quant.i.ty 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 pa.s.s three miles from Australian sh.o.r.es they cease, at all events technically, to be under Australian control, and pa.s.s under the control of the Commander-in-Chief. On arrival in Egypt they pa.s.sed under the control of General Sir John Maxwell, G.O.C.-in-Chief, Egypt. The medical section pa.s.sed 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 a.s.sist 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. Ma.s.son & Co., asked me to write the article "Cholera"

for the French standard textbook on pathology. My opinion was therefore quite unprejudiced by the present circ.u.mstances.

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 a.n.a.logy, 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 establis.h.i.+ng 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 a.s.sistants at the Pasteur Inst.i.tute, 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 ot.i.tis 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.

ADMISSIONS AND DEATHS INTO NO. 1 AUSTRALIAN GENERAL HOSPITAL _From February to July inclusive_

---------+-----------+-------------+----------------------------------- Admissions. Deaths. Cause of Death.

---------+-----------+-------------+----------------------------------- February 1,360 1 Malignant purpura March 1,791 12 6 Pneumonic group 3 Measles, etc.

1 Meningitis 1 Abscess, liver 1 Tumour, brain April 1,343 12 2 Pneumonic group 7 Measles, etc.

1 Meningitis 1 Septicaemia 1 Injury May 2,650 35 27 Wounds (1 teta.n.u.s) 1 Meningitis 1 Poliomyelitis 1 Cardiac 1 Pancreat.i.tis 1 Appendicitis 3 Pneumonic group June 2,862 20 11 Wounds 1 Perinepritis 1 Nephritis, chronic 1 Septicaemia 1 Broncho-pneumonia endocarditis 1 Pneumonia 1 Meningitis 2 Enteric 1 Dysentery July 2,099 19 6 Wounds 1 Fracture, tibia 1 Enteric 6 Dysentery 1 Diphtheria 3 Meningitis 1 Enteritis ---------+-----------+-------------+-----------------------------------

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.

AUSTRALIAN IMPERIAL FORCE