 Section 11 of With the Royal Army Medical Corps in Egypt by Sergeant Major R.A.M.C. This LibriVox recording is in the public domain. Chapter 10. Camp Sanitation and Conservancy, Disinfection and Destruction of Insect Pests So, in theory, the work of the Army Medical Service falls naturally into certain clearly separated divisions and subdivisions. In the hard, practical, hand-to-mouth life of active service, these demarcations tend to disappear. There are times when we must all be ready for a long day's stretch of work on a shell-swept field, or a night of dressing and bandaging, or a spell of water duty, or even, as befell the writer more than once, a turn with spade and pick-hacks when it became necessary to throw up cover for a dressing-station or bear a post to expose to the enemy's fire. But there is one duty uniformly present to the R.A.M.C. man, officer, and other rank, or OR, alike, no matter where in his speciality lies. We are all, or ought to be, trained sanitarians, from the Surgeon General in his watchtower on the Medical Mountaintop down to the humblest General Duty Orderly, or G.D.O., scrubbing lockers in a hospital backyard. It has been said, rather un-euphemistically, that an army marches on its belly. It would be much truer, in modern warfare at least, to say that an army's pace and progress are those of its fit, healthy man, and on the number of these depends the military effectiveness of its advance, indeed, whether it ever gets there at all. Man and particularly the fighting man cannot live by bread alone, and without any desire to minimise the importance of a good commissariat service, the Egyptian branch of which, at the time of writing, is sending daily many hundreds of tons of foodstuffs right across Sinai Peninsula. The medical service may truthfully claim to have done almost as much for the British soldier with its liquor Cressoles, its TAB, and all the rest of its preventative paraphernalia against disease and unfitness. In the expeditions sent across the Sinai Desert against the Turks in 1916-17, the territorial and climatic conditions affecting camp life and the march were so novel as to render almost the previous hard-won experience of our ambulance and sanitary sections. All preconceived ideas had to be adapted to the new and strange environment. This was especially true in the vital matter of the supervision of camps, whether on the frontal lines, the lines of communication, or at the bases. The popular and picturesque idea of camp life on the march, a little township of white canvas filling a dale, or covering a hillside under a starry night, with here and there the red glint of fires round which the tired soldiers sit, preparing their food, or smoking and telling yarns of past battles, until the last post sounds, and all retire to the warrior's traditional dreamless sleep, all this, if it ever existed, has long passed into the limbo of discarded things. Military camps nowadays are sternly utilitarian affairs, and especially so in a country like the Sinai Peninsula, where we were constantly marching into districts but newly vacated by an enemy of inconceivably filthy habits, and when our lines of communication were forever lengthening and growing more populace, and our base at Cantara becoming more and more congested with every kind of and everything connected with, fighting man or burden-carrying beast. Compared to the base at Cantara, especially in the early part of 1916, our sanitary sections were faced by what were perhaps the heaviest and most difficult duties encountered in the whole of this campaign. Fast numbers of troops and animals were continually arriving from the west, and after a more or less prolonged stay departing eastward, their camping sites being occupied almost immediately by newcomers who, in their turn, passed on. The British military system, which attaches all units to a division and moves each division on block, provides no permanent stationary camp staff by which continuity in sanitary supervision of these much-used sites could be ensured. The result was that departing sanitary units were often hard put to it in the work of cleaning up for their successors, and, in some early instances, a hasty and unexpected order to move out would render such work impossible. In these cases, the incoming sanitary section might find itself face-to-face with certain initial difficulties, not legitimately its own. Cantara, in fact, constituted a fine training ground in readiness and resource for the enthusiastic student of Camp Hygiene. It was here that many problems were worked out, the solution of which had important bearing on the future. The close congregation of so many human beings, British soldier and Egyptian laborer, and such fast numbers of horses, mules and camels, necessitated immediate recognition of the bedrock principles of sanitation involved, and the taking of prompt action thereon, or a sharp lesson or sure to follow. Under tropical or semi-tropical conditions, military hygiene is a matter of hours and days, not of weeks and months, as in more temperate regions. The main duties of our R.A.M.C. sanitary sections, whether at Cantara or with the desert column, were much the same. They fell roughly under four heads, one, supervision of water supply and the treatment of food, two, disposal of excreta and camp refuse, three, prevention and destruction of insect pests, and four, war against disease generally by the various methods of disinfection. The provision of water to the Sinai Desert Force, as has been previously explained, was affected by installing large filtering works on the western side of the Suez Canal. The water in the shipway is of course seawater, and therefore undrinkable, except at prohibitive cost in distilling machinery, but, providentially, there exists, hard by, a supply of fresh water, namely the sweet water canal, which is as unlimited in quantity as the Nile itself, for it is in direct connection with that river. The filtering works drew water from this source, and, after filtration and other treatment, passed it in a purified condition under the Suez Canal bed into large reservoirs on the other side, whence powerful pumping machinery drove it through the pipeline across the desert. The purification of this water was no easy task. Our bacteriologists discovered it not only to contain an abundance of diseased germs, but to be infested with a particular kind of parasite worm, which was the cause of a tropical disease, Bellhaziosus, for which there is no acetane cure. This water, therefore, had to be subjected to a special sterilizing process, treatment with acid-sodium sulfate, in addition to the usual filtration methods, a task of enormous magnitude owing to the vast quantities of water needed daily by the troops. But even when we had succeeded in purifying the water and got it delivered to the end of the pipeline, wherever that happened to have reached, the work of the water-duty men could be said to be little more than well begun. The water had to be conveyed to the advanced camps of the desert column, in most cases several miles out over the trackless sand. The only possible method of achieving this was by camel transport. The water was transferred to light oblong tanks, Phantasus or Phanatus, of which each camel carried a pair, and it had to be safeguarded against contamination at every stage. At nearly all times in the advance the rail was many miles ahead of the pipe. The water was siphoned into tank trucks and again transferred to the camel Phanatus at the railhead. Arrived at the camps it had once more to be handled. Some of the Phanatus would go to the British and some to the native quarters, for use either by the cookhouses or to fill the water-bottles of the men. The siphon pipes and utensils came into contact with the water, and all were liable to contamination. Upon the RAMC fell the responsibility of devising methods by which the risk to the purity of the water should be everywhere reduced to a minimum by careful supervision of all that it contained and all who touched it. The system of dealing with the Phanatus was an early object of reform. We found that these were issued indiscriminately to British and native alike. We caused this practice to be abandoned, and had a number of the Phanatus marked with a black N, these only being used for the native camps. Great care was also enjoyed in keeping the screw nozzles of all Phanatus in place, except at the moment of drawing water, and especially when the vessels were empty, to ensure that no infective material gained access to them. At the base and on the lines of communication, the water was usually delivered to store tanks, of which each camp would possess one or more. The hose pipes employed to fill these tanks were liable to contamination by being carelessly thrown down upon the sand when out of use. Our inspectors had to be perpetually on the watch to veto this objectionable practice. The water bottles of the troops needed frequent inspection to ensure their cleanliness. Systematic sterilization of these bottles was carried out at regular intervals. At the time of our advance, a likely contingency to arise would be that the mobile column would have out-distanced its regular water service, and would be forced to draw upon any local wells that might exist in the neighbourhood of the camping ground. Where time and circumstances permitted, these wells were always treated by chlorination or other means by our sanitary sections before the troops were allowed to approach them. Of course, during actual fighting, extending over several days, when the tide of battle ebbed and flowed over a wide area of country, it was often impossible in practice for our water-duty men to accomplish much in this way. The local sources of water were also frequently nothing but a few scattered irregular pools, the purification of which was clearly impracticable by any ready means. And yet no other supply was available. To meet this contingency, the system of water sterilization within the drinking bottle itself was inaugurated, each man carrying with him the necessary chemicals in tablet form. This, as an emergency measure, was found to work very well under desert conditions. The difficulty, however, was to get thirst tormented men to wait the requisite half hour after having added the tablets to the contents of their bottles. Thirst on the desert must be classed among the things indescribable. To suffer it unavoidably is bad enough, but to suffer it with the means for its instant alleviation ready to hand, is like remaining in a burning house with a fire escape at the window. It looks and feels too much like deliberate suicide. One of the most anxious of all are AMC duties in connection with camp life during this time, especially at Cantara and at the large semi-permanent camps along the lines of communication of the desert column, consisted in the safeguarding of food supplies from contamination. The tinned and boxed stuff could be left to take care of itself, but soft, perishable stuff like fresh meat, bacon and bread, of which enormous quantities were daily handled in the Army Service Corps or ASC dumps and camp commissariat departments needed constant overseership. The ASC depots were everywhere like country fares, crowded with men and beasts of burden, and it was no easy task to keep sanitary order in and about them. The hordes of Egyptian labourers, camelmen, etc., by which all food supplies were repeatedly handled before they reached the camp cookhouses and stores, were also an obvious source of contamination. All that could be done was to insist, as far as practicable, on personal cleanliness among those handling food material, to ensure that all unprotected goods at the ASC dumps were stored in proper shelters, clear of the ground, and to press for the adoption of a system of washing fresh meat in a weak solution of salt or vinegar on its receipt by the camp cooks. We did a great deal also in causing the provision of fly-proof ladders, grocery storehouses and sheds for the preparation of food, at all but the most mobile camps, and in reforming cookhouse arrangements generally. On the desert the work of the Army cooks is beset with difficulties. Such, however, was done to mitigate insanitary conditions, chiefly in the direction of providing shelter from the sun and driving sand. It was found that canvas screens on light wooden supports, which were portable and easily erected, went far towards disposing of the sand nuisance. But from the unpleasantness of having to eat gritty food, the access of sand to the cooking utensils and preparing benches constituted a real danger. The sand about a camp, unless the utmost care is taken, rapidly acquires a highly infective character, particularly where draft animals are bound. This brings us to a branch of RMC activity in the field, which has necessarily received the closest attention from the medical authorities of the Egyptian expeditionary force. A peculiarity of a camp on the loose fine sand of the desert, where high winds are a common feature, is that the soil of any part of the camp area may, by agency of the wind, transfer itself to any other part. Particles of sand that at one moment lay among the camel lines or round the latrines may, a minute or two later, be mixing with the soldier's food. It is, of course, impossible to prevent this perilous interchange of atoms. All that can be done is to render the drifting sand as harmless as may be, by rigorous observance of all camp sanitation and conservancy laws. And with this problem of the sand is indissolubly connected that of the spread of infection by flies, the preventative measures involved to deal with the one evil being largely applicable to the other. The main principle on which our sanitary sections worked in the Sinai area was to dispose of all excreta of man or beast and all camp refuse with such promptitude and thoroughness that neither flies nor sand could get much chance with them. No doubt in the large semi-permanent camps with which the whole line of route across the Sinai Peninsula abounded, the multiple-seated box latrine over a deep pit was the only practicable contrivance. If the woodwork was of the right pattern, properly put together and fitted accurately over the pit so as to exclude flies, we found that it answered its purpose fully. This defect lay in the fact that the hot eastern sun caused the wood to warp and shrink and thus soon provided numberless means of entry and exit for flies, the latrine becoming a breeding place for these. This difficulty was overcome by regular spraying of the pits with an antiseptic, such as Lefroy's Fluid, which served to keep the flies at a respectful distance. The unportability of these box latrines, however, rendered their use prohibitive by a column on the march. For the mobile camps, the single wet bucket system was almost universally adopted. Here the latrine unit consisted of a bucket or drum surmounted by an accurately fitting but easily removable wooden top. This top was simply a ring seat with a hinged cover, so contrived that it would remain open only when in use. Each bucket contained a solution of creosol to about a third of its depth and, when full, was removed and replaced by an empty bucket by the native latrine duty man. The disposal of urine, so formidable a task with a large force operating in ordinary country, proved a comparatively simple problem in the absorptive soil of the desert. We found all that was necessary was to dig a fairly deep pit and fill it with drainage material such as stones or pieces of rock in which a number of light sheet iron tubes or trumpets could be partially embedded. A thick layer of sand, well beaten down round the bases of the tubes, completed the contrivance. A precautionary spraying of the surrounding soil with an antiseptic was regularly carried out. The device proved to be entirely fly-proof and on striking camp nothing more was needed than to pull up the trumpets and fill in the holes with sand. The trumpets being graduated in shape fitted one into the other and were thus readily portable. They were also cheap, simple and easily made. Wastewater from cookhouses and ablution places was dealt with by soaking pits constructed on similar lines, but in place of upstanding tubes partially sunk petrol or other tins with colander bottoms were fitted. The trapped contents of these tins were periodically removed and consigned to the incinerator. There are only two methods known to army sanitary science for the disposal of the solid or semi-solid excreta, human or animal, and the general refuse of a camp, that of deep burying or of burning. Though it involved much labour and time and was theoretically unsatisfactory in so light and shifting a soil as that of the desert, was at times unavoidably resorted to during our advance over Sinai. Wherever practicable, however, the system of destruction by fire was adopted. Large destructors of the well-tried and approved closed pattern were installed and the conservancy needs of the settlement thus adequately met. Camp conservancy on a large scale presents many difficulties as the experience of our sanitary sections at Cantara amply illustrates. Here one of the great problems was the disposal of horse and other manure created by the large number of animals in the vicinity. Under this head it may be interesting to mention the experiences of one particular section. This unit, on its arrival in Cantara, found itself face to face with the necessity of destroying daily 140 cubic yards of horse manure. A very efficient method of dealing with this material on the desert is to open it out on a wide area, when a day's sunshine will not only dry it sufficiently to render it easily combustible, but will destroy all fly larvae and eggs. The manure is then raked up into long mounds, fore and aft to the prevailing wind and burned. This method, however, could not be adopted at Cantara, owing to lack of space. There was nothing for it, therefore, but to construct special incinerators. With no other material than a number of old sheets of corrugated iron, some iron bars and stanchions, and a quantity of sandbags, our men with their own hands succeeded in building a destructor, which proved itself equal to the task of first drying and then consuming 40 cubic yards of manure a day. This contrivance so impressed the local commander of the Royal Engineers, or CRE, that he immediately placed at the disposal of our sanitary men sufficient stone, cement, iron, etc., together with a force of native workmen for the production of other incinerators. Within a month we had a complete incinerating station going, with four destructors at full blast and were able to cope with the situation. Taking the experiences and achievements of this particular section as a type of all others, it may be useful to give one or two more incidents in its career, as illustrating the extent and variety of duty which an R.A.M.C. sanitary unit may be called upon to perform. When an animal dies on the desert, its native owner just leaves the disposal of its carcass to the sun, the wind, and the crows. The method is not without a certain effectiveness, as the number of bleached and innocuous skeletons one meets during a dyes ride along any desert caravan route amply testifies. But the system does not do for the British army on active service, nor did a substitute for it at Cantara, that of indiscriminate burial of deceased animals in any odd corner of the camp area commends itself to our sanitary men. On coming into power in the district, the OC of the section promptly obtained an interdict against the practice, and had a special, very secluded site marked out as an animal cemetery, to which all dead animals in the division had to be brought and properly interred under the direction of an R.A.M.C. inspector. The same sanitary unit of the R.A.M.C. did good work of a like kind during the Battle of Romany, to which area it had by then moved up. This battle was fought in extremely hot weather. In the engagement a great number of horses, mules and camels were killed, and their carcasses littered the ground in situations where, if not immediately dealt with, they could not have failed to constitute a danger to the health of the troops. While, therefore, our field ambulances were caring for the human killed and wounded, our sanitary squads were ceaselessly busy in this other direction. The work of seeking out these dead animals and putting them underground out of harm's way seems to have been a gargantuan task, taxing to the utmost the strength and endurance of our men. It was carried on literally day and night, and often under heavy shell fire. The difficulty of the work was greatly accentuated by the fact that no native assistance whatever could be obtained, as all the personnel of the Egyptian labour corps had been ordered out of the zone of action. Another incident of this engagement, with which our men had to cope, was the destruction by enemy shell fire of a great many of our latrine appliances. Pending the arrival of new supplies from the base, all sorts of expedient measures had to be installed for the maintenance of sanitary order. At this time too, Turkish prisoners were coming in in huge crowds. Every one of these had to be regarded as the potential source of a cholera epidemic and treated accordingly. All their excreta was systematically dosed with strong antiseptics, then deeply buried with quick lime. At a later period, the men of the division to which our typical sanitary section belonged were attacked by scabies. One of the essentials in the treatment of this disorder consists of bodily immersion in a parasitic-eyed fluid. But how were hundreds of men to be bathed in the open desert? The section had its big, thresh-steamed disinfectors on the spot and could deal with the men's clothing and blankets, but to sterilise the clothing and omit the antiseptic bath would have been mere waste of time. The difficulty was got over by sinking a large hole in the sand, rewetting it four square with sandbags, and then lining it with a big tarpaulin sheet. By these simple means, an excellent dipping-pull, capable of holding 20 men together, was created, and thereby large numbers were relieved of one of the most maddeningly irritating complaints that human flesh is heir to. Scabies is actually no more than a name given to the condition produced by a minute parasite. A carous scabii, the female of which burrows into the skin and there deposits her eggs, thus providing relays of torment for her unfortunate soldier-host. The weighty and widely disseminated influence of insects on the efficiency of troops on active service, especially in a hot country, was early recognised by the medical authorities of the Egyptian Expeditionary Force. The term insect is used here not according to its strict entomological definition of a creature with six legs, but is applied to any creeping, leaping or flying atom capable of doing or conveying harm to man. Most insects, probably all but two or three kinds, come under this category in one way or another, and it is therefore general sound policy in military sanitary science to affect their destruction when and wherever possible. Leaving out of account the butterflies, to whom, apart from aesthetic considerations, neither use nor abuse, has yet been attributed, the honeybee would seem to be almost the only known insect above suspicion in this regard. It may be urged that the honeybee has a sting and is prone to use it on humanity with or without provocation. But leading Apiarians are agreed that the poison in a bee sting has no ultimately harmful effect on humankind. While it has been almost certainly established that, subcutaneously applied, the complicated blend of acid, alkali and alkaloid forming bee sting poison is of direct therapeutic value in most rheumatic affections. That it acts as a preventative of rheumatism, the writer is in possession of what may be regarded as nearly overwhelming evidence. Of the many varieties of insects preying upon our troops in and about Egypt, the anaphyline gnats or mosquitos, as being the conveyers of malaria, received our first attention. There is only one way to prevent malaria, and that is to remove its cause. The infection-carrying mosquito. And there is but one effective means of getting at the mosquito, to attack it at that stage of its life, which is passed as an aquatic larva. In the East, practically wherever there are standing pools or marshy waterlogged ground, there the anaphyline gnat and its first cousin, the kulex gnat, which is the presiding evil genius over the propagation of dengue fever, would be found actively breeding. In such waters the larvae may be seen swarming in countless thousands. In all districts where such breeding areas existed, we instigated a systematic campaign against the evil. What was done at Kantara may be taken as typical of the work carried on elsewhere. Kantara, it seems, has always had a bad reputation for malaria, owing to the existence of much low-lying swampy ground to the westward of the canal. Very early in our occupation of the district as a military base for the Sinai expedition, mosquitoes became a pest there, and cases of malaria occurred in rapidly augmented numbers. Thereupon the local sanitary section set to work to abate the nuisance. The adjacent country was systematically explored, and innumerable ponds and stagnant patches of water were either filled in or drained. Where, however, this permanent removal of the mosquito's breeding resorts proved impracticable, the well-tried system of petroleum spraying was adopted with excellent effect. But by far the most efficient means for the extermination of the gnat larvae adopted by the Kantara section was that of encouraging the breeding of love-ivorous fish in the unfillable pools and swamps that still abounded in the neighbourhood. It was found that the small fry throve amazingly wherever they were introduced, and a corresponding diminution of the mosquito nuisance took place. By the close of the year, 1916, it had become a rare thing to see a mosquito at all in Kantara, and the cases of malaria had been reduced almost to zero. There is little doubt that, by this prompt action, our sanitary men preserved from sickness many hundreds of soldiers whose services would otherwise have been lost to the country. An inveterate and ceaseless war against flies may be said to have come next in importance in the RAMC Insecticidal Propaganda in Egypt. Of flies there were species innumerable of every size and colour and degree of offence, but for our purpose they could be all put in one category, in that they were all either proved or suspected carriers of disease germs. The campaign against flies naturally divided itself into two distinct issues, measures of prevention or at least mitigation of the plague, and methods devised to nullify the ill effects accruing from its existence. Prevention of an evil is always an easier task than its subsequent removal, and, as with the mosquitoes, we set to work to deprive the flies of all possible breeding places. Entire success in this direction was, of course, not thought of. In camp life on active servers, where large numbers of animals and natives accompany the force, no conceivable vigilance will ensure complete immunity from the fly nuisance. Much, however, can be done to mitigate the evil. At all stages of its existence, ovum, lava, pupa, and adult insect, the fly is dependent on decaying organic matter, either for incubative warmth or partial sustenance. This fact guided us in all dispositions. We enjoined the prompt destruction by fire of all manure and kitchen refuse. As far as practicable, the consumption of food in sleeping tents was forbidden, and the men were cautioned against leaving particles of food about. Stores were kept carefully covered. The matter collected in the traps of sullage pits was removed at short intervals and burnt. Deep pit box latrines were frequently inspected to ensure that no means of ingress for flies existed. The ground about all latrine areas was periodically sprayed with antiseptics. In the other direction of endeavour, the nullification of ill effects due to existing flies, equally drastic measures were set in force. On the one hand, the infection of the fly by man, and on the other hand, the contamination of man's food by the germ-carrying fly received closest attention. In all hospital lines, the dejecta of patients was disposed of in such a way as to render impossible any access of flies to them, and all hospital food reminders and utensils were kept under cover until their destruction or purification could be affected. The base camps and semi-permanent camps on lines of communication were provided with fly-proof stores for all exposed foodstuffs and fly-proof huts wherein food could be prepared. In mobile camps this was, of course, impossible, and here the cooking quarters were kept under rigorous surveillance, and any carelessness in the undue exposure of food material or leaving kitchen refuse lying about was sternly dealt with. As a last available measure, destruction of the adult flies themselves was everywhere attempted with more or less success. All kinds of fly-catchers were provided, and the men encouraged to exercise their ingenuity in devising further means to the same end. On the whole it may be said that the combined result of all these efforts to combat the fly nuisance in the Egyptian expeditionary force was such as to justify the time, thought and money expended on it. It is fairly certain that it had a direct, though not easily, estimable bearing on the health of the troops. Quite as important as this vendetta against flies and mosquitoes was that carried out against bodily insect pests among the soldiers. The subject hardly commends itself to the heroic temperament, but the fact remains that a proper understanding of the matter is as much part of a good R.A.M.C. man's equipment as the knowledge which enables him to bind up his brother's wounds. Lice, bugs and fleas. We discard here the genteel Latin terms usually applied by writers to these little errors of creation must frankly be classed among the horrors of warfare, especially a war waged in a hot eastern land under the modern intensive conditions. Also, their presence or absence has a direct twofold bearing on the fighting efficiency of troops. The louse and flea are proved carriers of disease germs, the former certainly of typhus and relapsing fever and probably enteric, the latter a convicted accessory in the propagation of plague, while the bug, though nothing has yet been definitely brought home to him, is highly suspect in more directions than one. But the communication of infectious disease is only part of the ill wrought upon military humanity by these parasites, and the writer, from an unfortunately extended experience of them, both with the Dardanelles army and the Egyptian expeditionary force, is constrained to think it not the principal part. It is, as enemies to sleep and rest, that body vermin must be mainly considered. In this regard, their direct influence on the fighting efficiency of the troops need no demonstration to any having experience of the trouble. No matter how hard a soldier works, providing he can get his rest and sleep in between spells of duty, he can go on indefinitely day after day. But a very few of these unwelcome guests can make sleep impossible, even to utterly exhausted men. The writer has seen a whole tent full of men, himself among the number, continuously employed half a night through in a more or less hopeless endeavour to get at the cause of the common disquiet by the light of one miserable, guttering candle-end. Over and over again he has seen men going on duty in the morning, dazed and unsteady, solely from this cause. The condition is a perilous one for a soldier on active service. It makes for inefficiency in all directions, and probably accounts for half the disciplinary mishaps that occur in camp and trench life by creating a state of mental dullness and indifference. The trouble has, of course, been a common one to all fronts in this war, but possibly it reached a more acute stage in the East by reason of favouring climatic conditions. Our medical officers from the outset were fully alive to the necessity of keeping the troops free of bodily vermin, and all clothing and blankets were passed through the steam disinfecters as frequently as possible. Where this was not practicable, and there were times, especially on Gallipoli, often long weeks at a stretch when nothing of the kind could be attempted, the men were instructed to employ any odd moments of leisure in the daytime in careful personal search for undesirables. Indeed, this sort of fatigue became almost universal throughout the ranks, and was probably the most useful method of all in the aggregate. With the Sinai Expeditionary Force, however, where we had the use of the Broadgate Railway, we were able to bring to bear on the nuisance a most potent weapon in the shape of a travelling van disinfecter worked by steam from the engine. This device was the invention of a prominent member of the Army Medical Service, and it did Yeoman's service indeed. It could be attached to any ordinary ration train, and run up into the midst of the camps, where it had merely to be shunted with the engine, and came at once into its sphere of usefulness. It consisted of two vans, capable of holding between them 200 or 300 complete kits. When loaded, these vans were closed up, and the necessary heat obtained by running the steam from the engine through a system of pipes. However the troops could be got at by this railway disinfecter, we were able to keep the body parasite troubled down to reasonable proportions. But, like the fly plague, success with it was only relative. In the matter of noxious insects, Egypt will probably sustain its record of unchangeableness to the end. End of Section 11, Section 12 of With the Royal Army Medical Corps in Egypt by Sergeant Major R.A.M.C. This LibriVox recording is in the public domain. Chapter 11, Epidemic Diseases, Measures Taken to Prevent and Combat Them The Battle of Romany against the Turks began on August 4, 1916, and ended six or seven days later with the complete rout of the enemy by our fighting troops. What may be called the Battle of Romany against the cholera began on August 7, and after some two months' close grim tussle ended with just as complete a victory for our medical service. The analogy may, with profit, be carried a little farther. In the first engagement, long and careful preparation and organisation resulted in a crushing defeat to the enemy at relatively small cost in killed and wounded to our own side. In the second engagement equally extensive precautions and painstaking dispositions resulted in the stamping out of an epidemic which, under the peculiar circumstances, might well have developed into a prime disaster to our arms. If the cholera had been once allowed to get foothold among our crowded desert camps with their hosts of native followers and complex difficulties as to sanitation and water supply, there is no saying what might have happened. What really happened is that from first to last seven British soldiers died of the disease. Why this death toll stopped at seven and did not mount up to seventy or seven hundred, or for the matter of that seven thousand, and why within two months of its first appearance all danger to our army from this scourge had been blotted out, makes up a story which cannot fail to be of interest to all who rest their faith in the world's ultimate regeneration mainly upon the gospel of brains and hard work. It had been long foreseen that the presence of the Turks on the Sinai Peninsula constituted a double danger to Egypt. We were not afraid of their guns, but we did entertain a wholesome dread of disease infection through their agency. Moreover the peril from the latter must increase in direct ratio to the success of our arms. Every prisoner we took and every deserter that came over to our side was a potential carrier of disease germs. Every yard of ground rested from the enemy, meant more suspected terrain added to the already heavy responsibilities of our medical staff. As a matter of fact, though the outbreak of cholera in the Katya district close to the battlefield of Romani, undoubtedly originated in the drinking of water by our troops from infected wells, lately used by the Turks, we had ample evidence that the Turkish medical authorities had not neglected precautionary measures against cholera. All the prisoners taken at Romani bore evidence of having been inoculated with some anti-toxic emulsion, and interrogation of the men left little room for doubt that this was against cholera. The dispositions made by the medical staff of the Egyptian Expeditionary Force to prevent the occurrence of cholera among the troops of the Eastern Force, or to deal with it should an outbreak arise, date from very early in the year 1916. Cholera was known to be raging in Syria, where the enemy had his base. We had no means of ascertaining weather, or to what extent the Turkish army was infected. But we knew that, as soon as military contact between the two opposing forces was re-established, the danger to our own troops must be regarded as a very real one, and thorough and timely action was indicated. With characteristic foresight, therefore, and with the swift, unswerving energy for which he is equally noted, our Director of Medical Services in Egypt, Surgeon General Ma C.B., got down to work. The problem was a sufficiently complex one. Not only had the health, which meant the fighting capacity of the army to be preserved at its present high level, but the native population of Egypt itself had to be safeguarded. A widespread epidemic of cholera in Egypt at this time would have been no less than a catastrophe. We were, and still are, drawing upon that country for supplies of all sorts, among which must take almost first rank a supply of cheap native labour. The thirteen or fourteen million inhabitants of the Nile borderland have constituted an asset of the British Empire during this war, whose value is well nigh inestimable, and must, in the near future of the precious peacetime, prove itself of real imperial worth. But it was not enough to prevent the incidence of cholera in Egypt proper. We were employing many thousands of native labourers on various works on the Sinai Peninsula, a considerable number close up to the front line. Cholera amongst these would mean more than the temporary stoppage of these works. It might result in the total arrest of the stream of labour recruits to the district by giving it a bad name with the populace. In the early days of the new Suez Canal defensive scheme, fear of the Turks had well nigh paralyzed engineering progress by keeping away native labour. Fear of cholera would at this time, and doubtedly, have had a like effect. The main principle underlying the system which was now devised to combat the disease on the Sinai Peninsula was to give it no chance at any stage. The whole medical personnel, from firing line to base, was placed on the key-vive in regard to it. Practically the entire army was re-inoculated with the wonderful anti-choleraic emulsion, and this, when we consider that all inoculation, except that against smallpox is entirely voluntary in the army, speaks volumes for the sound common sense of our soldiers. The native camelmen and labourers were treated in the same way. The drinking of water from local wells and springs was rigorously interdicted, except where access to official supplies became impossible. To meet this emergency, as already stated, every soldier was provided with certain chemicals in convenient tablet form by which the contents of his water bottle could be quickly sterilized. The stricter sanitary rules as to the disposal of excreta in all camps were set in force. All cases of diarrhea, even of the simplest and mildest type, were uniformly regarded as suspicious, and the benefacted immediately isolated and closely watched until the harmlessness or otherwise of their ailment declared itself. Here the usefulness of the field laboratories was strikingly manifested, still specimens of all diarrhea cases being at once forwarded to the nearest laboratory for examination. This involved an enormous amount of work on the part of our RAMC bacteriologists, but the trouble was amply repaid by the certainty, practically ensured by the system, of the prompt detection of any early and isolated cases of cholera which might occur, and might otherwise be overlooked in their incipient stages until irreparable harm had been done. In the meantime, though no case of cholera had as yet appeared among the troops or the native laborers, arrangements were everywhere put in train to deal with the disease, as if it were already actually rife among us. The broad waters of the canal constituted as efficient a barrier to the passage of disease into Egypt, as it had proved to an attacking force. Traffic across the canal was therefore rigorously supervised, no one being allowed to pass from east to west, without having first stood the test of confinement in a quarantine camp for a period of eight days. A system of quarantine stations for this purpose was organised throughout the whole length of the canal on its eastern or desert side. At the same time sites for isolation camps were selected wherever our troops were congregated, so that in the event of an outbreak of cholera occurring, the unit involved could be at once separated from the mass of the troops and the possible spread of the disease thus limited. In addition to this, every RAMC unit throughout the force made its own preparations for the temporary isolation and treatment of cases which might occur, pending their removal to specially appointed cholera hospitals at the base on the canal bank. Here also was established a complete series of isolation hospitals, to which all cases of diarrhea among the troops of the desert column were immediately sent and there segregated until the exact nature of their trouble was ascertained. The Egyptian element of the Sinai force was equally well looked after, similar arrangements being everywhere made with regard to it. The difficulty of supervising the vast numbers of natives, labourers on the railway, Camelmen etc. scattered here and there along our line between Cantara and the front can scarcely be exaggerated. Not a man among them possessed naturally the most elementary idea of the laws of sanitation or of personal hygiene. All had to be drummed into them by sheer force of language and repeated demonstration. And when once respect for sanitary order and preventive measures against disease had been inculcated the utmost vigilance was needed to preserve the hard-won position. The organisation from the medical point of view of the Egyptian labour corps and Camel transport corps is dealt with elsewhere in these pages, but one remark on this head may here be made very pertinently. During the period which we have at present under review no single case of cholera occurred among the Egyptian labourers on Sinai Peninsula. The fact is little less than astounding when we consider the hazard of the time and it reflects unbounded credit on the R.A.M.C. officers and men upon whom fell only preventive work and responsibility. Westward of the Canal, preparations for dealing with a possible outbreak of cholera were instituted on, if anything, an even more extended sale. In fact the entire medical organisation of the country, military and civil, stripped for action. Wherever our troops were quartered, sites for isolation camps were marked out and special cholera hospitals established and equipped with trained staff and all necessary material. In the large towns each military general hospital had its cholera ward ready. One large hospital in Alexandria was so prepared that it could, at short notice, be devoted exclusively to cholera cases. Near Cairo, two extensive cholera compounds were established and every supernumerary hospital throughout the country made similar dispositions. Even then there remained one important matter to be considered. This was the segregation under strict quarantine of all contacts, individuals or groups of people who had been in contiguity with suspicious cases and must therefore be put away alike from their infected and healthy comrades until all possibility of their conveying disease had passed. This difficult problem was dealt with in the same dynamic, resourceful way as all the rest. The civil authorities throughout Egypt were equally prompt and thorough in their preparations to meet a possible epidemic. Where we had our thousands they had their hundreds of thousands to safeguard and the anxiety attendant on the problem was increased accordingly. A grave feature in this was the introduction into Egypt of vast wards of Turkish prisoners, all of whom had to be regarded as possible cholera contacts. This was a military necessity. We could not keep these men in the fighting zone, but once inside the prisoner's camps at Heliopolis and elsewhere they were so well looked after as to render the chance of their conveying infection almost negligible. The most likely means, however, of cholera reaching Egypt from the Sinai Desert lay with Egypt's own people. Members of the Egyptian labour corps, whose term of service had expired, naturally wanted to return to their own villages and people forthwith. All these, and any others, natives or Europeans, who might be journeying westward, were confined for eight clear days in the quarantine camps on the east bank of the canal. The canal, indeed, proved itself a blessing in this regard. In the absence of its wide, deep waters, easily policed and patrolled, it is doubtful whether any effective cordon could have been drawn between Egypt and the source of danger. The first actual case of cholera asiatica in the field occurred on August 7, 1916, three days after the attack of the Turks on our position at Romany. In the twelve days following, twenty-five other cases cropped up in swift succession, but then the onslaught of this much more insidious foe of the two was completely checked. The ensuing four days produced only one case more. In September there was one case, and in October one case, making in all thirty cases, of which seven proved fatal. Thereafter, the affection disappeared for good. This is the simple chronology of one of the most sinister threats that ever menaced a British army in the east, a danger that was brought to naught, almost to a literal reductio ad absurdum, by the instant and supreme organisation of all the resources of medical science against it. It is scarcely possible to do more than indicate the scope and variety, and indeed the immensity, of the work which devolved on all members of the Royal Army Medical Corps in carrying out the Surgeon General's plans in the same thorough way in which these were conceived. A few points, however, may here be enumerated. The detection of these thirty cases of true cholera in their initial stage, each one of which, if undiscovered, would have constituted a centre of infection, meant the detention in isolation hospitals of some 1,150 cases diagnosed as simple diarrhea. Stool samples from all these simple cases had to be taken and sent to the nearest field laboratory where they were microscopically examined. In the event of any suspicious organisms being discovered, these had to be proved in various ways, all of which involved the expenditure of much time and trouble. The spirillum of cholera is an elusive creature, profoundly erratic in its habits. It may be present in large numbers in a specimen derived from a very mild case, and absent altogether from the feces of a man virulently affected. Thus, in one of the cases which ended fatally, the diagnosis of true cholera depended entirely upon the clinician, the bacteriologist being unable to detect any specific evidence of the disease. The post-mortem examination, however, amply proved its existence. That, in this outbreak of cholera at Romany, the original infection was derived from the enemy, there can be no possible doubt. It directly arose from contravention by the troops of the rules laid down as to the drinking of water from indiscriminate sources. Take the regulation as to the use of the disinfecting tablets which every soldier carried with him during this battle, being rigidly observed. It is just likely there would have been no cholera among our troops. For this lapse of discipline, the present writer must for conscience's sake be the very last to blame the men concerned. To arrive at a water-hole in an oasis, frantic with thirst, and utterly exhausted by prolonged marching and fighting in the dust and intense heat of the desert, and then to wait a solid half-hour until a bottleful of water sterilized itself would have taxed the self-restraint of the best of us. As might be expected, the men did nothing of the kind. Having driven the enemy from these oases, they just crowded to the wells and blindly drank their fill, despite the abominably foul state in which most of these places had been left. Moreover, during this long drawn-out battle, although every effort was made to provide each man with a gallon of filtered water daily, and each mounted man had been furnished with two water-bottles, it was found impossible in some cases to get the camels out to the troops engaged, and these had to fend as best they might. In one instance it is known that the contents assumed to be drinking water of some barrels found abandoned by the enemy were consumed by our thirst-tormented troops. In army-medical matters, as in all other provinces of human endeavour, the best-laid plans of mice and men gang-aft-agley. Thus much for cholera, but cholera was only one of the epidemic diseases which might assail our armies in the field, and against which preventative measures had to be devised. There was enteric fever and its allied disorders, there was dysentery, or rather the dysentries, for our physicians now recognised two diseases of that name. There was the insidious affection called Epidemic Jaundice, which worked such havoc among our men at the Dardanelles, and there were all the infectious throat and lung complaints of which sinister throng diphtheria marches at the head. And there was still one more to be dreaded most of all, and never for a moment to be left out of the reckoning in any tropical campaign. The plague, the terrible black death, that mowsmen down like corn, and whose dissemination remains such a mystery to the doctors well into the twentieth century. To detail all that was done by the Army Medical Service in Egypt to safeguard our troops against each and all of these failed diseases, would be alike to weary the reader and to embark on a system of reiteration wholly foreign to the scope of this record. Our design is to present an account, clear and complete, yet as succinct as may be, of the work of the Royal Army Medical Corps in this particular area of the war, and we conceive this purpose to be sufficiently realised if we here limit ourselves to one more typical resume in the branch of that work at present under scrutiny. The methods of scientific warfare against plague differ materially from those against cholera, or indeed against almost any other epidemic disease. Plague is not catching in the popular sense of the word. Given certain conditions, a case of this disease in its most virulent form may occur in a crowded community. The sufferer may come into close contact with any number of people, and may even die in their midst, and neither in life nor death will he necessarily constitute a danger to others. The next case, it is true, is very likely to be in the same house, but it is just as likely to be in the next street or the next village. To the uninformed, there seems often no connection whatever between the various cases of plague in a district which together make up an epidemic. The one is taken, and the other left. Here, the fire breaks out, flames up, and dies down again, miraculously, you would say, right in the midst of the same inflammable material. There, it springs up again, perhaps in a spot where it seems just as miraculously impossible, and flaunts itself in the face of what looks like typical sanitary decorum. Or no epidemic worthy of the name may occur at all. The black death may work just like some well-concealed sniper afar off, picking off his man with leisurely yet unerring aim, when and wherever it pleases him. In this latter guise it may be said that there has always been plague in Egypt. During the plague season, which extends from April to the end of July, isolated cases are reported each year, and at the ports of Suez and Syed, situated each at an end of the canal, it is doubtful if any month of the year passes without sporadic instances of the disease cropping up. Here and there men fall and die in their tracks, and the Oriental murmurs kismet. Goes through the eastern equivalent of crossing himself, then piously, placidly, fares on with his day's work. But fatalism is of little use in the science of preventive medicine. As in India in past years, so in Egypt now, we had our troops to protect against this scourge, and with the help of India's experience, the medical authorities of the Egyptian expeditionary force went promptly about the task. The facts, as to the nature and origin of plague, will scarcely be within the knowledge of all reading these lines. It may be well, therefore, briefly to enumerate them here. Like so many tropical lesions, plague is primarily not a human disease at all. It is a specific disorder affecting certain animals. How many kinds we do not at present know, but we do know that rats and mice are peculiarly liable to it. Rats and mice are attracted to human dwellings all the world over, but particularly to the crowded insanitary quarters in tropical or subtropical towns and villages. It would therefore be quite easy to see how plague could be directly communicated by rats and mice to man, except for the fact, while ascertained, but always self-evident, that such direct communication seldom, if ever, took place. Herein lay the mystery surrounding propagation of the disease. It was evidently not catching in the ordinary sense. What then constituted the intermediary of infection? As is well understood now, plague in the human subject is the result of direct inoculation by the agency of the rodent flea. An infected rat or mouse dies, and its fleas, hitherto nourished on its germ-laden blood, are constrained to seek another field of subsistence, which will be preferably another rat or mouse, but failing these, the nearest human subject. The flea itself seems to be immune to the disease. It merely acts as a germ carrier. Its bite does not necessarily convey infection to its new human host, but its excreta, freely voided as it feeds, swarm with the bacillus pestis, the microorganism causing plague. These bacilli gain entrance to the circulatory system of the host through abrasions of the skin caused by scratching. The man, in fact, inoculates himself. The necessity for this direct blood inoculation in the propagation of plague explains the erratic character of its occurrence. The fleas from a rat which has died of plague may infect one man, or many, or none at all. A man sick of plague may harbour infected fleas still about him, in which case his attendance may be bitten, and so contract the disease. Or he may be free of the insects, and therefore incapable of harm, when his watchers escape. Again it is well known that rats travel long distances in search of food. They are also strong, capable swimmers, when necessity demands it. A plague-infected rat may thus visit a locality, ideally healthy in other respects, and may sow the seeds of the black death broadcast among the rats and mice of the locality. And thus an epidemic of plague may arise which may well pass for a visitation of an outrage providence, in default of any other apparent cause. Seeing that plague was endemic both in Egypt and India, that we had brought large numbers of native troops from the latter country to the former, and that we were now constantly importing special foodstuffs for these troops from their old to their new zone of action, seeing moreover that these foodstuffs came from ports where plague was normally present, and came in ships which would certainly harbour rats. It did not need a Solomon to realise the possibility of trouble on this side, and the wisdom of preparing for it. Where Solomon's special attributes, and for the matter of that, Job's as well, might have found perhaps a more adequate test. Lay not so much in devising measures of prevention against a plague epidemic, but in getting those measures loyally and thoroughly carried out by the troops mainly concerned, the native Indian regiments stationed for the most part at the various posts on or near the east bank of the Suez Canal. All was done, however, that could be done. The ideal way to prevent the occurrence of plague among human beings anywhere would be to exterminate all rats and mice within the inhabited zone. It may be admitted at once that any measure having this object in view, as regards our semi-permanent camping areas on the Suez Canal, would have resulted only in waste of time, money and labour. It would have been fordoomed to failure. The Egyptian rat is ubiquitous. From the very first, he elected to give us his company on the Sinai venture, and the chances are that no sanitary squad short of the entire army itself would have succeeded in dissuading him. All we could do was to limit as severely as possible the hospitality, thus involuntarily extended to him. We waged war against holes and corners. We caused all huts and other buildings in the camps to be so constructed as to afford the minimum of shelter to rats and mice. Double walls were astute, as also wooden floors, which provided hiding places for vermin beneath. We arranged for all storehouses to be turned out at short intervals. Nothing was allowed to be piled up directly against an outside wall. Old dugouts and superseded trenches were filled in. Latrines received special attention to ensure them being riddled with light and air. All kitchen refuse, food reminders, anything that might nourish a rat or mouse were hurried to the incinerators and never allowed to lie about. The destruction of these undesirable guests was encouraged in every conceivable way, save one, that of putting down poison. The reason for this exception was twofold. Where the rat population is limited to a few local residents or occasional visitors, the practice of setting poison bait is allowable. It will probably be effective, and at any rate is not likely to have an offensive result. But the wholesale poisoning of rats, in and about a locality densely populated by human beings is wrong in every way. The stench arising from their decaying bodies will probably render the place uninhabitable, even if the same cause fails to bring about an epidemic of sickness. But this is by no means the chief reason against a method of destroying vermin, which leaves their carcasses in various ungetoutable places, or indeed against any method of the kind, which does not allow a prompt disposal of the dead. In the work of plague prevention amongst human beings, it is all important to watch the rats and mice of a locality. All members of our medical personnel, from one end of the canal zone to the other, the sphere wherein the disease was most likely to show itself, were instructed to keep a sharp lookout for any undue mortality among the rodents. We knew that plague among these always preceded plague among men. If immediately the rats of a place began to die of plague, the human population was at once evacuated, the chances were that the disease would never communicate itself to the human elements at all. Herein lay our trump card in the game of life against the Black Death, and it will be at once realized how important it was not to allow the red herring trail of poison to be drawn across this invaluable scent. It would, of course, have been better to have had no rats at all to convey the disease. But this being impossible in Egypt, the next best thing was to be able to use them in the way described, a method which would have been denied to us if the indiscriminate use of poison had been allowed. The first cases of plague occurred among our Indian troops towards the end of April 1917, at a post on the east bank of the Suez Canal, some miles from its southern extremity. Within a few days of the first appearance of the disease, similar outbreaks were reported from four or five other stations in the length of the canal, and all on its eastern or desert side. But all our medical forces were ready mobilized against it, and it was never given a chance to develop into anything like a general epidemic. Like the Irishman on the outskirts of the street melee, wherever we saw a head we struck at it. As each centre of infection became known, all troops were promptly withdrawn and sequestered in isolation camps. The sick men removed to plague hospitals, the contacts to rigorous quarantine, and the post with everything it contained which was burnable was reduced to ashes. From first to last there were some 85 cases of plague, all among the Indian troops and members of the Egyptian labour corps. But by May the 24th, just a month from its first appearance, the whole of the affected zone had been cleared of the disease. Thereafter it was confined to the usual, rare, detached instances at this time of year among civilians at Suez and Port Said. As with the cholera, so with the plague, preventative measures, carefully thought out and applied with scientific thoroughness, had produced the usual, very inconspicuous and inglorious result. A number quite incalculable of fighting men were alive and well, and able to prosecute their business of slaying their country's enemies, men whose names would otherwise have gone to lengthen roles of honour, by how much the God of battle and of pestilence alone knows. Before closing this chapter on Epidemic Diseases as affecting the work of the R.A.M.C. in Egypt, it may be of interest to determine, as far as may be, the real direction from which this threat of a plague epidemic came upon our troops. Investigations carried out by one of our most experienced medical officers leave little room for doubt, that in the first instance, the infection was brought from India, either in the foodstuffs intended for consumption by the native Indian regiments, forming part of the Suez Canal Defensive Force, or by plague infected rats, taking passage in the cargo ships employed. These foodstuffs were conveyed in barges from the wharves at Suez up the canal to the different places where the troops were quartered. Our sanitary men traced the barges which had conveyed the cereal food to these posts, and discovered rats upon them, which on a postmortem were proved to be suffering from plague. The ships which had brought the foodstuffs to Suez were also traced and examined, and plague infected rats were captured upon them. Moreover, dead rats discovered at the infected places were in each case proved by dissection to have succumbed to the disease, and in each case also we obtained a history of abnormal mortality, having occurred among the rats and mice of the place some days before the outbreak among the troops. A clear and timely warning which had the medical instructions for instant evacuation being carried out would most probably have prevented altogether the spread of the disease to the garrison. The story points a moral, or rather it indicates pretty clearly one direction in which, when the war is over, the surplus energy of the nations could be very usefully employed. The idea of a worldwide war against rats is no new thing, but in the light of new discoveries in the science of preventive medicine it has certainly of recent years taken on a new significance. The rat, like all the rest of nature's living scavengers, has now outlived its usefulness. Mankind has no longer any need for such rough and ready, and faulty, and uncertain agents. There are too many millions of us in the world now for toleration of anything but the directest, speediest, and most efficient means to any desired common end. The rat, therefore, remains among us merely as a useless danger, and has got to go. Nothing, however, can be done in this matter unless all is done and all act together with one accord. Governments first, and then the various organisations, and then at bottom, the one man, the individual, the unit forming humanity, which is you, or the man in the next street, or the next continent. If we all wage war against rats, or the world, and his wife, this no longer necessary evil must soon abate, and eventually follow the ichthyosaurus and the dodo into the valhalla of extinct monstrosities. But a start in the business must be made by someone somewhere, and surely the owners of first action lies with the Egyptian who stands astride of the world's greatest commercial sea-road, and whom nature, and art alike, have constituted the middle man between west and east. Sultan has sane the first, might easily find a less tenable claim to the gratitude of posterity than that of the king of Egypt, in whose reign the country was delivered of at least two plagues, that of the Turks with their train of moral havoc, and of the rodents upon whom ride the seeds of death as thistle down upon the wind. End of Section 12. Section 13 of With the Royal Army Medical Corps in Egypt by Sergeant Major R. A. M. C. This LibriVox recording is in the public domain. Chapter 12 Field and Base Laboratories From the first, the medical authorities in Egypt were thoroughly alive to the fact that warfare carried on by white troops in a subtropical country would be attended by many dangers to life and health other than those due to the projectiles of the enemy. Past bitter experience had demonstrated the havoc which could be wrought among armies by infectious disease, where no scientific preventive organisation existed against it. In all theatres of the present war, therefore, such an organisation was brought into being, and in none with more scientific thoroughness than in that under the sway of the Egyptian expeditionary force. The local circumstances, indeed, were of such a nature as to render very carefully thought out arrangements of the kind not only important but vitally necessary to the success of our arms. From time immemorial, Egypt has been noted for plagues. An outraged deity may have been responsible for some of these. A much more credible hypothesis, however, is that they were due then, as in modern times, rather to the woefully unhygienic habits of the Egyptians themselves than to any special disfavour of Providence. The rain and epidemic diseases appear, to the profane official eye at least, to fall pretty equally on the just and the unjust. Rain, except at certain rare but monumental moments, is a negligible factor in Egypt. Disease, however, in such a hot and trying climate, might, if unchecked, easily deprive our army of half its effective strength. The R-A-M-C-E-E-F had its duty, therefore, plainly before it, and it did it well. It was clear that the work of disease prevention on a large general scale could not be left to the regimentally attached medical officers and the field medical units distributed throughout the forces from base to firing line. These were already more than fully occupied with local affairs. The creation of some central body was indicated, on whom should devolve the whole responsibility for watching the health of the troops and reporting to the director of military services the occurrence of certain diseases so that measures could be taken be times for their isolation and extinction. Early accurate diagnosis in respect of the first cases, which occur, is the vital factor in dealing with outbreaks of disease of the infectious type. But early diagnosis, or indeed, any recognition at all of the true nature of certain virulent disorders in their initial stages, is difficult and often impossible in the case of the army doctor working under the hurried conditions of the field and with a heavy sick parade to get through daily. It was decided, therefore, to organize a service of specialists upon whom this particular work should fall and the Central Military Bacteriological Laboratory was established at Alexandria. This body began its labours early in September 1915. It had at its head an officer who was a distinguished pathologist and who was assisted by a staff of medical officers who had undergone special training and experience in the various departments of bacteriological work. In addition to keeping scientific watch and ward over the health of the vast number of troops at the Alexandria base, this central laboratory undertook the organization and equipment of a number of travelling field laboratories which were to accompany the desert columns on the march and would thus be always ready on the spot to render specialist advice and help to the medical officers of regiments, ambulances and field hospitals in the diagnosis of doubtful cases. The Central Laboratory also acted as a training college for bacteriologist, medical officers and for laboratory attendants, thus providing a body of skilled personnel upon which the field units could draw. It also carried out the systematic bacteriological examination of the various water supplies upon which our troops depended. Samples of food materials, aerated beverages and the like were also constantly submitted to this head establishment for examination and report. From the date of its installation in September 1915 to the end of the year 1916, the laboratory carried through a total of over 18,000 distinct examinations of specimens submitted to it from various quarters in the command, and this single fact alone is eloquent testimony to its usefulness. The field laboratories have also done a vast amount of work, the importance of which must rank still higher in the prevention of epidemic disease because being right amongst the fighting troops they were able to undertake the examination of specimens brought to them while these were quite fresh and consequently more amenable to scrutiny. In the case of excreta especially, the lapse of only a few hours may render any attempt at a true diagnosis wholly abortive. The institution of these travelling field laboratories really marks one of the greatest medical advances in connection with the whole campaign in Egypt, and the experience gained amply demonstrates that they must in future be regarded as an indispensable accompaniment to any army operating in a hot climate. The necessity of early detection and isolation of the first cases of infectious disorders occurring amongst troops has already been remarked. In the case of tropical diseases, this becomes doubly important. As an example, the early symptoms of dysentery, one of the greatest scourges among white troops in a hot country, are not easily distinguishable at sight from those of simple diarrhea. Expert bacteriological examination alone can determine the matter. Under the old system it too often happened that a patient actually sickening for dysentery who in the press and hurry of the field sick parade had been diagnosed as suffering from slight diarrhea and had been given medicine and duty would thus be returned to his unit only to disseminate the disease broadcast among his healthy comrades. No doubt it was to this cause that much of the dysentery occurring on the Gallipoli Peninsula is to be attributed, and the same may be said in regard to outbreaks of enteric fever, malaria, diphtheria, and the like. The presence of the travelling laboratories in the field of operations has, however, reduced this risk to a minimum. In the case of cholera, indeed, it may be said that the field laboratories, by making possible the prompt detection and segregation of the first occurring cases, have rendered the chance of any widespread incidence of that terrible disease almost a negligible consideration. In the expedition against the Turks on the Sinai Desert, there were a number of these laboratories on the line, extending from Cantara to the front. Each laboratory was under the charge of an expert bacteriologist as medical officer, who had two or more trained R.A.M.C. orderlies as assistants. It formed a complete separate unit in itself, with portable huts specially devised for the work. But wherever it pitched, it was attached temporarily to that one of the field ambulance units of the divisions, which formed the most conveniently central situation in respect of surrounding medical camps. The location of the laboratory was immediately made known to all medical officers in the district, so that specimens of sputum, blood, excreta, and, in the case of suspected diphtheria, throat swabs could be forwarded to it with certainty and without delay. Wherever possible, the situation of each field laboratory was so contrived that not more than an average distance of five to seven miles intervened between it and the medical units which it served. Material for examination would be brought to it at all times by orderlies, either mounted or on foot, and the orderly either waited while a report on the specimen was being prepared, or the report was transmitted, when ready, to the unit concerned by telephone, telegraph, or special messenger. This field, bacteriological work, mainly consisted of the examination of excretery matter for the early detection of dysentery, careful watch being also kept for cholera vibraeus and indications of possible enteric. Stool specimens of all diarrheal complaints which occurred among the troops, being systematically taken for the purpose. All suspicious cases of throat trouble were also similarly treated, it being no uncommon thing for one of these field laboratories to have 30 to 50 swabs submitted to it for report in a single day. Cases of malaria and relapsing fever were watched for in the same way, many samples of blood from suspected cases passing through the hands of these peripatetic bacteriologists daily. The net result of this scientific version of carrying the war into the disease enemy's country was the eminently satisfactory state of the general health of our desert column, although that column was placed in an environment typically favourable to the occurrence of epidemic outbreaks of disease. If it be true, as one authority on the army medical work has laid it down, that medical knowledge and sanitary art have but one value in the field, which is gauged by their effort on the massing of rifles at the decisive point and moment, then the microscopes of our bacteriologists have triumphantly justified themselves even on a hypothesis with so pronounced a Bismarckian tinge. The equipment of these travelling laboratories constituted no easy task. The ordinary patterns of tents were manifestly unsuitable for the purpose, as abundance of light and fairly complete protection from sun, wind and sandstorms were necessary for the delicate microscopic and experimental work which would be constantly in progress. Some form of hut, which, while being light and portable, would also be possessed of a certain degree of stability, was required and eventually provided. These huts were made in sections which could be easily bolted together or taken apart, the sections consisting of wooden frames with canvas stretched over them. The microscopic and estimatory work of the laboratory was carried on in these huts, but all operations, such as sterilizing and boiling, which needed heat and therefore involved the risk of fire, took place in the open in specially devised shelters. Similarly stores of inflammable material, such as petrol, ether, alcohol, etc., were kept clear of the huts, these articles being preserved in straw-lined chambers deeply buried in the sand. Sleeping accommodation for the staff had also to be provided in the shape of the regulation tents. The necessary stock of chemicals, apparatus and glassware was carried in suitably designed cases, but the glass employed was reduced to a minimum by the employment of enameled ironware, wherever practicable. When the troops moved forward, the field laboratory moved with them. The huts were taken to pieces, the tents struck, all apparatus and material were stowed away in their respective travelling boxes, and the hole was loaded on the train for transport to the new site ordered. This, as a rule, was close to the railhead, wherever that might be at the time, the field ambulance camps being commonly grouped round about the far the most stretch of the line. The life of the field laboratory men was by no means unattended by danger. The more advanced units were constantly subject to attacks from enemy aircraft, and often the most delicate microscopic work had to be carried on under active bomb fire. It is one thing to face death with a rifle in your hand, heroically conscious of both power and will to return blow for blow. It is quite another to assist at a bombing foray with your eye glued to a microscope. Moreover, an explosion in a bacteriological laboratory full of jars of deadly acids and test tubes loaded with still more deadly cultures of disease germs has its own peculiar risks not exactly of the inspiring order. It is not difficult to imagine what might result if the contents of a number of tubes full of the microbes say of cholera and cerebrospinal meningitis were scattered broadcast over a countryside swarming with troops. End of section 13