A VISION OF THE 
 POSSIBLE 
 
 WHAT THE K.A.M.C. MIGHT BECOME 
 
 JAMES W. BARRETT 
 
Duke Medical Center Library 
 
 CONRAD BAILEY. 
 
 Old, Rare & Fine Books, 
 P.O. Box 85, BLACK ROCK, 
 Victoria. Australia 3193 
 
DATE DUE 
 
A VISION OF THE POSSIBLE 
 
WORKS BY 
 
 SIR JAMES W. BARRETT 
 
 Just Published. Two Volumes. With Maps and Dia - 
 grams. Demy 8vo, 25 s. net; postage 9 d., abroad is 4 d. 
 
 THE TWIN IDEALS: 
 
 An Educated Commonwealth 
 
 “ This highly interesting work ... a number of illu¬ 
 minating articles . . . not only is there no stodginess but 
 a good deal of very pleasant entertainment.” 
 
 Saturday Revievu. 
 
 “ Although he writes for Australia principally, all the 
 rest of the world will lose nothing by reading him.'* 
 
 Westminster Gazette. 
 
 (With (he Assistance of Lieut. P. E. DEANE, A.AM.C.) 
 
 Just Published With 34 Plates and 3 Maps. Demy 8 vo, 
 12s. 6d. net; postage 6 d. 
 
 THE AUSTRALIAN ARMY 
 MEDICAL CORPS IN EGYPT 
 
 An illustrated and detailed account of the early organisation 
 and work of the Australian Medical Unitsin Egypt in 1914-15. 
 
 “ Sir James Barrett’s handsome volume . . . interesting 
 as a story of human effort in time of stress and valuable as 
 a record of medical administration under difficulties ... a 
 work that should find many readers.” 
 
 British Medical Journal. 
 
 Just Published . With 23 Plates arid 3 Maps. Demy 8vo. 
 10 s. 6d. net. 
 
 THE WAR WORK OF 
 THE Y.M.C.A. IN EGYPT 
 
 With a Preface by SIR E. H. H. ALLENBY 
 
 Just Published. With a Plate and 2 Maps. Demy 8?’0. 
 9 s. net. 
 
 A VISION OF THE POSSIBLE: 
 
 What the R.A.M.C. might become. 
 
 An account of some of the Medical Work in Egypt, together 
 with a constructive criticism of the R.A.M.C. 
 
 H. K. LEWIS & CO LTD. 
 
A VISION OF THE 
 POSSIBLE 
 
 WHAT THE R.A.M.C. MIGHT BECOME 
 
 An Account of some of the Medical Work in Egypt ; together with a 
 Constructive Criticism of the R.A.M.C. 
 
 BY 
 
 JAMES W. BARRETT 
 
 K.B.E., C.B., C.M.G., M.D., M.S., F.R.C.S.(Exg.) 
 
 TEMPORARY LIEUT.*COL. R.A.M.C. 
 
 LA’lELY LIEUT.-COL. A.A.M.C. AND A.D.M.S. AUSTRALIAN FORCE IN EGYPT, CONSULTING OCULIST 
 TO THE FORCE IN EGYPT AND REGISTRAR FIRST AUSTRALIAN GENERAL HOSPITAL; OPHTHAL¬ 
 MOLOGIST TO THE MELBOURNE HOSPITAL, MEMBER OF COUNCIL OF MANAGEMENT AND LECTURER 
 ON THE PHYSIOLOGY OF THE SPECIAL SENSES IN THE UNIVERSITY OF MELBOURNE J CONSULTING 
 SURGEON TO THE VICTORIAN EYE AND EAR HOSPITAL; CONSULTING AURIST, E.K.F., 1910 - 17 - 18 ; 
 PRESIDENT INVALIDING AND CLASSIFICATION BOARDS, CAIRO AND DISTRICT, 1917-18 | MEMBER 
 COUNCIL BRITISH RED CROSS, EGYPT, AND ALSO Y.M.C.A., EGYPT 
 
 H. K. LEWIS & GO. LTD. 
 
 136 GOWER STREET, LONDON, W.G.l 
 1919 
 
I3'31v 
 
DEDICATED TO 
 
 MAJOR-GENERAL WESTERN 
 
 C.B., D.A.G., E.E.F. 
 
 IN GRATEFUL RECOGNITION 
 OF THE INTEREST TAKEN BY HIM IN 
 
 MILITARY MEDICAL SCIENCE 
 
Digitized by the Internet Archive 
 in 2018 with funding from 
 Duke University Libraries 
 
 ' https://archive.org/details/visionofpossible01 barr 
 
PREFACE 
 
 I have ventured in the following pages to set down 
 some of the conclusions formed by me after service in 
 the R.A.M.C. during three years of war. I had previ¬ 
 ously had nearly one year’s experience in the Australian 
 Army Medical Corps in Egypt, i.e. a service which repre¬ 
 sents a loose replica of the arrangements and methods 
 of the R.A.M.C. My experience of the R.A.M.C., 
 and contact with its traditions and with its regular 
 officers, have been very interesting and instructive. I am 
 leaving the service, however, with the conviction that 
 if its traditions are to be maintained, and if it is to 
 develop into the service it should be—a service of 
 which any nation may be proud—some of its archaic 
 methods must be modified; modern methods must be 
 introduced and provision made for greater flexibility. 
 It is undesirable to a degree that any great institution 
 should progress by mutations, it should be so con¬ 
 structed and balanced that it responds almost automatic¬ 
 ally to development in science, to improvements in 
 methods, and indeed to the spirit of the time. Change 
 by mutation implies abrupt alterations with their incon¬ 
 veniences, their hardships, their controversies, and all 
 that such things connote. 
 
 I have tried to set out plainly some account of my 
 own experience in connection with the service. I have 
 endeavoured to indicate its source of strength, and I 
 have also, with equal plainness, sought to indicate its 
 shortcomings. 
 
 vii 
 
PREFACE 
 
 viii 
 
 The reader may ask why at the end of a successful 
 war, where the sick and the wounded have, on the whole, 
 been well attended to, should it be necessary to deal 
 with the subject in this critical fashion; such readers 
 may be reminded of the Mesopotamian Commission, 
 of the Dardanelles Commission, and of the appalling 
 damage done by venereal disease. The criticisms do 
 not for one moment imply that men who were actually 
 sick were not looked after as well as they could be in 
 the circumstances, but it is quite possible that had 
 arrangements been better the circumstances might have 
 been very different, that neither of these commissions 
 need have been appointed, and there might have been 
 no venereal cases to deal with. 
 
 It is quite certain that Great Britain and the Empire 
 will require an army in the future, and it is quite as 
 certain that a highly trained and efficient R.A.M.C. will 
 be necessary. How is it to be recruited ? If there is 
 one attitude more characteristic than another of some 
 of the distinguished civilian medical practitioners 
 who have served in Egypt during the past three 
 years, it is that they will not recommend any young 
 men who mean to take medicine seriously to join the 
 R.A.M.C. as it is at present constituted. As one of 
 them put it, any decent young man who wants to live in 
 different parts of the world, who is fond of hunting, 
 riding, fishing, and shooting, and who is prepared to 
 do a fair day’s work, may be recommended to join the 
 R.A.M.C. Those who mean to make medicine and 
 surgery the preoccupation of their lives had better stay 
 out of it. Be it remembered too that this statement 
 was made by a distinguished surgeon who had previ¬ 
 ously been recommending his pupils to join. 
 
 The nation cannot contemplate such an attitude 
 
PREFACE 
 
 IX 
 
 with indifference, and I am convinced that national 
 action will be necessary to effect the changes 
 needed, and to convert an honest but somewhat 
 mediocre service into an organization of the first 
 order and efficiency properly endowed with scientific 
 imagination. 
 
 Is it not clear that an Army Medical Service should 
 lead the world in scientific medicine ? The conditions 
 are ideal, since men are provided with fair salaries and 
 a guarantee against want in the form of a pension; 
 they have abundant leisure, they have hospitals and 
 laboratories at their disposal, and the patients are under 
 discipline. Can any human being imagine conditions 
 better fitted for the development of a thorough know¬ 
 ledge of medicine, both on its curative and on its preven¬ 
 tive side ? There should be simply no limitation to the 
 nature of the problems they can attack, and such a 
 service should easily lead the world. What a contrast 
 employment in such a service offers to that of the 
 struggling surgeon or consultant, borne down by the 
 drudgery of having to seek for a living, provided with 
 insufficient instruments, dependent for improvement 
 on the increase of his patients, and always with the fear 
 of a poverty-stricken old age in front of him! Yet what 
 has the R.A.M.C. done ? I do not overlook certain 
 brilliant and individual instances of development, but in 
 the main what has been the scientific output from the 
 R.A.M.C. compared with that from any similar group of 
 privileged medical men % The best test to apply to the 
 result is to ask oneself how many medical practitioners 
 not members of the military service ever think of turning 
 to the R.A.M.C. for guidance. It is our business in the 
 following pages to try to show why this relative failure 
 has occurred. The matter is of great importance, since 
 
X 
 
 PREFACE 
 
 it is quite certain that any service of State medicine 
 will fail to produce the finest results unless different 
 principles of administration are introduced. 
 
 Of the organization of the R.A.M.C. before the war 
 I know little, and nothing of first-hand knowledge. Of 
 its organization and administration in other theatres of 
 war I possess only second-hand information, but positive 
 knowledge has been gained through a four years' experi¬ 
 ence in one theatre of war, Egypt, and through some 
 little acquaintance with the Head-quarters in London. 
 Owing to the position occupied by me as Consulting 
 Aurist Egyptian Expeditionary Force (E.E.F.), and as 
 President of a Standing Medical Board, a wide survey 
 over the field inEgypt has been obtained. Furthermore, 
 the Egyptian theatre has offered singular facilities for 
 weighing the advantages and disadvantages of the 
 system, by reason of the fact that it was self-contained, 
 and that it was consequently easy to ascertain and 
 note details anywhere from the fighting line to the sea¬ 
 ports. The statements contained in this work are 
 therefore concerned only with what has occurred in 
 Egypt during the four years of war, and represent my 
 own personal impressions. 
 
 In addition to purely military work, I occupied 
 other offices. In 1914 I was first secretary to the Aus¬ 
 tralian Branch of the British Red Cross in Australia, 
 and in 1915 Executive Officer to the British Red Cross, 
 Australian Branch, in Egypt. I became a member of 
 the Cairo Council of the British Red Cross Society in 
 Egypt and also a member of the War Work Committee 
 of the Y.M.C.A. During the four years of the war I 
 have practically acted as a liaison officer between the 
 Y.M.C.A. and the Army Medical Service. My oppor¬ 
 tunities therefore for obtaining knowledge respecting 
 
PREFACE xi 
 
 the administration of the Army Medical Service have 
 been considerable. 
 
 For convenience this volume is divided into five 
 Sections, namely: 
 
 Section I, which contains a resume of my personal 
 experience as a Consulting Oculist and Aurist to the 
 Forces in Egypt, and incidentally much information 
 respecting the details of administration in the Army 
 Medical Services. 
 
 Section II, which contains an account of the work 
 done by me as President of a Medical Standing Board, 
 and throws even more extensive light on the work of 
 the Medical Services in Egypt. 
 
 Section III, which deals with the problem of venereal 
 disease in Egypt. 
 
 Section IV, which deals with the relationship of the 
 Red Cross to the Army Medical Service, and 
 
 Section V, which contains a series of sympathetic 
 criticisms of the Army Medical Service itself, together 
 with a statement of the methods which appear to me to 
 be most likely to produce a higher order of efficiency. 
 
 Dean Inge has pointed out with force that the charac¬ 
 teristic British faults are rather intellectual than moral, 
 and that statement I believe to be substantially cor¬ 
 rect. It is certainly correct in the main so far as 
 the regular R.A.M.C. is concerned. I hope that those 
 who may read that which follows will understand 
 that my criticisms are directed in all instances 
 at the system in which the R.A.M.C. officers are 
 enmeshed and not at the officer himself. It is im¬ 
 possible for anyone, like myself, whose occupation 
 prior to the war was entirely civil to enter into an old 
 service, and come in contact with the finest type of 
 regular soldier, both combatant and medical, without 
 
Xll 
 
 PREFACE 
 
 being impressed with the character of such men. 
 Whatever limitations they may have, limitations largely 
 imposed on them by the conditions under which the 
 nation forces them to work, there is no doubt that it is 
 their character which has saved the nation, and indeed 
 civilization, from complete destruction. No more tragic 
 or terrible story than that of the successful defence of 
 France during 1914 and 1915 can ever be told. These 
 men, ill equipped with the machinery of modern warfare, 
 were compelled to face the most magnificent fighting 
 machine the world has ever seen, and they saved the 
 nation that sent them ill equipped by dying where they 
 stood. TheE.A.M.C. officer, no less than the combatant 
 officer, played his part, and I shall be humiliated indeed 
 if anyone who may read the criticisms which follow 7 
 should imagine for one moment that I have forgotten 
 the sendee these men have rendered to mankind. 
 
 The R.A.M.C. includes a number of regular officers 
 w 7 ho are as keen professionally as anyone could 
 wish, but who, entangled in the system in which they 
 live, are inarticulate; they cannot write as I am 
 now writing, they cannot speak as I propose to speak ; 
 if they did so it is more than likely that their career 
 would not be as comfortable as they desire, and that 
 its duration would be curtailed, for it is not a sendee 
 that encourages self-criticism, whether written or spoken. 
 By the time such men reach positions in wffiich they are 
 able to put their reforming ideas into practice, they are 
 becoming old, their enthusiasms are colder, their pen¬ 
 sions are close at hand, and they cannot afford to risk 
 the disturbances that all radical changes in any great 
 service are bound to cause. Indeed many of them agree 
 with much that follows and would give a great deal to 
 be able to express themselves freely. Would it were 
 
PREFACE 
 
 xiii 
 
 possible that they could do so, because in many instances 
 they would be able to criticize more effectively than I 
 can, by reason of their more intimate knowledge of detail. 
 In order that the matter may not be misunderstood, 
 and that it may not be possible for anyone to imagine 
 that the criticisms that follow are in any way personal, 
 it has been decided to omit all names from the text. 
 The problem does not involve criticism of the conduct 
 of individuals, but of the duties attached to offices. 
 
 In conclusion may I emphasize the fact that I am 
 leaving the service with feelings of the most affection¬ 
 ate respect for a number of regular R.A.M.C. officers 
 with whom I have been associated, for their honesty, 
 their courtesy, and for their moral worth, and I only 
 hope that some of them may retain for me a fraction 
 of the regard that I shall ever feel for them. 
 
ERRATA 
 
 Page 65, line 6 from bottom, for “ direct” read “directly.” 
 
 „ 88, „ 3, for “table” read “tables.” 
 
 ,, 92, Table (a). The first column of figures alone refers to Officers ; 
 
 “ Hospitals, Convalescent Depots ” should be under “ Other 
 Ranks.” 
 
 ,, 97, line 18, omit “in.” 
 
 ,, 97, ,, 23, after “ gonorrhoeal ” add “clinically.” 
 
 ,, 97, ,, 5 from bottom, for “ one eye” read “ three eyes.” 
 
 „ 99, ,, 6 „ „ for “standard” read “ standards.” 
 
 ,, 102, ,, 7 ,, ,, in “ a 6/24 vision” omit “ a.” 
 
 ,, 102, „ 4 ,, ,, insert “and” before “ distances.” 
 
 „ 102, ,, 3 ,, ,, for “ of ” read “ with.” 
 
 ,, 104, „ 3 of first par., for “ can ” read “ should.” 
 
 „ 105, „ 6, omit “these.” 
 
 „ 117, ,, 13, for “ referred to ” read “ described.” 
 
 „ 118, ,, 18, for “ again ” read “ once more.” 
 
 ,, 131, „ 7, for “ with ” read “ to. ” 
 
 ,, 140, ,, 8 from bottom, for “these ” read “ the.” 
 
 ,, 144, ,, 17, for “ reply usually ” read “ usual reply.” 
 
 ,, 154, „ 2, for “ failure ” read “ neglect.” 
 
 ,, 165, ,, 5 second par., insert “and” before “Consulting Preventive.” 
 
 ,, 173, ,, 12 from bottom, for “high” read “great.” 
 
CONTENTS 
 
 SECTION I 
 
 A RESUME OF PERSONAL EXPERIENCES AS A 
 CONSULTING OCULIST AND AURIST TO THE 
 FORCES IN EGYPT 
 
 CHAPTER I 
 
 The Management of Diseases of the Ear, Nose, 
 
 and Throat .... i 
 
 CHAPTER II 
 
 The Management of Diseases of the Ear, Nose, 
 and Throat ( continued ) 
 
 SECTION II 
 
 THE WORK OF STANDING MEDICAL BOARDS 
 CHAPTER III 
 
 Standing Medical Boards ... 2*5 
 
 CHAPTER IV 
 
 The Memorandum 
 
 XV 
 
 31 
 
XVI 
 
 CONTENTS 
 
 CHAPTER V 
 
 PAGE 
 
 Boarding System ...... 64 
 
 CHAPTER VI 
 
 Boarding System ( continued ) .... 74 
 
 CHAPTER VII 
 
 Statistical Results of the Work ... 78 
 
 CHAPTER VIII 
 
 Repatriation Boards ...... 96 
 
 CHAPTER IX 
 
 Standards of Vision ...... 99 
 
 CHAPTER X 
 
 The Battle of March 21, 1918 . ... .111 
 
 SECTION III 
 
 THE MANAGEMENT OF VENEREAL DISEASE 
 CHAPTER XI 
 
 The Problem of Venereal Disease . . .117 
 
CONTENTS 
 
 XVII 
 
 SECTION IV 
 
 THE RELATIONSHIP OF THE RED CROSS TO 
 THE ARMY MEDICAL SERVICES 
 
 CHAPTER XII 
 
 PAGE 
 
 The R.A.M.C. and the Red Cross . . .131 
 
 SECTION V 
 
 THE REORGANIZATION OF THE R.A.M.C. 
 CHAPTER XIII 
 
 What is the Organization of the R.A.M.C. ? .138 
 
 CHAPTER XIV 
 
 Consultants and Presidents of Standing Medical 
 
 Boards ....... 146 
 
 CHAPTER XV 
 
 Education, Changes of Personnel, and Promotion 164 
 
 CHAPTER XVI 
 
 Summary ........ 162 
 
 CHAPTER XVII 
 
 Conclusion.176 
 
 INDEX .181 
 
 b 
 
MAPS AND PLATE 
 
 FACING PAGH 
 
 Egypt and the Western Desert : The Oases . . 4 
 
 The Canal Zone, Sinai, and Palestine ... 8 
 
 The Foot of a Soldier who wished to be Classified “ A ” 42 
 
GLOSSARY AND EXPLANATIONS 
 
 D.G.M.S. . 
 
 The Director General of Medical Services. 
 
 D.M.S. . 
 
 Director of Medioal Services. 
 
 D.D.M.S. . 
 
 Deputy Director of Medical Services. 
 
 A.D.M.S. . 
 
 Assistant Director of Medical Services. 
 
 D.A.D.M.S. 
 
 Deputy Assistant Director of Medioal Servioes. 
 
 M.O. 
 
 Medical Officer. 
 
 S.M.O. . 
 
 Senior Medical Officer. 
 
 C.C.S. 
 
 Casualty Clearing Station. 
 
 O.C. 
 
 Officer Commanding. 
 
 E.E.F. 
 
 Egyptian Expeditionary Force. 
 
 D.A.G. . 
 
 Deputy Adjutant-General. 
 
 A.A.G. . 
 
 Assistant Adjutant-General. 
 
 D.A.A.G. . 
 
 Deputy Assistant Adjutant-General. 
 
 3rd Echelon 
 
 Records Department. 
 
 G.R.O. . 
 
 General Routine Orders. 
 
 R.A.M.C. . 
 
 Royal Army Medical Corps. 
 
 A.S.C. 
 
 Army Service Corps. 
 
 R.E. 
 
 Royal Engineers. 
 
 A.O.D. . 
 
 Army Ordnance Department. 
 
 A.M.S. . 
 
 Army Medical Service. 
 
 A.V.C. . 
 
 Army Veterinary Corps. 
 
 A.P.D. . 
 
 Army Pay Department. 
 
 A.I.F. 
 
 Australian Imperial Force. 
 
 N.Z.E.F. . 
 
 New Zealand Expeditionary Force. 
 
 L. of C. . 
 
 Lines of Communication. 
 
 G.H.Q, . 
 
 General Head-quarters. 
 
 The A Branoh . 
 
 Adjutant-General’s-Department. 
 
 Categories: 
 
 
 “A” . 
 
 Fit for General Service. 
 
 “B.i. FrontLine”"* 
 
 “ B.i. L. of C.” 
 
 1 
 
 “ B.ii. L. of C.” 
 
 ^Various Grades short of General Service. 
 
 “ B.iii. L. of C.” 
 
 J 
 
 “ D.” . 
 
 Temporarily Unfit. 
 
 D.A.H. . 
 
 Disordered Action of the Heart. 
 
 V.D.H. . 
 
 Valvular Disease of the Heart. 
 
 XIX 
 
XX 
 
 GLOSSARY AND EXPLANATIONS 
 
 The following Standards were laid down as a guide to placing men in the 
 various Categories: 
 
 Category “ A .”—Able to march, able to shoot, hear well, and stand 
 active-service conditions. 
 
 Category “ B ."—Free from serious organic disease and in addition, if 
 classified “ B.i. Front Line ” and “ B.i. L. of C.” able to march 
 at least five miles, see to shoot with glasses, and hear well. 
 
 Category “ B.ii. L. of C .”—Able to walk to and from work a distance 
 not exceeding five miles, see and hear sufficiently for ordinary 
 purposes. 
 
 Category “ B.iii. L. of C.”—Only suitable for sedentary work or on 
 such duties as storemen, batmen, cooks, orderlies, sanitary duties, 
 etc. Also, if skilled tradesmen, fit to work at their trades. 
 
A VISION OF THE POSSIBLE 
 
 SECTION I 
 
 A RESUME OF PERSONAL EXPERIENCES AS 
 A CONSULTING OCULIST 1 AND AURIST 
 TO THE FORCES IN EGYPT 
 
 CHAPTER I 
 
 THE MANAGEMENT OE DISEASES OF THE EAR, NOSE, 
 AND THROAT 
 
 In 1915 I was a member of the Australian Army Medical 
 Corps, and was appointed Consulting Oculist (and in¬ 
 formally Consulting Aurist) to the Force in Egypt. The 
 conditions in Egypt in 1915 were almost indescribable. 
 The pressure was intense and all medical officers were 
 occupied in hastily improvised efforts to meet the 
 oncoming rush from the Dardanelles. When, however, 
 Egypt settled down in 1916 to what at first appeared 
 to be a small undertaking, the aural problem was 
 systematically attacked. On my return to Egypt in 
 March 1916, after being invalided to England, the 
 D.M.S. informed me that he had another Consulting 
 Oculist, but that he required a Consulting Aurist, that 
 the hospitals contained a large number of men suiiering 
 from ear diseases, and that such men were being in¬ 
 valided on an extensive scale; he directed me to visit 
 
 1 For Ophthalmic ^ork see Chapter IX., page 99 et *eq. 
 
 1 
 
2 
 
 A VISION OF THE POSSIBLE 
 
 all parts of the Field, to ascertain the precise position, 
 and make recommendations to him. 
 
 I found two or three aurists doing excellent work 
 either with their own or with improvised instruments, 
 as there were very few appliances suitable for aural 
 work in the country. 
 
 A large number of medical officers apparently did 
 not realize that there was such a person as an aural 
 specialist; consequently if a man appeared before one of 
 the miscellaneous boards with a running ear, he stood 
 an excellent chance of being invalided to England, and 
 the number was added to by scores of such cases invalided 
 to England from India, but detained in Egypt. The 
 first requirement was to obtain aural specialists, and 
 place them in certain strategical positions, to provide 
 them with suitable instruments, and then to determine a 
 policy. The D.M.S. effected these changes after con¬ 
 sultation with me, and gradually aurists were appointed 
 to each of the large hospitals, and the work commenced. 
 As the line extended into the desert, aurists were placed 
 at the rail-heads and on the line to act as screens, 
 i.e. to examine all aural cases which passed through 
 and determine whether they were cases which should 
 be retained at the front or which should be sent down 
 the line. 
 
 As the figures quoted later show, had the usual 
 practice of performing radical mastoid operations on 
 cases of chronic otorrhoea been followed, one or two 
 base hospitals would have been required for the sole 
 purpose of accommodating such cases. I advised the 
 D.M.S. that in my judgment the risk to life from chronic 
 otorrhoea was practically negligible if the purification 
 method of treatment was carried out in a regular and 
 systematized way, and that if he would permit me I 
 
DISEASES OF EAR, NOSE, AND THROAT 3 
 
 would see that the whole of the medical service became 
 acquainted with the principles of the problem and that 
 treatment was carried out thoroughly whilst the men 
 were kept under observation; furthermore, that a com¬ 
 petent aurist would be able to set aside doubtful cases 
 which could receive special consideration. Whilst there 
 was a remote risk of an accident taking place by the adop¬ 
 tion of such a practice, the service would gain hundreds, 
 and as it subsequently turned out, several thousands of 
 soldiers. Per contra the real risk of hundreds of opera¬ 
 tions of luxury would be avoided. He authorized me 
 to take this course, details of which are set out in the 
 statement which follows. It is interesting to note in 
 passing that the anticipated accidents never material¬ 
 ized on any extensive scale. As far as could be ascer¬ 
 tained, the deaths from aural septicaemia in four years 
 were about a dozen, and in most cases the men had 
 never reported sick, and consequently there had been 
 no treatment. 
 
 The following extract from the Journal of Laryng¬ 
 ology , 1918, gives a general idea of the proceedings in 
 the early period of the war: 
 
 SUMMARY OF REPORT ON DISEASES OF THE EAR, 
 NOSE, AND THROAT IN EGYPT IN 1915 
 
 Part I 
 
 On arrival in Egypt in June 1915, there was no auri6t available, 
 and by direction an aural clinic was established at No. 1 
 Australian General Hospital, Heliopolis, in conjunction with 
 the Ophthalmic Clinic, and was managed by the same staff, 
 namely, two or three assistant surgeons, one medical student, 
 and two nurses in the out-patient department, with the use of 
 a ward of 100 beds. The assistant surgeons were mainly : 
 Captain Morlet, Captain Stevens, Captain MacLellan, Captain 
 Burke, and Captain Rosenfield, A.A.M.C., and Mr. Cook and 
 Mr. YY harton, medical students. The work was even heavier 
 
4 A VISION OF THE POSSIBLE 
 
 than the ophthalmic work, largely owing to the outbreak of 
 measles which occurred amongst the Australian troops soon 
 after landing in Egypt. Work continued so far as I was con¬ 
 cerned until I was invalided to England in November 1915. 
 The first part of this report deals entirely with the period 
 referred to in 1915. 
 
 1. General .—The problem of dealing with diseases of the 
 ear, nose, and throat differs essentially from that presented to 
 the oculist. As pointed out in another place, the work of the 
 oculist in the army is a diminishing quantity up to a point, 
 because once the refractions of those complaining have been 
 worked out and glasses fitted, the refraction work is at an end, 
 except in so far as new drafts are concerned. On the other 
 hand, there are a very large number of soldiers who have been 
 enlisted suffering from otorrhoea with foul discharge, a condition 
 which in many cases had existed for years previously. They 
 make their appearance at the base hospitals and require atten¬ 
 tion, and are disposed of in the manner indicated later. There 
 are in addition a large number of ear, nose, and throat cases 
 who suffer from enlarged tonsils, adenoids, nasal obstructions, 
 or diseases of the sinuses, contracted prior to enlistment. The 
 precise number of men who suffered from these varying con¬ 
 ditions cannot be exactly estimated, but in Egypt they were 
 several thousands. But when all these men have been finally 
 disposed of, there remains a steady inflow of new cases who 
 suffer from ear, nose, and throat diseases contracted whilst on 
 service. It follows, therefore, that the clinical problem of ear, 
 nose, and throat diseases is not a diminishing one to the same 
 extent as the problem presented to the oculist, and the provision 
 necessary to be made consequently differs considerably. The 
 military work in both cases is important and similar in character. 
 
 2. Statistical .—The following figures furnish a rough classifi¬ 
 cation of the diseases treated, but they do not indicate the 
 total. It should be remembered that in addition to the cases 
 treated at Heliopolis, many cases were seen at No. 2 Australian 
 General Hospital, at Helouan, and elsewhere : 
 
 Aural, Nasal, and Throat Cases 
 
 Acute Catarrh (Middle Ear) .... 95 
 
 Chronic Catarrh (Middle Ear) .... 435 
 
 Oto-Sclerosis. . . . . . .138 
 
DISEASES OF EAR, NOSE, AND THROAT 5 
 
 Cerumen ....... 190 
 
 Otitis Externa . . . . . .143 
 
 Concussion Deafness ..... 139 
 
 Nasal Catarrh . . . . . . 114 . 
 
 Septal Deflection ...... 96 
 
 Adenoids . . . . . . . 74 
 
 Polypi ........ 4 
 
 Enlarged Tonsils . . . . . . 12 
 
 Antra and Sinuses . . . . . 14 
 
 Pharyngeal Catarrh . . . . . 11 
 
 Aphonia ....... 8 
 
 Laryngeal Growth ..... 1 
 
 1,474 
 
 Operations Performed 
 
 Aural : 
 
 Mastoid Operations . . . .17 
 
 Removal F. B. .... 3 
 
 - 20 
 
 Nasal: 
 
 Adenoids . . . . .73 
 
 Spurs ...... 34 
 
 Polypi ...... 14 
 
 -131 
 
 Throat: 
 
 Tonsils ....... 41 
 
 162 
 
 The experience was that, even at the outset, far more clinical 
 work was done in the aural than in the ophthalmic division. 
 
 3. Severity of Acute Otitis .—The chief characteristic of the 
 cases seen at Heliopolis was the severity of the attacks of acute 
 inflammation of the middle ear. It shpuld be remembered that 
 severe cases of measles and broncho-pneumonia were frequent. 
 There were generally about 100 measles cases under treatment, 
 and a steady stream of cases of acute inflammation of the middle 
 ear flowed into Heliopolis, sometimes in association with 
 measles, sometimes without apparent association. The men, 
 
6 
 
 A VISION OF THE POSSIBLE 
 
 however, suffering from acute inflammation of the ear were 
 often seriously ill, the temperatures were often 103° Fahrenheit, 
 and at the end of a sharp attack the convalescent patient 
 looked thoroughly exhausted. The severity was so marked, 
 and the condition so unusual, that the pathologist of the hospital, 
 Captain Watson, made careful search, but found nothing except 
 staphylococcus. 
 
 4. Adenoids .—Another feature was the prevalence of adenoids. 
 It is difficult to believe that these men enlisted with adenoids, 
 since I have never seen so many adenoids in adults during a 
 long period of private practice, and I am inclined to attribute 
 the prevalence to the dust of the desert, laden as it is with 
 organic matter, and to the severe colds from which these men 
 suffered. 
 
 5. Otitis Externa .—It will be noticed that under the heading 
 “ Otitis Externa” there are a considerable number of cases. 
 The prevalence of this condition usually associated with otor- 
 rhoea, but sometimes independent of it, continues to the present 
 day. This extensive distribution of furunculosis is in my 
 experience peculiar to Egypt. 
 
 6. Concussion Deafness .—A large number of men complained 
 of deafness due to shell-shock. A number of the cases were not 
 genuine, but a considerable number presented the usual 
 symptoms of unilateral deafness due. to gunfire. In some 
 cases the membrane was ruptured, but they were not very 
 numerous. Bilateral cases of concussion deafness were in almost 
 every instance cases of hysterical deafness, and they under¬ 
 went a remarkable recovery when placed on rigid treatment, 
 and particularly when subjected to faradization through the 
 mastoids. 
 
 7. Malingering .—The difficulty of discriminating between 
 the real and the false is much greater in the case of deafness 
 than of blindness, because an ear which appears fairly normal 
 may be associated with oto-sclerosis and deafness. A number 
 of mis-statements were made by men with regard to their 
 hearing and a number of devices were resorted to in order to 
 detect the fraud. Of these, the most successful were the 
 bandaging of the eyes and the testing of the hearing at different 
 distances by unknown sources of sound. The examinee is 
 unaware of the distances at which a noise-producing apparatus 
 is placed, and gives discrepant answers. He is further unaware 
 
DISEASES OF EAR, NOSE, AND THROAT 7 
 
 of the nature of the Rinne test by the tuning fork, or of the 
 fact that in middle-ear deafness a tuning fork placed in the 
 vertex is not infrequently heard best in the damaged ear, 
 or in an ear artificially plugged. By these and a set of many 
 other devices, it was possible to show that in a number of 
 cases the degree of hearing possessed did not correspond with 
 the physical appearances of disease, and that it varied from 
 minute to minute. Before leaving this subject, however, I 
 should like to say again, both with regard to the ophthalmic 
 and the aural work done, that I should be sorry indeed to 
 suggest that this attitude applied to more than a very small 
 percentage of the men who came to the hospital, and who 
 really represent what may be termed the “ pathological residuum 
 of the army.” 
 
 8. Operations of Election .—As regards nose and throat diseases 
 a large number of patients presented themselves suffering 
 from deviation of the septum and nasal spurs. It was obvious 
 that they had suffered from these conditions all their lives, 
 and that they had never troubled about them before. They 
 were accordingly sent back to duty in the majority of cases 
 with the advice that they could get them attended to when 
 the war was Over. 
 
 9. Fitness for Service .—In the case, however, of the men who 
 suffered from some degree of deafness, or from chronic otorrhcea, 
 the important question arose of their fitness for service. If all 
 the patients who suffered from chronic otorrhcea were to be 
 discharged from duty, a number of fit men would be dismissed 
 from the army after the heavy expense had been incurred in 
 sending them to and from Egypt. The risk of cerebral or general 
 infection from otorrhoea is very small. This fact is abundantly 
 proved by the large number of soldiers who suffer from this 
 condition, and who have disregarded it for many years, or for 
 the whole of their lives, and from the rarity with which cerebral 
 or general infection is seen. During the whole of my work in 
 Egypt, extending now for eighteen months, I have seen only 
 two cases of generalized septic infection from otorrhcea. It 
 seemed better to instruct the patient carefully respecting the 
 cleaning of the ear, to curette out any polypi or granulation 
 tissue, and to send him back to work. So far as deafness is 
 concerned, a considerable degree of deafness, definitely proved, 
 seems to me to warrant placing the soldier in Class “ B ” per- 
 
8 
 
 A VISION OF THE POSSIBLE 
 
 manently. A moderate degree of deafness, nevertheless, permits 
 him to discharge all duties except forward sentry work. It is 
 not safe to put a man who is deaf, or thinks he is deaf, in such 
 a position. The broad view was taken, that as this is a national 
 war all men possible should be employed. These deaf or 
 partially deaf men are all capable of earning a living in civil 
 life in some capacity or other, and indeed do so. There must 
 be some position in the army for which they are fitted. 
 
 Part H. 1916 and 1917 
 
 10. Improved Organization .—On return to Egypt in March 
 1916, I was appointed Consulting Aurist to the E.E.F., and 
 have occupied that position ever since. In 1916 Egypt was well 
 organized. The period of improvisation was over, appliances 
 were available, and the problem was essentially different. A 
 large number of clinics were established, aurists being placed 
 at the principal base hospitals and, as time progressed, also in the 
 stationary hospitals, in casualty clearing stations, and even in 
 the field ambulances. 
 
 11. Functions of Aurists .—The functions, however, of the 
 aurists in the base hospitals, and in the other units on the lines 
 of communication, were essentially different. The usual practice 
 has been to transfer a man to the base who reports sick with 
 ear, nose, or throat disease for the first time, unless the case 
 is trivial. The case is thoroughly examined and treated at the 
 base hospital, and is then returned to the front, a full clinical 
 report being sent to the A.D.M.S. of the division. The case 
 cannot be sent down a second time unless symptoms have 
 redeveloped, and without examination by an aurist in a field 
 ambulance or on the lines of communication. Consequently it is 
 the business of the aurist placed on the lines of communication 
 to treat and return to the front all comparatively unimportant 
 cases, and to transmit to the base, as speedily as possible, any¬ 
 thing of importance. As these arrangements were completed, 
 the bulk of the work was transferred from the base to the fore¬ 
 part of the lines of communication. 
 
 12. Distribution of Cases .—The statistics show that the aural 
 cases constituted two-thirds to three-quarters of the total work 
 of the aurist. Nasal, pharyngeal, and laryngeal diseases, apart 
 from diphtheria and tonsillitis, constituted one-quarter to one- 
 

DISEASES OF EAR, NOSE, AND THROAT 9 
 
 third of the total, and of the aural diseases, the infections group, 
 namely furunculosis and chronic otitis media, were at least 
 two-thirds of the total. 
 
 13. Treatment Adopted. —For the purpose, then, of producing 
 efficient soldiers, the problem became one of the management 
 of otitis media and furunculosis. The method of treatment 
 adopted in these cases is indicated in the circular which follows. 
 I think it is probably correct to say that never before in any 
 civil clinique has the treatment been carried out in the same 
 thorough and systematic manner. It would certainly be im¬ 
 possible in civil life to be sure that people dry out the last 
 minim of pus in the ear in the same way that the instructed 
 soldier does. The result has been remarkable, and every 
 specialist in Egypt has been impressed with the fact that 
 otitis media, with foul discharge, of long standing, sometimes of 
 years, has been brought under control and often cured in a 
 few weeks by this simple purification method. They have 
 further become convinced that the radical mastoid operation, 
 so often performed in civil practice, begins to appear in the 
 light of a luxury, as it certainly is not usually a necessity. 
 There are, so far as I am aware, very few cases in which a 
 general infection has taken place from an ear which was 
 under treatment. The few infections, about a dozen, which did 
 take place during nearly three years were mostly in cases which 
 had not reported sick, and had apparently never received treat¬ 
 ment. 
 
 14. Statistical. —The statistical table which follows applies 
 only to a portion of the period. It is not published with a view 
 of giving any idea of the absolute number of cases treated, but 
 with a view to indicating their relative distribution : 
 
 Statistics relating to Distribution of Diseases of the Ear, 
 Nose, and Throat 
 
 Aural Diseases: 
 
 External Ear: 
 
 Cerumen .... 
 Otitis Externa and Furunculosis 
 Eczema ..... 
 Inj uries and Foreign Body 
 
 332 
 
 352 
 
 47 
 
 7 
 
10 
 
 A VISION OF THE POSSIBLE 
 
 Aural Diseases ( continued): 
 Middle Ear : 
 
 Acute Otitis Media (dry) . 
 
 23 
 
 Chronic Otitis Media (dry) 
 
 . 371 
 
 Acute Otitis Media (suppurative) 65 
 
 Chronic Otitis Media (euppura- 
 
 tive) 
 
 . 1,173 
 
 Mastoiditis 
 
 33 
 
 Gunshot wound 
 
 5 
 
 Injury .... 
 
 8 
 
 Miscellaneous . 
 
 25 
 
 Internal Ear. 
 
 30 
 
 Nasal Diseases: 
 
 Acute Rhinitis 
 
 6 
 
 Chronic Hypertropic Rhinitis . 
 
 127 
 
 Chronic Atropic Rhinitis 
 
 53 
 
 Injury ..... 
 
 7 
 
 Septal Deviation . 
 
 88 
 
 Polypus .... 
 
 36 
 
 Epistaxis .... 
 
 13 
 
 Sinusitis (General). 
 
 19 
 
 Sinusitis (Frontal) . 
 
 10 
 
 Sinusitis (Maxillary) 
 
 21 
 
 Gunshot Wound . 
 
 19 
 
 Miscellaneous 
 
 30 
 
 Naso-Pharynx Disease ■: 
 
 Adenoids .... 
 
 • 
 
 Pharyngeal Diseases 
 
 Tonsillitis .... 
 
 . 248 
 
 Enlarged Tonsils . 
 
 . 241 
 
 Pharyngitis .... 
 
 56 
 
 Diphtheria .... 
 
 5 
 
 Miscellaneous 
 
 15 
 
 565 
 
DISEASES OF EAR, NOSE, AND THROAT 11 
 
 Larynx, Disease of: 
 
 Acute Laryngitis . . . . 15 
 
 Chronic and Subacute Laryngitis . 61 
 
 Neurosis and Aphonia ... 26 
 
 Paralysis ..... 2 
 
 Tubercle ..... 2 
 
 Gunshot Wound .... 5 
 
 Miscellaneous .... 36 
 
 - 147 
 
 Miscellaneous and Malingerers . . . .22 
 
 3,662 
 
 Operations Performed 
 
 Aural: 
 
 Removal of Polypi and Granulations 60 
 
 Mastoid 
 
 
 
 43 
 
 Furuncle 
 
 # 
 
 
 13 
 
 Miscellaneous 
 
 • 
 
 • 
 
 14 
 
 Nasal: 
 
 Submucous Resection 
 
 
 
 23 
 
 Turbinated Excision 
 
 
 
 84 
 
 Turbinated Cautery 
 
 
 
 24 
 
 Polypi .... 
 
 
 
 61 
 
 Maxillary Antrum . 
 
 
 
 28 
 
 Frontal Sinus 
 
 
 
 1 
 
 Miscellaneous 
 
 
 
 24 
 
 — 245 
 
 Naso-Pharyngeal : 
 
 Adenoids ...... 39 
 
 Pharyngeal: 
 
 Operations on Tonsils . . .170 
 
 Miscellaneous .... 1 
 
 -171 
 
 685 
 
12 
 
 A VISION OF THE POSSIBLE 
 
 15. Shell-Shock .—A good deal of discussion has arisen from 
 time to time as to whether there is such a thing as deafness as 
 the result of shell-shock or nervous disturbance. The malingerer 
 is not uncommon, but he can usually be detected. Men suffering 
 from hysteria are not uncommon, certainly far more common 
 than in civil practice. Unilateral deafness due to gunfire or 
 shell explosion is not uncommon, and rupture of the drum 
 due to the same cause is not infrequent; but when we have 
 eliminated the malingerer, the sufferer from bilateral hysterical 
 deafness, and unilateral deafness due to gunfire, is there such 
 a thing as bilateral deafness due to shell-shock ? Personally I 
 have not seen such a case, but some of the aurists in Egypt state 
 they have seen odd cases where the deafness appeared to be 
 labyrinthine in origin. I feel inclined to sum up the position 
 with regard to deafness in the same manner as I summed it up 
 with regard to blindness : that deafness due to genuine shell¬ 
 shock was a rare condition; that hysterical deafness, due to 
 nervous collapse under the circumstances of war, was fairly 
 common, and usually remedied with ease. In the discrimination 
 between the cases of organic disease and the cases of hysterical 
 deafness, the caloric test was freely used. Where the result 
 was negative, the fine question was opened up as to wdiether 
 the loss of the vestibular reaction implied the destruction of the 
 cochlea. An attempt was made to settle the question by the 
 use of the Wassermann reaction, as at least one case of loss of 
 cochlear function, supposed to be due to shell-shock, turned out 
 to be due to syphilis. 
 
 Conclusion .—The principal business of the aurist in the war 
 zone is to see that cases of chronic otitis media are efficiently 
 cared for, and are kept on duty at the front. Apart from this 
 paramount duty, he will have a good deal of work to do in recom¬ 
 mending cases of deafness due to dry catarrh for classification, 
 and a certain amount of work to do on the lines usually followed 
 by a specialist in civil practice, subject to the proviso that any 
 condition that may have existed prior to the war can wait till 
 the war is over for rectification, unless it distinctly interferes 
 with the man’s efficiency as a soldier. 
 
CHAPTER II 
 
 THE MANAGEMENT OF EAR, NOSE, AND THROAT 
 
 diseases ( continued ) 
 
 The following article appeared also in the R.A.M.C. 
 Journal, 1917 : 
 
 A note appears in the November 1916 number of the Journal 
 of The Royal Army Medical Corps, from the pen of Major James 
 Kerr Love. The title of the note is “ Hearing in the Army," 
 and the article raises a number of problems to which I desire 
 to make very brief reference. 
 
 Those experienced in the matter will entirely agree with the 
 statement made by him that: 
 
 (1) Most of the cases of deafness amongst those invalided 
 
 home are due to middle-ear suppuration, and 
 
 (2) That middle-ear suppuration has in most cases existed 
 
 before the war began—indeed for years before the 
 enlistment of the soldier. 
 
 The question, however, immediately arises: Is it necessary 
 to invalid a soldier because he has a suppurating ear ? Statistics, 
 I understand, cannot be published during the continuance of 
 the war, but those who are thoughtful might well ask what 
 would be the practical effect of agreement with such a policy ? 
 The facts are that the majority of cases of suppurating ear 
 possess good or fair hearing ; of the minority, a number can be 
 much improved by treatment, and the residuum of cases, in 
 which the hearing is greatly deficient, or the discharge un¬ 
 manageable, is comparatively small in number. The majority 
 of these cases have existed for considerable periods of time, 
 and have not been subjected to regular treatment, and when 
 placed under regular supervision and treatment by the purifi- 
 
 13 
 
14 
 
 A VISION OF THE POSSIBLE 
 
 cation method do very well. The treatment can be applied 
 without much difficulty at the front, after preliminary treatment 
 at the, base. 
 
 Furthermore, is it not obvious that this is a national war, 
 waged by a national army, and that as these men, in civil life, 
 are able to earn a living in some capacity, so when the nation 
 has turned its attention to military matters there must be 
 some occupation in which even those with defective hearing 
 can find opportunity for useful service ? Is it not the case that 
 the problem usually faced in recruiting has now been completely 
 altered ? An army of limited size can be, and should be, com¬ 
 posed of picked men with as few defects as possible, but the 
 existence of the same standard in a national war may make a 
 serious difference in the number of men available. 
 
 So far as the test of hearing is applied on admission with 
 the object of eliciting remedial defects, there can be no criticism, 
 but I should be sorry to depend on the answers to test questions 
 for a determination of the acuity of hearing of all recruits. 
 Nothing in my judgment is so difficult as the determination of 
 the amount of hearing possessed by anyone who is unwilling to 
 hear, and candidates who may desire to evade service would 
 be very difficult to deal with by the estimation of their capacity 
 to hear whispering at specific distances. It is true that this 
 criticism will not apply to the great majority of candidates, 
 but amongst the minority the person who will offer the most 
 difficulty is he who possesses some aural disease and tries to make 
 the most of it. For this type of candidate there is no more 
 suitable method of testing than the use of the tuning fork with 
 the various devices well known to aurists. 
 
 Nothing has been more striking in my experience of suppura¬ 
 tion of the middle ear than the infrequency of general septicaemia. 
 Ears wholly neglected by men for many years rarely land their 
 possessor in serious trouble. Whether their comparative im¬ 
 munity is due to the free exit for discharge, to the development 
 of antibodies, or to the creation of an anatomical bar to 
 infection, it is difficult to state ; but of the fact there is no doubt 
 whatever, and those who have handled considerable numbers 
 of cases have been surprised at the relative infrequency with 
 which the radical mastoid operation is necessitated. The 
 purification method of treatment carried out under discipline 
 reduces the problem to very small proportions. The experience 
 
DISEASES OF EAR, NOSE, AND THROAT 15 
 
 of the war will cause many of us to modify our notions respecting 
 the management of chronic otitis media. 
 
 In 1918, it was possible to keep statistics with 
 greater accuracy, and the following table shows the 
 nature of the work done : 
 
 Summary of Diseases of the Ear, Nose, and Throat 
 Period * $January 1 to September 31, 1918 
 
 Aural Disease : 
 
 External Ear : 
 
 Cerumen ... .1,035 
 
 Otitis Externa and Furunculosis 1,411 
 
 Eczema ..... 290 
 
 Injuries and Foreign Bodies . 52 
 
 Middle Ear: 
 
 Acute Otitis Media (dry) . 193 
 
 Chronic Otitis Media (dry) . 991 
 
 Acute Otitis Media (suppurative) 605 
 Chronic Otitis Media (suppurative) 2,969 
 Mastoiditis .... 95 
 
 Gunshot Wound ■ . . . 31 
 
 Injury ..... 30 
 
 Miscellaneous .... 299 
 
 Internal Ear . . . . .174 
 
 - 8,175 
 
 Nasal Disease : 
 
 Acute Rhinitis .... 94 
 
 Chronic Hypertropic Rhinitis . . 486 
 
 Chronic Atropic Rhinitis . . 93 
 
 Injury ...... 37 
 
 Septal Deviation .... 421 
 
 Polypus ..... 141 
 
 Epistaxis ..... 92 
 
 Syphilis ..... 9 
 
 Sinusitis (General) .... 35 
 
 Sinusitis (Frontal) .... 46 
 
16 
 
 A VISION OF THE POSSIBLE 
 
 Nasal Disease ( continued): 
 
 Sinusitis (Maxillary) ... 95 
 
 Gunshot Wound .... 41 
 
 Miscellaneous . . . .174 
 
 - 1,764 
 
 Naso-Pharynx Disease : 
 Adenoids 
 
 139 
 
 Pharyngeal Disease : 
 Tonsillitis 
 Enlarged Tonsils 
 Pharyngitis . 
 Diphtheria 
 Miscellaneous 
 
 1,150 
 
 389 
 
 235 
 
 169 
 
 91 
 
 - 2,044 
 
 Larynx, Disease of: 
 
 Acute Laryngitis . 
 
 • . 
 
 151 
 
 Chronic and Subacute Laryngitis 
 
 84 
 
 Neurosis and Aphonia . 
 
 , , 
 
 70 
 
 Paralysis 
 
 • . 
 
 11 
 
 Neoplasm 
 
 . 
 
 6 
 
 Tubercle 
 
 • . 
 
 29 
 
 Syphilis 
 
 • • 
 
 17 
 
 Gunshot Wound 
 
 # . 
 
 10 
 
 Miscellaneous 
 
 # # 
 
 21 
 
 Miscellaneous and Malingerers . . . 127 
 
 Total . . . 12,648 
 
 Operations 
 
 January 1 to September 30, 1918 
 
 Aural: 
 
 Removal of Polypi and Granulations 141 
 
 Mastoid ..... 48 
 
 Furuncle . . . . .134 
 
 Miscellaneous .... 51 
 
 374 
 
DISEASES OF EAR, NOSE, AND THROAT 17 
 
 Nasal: 
 
 Submucous Resection 
 
 
 83 
 
 Turbinated Excision 
 
 
 . 112 
 
 Turbinated Cautery 
 
 
 108 
 
 Polypi .... 
 
 
 115 
 
 Maxillary Antrum . 
 
 
 65 
 
 Frontal Sinus 
 
 
 7 
 
 Miscellaneous 
 
 
 36 
 
 -526 
 
 Naso-Pharyngeal: 
 
 Adenoids . . . . . .111 
 
 Pharyngeal: 
 
 Operations on Tonsils . . . 282 
 
 Miscellaneous . . . . 11 
 
 - 293 
 
 Laryngeal: 
 
 Tracheotomy ...... 5 
 
 Miscellaneous: 
 
 General . . . . . . 11 
 
 1,320 
 
 Statistics Relating to Infectious Aural Diseases 
 
 January 1 to September 30, 1918 
 
 Otitis Externa and Furunculosis 
 
 . 1,411 
 
 Eczema ..... 
 
 . 290 
 
 Acute Otitis Media (suppurative) . 
 
 . 605 
 
 Chronic Otitis Media (suppurative) . 
 
 . 2,969 
 
 Mastoiditis ..... 
 
 95 
 
 
 5,370 
 
 In order to make the system workable, the following 
 
 2 
 
18 
 
 A VISION OF THE POSSIBLE 
 
 instructions were issued to every Medical Officer in 
 Egypt : 
 
 INSTRUCTIONS IN REGARD TO CHRONIC 
 OTITIS MEDIA 
 
 1. There are in Egypt a very large number of men who are 
 suffering and have suffered from chronic suppuration of the 
 middle ear and furunculosis. The number amounts to several 
 thousands, and in a very large number of cases this is their only 
 disability. If the disease were regarded as a military disability, 
 the strength of the force would be affected to a great extent. 
 Largely owing to the experience gained, it has become obvious 
 that with reasonable care the risk of general infection is slight, 
 and as a matter of fact many of these men have suffered from 
 chronic otitis media through the greater part of their lives. 
 Chronic otitis media, therefore, only becomes a military dis¬ 
 ability when it seriously involves hearing, or in the rare cases 
 when it threatens general infection. 
 
 2. The practice usually adopted is to send a man who reports 
 for the first time with this condition into the nearest hospital avail¬ 
 able, so that the ear may be thoroughly examined, cleaned, and 
 freed from granulation and polypi. The man is then taught how 
 to clean the ear himself, in accordance with the circular which 
 follows. He is then returned to his unit and a full report of 
 his case is sent to the A.D.M.S. of his division by the officer 
 commanding the hospital in which he has been treated. 
 
 3. There are, however, a number of minor cases which do not 
 need hospital treatment. These men are seen by aurists in the 
 field ambulances and by aurists in the C.C.S.s or stationary 
 hospitals on the lines of communication. These aurists can deal 
 with those who require brief attention, and return them to the 
 lines speedily, and, consequently, the number sent to the base 
 hospitals can be reduced to comparatively small proportions. 
 A case returned with report to the [A.D.M.S. Division should 
 not be sent down the line a second time, unless symptoms have 
 appeared which indicate general infection, genuine deafness, or 
 a marked local aggravation. 
 
 4. In general, cases may well be returned to the front in which 
 discharge has ceased, or is mucoid and quite moderate in 
 quantity. Cases in which there is profuse purulent discharge 
 
DISEASES OF EAR, NOSE, AND THROAT 19 
 
 which does not give way readily to the purification treatment 
 should be submitted for classification, but such cases are few in 
 number. 
 
 5. It will be understood from the foregoing that every effort 
 should be made to prevent these cases being sent down the 
 line unless it is absolutely necessary, and equally, that the few 
 cases which show serious symptoms should be passed to the 
 base as quickly as possible. 
 
 6. The following indicates the procedure it is most con¬ 
 venient to adopt in the purification method of treatment: 
 
 (1) The patient should pass the hand of the side opposite 
 
 to the ear affected over the top of the head and seize 
 the upper part of the ear with the finger and thumb. 
 The ear should then be drawn upward. This 
 straightens out the ear canal. A small piece of wool 
 should be firmly wrapped round a wooden match and 
 introduced into the ear passage with the disengaged 
 hand to a depth of about three-quarters of an inch 
 to one inch. No force should be used, but, with care, 
 the matter can be mopped out and the ear rendered 
 quite dry. 
 
 It is desirable to cut off the end of the match used for 
 ignition. 
 
 (2) The head should be turned on the sound side, and 
 
 the diseased ear passage filled with the drops (which 
 should be warmed in winter). The drops should be 
 allowed to remain in the ear five minutes. 
 
 (3) The ear passage should again be thoroughly dried out. 
 
 (4) A small piece of wool should then be placed in the ear 
 
 to exclude dirt. 
 
 The most convenient drops for general use are : 
 
 Spirit Vini Rectif 1 
 
 Lotio Acidi Carbolici (1 in 15) J ^ ua P ar ^ s> 
 
 The patient should be inspected by the medical officer 
 once a week. 
 
 7. Aural specula are available for M.O.s to units, and 
 ear, nose, and throat instruments are supplied to field ambu¬ 
 lances and C.C.S.s on a definite scale, so that every facility 
 is given for the development of the policy indicated in the 
 circular. If any difficulties arise, representation is to be 
 made, through the usual channels, to the D.M.S. 
 
20 
 
 A VISION OF THE POSSIBLE 
 
 The following circular was issued to all Casualty 
 Clearing Stations and Stationary Hospitals : 
 
 INSTRUCTIONS FOR AURISTS IN CASUALTY CLEARING 
 STATIONS AND STATIONARY HOSPITALS 
 
 So far as diseases of the ear, nose, and throat are concerned, 
 the duties are mainly to advise which patients should be re¬ 
 tained at the front, and which should be returned to the base. 
 
 Soldiers complaining of ear, nose, and throat diseases who have 
 never reported sick with those diseases before are to be sent 
 to the base unless the complaint is trivial. At the base they 
 are fully examined and treated, and when returned to duty a 
 full clinical report is sent to the A.D.M.S. of the division, 
 who forwards it to the medical officer of the unit. There, con¬ 
 sequently, should be no reason for sending these men back a 
 second time unless some serious complication or development 
 has occurred. There is an aurist in one field ambulance in 
 each division, and a man returned in this way may have 
 seen this officer. If he has, and this, officer has recommended 
 his return to the base, such recommendations should not be 
 lightly interfered with. For those who have not seen an aurist 
 in the field ambulance, their disposal is a matter for your own 
 judgment. If the case is simple, and in your opinion can be 
 readily dealt with in a few days, it can be treated either in the 
 C.C.S., or sent back to the lines with a note to the medical 
 officer in charge. 
 
 The following are some of the conditions which necessitate 
 return to the base : 
 
 (1) Any case which shows pronounced and genuine deaf¬ 
 
 ness not remediable by simple means. 
 
 (2) Any discharging ear accompanied by genuine and 
 
 severe pain. 
 
 (3) Any discharging ear with oedema over the mastoid. 
 
 (4) Any discharging ear with high temperature or other 
 
 signs of general infection. 
 
 Any case returned must be accompanied by an explicit report. 
 
 Your function is mainly to secure the immediate transmis¬ 
 sion of serious cases to the base, and to keep the whole of the 
 lighter and the trivial cases at work at the front. 
 
DISEASES OF EAR, NOSE, AND THROAT 21 
 
 Any instruments or appliances you may require are to be 
 obtained through the ordinary channels. 
 
 Even with these precautions the system could not 
 work satisfactorily without the hearty support of the 
 A.Ds.M.S. of the forward area, and two conferences 
 were held with these officers under the presidency of the 
 D.D.M.S., so that the problem might be fully con¬ 
 sidered. It was ultimately agreed that every ear case 
 which was not trivial should be sent to a base hospital 
 in the first instance, and that when he was discharged 
 to duty the medical officer commanding the hospital 
 should forward the following certificate to the A.D.M.S. 
 of the Division. By this means the A.D.M.S. of the 
 Division became aware of the extent and nature of ear 
 diseases amongst his men, and was enabled to keep in 
 touch with the movement. 
 
 The following is a sample of the note usually for¬ 
 warded to the A.D.M.S. Division : 
 
 No . 
 
 Name . 
 
 Number . Unit . 
 
 Rank . 
 
 A letter was sent respecting this man to . 
 
 on . day of .191... 
 
 No, 
 
 EAR, NOSE, AND THROAT CASES 
 
 To the Medical Officer of the Unit 
 
 The Soldier respecting whom particulars are hereby given was 
 discharged from 
 
 .. Hospital 
 
 on the . day of .191.. 
 
22 
 
 A VISION OF THE POSSIBLE 
 
 PARTICULARS : 
 
 Name . 
 
 Number . Rank . 
 
 Unit . 
 
 He was discharged to duty. 
 
 He was discharged to Convalescent Home. 
 
 He was suffering from . 
 
 The following treatment is recommended 
 
 This man was examined by the Consulting Aurist, who concurs in 
 this Report. 
 
 Signed 
 
 The result of these efforts was that ear disease became 
 negligible in importance, though it remained consider¬ 
 able in extent, because every medical officer in the 
 army understood how to handle it. I wish, however, to 
 lay stress on the fact that this result, which added 
 thousands of men to the effective strength of the 
 E.E.F., was not only due to the hard and painstaking 
 work of the thirty-odd aurists who were distributed 
 about the Field, but to the educational means adopted. 
 The whole service was taken into confidence, the prob¬ 
 lem was explained, and the help of the medical officer 
 was invited. This policy wiped out what had become 
 an almost intolerable nuisance, namely, the constant 
 procession to the base of men with ear diseases. With 
 the knowledge gained the medical officers were con¬ 
 fident in their judgment and knew that the risks run 
 were negligible. 
 
 Let me ask what would have been the effect, had a 
 similar method been applied to other medical prob- 
 
DISEASES OF EAR, NOSE, AND THROAT 23 
 
 lems ? Why should not, an A.D.M.S. or Consultant for 
 Venereal Diseases have been appointed, whose province 
 it was to know everything relating to venereal diseases 
 which could be known; and if after receiving his 
 advice the D.M.S. had taken the whole service into 
 his confidence as to the best method of dealing with the 
 problem ? Wherever this method has been applied it 
 has been successful. There was in the E.E.F. an able 
 heart specialist, and ultimately his services were em¬ 
 ployed by establishing a heart clinic at the hospital 
 in association with an assistant in a command depot, 
 so that men's hearts were judged, not so much from 
 the result of physical examination, but from the 
 capacity of the heart to stand graduated work. The 
 result of the work of these two specialists, namely, 
 the specialist in the hospital and the subordinate 
 in the command depot, was practically to eliminate 
 D.A.H. as a disability. Soldier's heart ceased to be 
 of much importance, and by a similar educational 
 process everyone gradually understood the problem. 
 In my judgment, one of the failures of the R.A.M.C. 
 has been the inability to recognize the importance 
 of stimulating enthusiasms by explaining the issue. 
 Wherever the converse course has been followed, with 
 the necessary restrictions, it has been signally suc¬ 
 cessful. 
 
 Surgical Instruments, Etc. 
 
 The instruments, appliances, and drugs supplied by 
 the War Office were, on the whole, very good. After 
 much discussion, a proper system was established. 
 The Consulting Oculist, Consulting Aurist, and the Con¬ 
 sulting Dentist periodically visited the base stores, and 
 the officer commanding the store invariably consulted 
 
24 
 
 A VISION OF THE POSSIBLE 
 
 them before ordering supplies from London. They 
 standardized instruments, and did their best to meet 
 the requirements of the various specialists without 
 being extravagant, and kept a monthly return of the 
 supplies. For some time, however, the D.M.S. insisted 
 on some of the requisitions going to him, and he only 
 referred to the Consultant when he thought fit. The 
 result was unsatisfactory and the more sensible plan 
 alluded to was adopted. The final result was that 
 indents for instruments required countersigning by the 
 Consultant of the several departments, and by this 
 method supplies of instruments were kept down to a 
 reasonable basis. For, as time passed by, civilian 
 specialists full of enthusiasm arrived in Egypt, and 
 commenced to order (say) Howard’s, or Smith’s, or 
 Jones’s specula; and had the system been allowed to 
 continue, Egypt would soon have contained a museum 
 of all sorts of odd instruments. These practitioners 
 were, however, sensible, and when the position was 
 explained to them were quite willing to adopt instru¬ 
 ments of a uniform pattern. 
 
 Like some other branches of the service, towards the 
 end of the war this division became very efficient. 
 
SECTION II 
 
 THE WORK OF STANDING MEDICAL BOARDS 
 
 CHAPTER III 
 
 STANDING MEDICAL BOARDS 
 
 At the end of 1916, Standing Medical Boards in Egypt 
 were in an extraordinary position. Each hospital or 
 camp held its own Board with varying personnel, with 
 the sole exception of Cairo, where the A.D.M.S. Delta, 
 himself a physician, presided over a certain number of 
 the Boards for such time as he was able to give. The 
 result was that a large number of men were invalided to 
 the United Kingdom for trivial diseases. The classifica¬ 
 tion standards varied not only with the different Boards, 
 but also with different sittings of the same Boards, 
 because of the varied personnel of the Board, and the 
 finding of the Board was difficult to ascertain if the 
 man moved to another hospital or camp. The medical 
 history sheet had been abolished during the war and 
 nothing had been substituted for it. 
 
 At about the end of 1916, whilst the multiple Board 
 system was being generally adopted, the Germans 
 threatened to submarine all hospital ships, and, in con¬ 
 sequence, invaliding from Egypt was reduced to a 
 minimum. It is a remarkable fact that, when the 
 position eased with the appointment of the Spanish 
 Commissioners, a great majority of the men suffering 
 
 25 
 
26 
 
 A VISION OF THE POSSIBLE 
 
 from ailments for which they would formerly have been 
 invalided had practically recovered, and were doing 
 duty. 
 
 At the beginning of 1917, as the Army grew, the 
 A.D.M.S. Delta was unable to continue the work, and 
 the D.M.S. asked whether I was willing to undertake it. 
 He explained that it was an experiment, an experiment 
 that might well be tried, and he hoped I might be 
 successful. I agreed to do so, and became President of 
 all the Boards in the E.E.F. exclusive of Alexandria. 
 The Board in Alexandria was soon afterward similarly 
 placed under the presidency of Lt.-Col. Eason, C.M.G. 
 The D.M.S. gave me two pieces of advice, characteristic 
 of all that is best in the old army, namely, to be 
 impervious to influence of any description that might 
 be brought to bear, and to accept the statement of any 
 officer who appeared before the Board as true, unless 
 there was overwhelming evidence to the contrary. 
 The work began. There were no standards known to 
 me, I did not know at that time precisely what the 
 soldier did, and I had nothing to guide me except a 
 G.R.O. which is referred to later. There was no proper 
 form on which returns should be made, and the principles 
 which were to guide the work of the Board were not 
 well known. It is unnecessary to follow the development 
 step by step, but the work became enormous in its 
 extent, and the duties of the Board became those of 
 recommending soldiers to be invalided to England, 
 recommending the classification which should be 
 adopted if they remained in Egypt, advising the Com¬ 
 missioner of Pensions respecting pensioners, making 
 recommendations respecting men who applied for com¬ 
 missions, and finally making a most extensive set of 
 recommendations relating to the repatriation of prisoners 
 
STANDING MEDICAL BOARDS 
 
 27 
 
 of war. In about four months’ time I had begun to 
 grasp the principles concerned, and, after discussion, 
 the D.M.S./E.E.F. issued the following memorandum : 
 
 MEMORANDUM RELATING TO THE INVALIDING AND 
 CLASSIFICATION PROBLEM 
 
 Invaliding .—Sick or wounded who, in the opinion of the 
 medical officer in attendance and the commanding officer of 
 the hospital, are not likely to be fit for military service in any 
 class within five months, should be brought before one of the 
 Invaliding Boards appointed for the purpose. The Invaliding 
 Board will, after careful examination, answer the question 
 whether the patient is likely to be fit for any kind of military 
 service for five months ; and if the answer be in the negative, 
 will recommend he be classified “ C” (t.e. invalided to England). 
 
 The members of Boards are reminded that length of service 
 in Egypt or other compassionate considerations are not to be 
 considered by them. Their function is limited to giving a direct 
 answer to the question above stated. 
 
 Temporary “ B” Class .—Patients discharged from hospital 
 (or convalescent depots) who, in the opinion of the medical 
 officer and the officer commanding the hospital, are likely to 
 be fit for Class “ A ” within five months, and are fit for some 
 military service at the time of discharge, may be marked “ Tem¬ 
 porary Base/’ 
 
 When so discharged to Base Depots, the officer commanding 
 shall send a nominal roll and concise clinical information. These 
 particulars will be transmitted to the O.C. Base Depot, through 
 the A.D.M.S. of the District in which the Base Depot is placed. 
 It is to be understood that the man is only to be marked “ T.B.” 
 for a specified period, and in no circumstances is the period to 
 exceed three months primarily. 
 
 “ B ” Class .—Men discharged from hospital who are not 
 likely to be fit for Class “ A” at the expiration of five months, 
 and who are fit for some kind of military service at the time 
 of discharge, should be classified “ B. i,” “ B. ii,” or “ B. iii,” 
 in accordance with existing orders and practice. 
 
 It is better that this classification should be effected whenever 
 practicable at the time of discharge from the hospital, and 
 at the hospital. 
 
28 
 
 A VISION OF THE POSSIBLE 
 
 Men not Previously Classified. —There are a large number of 
 men who have not been previously classified, or concerning 
 whose classification there are no records available. The A.D.M.S. 
 or the D.D.M.S. of the District may establish Temporary Classifi¬ 
 cation Boards with authority to class those men “ A ” whom 
 those Boards think “ fit.” All men who are regarded by the 
 Temporary Board as not certainly fit for Class “A” should 
 be referred for classification to the Standing Boards of which 
 Lieutenant-Colonel Eason and Lieutenant-Colonel Barrett are 
 presidents. 
 
 Mode of Record. —In all cases of classification the “ Medical 
 Classification form ” should be filled up and signed by the 
 members of the Board in triplicate. One copy must be sent 
 to the A.D.M.S. or D.D.M.S. of the District, one to the A.A.G. 
 3rd Echelon, and one to the Officer Commanding the Unit. In 
 those districts where the A.D.M.S. or D.D.M.S. wish to ratif}' 
 the proceedings, the latter two copies cannot be dispatched 
 until formal approval has been given. The decision of the Board, 
 whether “ A,” “ B,” or “ T.B.” together with the disability and 
 principal clinical notes copied from the Medical Classification 
 form should be entered in A.B. 64 (the man’s paybook), except 
 in those cases where it is thought desirable to transmit the 
 information confidentially to the man’s unit, when a separate 
 memorandum should be forwarded to the A.A.G. 3rd Echelon 
 for transmission. 
 
 Examination at the Base Depots. —All men marked “ T.B.” 
 should be paraded on arrival at the Base Depot before the 
 medical officer in whose charge they are placed, and he shall 
 examine them once a week, recording his opinion. When he 
 thinks they are fit for duty, or when the term for which they 
 have been classed “ T.B.” expires, they shall be brought before 
 the Standing Classification Board, who may extend the period 
 or classify them definitely. The Standing Board may, however, 
 call for presentation of any or all of these “T.B.” cases at any 
 time it desires. 
 
 The medical officer in charge of the case should be present 
 at the sitting of the Board, or, if that be impossible, shall furnish 
 a report in writing respecting the cases dealt with. 
 
 Men in Garrison Battalions and Other Men marked “ B .”— 
 All men in Garrison Battalions, or other men classed “ B,” shall 
 be examined once a month by the medical officer of the unit, 
 
STANDING MEDICAL BOARDS 
 
 29 
 
 who shall record his opinion. If he is of opinion that any 
 change of classification is requisite, he shall present the case 
 at the next sitting of the Standing Medical Board. He should 
 be present at the sitting of the Board, or, if that be impossible, 
 shall furnish his information in writing. 
 
 It is understood, however, that the Standing Medical Board 
 may call for the presentation of any or all of the cases in his 
 charge if at any time it be thought necessary. 
 
 Procedure .—It should be clearly understood that cases 
 cannot be presented to any Invaliding or Classification Board 
 without a definite clinical report from a medical officer. It is 
 this report which forms the basis of the proceedings of the 
 Board, and the facts it embodies are the cause of its action. 
 
 This document was of course based on a General 
 Routine Order (G.R.O.), but wasissued as an instruction 
 to all medical officers in Egypt. The proceedings of the 
 Boards immediately became intelligible. The work 
 was systematized and the foundation was laid for further 
 developments. For the first time medical officers under¬ 
 stood precisely what was expected of them. Working 
 on this basis, problem after problem made its appear¬ 
 ance, difficulty after difficulty arose, and these were 
 submitted to the A.D.M.S. or D.M.S. as the case might 
 be, and rulings obtained, sometimes by a direct order 
 from the D.M.S., sometimes by G.R.O. In addition to 
 this, a series of Army Council instructions made their 
 appearance defining procedure and setting physical 
 standards under certain conditions. Furthermore the 
 knowledge of the consulting surgeons and physicians 
 was utilized and gradually a set of clinical standards 
 was laid down. All this work, however, took several 
 months, and by the time it was approaching fruition 
 the mass of orders, amendments of orders, Army 
 Council Instructions, and G.R.O.s had become be¬ 
 wildering. With the permission of the D.M.S. I then 
 set to work to codify the law as it stood up to date 
 
30 
 
 A VISION OF THE POSSIBLE 
 
 after consultation with the presidents of the other 
 Boards, and in February 1918 a complete statement 
 of the position was issued to every medical officer in 
 Egypt in the form of a printed document of thirty-one 
 pages. 
 
 Orders, Amendments of Orders, and Army Council 
 Instructions continued to appear, and a revised edition 
 was prepared in somewhat altered form and made 
 ready for issue just before the termination of the war. 
 This revised edition now follows in full, and represents 
 the culmination of two years’ work. 
 
CHAPTER IV 
 
 THE MEMORANDUM 
 
 Authority .—The following is a precis of the regulations 
 laid down with reference to Classification Boards, and 
 compiled from General and Routine Orders, quoted 
 textually or amended in places in conformity with the 
 instructions of subsequent General Routine Orders. 
 
 Those who are desirous of verifying their reference 
 or of testing the accuracy of the precis are referred to 
 the following General Routine Orders. 
 
 I. MEDICAL CATEGORY ON DISCHARGE FROM 
 HOSPITAL 
 
 Officers and men discharged from Hospital will be classified 
 as under : 
 
 Class “A.” Officers and men fit for general service in any 
 theatre of war. 
 
 Class “ A” will be sub-divided for purely military 
 purposes into two headings as under: 
 
 “ A.i.” Officers and men fit for general service in any 
 theatre of war in all respects, both as regards 
 training and physical and mental qualifications. 
 
 “ A.ii.” Officers and men requiring further training before 
 classified “ A.i.” 1 
 
 Note .—All Officers and men falling under either of the above 
 headings will, on discharge from Hospitals, be classified by the 
 
 1 G.R.O, 3480, dated 31/1/18. 
 
 31 
 
32 
 
 A VISION OF THE POSSIBLE 
 
 medical authorities Class “ A ” and will be sub-classified “ A.i ” 
 or “A.ii” by Officers Commanding Base Depots. 
 
 Class “ B.” Will be sub-divided under the following headings: 
 
 “B.i.” Not fit for general service, but fit for service in 
 Garrison Units, Area Employment Companies, or 
 duties of an analogous nature in the E.E.F. 
 
 “B.ii.” Not fit for general service, but fit for service in 
 Garrison Units, Area Employment Companies, or 
 on garrison or regimental outdoor employment in 
 the E.E.F. 
 
 “ B.iii.” Not fit for general service, but fit for service in 
 Garrison Units, Area Employment Companies, or 
 sedentary work as clerks, storemen, cooks, batmen, 
 orderlies, or on sanitary duties, etc., and, if skilled 
 tradesmen, at their trades in the E.E.F. 
 
 Classification Boards will give an opinion as to how men 
 Classified “B.i,” “B.ii,” or “B.iii” should be employed, i.e. fit 
 for lorry driver, horse transport duties, cyclist orderly, general 
 work, sanitary duties, and in the case of men possessing a trade, 
 whether he is fit for employment at it, and in all cases whether 
 (1) fit for front-line formation, (2) for work on L. of C. 
 
 This will in every instance be entered in A. B. 64. (A. (M) 71 .) l 
 
 Class “D.” Temporarily unfit for service in Categories “A” 
 or “ B,” but likely to be fit within six months. 
 Class “D” will be subdivided as under: 
 
 “ D.i.” Officers and men in Command Depots. 
 
 “ D.ii.” Officers and men in Base Depots. 2 
 
 Note. —Category “ D ” is purely a temporary one, and men in 
 a higher category automatically become “ D ” if under medical 
 or dental treatment. When such medical or dental treatment 
 is finished they automatically rejoin their original category until 
 transferred upwards by the Medical Officer of the Unit or Medical 
 Board, or downwards by Medical Board. 
 
 I. (a) Indian Officers and Other Ranks (including Followers) 
 discharged from Hospital will be classified as under: 
 
 Class “A.” Fit. 
 
 “ B.” Fit for Service on L. of C. only. 
 
 “ C.” Invalids for India. 
 
 “D.” Temporarily unfit for front line. 
 
 1 G.R.O. 3586, dated 1/3/18. 
 
 2 G.R.O. 3480, dated 31/1/18, 
 
THE MEMORANDUM 33 
 
 II. DISPOSAL OF OFFICERS AND OTHER RANKS 
 CLASSIFIED CLASS “ A ” 
 
 (a) Staff, Departmental, and all other Officers extra-regiment- 
 ally employed will, on being discharged Class “ A” from Hos¬ 
 pitals, Convalescent Homes, and Command Depots, be sent 
 direct to j oin the unit or formation in which they were serving. 
 
 (b) Officers belonging to Garrison Battalions, on being dis¬ 
 charged Class “ A ” from Hospitals, Convalescent Homes, and 
 Command Depots, will be sent direct to rejoin their Units. 
 
 (c) Officers of the Imperial Camel Corps, on being discharged 
 Class “ A ” from Hospitals, Convalescent Homes, and Command 
 Depots, will be sent to the Administrative Centre, Imperial 
 Camel Corps, Abbassia. 
 
 (d) All Officers, with the exception of those referred to above 
 under sub-headings (a), ( b ) and (c), on discharge Class “ A ” 
 from Hospitals, Convalescent Homes and Command Depots, 
 will be sent to their respective Base Depots. 1 
 
 Note. —Officers and Other Ranks discharged Class “ A ” from 
 Field Ambulances will be sent direct to join their Units. Nominal 
 Rolls of Officers and Other Ranks discharged from Field 
 Ambulances direct to their Units will be sent by the O.C. of the 
 Discharging Medical Unit to the O.C. of the Unit concerned 
 and to the D.A.G. 3rd Echelon. 
 
 I. (b) All Indian Ranks and Followers will on discharge from 
 Base or Stationary Hospitals or C.C.S.s be sent, Cavalry, R.A., 
 S. & T., Veterinary and Remounts Depots, to the I.C.B.D., all 
 others including Medical Details to the I.I.B.D. 
 
 N.B.—Indian Officers, Other Ranks, and Followers discharged 
 as “ A ” from Field Ambulances will be sent direct to join their 
 Units. 
 
 Details admitted to Detachment No. 5 Indian General Hospital, 
 Alexandria, from Camp “A ” will, if discharged as “ A,” be sent 
 to join that camp and not to the Indian Base Depots. 
 
 m. DISPOSAL OF OFFICERS AND OTHER RANKS 
 CLASSIFIED “ B.i,” B.ii,” AND B.iii” 
 
 (1) All Officers and Other Ranks of Yeomanry and Infantry 
 Units (excepting personnel of Garrison Battalions, who will be 
 sent direct to rejoin their Units) will, if classified “ B.i,” “B.ii,” 
 
 1 G.R.O. 3480, dated 31/1/18. 
 
 3 
 
34 
 
 A VISION OF THE POSSIBLE 
 
 or “ B.iii,” be sent, on discharge from Hospitals or Convalescent 
 Homes or Depots west of the Canal, to No. 800 Area Employ¬ 
 ment Company, Labour Corps, Alexandria. 
 
 (2) All Officers and Other Ranks of Yeomanry and Infantry 
 Units (subsequent to the above proviso regarding Garrison 
 Battalions) will, if classified “B.i,” “ B.ii,” or “B.iii,” by 
 Medical Boards east of the Canal, be sent to their respective 
 Base Depots. 1 
 
 (3) All Officers and Other Ranks of arms of the service other 
 than Yeomanry and Infantry will, if classified “ B.i,” “ B.ii,” 
 or “ B.iii,” and found medically unfit to remain in employment 
 with their Units, be sent to join their respective Base Depots, 
 irrespective of the location where they were medically classified. 
 
 (4) Personnel attached to technical units for trade testing or 
 to Instructional Units for training in technical trades will, if 
 classified “ B.i,” “ B.ii,” or “ B.iii,” be sent, on discharge from 
 Hospitals, Convalescent Homes, and Depots west of the Canal, 
 to No. 800 Area Employment Company, Labour Corps, Alex¬ 
 andria; if classified “B.i,” “B.ii,” or “B.iii” by Medical 
 Boards east of the Canal, they will be sent to the General Base 
 Depot. 
 
 Note. —All Officers and Other Ranks classified “ B ” will be 
 at the disposal of the D.A.G. 3rd Echelon. 
 
 Indian Tkoops 
 
 Men classified as “ B ” will be attached to the Indian Detail 
 Camp, Suez, and be utilized as required under orders of the 
 D.A.A.G. 3rd Echelon, Indian Section, subject, in the case of 
 registered instructors and specialists, to the approval of the 
 D.A.G./G.H.Q. 
 
 IV. DISPOSAL OF OFFICERS AND OTHER RANKS 
 CLASSIFIED “ D.i ” 
 
 All officers and Other Ranks classified “ D.i ” will, on discharge 
 from Hospitals and Convalescent Homes, be discharged to 
 Command Depots. 
 
 (a) Officers and Other Ranks discharged from Hospitals and 
 Convalescent Homes in and near Cairo will, if classified “ D.i,” 
 be sent to the Command Depot, Abbassia. 
 
 1 G.R.O, 3480, dated 31/1/18. 
 
THE MEMORANDUM 
 
 35 
 
 (b) Officers and Other Ranks discharged from Hospitals and 
 Convalescent Homes in and near Alexandria will, if classified 
 “ D.i,” be sent to the Command Depot, Mustapha. 
 
 (c) Officers and Other Ranks discharged from Hospitals east 
 of the Canal will be sent to the Command Depot, Abbassia. 1 
 
 Note. —The medical classification “D.ii” only applies to 
 Officers and Other Ranks temporarily unfit for Class “A” or 
 Class “ B ” undergoing medical treatment in Base Depots. 
 
 V. MEDICAL INSPECTION 
 
 All Class “D” Officers and Other Ranks in Command and 
 Base Depots will, as long as they remain there, be examined 
 once a week by the Medical Officer, who will relegate them to 
 their original category on the completion of treatment, unless 
 in his opinion they should be reclassified, when he will arrange 
 for their examination by a Standing Medical Board (A./10234). 2 
 
 Base Depots 
 
 (a) “ D ” Class Indian Ranks andFollowers at the Indian Base 
 Depots will be examined weekly for the first five weeks by a 
 Medical Officer. If still unfit for “A” at the end of that period, 
 and likely to continue so unfit for a considerable time, they will 
 then be brought before a Medical Board for reclassification. 
 
 (b) AllOfficers under whom Class “ B ” Other Ranks are serving 
 are responsible that all men whose paybooks do not show them 
 as “ B.i,” “B.ii,” or “B.iii” are medically inspected weekly 
 with a view to their being brought before a Medical Board for 
 reclassification. Boards for this purpose will be assembled 
 under instructions to be issued by the D.M.S.* 
 
 Note. —It must be clearly understood that no Officer or soldier 
 is to be placed in Class “ B ” except by a Medical Board. 
 
 All personnel whose medical category is “ P.B.” 4 will be 
 examined monthly (unless such personnel are over forty-one 
 years of age) ; the examination to be completed by the tenth of 
 each month. 5 
 
 (b) All Officers under whom Class “ B ” Indian Ranks and 
 Followers are at present serving are responsible that these are 
 
 1 G.R.O. 3480, dated 31/1/18. * G.R.O. 3480, dated 31/1/18. 
 
 a G.R.O. 3586, dated 1/3/18. 8 G.R.O. 2287, dated 19/3/17. 
 
 4 “ P,B,” means Permanent Base, a term now replaced by Base “ B,” 
 
36 
 
 A VISION OF THE POSSIBLE 
 
 medically inspected every three months with a view to their 
 being brought before the Standing Classification Board for re¬ 
 classification. 
 
 Medical Examination of Personnel belonging to Garrison 
 
 Battalions 
 
 With reference to General Routine Order No. 2496 of Feb. 5, 
 1917, and No. 2287 of March 19, 1917 : 
 
 The attention of All Officers Commanding Units and Forma¬ 
 tions is drawn to the fact that all personnel belonging to Gar¬ 
 rison Battalions in the Egyptian Expeditionary Force who have 
 not hitherto been classified should be sub-classified forthwith 
 irrespective of age. 
 
 Area Employment Companies 
 
 Men in Area Employment Companies will be examined by an 
 R.A.M.C. Officer every three months. 1 Such men as this Officer 
 considers should be reclassified will be referred to a Standing 
 Medical Board. 
 
 W.O.s, N.C.O.s, and men of “ B ” Category transferred to 
 R.A.F., M.P., R.E., other than Field Units, A.S.C., R.A.M.C., 
 A.O.C., A.V.C., and A.P.C., in substitution of “ A ” class person¬ 
 nel, will be examined by Medical Boards once in three months for 
 the purpose of reclassification, commencing from June 1,1918.* 
 
 In the case of personnel between the ages of forty and forty-six 
 reclassified “A,” a certificate signed by the Officer Command* 
 ing the Unit and the Medical Officer, stating that such per¬ 
 sonnel are fit for service with front-line Units, will accompany 
 nominal rolls rendered to the D.A.G. 3rd Echelon.* 
 
 VI. ESTABLISHMENT 
 
 The permanent attachment of “ B ” men to approved estab¬ 
 lishments on the Lines of Communication or at the Base will 
 be sanctioned by the D.A.G./G.H.Q., only, who will notify his 
 decisions to the D.A.G. 3rd Echelon. 4 
 
 No Officer or Other Rank of Class “ A,” Class “ D,” or Class 
 “ B” in a Base Depot will be employed on extra-regimental 
 
 1 G.R.O. 3802, dated 18/4/18. » G.R.O. 4253, dated 26/6/18. 
 
 » G.R.O, 3387, dated 2/6/18. 4 G.R.O. 3480, dated 31/1/18. 
 
THE MEMORANDUM 37 
 
 employments on the L. of C. without the sanction of the 
 
 d.a.g./g.h.q. 
 
 “ B ” Class personnel will be shown separately on A.F. B.213 
 (or A.F. B.213a in the case of A.S.C. units) when held in addi¬ 
 tion to War Establishment, for instance in the case of Hospitals, 
 Base Depots, etc. 
 
 The establishment of Class “ B ” sanctioned will be shown in 
 the War Establishment column and any deficiencies in the 
 “ Wanting to complete ” column. 
 
 Indian Troops 
 
 The permanent attachment of “ B ” men to establishments 
 on the L. of C. or at the Base, which have been approved by the 
 D.A.G./G.H.Q. will be sanctioned by the D.A.A.G. 3rd Echelon, 
 Indian Section. 
 
 Applications for sanction to special additional establishments 
 of “ B ” personnel will be submitted to D.A.G./G.H.Q. 
 
 “ B ” personnel employed on authorized establishments away 
 from Suez will, when no longer required, be returned to the 
 Indian Detail Camp at that place. 
 
 “ B ” Class personnel will be shown separately on A.F. B. 213. 
 
 VII. ARMY BOOK 64 
 
 When a man has been placed in Class “ B ” an entry to that 
 effect, together with the disease and date, will be made on inner 
 page of the back cover of Army Book 64, under the record of 
 inoculations. 
 
 This entry will be signed in full by one of the members of the 
 Board which places the soldier in this class. 
 
 When a man who is Class “ B ” is reclassified “ A,” an entry 
 to that effect will be made in the inner page of the back cover of 
 Army Book 64, and signed in full by one of the members of the 
 Board by whom the soldier has been reclassified. 
 
 Men sent to Field Ambulances, Casualty Clearing Stations, 
 and Hospitals will take with them their Army Book 64. 1 
 
 Indian Troops 
 
 When a man has been placed in Class “ B ” an entry to that 
 effect, together with some cause of his disability and date of 
 
 1 Cf.R.O. 3480, dated 31/1/18, 
 
38 
 
 A VISION OF THE POSSIBLE 
 
 classification, will be made on the inner page of the back cover 
 of his A.B. 64 (paybook) under the record of inoculations. This 
 entry will be signed in full by one of the members of the Board 
 which placed the man in this class. 
 
 It must be clearly understood that no Indian Officer, O.R., or 
 Follower is to be placed in Class “B” except by a Standing 
 Medical Board. 
 
 Steps must be taken to ensure that men sent to an Ambulance 
 or Hospital are in possession of their A.B.s 64. 
 
 No Indian Officer, O.R., or Follower of Class “A,” “ B,” or 
 “ D ” in the Indian Base Depots or Indian Base Hospitals will be 
 employed extra-regimentally outside these Depots or Hospitals 
 without the sanction of D.A.G./G.H.Q. 
 
 Formations which already have a sanctioned establishment of 
 attached “ B ” personnel must submit applications for further 
 additions thereto to the D.A.G./G.H.Q. for sanction. 
 
 VIII. NOMINAL ROLLS 
 
 All Officers commanding Units and formations and all officers 
 not serving with definite Units and formations having Class 
 “ B ” personnel (Yeomanry and Infantry) under their employ 
 who have not been transferred to Garrison Battalions or to 
 Area Employment Companies, Labour Corps, will submit rolls 
 of the same from time to time to the D.A.G. 3rd Echelon, with 
 a view to transfers to Garrison Battalions or to Area Employ¬ 
 ment Companies being effected. Such nominal rolls should 
 clearly indicate whether the men are extra-regimentally em¬ 
 ployed, or whether they are available as reinforcements for 
 Garrison Battalions. 1 
 
 IX. STANDING MEDICAL BOARDS 
 
 Standing Medical Boards discharge five functions, namely: 
 
 1. Classification. 
 
 2. Invaliding. 
 
 3. Medical Reports relating to Pensions. 
 
 4. Recommendations regarding appointments to Com¬ 
 
 missions. 
 
 5. Recommendations regarding repatriation of Prisoners 
 
 of War. 
 
 1 G.R.O. 3480, dated 31/1/18. 
 
THE MEMORANDUM 
 
 39 
 
 There are five Standing Medical Boards in the E.E.F., but 
 they do not all discharge identical functions. Their location 
 and functions are as follows : 
 
 1. Palestine L. oe C. (as far as El Arish) 
 
 The above functions are discharged by this Board with the 
 exception of Invaliding. 
 
 2. Canal Zone 
 
 The above functions are discharged by this Board with the 
 exception of Invaliding. 
 
 3. Delta District 
 
 (a) At each Hospital there is a Standing Medical Board, 
 presided over by the President Standing Medical Boards, Delta 
 District, with two Medical Officers appointed for the purpose 
 form time to time by the O.C. of the Unit. 
 
 The Board meets once weekly, or oftener if necessary. It recom¬ 
 mends the classification or invaliding of cases submitted to it; 
 the examination of applicants for commissions, when so instructed 
 by the A.D.M.S. Delta District; and Medical reports with regard 
 to Pensions on cases submitted by the A.D.M.S. Delta District, 
 and classifies Prisoners of War for the purpose of repatriation. 
 
 (b) Boards which discharge all these functions, except In¬ 
 validing, similarly constituted and presided over by the 
 President Standing Medical Board, Delta District, are held at 
 Convalescent Depots, Command Depots, and various other 
 Camps and Depots. 
 
 4. Alexandria District 
 
 Classification Boards for dealing with “ B ” and “ D ” cases 
 are held at the Command Depot, Sidi Bishr, Reception Station, 
 Mustapha, and Metras Camp. They are presided over by the 
 President Standing Medical Board, Alexandria District, the 
 other members being appointed from time to time. 
 
 Each Hospital in Alexandria, however, has its own Board for 
 performing the work done by the Standing Medical Board in 
 the Delta District. 
 
40 
 
 A VISION OF THE POSSIBLE 
 
 5. Special Invaliding and Commissions Medical 
 Board, R.A.F. 
 
 A special Invaliding Board sits at Mustapha to carry on in 
 the E.E.F. the instruction of A.C.I. No. 960, dated 16/6/1917, 
 as follows : 
 
 1. The question as to whether a Flying Officer or Observer of 
 the Royal Flying Corps, who has been temporarily incapacitated 
 by illness or injury, is fit to resume flying or observing, or whether 
 he is permanently unfit for flying or observing, will in all cases, 
 subject to the exceptions dealt with in para. 4, be left to the 
 decision of the Special Medical Board for the Royal Flying Corps 
 at the Air Board Office, Strand. 
 
 2. In the case of an Officer who has so far recovered that in 
 the opinion of a Medical Board he is likely to be able to resume 
 flying or observing within a specified time, he should be returned 
 to light duty without flying for a period not exceeding one month. 
 At the expiration of this period the Officer will be brought before 
 the Special Board for a decision as to his capacity to resume 
 flying. 
 
 3. An Officer whose condition is such that in the opinion of a 
 Medical Board he is unlikely ever again to be fit for flying or 
 observing will be brought before the Special Medical Board at 
 the end of his first period of light duty, and the question of his 
 permanent incapacity for flying or observing will be decided by 
 the latter Board. 
 
 4. If, however, the ailment or injury is of such a trivial nature 
 that in ordinary circumstances he would not be required to 
 attend before a Medical Board, the above rules need not be held 
 to apply. In such cases the Officer may be returned to flying 
 duty without reference to the Special Medical Board. 
 
 5. When the Special Medical Board for the Royal Flying 
 Corps has pronounced an Officer permanently unfit for duty as 
 pilot or observer, the finding as regards flying will not be reviewed 
 by subsequent Medical Boards. Such Boards may, however, 
 recommend that he be again examined as to his fitness for flying 
 duty by the Special Medical Board for the Royal Flying Corps 
 if it is considered that his condition warrants such a recommenda¬ 
 tion, but will express no opinion of their own as to his fitness 
 for such duty. 
 
 Officers who are unfit for flying are not necessarily unfit for 
 general service in other respects. 
 
THE MEMORANDUM 41 
 
 6. Sick or wounded Flying Officers or Observers will be 
 ordered to report as follows : 
 
 (i) If from overseas, to the Air Board Office. 
 
 (ii) (a) If away from their Unit less than 14 days, to their 
 Unit. 
 
 (b) If away from their Unit more than 14 days, to their 
 Group Headquarters, R.F.C. 
 
 The R.A.F. Commissions Board also sits at Mustapha to 
 examine all candidates for Commissions in the R.A.F. in accord¬ 
 ance with instructions received from time to time from the 
 G.O.C./R.A.F. Middle East, or the Medical Supervisor, Air 
 Board, London. 
 
 X. DUTIES OF STANDING MEDICAL BOARDS 
 
 It is clear that Standing Medical Boards are not clinical 
 investigation agencies. They are Boards of Assessment formed 
 to determine the fitness of a soldier for duty in terms of the 
 evidence furnished by the Medical Officer in charge of the case. 
 A concise clinical report should accompany each case when 
 presented to the Board, and it should be supplemented whenever 
 necessary by a report from the Consulting Surgeon or Physician, 
 from an Oculist, Aurist, Neurologist, Heart Specialist, or other 
 Expert. This information should be obtained before the case is 
 sent to the Board, in those cases in which it is necessary to obtain 
 it; otherwise it involves two attendances at a Board meeting 
 on the part of the soldier instead of one. It is the business of 
 the Board to weigh the evidence furnished, and to make an 
 assessment accordingly. 
 
 It must also be clearly understood that Standing Medical 
 Boards are not bound by the opinion of specialists to whom 
 cases are referred. A Board cannot divest itself of responsi¬ 
 bility in making a decision, and, valuable as may be the opinion 
 of specialists or medical officers upon individual cases, the 
 Boards themselves are free to come to any decision they think 
 fit in view of all the circumstances of the case. 
 
 The object of a Classification is to determine the fitness of 
 a soldier for the various occupations to which he may be assigned. 
 A Medical Board in endeavouring to effect this estimation will 
 be confronted with two sets of circumstances. 
 
 A soldier may possess a definite organic and more or less 
 measurable disability. It becomes a matter of judgment how 
 
42 
 
 A VISION OF THE POSSIBLE 
 
 far this definite disability interferes with his utility, and this 
 clearly depends on the driving force of the individual; in other 
 words, some men will find a considerable defect giving little or 
 no trouble, other men are overwhelmed with a very minor 
 defect. It consequently becomes necessary for the Board to 
 determine whether the disability is such as should be overcome 
 by a normal man of average mentality and morale. 
 
 The following instance will illustrate: 
 
 A soldier presented himself to a Standing Medical Board. He 
 was a healthy, well-made young man with a defect of the left 
 foot. He stated that the left foot had been crushed on a railway 
 ten years before. The great toe and metatarsal bone had been 
 removed, together with the greater part of the second toe, so 
 that the point of support of the foot was the head of the second 
 metatarsal bone. The Board was about to mark him “ B.ii ” 
 on the ground of his inability to march, when he requested to be 
 marked “ A ” and said he felt perfectly fit. He was tested by a 
 three-mile march and by a run through sand, and showed that 
 he was quite capable of doing what was necessary. It is quite 
 fair to say that, apart from his own determination, any set of 
 Medical Officers would have marked him well in the “ B ” class. 
 
 The estimation, therefore, of the effect of a physical disability 
 is to be co-related with some estimate of the mentality and 
 morale of the soldier concerned. 
 
 It is evident that too much weight must not be laid on the 
 man’s own estimate of his capacity or incapacity to overcome a 
 disability. The problem before a Board is, given a known 
 mentality and morale in the case of a soldier, what will be the 
 effect of associating him with other human beings who possess a 
 normal outlook, and of subjecting him to healthy discipline. 
 
 XI. PROCEDURE ON DISCHARGE FROM HOSPITAL 
 
 Sick or wounded, who, in the opinion of the Medical Officer in 
 attendance, and the Commanding Officer of the Hospital, are not 
 likely to be fit for military service in any class within five months, 
 should be brought before one of the Invaliding Boards appointed 
 for the purpose. The Invaliding Board will, after careful examina¬ 
 tion, answer the question whether the patient is likely to be fit 
 for any kind of military service within five months ; and if the 
 answer be in the negative, will recommend a change to England. 
 
 The members of the Boards are reminded that service in Egypt 
 
The Foot of a Soldieb who wished to be Classified “ A.’ 
 

THE MEMORANDUM 
 
 43 
 
 or other compassionate considerations are not to be considered 
 by them. Their function is limited to the careful answer to 
 the question above stated. 
 
 “ D ” Class. —Patients discharged from Hospital or Conval¬ 
 escent Depot, who are temporarily unfit for Class “ A ” or 
 “ B,” but who are likely to be fit within five months, should be 
 classed “ D.i ” and sent to a Command Depot, should graduated 
 training be thought advisable. Men on discharge from Hospital 
 or Convalescent Depot who still require medical or dental treat¬ 
 ment as out-patients should be classed “ D.ii.” When discharged 
 to Base or Command Depots, the Officer Commanding the 
 Hospital or Convalescent Depot shall send with them a nominal 
 roll and concise clinical information. These particulars will be 
 transmitted to the Base or Command Depot through the A.D.M.S. 
 of the District in which the Depot is situated. 
 
 “ B ” Class. —Men discharged from Hospital (temporarily) 
 unfit for Class “ A,” but who are fit for some kind of Military 
 Service, should be classified “ B.i,” “ B.ii,” or “ B.iii,” in accord¬ 
 ance with the existing orders and practice. 
 
 This classification should be effected whenever practicable at 
 the time of discharge from the Hospital, and at the Hospital. 
 
 XII. CLASSIFICATION BOARDS 
 Personnel Eligible for Classification Boards 
 
 Men not Previously Classified. —A.D.sM.S. District may, with 
 D.M.S.’s concurrence, hold special Boards, under the following 
 circumstances : 
 
 Should there be an accumulation of men who have not been 
 classified since arrival in Egypt or concerning whom there is 
 no record available of any previous classification, this Local 
 Board, with a Senior Officer as President, may have authority 
 to classify such men “A” as the Board consider fit for this 
 category. All men whose cases are regarded as doubtful, or 
 who, in the opinion of the Local Board, belong to Class “ B,” 
 will be referred to a Standing Board. 
 
 Unclassified men in the Field may, if considered fit for Class 
 “ A ” duties, be classified by the M.O. i/c, date and classification 
 being entered in A.B. 64. 
 
 Any previously unclassified man found unfit for Class “A” 
 should be referred to a Standing Classification Board, 
 
44 
 
 A VISION OF THE POSSIBLE 
 
 Men in Garrison Battalions not previously classified must 
 be submitted to Boards and sub-classified irrespective of age. 
 
 “D” Class Personnel 
 
 “ D” Class Officers and Other Ranks in Command and Base 
 Depots are examined once a week by the Medical Officer, who 
 relegates them to their original category on the completion of 
 treatment, unless in his opinion they should be reclassified when 
 he arranges for their examination by a Standing Medical Board. 
 
 “D” Class Indian ranks and followers at the Indian Base 
 Depots are examined weekly for the first five weeks by a Medical 
 Officer. If still unfit for “A” at the end of that period, and 
 likely to continue so unfit for a considerable period, they are 
 then brought before a Medical Board for reclassification. 
 
 A Standing Classification Board may, however, call for the 
 presentation of all or any “ D ” Class at any time this may 
 appear to be desirable. At each sitting of a Board the Officer 
 in medical charge of the case should be present if possible. A 
 short report in writing should be furnished for each case brought 
 before a Board. 
 
 “ B h Class Personnel 
 
 All “ B ” Class personnel (unless such personnel is over forty- 
 one years of age, and other than those in Area Employment 
 Companies or transferred to R.A.F., M.P., R.E. other than Field 
 Units, A.S.C., R.A.M.C., A.O.C., A.V.C., and A.P.C., in sub¬ 
 stitution of “ A ” Class personnel) are examined once a month 
 by the Medical Officer of the Unit. If the M.O. of a Unit is of 
 opinion that any change of Class is desirable, he presents such 
 cases at the next sitting of the Standing Classification Board. 
 The M.O. concerned should be present at the sitting of the 
 Board, or, if that be impossible, should furnish his information 
 in writing. 
 
 Medical Officers attached to Garrison Battalions will keep 
 nominal rolls recording the results of the monthly inspections, 
 showing in every case whether the man is : 
 
 (a) Recommended for transfer to a higher category. 
 
 (b) Retained in existing category. 
 
 (c) Referred to a Board for transfer to a lower category. 
 
 A note as to progress, or the reverse, should be made in each 
 
 case. In this manner a permanent record of these inspections 
 
THE MEMORANDUM 45 
 
 and their results will be available, and rolls should be submitted 
 to the A.D.M.S. for perusal after each inspection. 
 
 It is understood, however, that a Standing Classification Board 
 may call for the presentation of any “ B ” Class men, if at any 
 time it be thought necessary to do so. 
 
 W.O.s, N.C.O.s, and men of “ B ” Category transferred to 
 the R.A.F., M.P., R.E. other than Field Units, A.S.C., R.A.M.C., 
 A.O.C., A.V.C., and A.P.C., in substitution of “A” class per¬ 
 sonnel, and men in Area Employment Companies will be examined 
 by an R.A.M.C. Officer every three months. Such men as this 
 officer considers should be reclassified will be referred to a 
 Standing Classification Board. 
 
 Men in Area Employment Companies placed in Category 
 “ A” will be transferred to a first-line unit. 
 
 XIII. PROCEDURE PRELIMINARY TO A MEDICAL 
 
 BOARD 
 
 It should be clearly understood that cases cannot be presented 
 to any Invaliding or Classification Board without a definite 
 clinical report from a Medical Officer. It is this report which 
 forms the basis of the proceedings of the Board, and the facts 
 it embodies are the cause of the Board’s action. 
 
 Nominal Rolls of Officers and other ranks presented to a Medical 
 Board should be made out on the Special Classification forms 
 
 < 41QQ 
 
 (A.P. & S.D. Alexandria LZ^ -r A. 7.18.20 M. R.B.). 1 
 /50025A 
 
 In the case of Officers these forms should be made out in 
 quadruplicate, in the case of W.O.s, N.C.O.s, and other ranks, 
 in triplicate. 
 
 In filling in the forms, some points demand attention: 
 
 When preparing nominal rolls for a Classification Board the 
 columns “Disability,” “New Classification,” and “ Clinical 
 notes ” are to be left blank for the remarks of the Board. The 
 remaining columns are to be completed in every detail by the 
 Medical Officer preparing the roll. 
 
 The clinical evidence should be presented on a separate sheet. 
 
 Initials of Officers and Other Ranks must always be given, as 
 well as Unit, and in the case of Other Ranks regimental number. 
 
 Names of Officers and Other Ranks should be recorded on 
 separate sheets. 
 
 1 Seo page 95. 
 
46 
 
 A VISION OF THE POSSIBLE 
 
 British, Colonial, and E.L.C. Officers or men must never be 
 on the same sheet. 
 
 Nominal rolls should be prepared by arms, i.e. Personnel of 
 Infantry, Yeomanry, R.A., R.E., etc., should appear on different 
 sheets. If possible, Infantry should be shown by divisions. 
 
 The age stated should be the age as given in the paybook of 
 the soldier, and not his age as stated by himself. 
 
 Care should be taken to inquire from him the nature of his 
 occupation in civil life. 
 
 The disability must be clearly defined, and the terms used 
 should, whenever possible, be those of the Official Nomenclature 
 of Diseases. 
 
 XIV. PROCEDURE AT MEDICAL BOARDS 
 
 In the case of Officers, before proceeding to classification, the 
 Standing Medical Boards must ask the Officer whether he has 
 been previously Boarded in Egypt, and if he answers in the 
 affirmative the Board will be postponed till the receipt of the 
 proceedings of the previous Board have been obtained. 
 
 In order to avoid delay the proceedings should be asked for 
 by wire. 
 
 A Board should not in general proceed with the business of 
 classifying a man, unless his paybook is produced and examined, 
 In the event of a new paybook being issued, the old entries 
 relating to Classification should be entered in the new book. 
 
 The classification recommended by the Board, the nature of 
 the disability, and the notes contained in the right-hand columns 
 should be entered in the man’s (paybook) A.B. 64, after approval 
 of the Board’s recommendation by the A.D.M.S. of the District. 
 
 In those cases in which it is undesirable that the man should 
 be aware of the nature of this clinical information, it can be 
 forwarded to the A.D.M.S. of his Division if he belongs to a 
 Division after Boarding, but a man of “ A ” class who is Boarded 
 “ B ” class ceases to belong to a Division, and must be allotted 
 to a fresh Unit. To meet this case, the D.A.G. 3rd Echelon has 
 undertaken to forward any information sent to him to the Officer 
 Commanding the Unit to which such a man will ultimately be 
 allotted. 
 
 Too much stress cannot be laid on the importance of the 
 accurate entry in a man’s A.B. 64 of this clinical information. 
 Nearly all the difficulties which have arisen in connection with 
 
THE MEMORANDUM 
 
 47 
 
 multiple Boards, and of overlong stay in Hospital, have arisen 
 from failure to pass clinical information on with the soldier. 
 In its absence, each Medical Officer has to begin the work over 
 again. 
 
 The following instance is worth narration as showing what 
 can occur: 
 
 A soldier suffering from hysterical protrusion of the abdomen 
 was classed “ A ” and sent up the line, a full report being sent to 
 the A.D.M.S. of the Division. Before he reached the Division 
 a Medical Officer saw him and sent him into Hospital, whence he 
 was returned to the Base to a Hospital he had not been in before. 
 He was again brought before two Medical Boards, and classed 
 “ A ” and sent to a Camp. After some stay in the Camp, a newly 
 arrived Medical Officer saw him and returned him to Hospital 
 for constipation. He was then sent to Helouan for mechanical 
 treatment, where he was again seen by a Medical Officer who 
 was unaware of the former proceedings. This proceeding 
 occupied some months, and might have been obviated if it had 
 been possible to see that full clinical notes accompanied him at 
 each stage of the journey. Concise entries in A.B. 64 offer the 
 simplest means of obviating this difficulty. 
 
 It has been brought to notice that in certain instances men 
 belonging to administrative branches of the Army have been 
 placed by Travelling Medical Boards in Category “ A” subject 
 to their being employed in an administrative unit. 
 
 It must be clearly understood that no man is to be placed in 
 Category “A” unless he is fit for general service in any unit or 
 arm to which he may subsequently be posted or transferred, and 
 that limitations such as that quoted above are not to be taken 
 into consideration. 
 
 In all cases of classification the Medical Classification 
 Form should be completed and signed by the Members of the 
 Board. One copy must be sent to the D.D.M.S. Corps, or 
 A.D.M.S. District, one to the D.A.G. 3rd Echelon, and one to 
 the Officer Commanding the Unit. In such Districts or Corps 
 where the A.D.M.S. or D.D.M.S. wish to ratify the proceedings, 
 the latter two copies cannot be dispatched until formal approval 
 has been given. The decision of the Board, whether “ A,” 
 “B,” “ C," or “D” together with th"' disability should be 
 entered in the man’s A.B. 64. 
 
48 A VISION OF THE POSSIBLE 
 
 Examination at Base and Command Depots 
 
 As laid down in General Routine Order No. 3480, dated 
 31/1/1918. 
 
 Copies and extracts of Medical Boards affecting the A.I.F. 
 or N.Z.E.F. should be sent to H.Q.A.I.F., or N.Z.E.F., Cairo, 
 as the case may be (D.M.S. 3273/1/G, dated 9/11/17). 
 
 XV. DISPOSAL OF OFFICERS AND MEN AFTER 
 BOARDING 
 
 The regulations governing the disposal of Officers and men 
 are laid down fully in the precis of G.R.O.s and need not be 
 recapitulated here. One or two cases, however, require special 
 attention and are detailed below: 
 
 The Case of Men classified “ A ” sent to Front 
 Line and returned 
 
 The following memorandum establishes a procedure for the 
 disposal of such cases : 
 
 No. 2354/G, dated 11/7/17. 
 
 It has been found necessary to establish special Classification 
 Boards. Men classed by these Boards as “A” are sent to the 
 front-line Units, and, as far as possible, the Board sends notes 
 of each man so classified to the M.O. of the Unit to which the 
 man belongs. 1 
 
 Nevertheless the M.O.s of Units send these men back for the 
 disability which, in the opinion of the Board, does not preclude 
 them from being Class “ A.” Thus it comes about that there is a 
 continual traffic up and down the line of these men. In order 
 to reduce this useless up-and-down traffic to a minimum would 
 you please cause all M.O.s of Units to send in a full detailed 
 statement with each man sent sick because of a disability which 
 they consider unfits him for Class “ A.” On admission to a 
 Field Ambulance the O.C. of the Field Ambulance will record 
 his opinion on the statement furnished by the M.O. i/c Unit, 
 and finally the man will be brought before the A.D.M.S. Division, 
 who will decide as to the necessity for evacuation, and in the 
 event of evacuation will give clear reasons for his opinion that 
 the man is unfit for Class “ A ” and will record this opinion on 
 the statement furnished by the M.O. i/c Unit. This document 
 
 1 D,M,S,/E,E,F, 2354/G, dated 11/7/17. 
 
THE MEMORANDUM 
 
 49 
 
 will accompany the man until he next appears before a Classifica¬ 
 tion Board. In the event of a man being with a non-Divisional 
 Unit, a similar procedure will be adopted by the A.D.M.S. of the 
 area in which the man's Unit is located. 
 
 This recommendation from the Front is usually referred to as 
 the Triple Certificate. 1 
 
 The triple certificate applies equally to Officers and other 
 Ranks and to Indian troops sent from Divisions. 3 
 
 Personnel between the Ages of Forty and Forty-six 
 Reclassified “ A ” 
 
 In the case of personnel between the ages of forty and forty- 
 six reclassified “ A " a certificate signed by the Officer Com¬ 
 manding the Unit and the Medical Officer, stating that such 
 personnel are fit for service with front-line Units will accompany 
 nominal rolls rendered to D.A.G. 3rd Echelon.* 
 
 XVI. STANDARDS OF CLASSIFICATION ADOPTED IN 
 SPECIAL DISEASES 
 
 The following notes, based on Army Regulations or on a 
 considerable experience of Standing Boards, are furnished as a 
 general guidance to Medical Officers: 
 
 STANDARDS OF VISION FOR OFFICERS, RECRUITS, 
 AND SERVING SOLDIERS 
 
 A.C.I.s 1367 of 1916, 211, 1371 (para. 1) and 1476 of 1917 
 are hereby cancelled and the following substituted: 
 
 1. Officers (Permanent, Temporary, Special Reserve, 
 AND T.F.) 
 
 (1) A candidate for a commission will be considered fit if his 
 vision, “ without the aid of glasses, is not less than 6/60 with each 
 eye, provided that with the aid of glasses, if necessary, his vision 
 is not less than 6/9 in one eye (R. or L.) and 6/18 in the other.” 4 
 
 (2) A candidate for a commission will be considered fit if he 
 has one eye (R. or L.) with vision of not less than 2/60 and with 
 a good field of vision as tested by hand movements, provided 
 
 1 D.M.S. 2354/425/G, dated 9/4/18. * G.R.O. 4253, dated 26/6/18. 
 
 * D.M.S. 4643/15/G, dated 8/6/18. 4 A.C.I. 421, dated 2/4/18. 
 
 4 
 
50 
 
 A VISION OF THE POSSIBLE 
 
 that “ his vision in the other eye is 6/6 or not less than 6/12 
 without glasses and capable of correction to 6/6 with the aid of 
 glasses.” 
 
 2. Recruits 
 
 Instructions to Examining Medical Officers 
 
 When necessary to retest the vision of a recruit the following 
 procedure will be adopted : 
 
 If a recruit can read without glasses not less than 6/12 with 
 each eye, he may be accepted for Category “ A ” without an 
 examination by an Ophthalmic Specialist. 1 
 
 If the vision is below this standard the recruit shall be sent for 
 examination to an Ophthalmic Specialist. 
 
 Instructions to Ophthalmic Specialists 
 
 Category “A.” —A recruit will be considered fit for Category 
 “ A” if his vision, “ without the aid of glasses, is not less than 
 6/60 with one eye (R. or L.) and not less than 2/60 with the other, 
 provided that, with the aid of glasses if necessary, his vision 
 is not less than 6/12 with one eye, and that both eyes have good 
 fields of vision as tested by hand movements.” 
 
 Category “ B.” —“ B.i.” A recruit whose vision is not equal 
 to the standard laid down for Category “ A ” will be considered 
 fit for Category “ B.i” if his vision, “ without the aid of glasses, 
 is not less than 3/60 with the better or only eye, provided that 
 with the aid of glasses his vision is not less than 6/18 with one 
 eye.” 
 
 “ B.ii.” —A recruit whose vision is not up to the standard laid 
 down for Category “B.i” will be considered fit for Category 
 “ B.ii” if his best obtainable vision with the better or only eye 
 (with or without glasses) is not less than 6/60. 
 
 Men in the Labour Corps whose best obtainable vision, aided 
 if necessary with glasses, is less than 6/24 with the better or only 
 eye will be considered unfit for dangerous employment such as 
 dock labour, railway shunting, etc. 9 
 
 “ B.iii.” —The standard of vision for clerks will be the same 
 as for “ B.i,” while that for other occupations referred to in 
 paragraph 6 B.iii of A.C.I. 1606 of 1917, viz.: 
 
 Storemen, batmen, cooks, orderlies, sanitary orderlies, or 
 skilled tradesmen—will be the same as for “ B.ii.” 
 
 1 A.C.I. 421, dated 2/4/18. 
 
 9 A.C.I. 421, dated 2/4/18, 
 
THE MEMORANDUM 
 
 51 
 
 Note. —(1) A manmay be passed into category “ B.i,” “ B.ii, ’ 
 or “ B.iii” if one of his eyes has been lost or is completely blind, 
 provided that the remaining or better eye is up to the required 
 standard, and has a good field of vision as tested by hand 
 movements. 
 
 (2) No man will be accepted for any form of military sendee 
 with a lower standard of vision than that laid down for “ B.ii.” 
 
 3. Serving Soldiers 
 
 In retesting the vision of serving soldiers the standard will 
 be the same as for recruits, but men who have been found capable 
 of carrying out their duties efficiently need not necessarily be 
 placed in a lower category on account of their eyesight not being 
 equal to the standard laid down for the category in which they 
 are serving. 
 
 4. Commissions in the R.A.F. 
 
 The standard of vision set down for Candidates for Commis¬ 
 sions in the Flying Corps is as follows : 
 
 1. The standard vision for Pilots, Observers, and Balloon 
 Officers will in future be as laid down hereunder: 
 
 Without Glasses. With Glasses. 
 
 Pilots: 
 
 Better eye . . 6/12 6/6 
 
 Worse eye . . 6/18 6/12 
 
 Observers and Balloon Officers: 
 
 Better eye . . 6/18 6/9 
 
 Worse eye . . 6/18 6/12 
 
 Correcting glasses must be obtained when necessary, and be 
 adapted for wear beneath goggles. 
 
 Good colour sense must be insisted upon, and for the purpose 
 of testing this the Edridge Green Lamp will be used; doubtful 
 results being confirmed by the Edridge Green Bead Test. 
 
 2. Candidates having more than two dioptres of hypermetropia 
 will not be accepted as Pilots, but this condition need not dis¬ 
 qualify them from acting as Observers or Balloon Officers. 
 
 For practical purposes the condition may be judged by testing 
 the vision with a + 2. O.D. Lens. A candidate should not then 
 be able to read the test type lower than 6/12. (A.C.I. 1016 of 
 
 1917.) 
 
52 
 
 A VISION OF THE POSSIBLE 
 
 5. Tank Cokps 
 
 1. Officers. — Candidates for Commissions in the fighting 
 personnel of the Tank Corps will be accepted— 
 
 (a) If the vision is in each eye without glasses not less than 
 
 6/18, or 
 
 (b) If the vision without glasses in one eye (R. or L.) is not 
 
 less than 6/9 and in the other not less than 6/60. 
 
 2. Other Banks. —As laid down for Officers in sub-paras. (1) 
 (a) and ( b ). 
 
 6. Drivers in the R.A., R.E., A.S.C. (M.T.), & A.S.C. (H.T.) 
 
 Men will only be accepted as drivers in the R.A., R.E., A.S.C. 
 (M.T.),and A.S.C. (H.T.) if their vision without glasses is not less 
 than 6/18 in one eye and not less than 6/60 in the other, and 
 provided that they have a good field of vision in each eye as 
 tested by hand movements. (A.C.I. 664 of 1918.) 
 
 7. Loss of One Eye (Officers) 
 
 By A.C.I. 1587, dated 14/8/1916 the loss of an eye is not con¬ 
 sidered as constituting a bar to fitness for general service. 
 This means that Officers who have lost an eye will be classed 
 “ A ” unless there is some other disability. 
 
 8. Trachoma 
 
 1. In future soldiers suffering from undoubted Trachoma will 
 be discharged from the service as soon as the disease is definitely 
 diagnosed. 
 
 2. When a man suffering from Trachoma is about to be dis¬ 
 charged from the service, a notification of the facts will be sent 
 to the Civil Medical Officer of Health of the District in which the 
 man intends to reside. 1 
 
 This notification will be in addition to that referred to in 
 A.C.I. 449 of 1917 which is made on A.F. W. 3555 to the Local War 
 Pensions, etc., Statutory Committee. 
 
 9. Hearing 
 
 So far as Hearing is concerned, methodical standards cannot 
 be applied with the same degree of certainty as in the case of 
 vision, but the following principles will serve for guidance : 
 
 The possession of one perfectly sound ear is quite sufficient 
 
 1 A.C.I. 574, dated 4/4/17. 
 
THE MEMORANDUM 
 
 53 
 
 to fit a man for general service. The case is comparatively 
 simple, because the possession of one perfectly sound ear with 
 total deafness in the other ear is a most uncommon combination. 
 
 The possession of hearing somewhat less than normal in both 
 ears well permits of classification “ A.” 
 
 There are practically three standards of hearing in use— 
 
 (a) Ordinary good hearing warrants classification “ A.” 
 
 (b) Hearing short of this standard but sufficiently good for 
 
 Garrison Battalion Guard work warrants classification 
 B.i Front Line, B.iL. of C., or B.ii L. of C. The duties 
 in these three categories so far as hearing is concerned 
 do not differ, and the classification B.i Front Line can 
 be made in every instance when there is no other 
 disability. 
 
 (c) If the man is so deaf that he is not fit for Garrison Bat¬ 
 
 talion Guard work he must be classed B.iii L. of C. 
 
 Otitis Media is not a bar to general service unless it is intract¬ 
 able and profusely purulent, an uncommon condition. Total 
 Deafness warrants the adoption of Class “ B.iii” A totally deaf 
 man has made an excellent hospital orderly. 
 
 10. Teeth 
 
 Speaking generally, dental troubles are not a bar to General 
 Service. It is a practice of the Boards by arrangement with the 
 Consulting Dentist E.E.F. to recommend patients “for Dental 
 Treatment” where (1) the man is “A” Class or (2) “B” 
 Class and suffering from impaired health in consequence of dental 
 defect. The dentist to whom the case is referred then uses his 
 judgment as to the best technical methods to be employed. 
 
 Men who have had a number of teeth extracted and require 
 dentures must wait a definite though varying period for the 
 absorption of the alveolus which always occurs if a tooth or teeth 
 are extracted; such men should be marked B. i or B.ii according 
 to other indications present for the necessary period of waiting, 
 which in most cases should not exceed one month. 
 
 These men should be examined by the dental officers once a 
 week and lists of such cases sent to Presidents of Boards, giving 
 the dates when the mouths will be ready for the insertion of 
 dentures. 
 
 11. Varicocele 
 
 Varicocele is certainly never a disability, as suspensory 
 
54 
 
 A VISION OF THE POSSIBLE 
 
 bandages are available, and there is no proof that Varicocele 
 produces anything worse than a Transient Neuralgia. 
 
 12. Hernia 
 
 Hernia is regarded as a bar to general service at present, and 
 men suffering from Hernia are fitted with trusses and classified 
 “ B.i ” (L. of C.). This procedure does not necessarily hold 
 good in the case of Officers. Clear definition, however, is re¬ 
 required as to what constitutes a Hernia, and the practice has 
 been to describe as Hernia only cases in which the Intestine or 
 Omentum has definitely entered the canal and remained there ; 
 cases of men who have a protrusion on coughing only have been 
 definitely ruled out as not possessing a Hernia. 
 
 Cases suitable for, and who consent to undergo, operation 
 are not fit for full service for 3^ months after operation, and 
 consequently require marking D.i or D.ii for a definite period 
 when convalescent. 
 
 13. Nervous System 
 
 A large number of men complain of headaches, giddiness in 
 the sun, and nervousness. It has been the object of the Board, 
 in such cases, to ascertain whether there is any definite evidence 
 of Neurasthenia, and stress is laid on two points,—the exaggera¬ 
 tion of the knee-jerks and tremor of the tongue. Tremor of 
 the limbs can be simulated ; tremor of the tongue cannot. If a 
 man is definitely and genuinely neurasthenic, he is better classed 
 “ B " and given steady work at the base for a time. It is in such 
 cases that a Garrison Battalion acts as a Therapeutic Agency. 
 The “D ” classification has not hitherto been successful in such 
 cases. 
 
 Similar observations apply to cases of pronounced Hysteria, 
 which are best handled in much the same way. 
 
 Hysterical Aphonia is not uncommon. If it does not give 
 way promptly to local treatment, such men are better classed 
 “ B ” and given steady manual work, little or no notice being 
 taken of the lack of voice. Recovery is usually speedy. 
 
 14. Shell Shock 
 
 Shell Shock will be included in the revised nomenclature of 
 diseases, and I am to request that only cases in which there is 
 evidence of direct contact with the effects of explosion, although 
 
THE MEMORANDUM 
 
 55 
 
 not producing visible wound (as, for example, cases which have 
 been buried or blown up by explosion), will be regarded as “ shell 
 shock (wound).” No diagnosis of this kind will be made, how¬ 
 ever, until the evidence as to direct contact with an explosion 
 has been obtained from the Officer Commanding the man’s unit, 
 or other responsible witness. 1 
 
 Other cases of so-called Shell Shock symptoms or nervousness 
 will be classified in accordance with the nomenclature of diseases, 
 e.g. Neurasthenia, Hysteria, or in such other manner as meets 
 the particular case. 
 
 Cases of “ Shell Shock ” will only be reported as wounded 
 (Shellshock) when the O.C. of a stationary or general hospital 
 has notified the Unit in the Field that this should be done, as laid 
 down in the following paragraph. 
 
 The disposal and classification of Officers and Other Ranks 
 who, without visible wounds, have become non-effective from 
 physical conditions, claimed or presumed to have originated 
 from the effects of British or enemy weapons in action, will be 
 governed by the following regulations: 
 
 The M.O. of a Unit or the O.C. of a Medical Unit who in the 
 first instance deals with the case coming into the above category 
 will not record any diagnosis. The case will be disposed of in 
 the first instance as “ Sick, admitted to Hospital,” and the 
 Medical Officer will enter on the Field Medical Card, or other 
 transfer papers, the letters “ N.Y.D.” only, and note any 
 definitely known facts as to the true origin or the previous history 
 of the case. 
 
 The responsibility for the final diagnosis will rest with the 
 
 O.C. of the FIRST STATIONARY HOSPITAL Or GENERAL HOSPITAL 
 to which the Officer or man is admitted.® 
 
 The Officer will inform the O.C. the unit to which the Officer 
 or man belongs in cases where the diagnosis arrived at is “ Shell 
 Shock.” 
 
 O.C.s will in such cases return the officer or man as “ Wounded, 
 (Shell Shock) previously reported sick, admitted to Hospital.” 
 
 In no circumstances will the expression “ Shell Shock ’ be made 
 use of verbally or be recorded in any Regimental or Casualty report 
 or in any hospital or other document except in cases classified in 
 accordance with the above. 
 
 1 W.O. letter 24/Gen. No. /5425, A.M.D. (2), dated 21/3/17, 
 
 * G.R.O. 346, dated'17/10/17 
 
56 
 
 A VISION OF THE POSSIBLE 
 
 15. Epilepsy 
 
 Cases of undoubted Epilepsy where fits are not frequent are 
 boarded “ B.iii.” Where fits are increasing in frequency the 
 eases are best invalided to England. 
 
 16. Pulmonary System 
 
 A eommon defect is Chronic Bronchitis, with and without 
 Asthma. When this results in definite Dyspnoea, the “ B" 
 classification has generally been adopted. It should be borne 
 in mind that these men when examined exhibit physical signs of 
 varying description. Rhonchi may be present in the morning, 
 and absent at midday, and a broad survey of each case becomes 
 requisite. 
 
 17. Tuberculosis 
 
 Cases will be referred to in the invaliding section. 
 
 18. Vascular System 
 
 The commonest cause of disability is that classed as D.A.H., 
 which is so well-known to all Medical Officers. It includes so 
 many diverse conditions that it will be impossible to refer to it 
 at any length in this connection. There are now special arrange¬ 
 ments made for these cases in Cairo and Alexandria so that 
 they can be examined by specialists and subsequently classified 
 by Boards. 
 
 Cases of D.A.H. are best classified Debility, Tachycardia. 
 
 Valvular Disease of the Heart almost invariably warrants 
 placing the soldier in the “ B ” class, although there have been 
 men with Mitral Incompetence, well compensated, who played 
 an excellent game of football, but nevertheless, in the opinion 
 of the Heart Specialist, were not fit for service in the front line, 
 
 19. Renal System 
 
 It need hardly be said that cases which have recovered from 
 Nephritis are better classed “ B ” and kept at the Base for a 
 substantial period. 
 
 Cases of Bilharzia are either classified “ B.iii ” or in exceptional 
 cases recommended “ Change to England.” As “ B.iii ” men 
 they do very well, but if called on to march or do severe physical 
 work the symptoms usually become aggravated. 
 
THE MEMORANDUM 
 
 57 
 
 Cases of Enuresis where definitely proved require some con¬ 
 sideration. The majority of surgeons think they should be 
 classed “ A ” if they are otherwise fit. 
 
 20. Digestive System 
 
 Cases of Chronic Intestinal infection or Chronie Gastritis 
 form a class which, unlike most of the other diseases, do better 
 in Great Britain than in Egypt, and the Boards have felt dis¬ 
 posed in severe and definite cases of the kind to recommend 
 “ Change to England.” 
 
 In the case of Debility after Dysentery, service at the Base for 
 some months is frequently indicated, and consequently classifica¬ 
 tion “ B.” 
 
 21. Locomotor System 
 
 The cases falling under this heading are perhaps the most 
 numerous with which the Boards have to deal, and they offer 
 most diverse problems. We propose to deal with them seriatim. 
 
 The loss of an arm in the case of an Officer does not constitute 
 a bar to general service, t.e. Class “A,” consequently he must be 
 marked “ A ” if the loss of the arm is the sole disability. 
 
 In the case of the men, a Board has taken the following view : 
 
 If the man is right-handed and has lost the right arm, and 
 consequently re-education is necessary, he is better sent to 
 England. 
 
 If he has lost the left arm and is right-handed, or vice versa, 
 he is fit for “ B.iii,” other things being equal. 
 
 There are, however, cases where a man who retains a limb is 
 worse off than if he had lost it. Such cases are the Flail arm, 
 Drop Wrist, and other results of nervous injury ; also cases of 
 Ankylosis of both Shoulder and Elbow Joints of such a nature 
 that a fall would immediately cause fracture. The view taken 
 is that these cases are better transferred to England. 
 
 Some special attention must be given to Ank 3 7 losed Joints. 
 In the opinion of surgeons, certain degrees of Ankylosis are not 
 a bar to Class “ A ” in all cases, but each case requires special 
 investigation. 
 
 The loss of a finger is not a bar to Class “ A.” 
 
 The total loss of both the Index and Middle finger of the right 
 hand is a bar to Class “A” 
 
 The possession of a stiff finger is not a bar to general service, 
 but the possession of a contracted finger may be. A rifle may be 
 
58 
 
 A VISION OF THE POSSIBLE 
 
 well handled by a man with a stiff finger, but it cannot be 
 handled by a man with a contracted finger. 
 
 Officers .—From the foregoing, it -will be quite obvious that 
 if the loss of an arm is not a bar to general service in the case of 
 Officers, there can be very few defects of an arm which can con¬ 
 stitute a reason for classing an Officer “ B.” 
 
 The Hip Joint .—Cases of Hip-joint Disease are not very 
 common and have invariably been investigated by X-ray photo¬ 
 graphs. Without such an examination, an accurate assessment 
 is difficult to effect. 
 
 Knee Joint. —A large proportion of the Knee-joint cases seen 
 in Egypt are due to football and in too many cases necessitate 
 classification in the “ B ” class. 
 
 The group of cases included under Flat Feet, Hallux Valgus, 
 Hallux Rigidus, Corns, and Pes Cavus constitute a very common 
 disability. They often occur in men who are otherwise perfectly 
 fit in every respect, and give rise to great difficulty in classifica¬ 
 tion. They require 6ome little consideration. 
 
 In the opinion of some surgeons, Flat Foot is not so important 
 as.Hallus Rigidus, and right-angled contraction of the ankle. 
 Mere Flat Foot without eversion, with a good flexible great toe 
 and an ankle which can be flexed to practically a right-angle, is 
 really no disability. The development and tone of the calf 
 muscle should also be taken into account in these cases. 
 
 Flat feet should not be regarded as a disability unless accom* 
 panied by eversion. The so-called flat foot of the sculptor is of 
 little importance. 
 
 The attention of recruits and serving soldiers should on no 
 account be called to this condition unless they themselves bring 
 it to notice. 1 
 
 The general practice adopted by the Boards has been as 
 follows : 
 
 Flat Feet in the slighter cases, without eversion, is not a dis¬ 
 ability. 
 
 Flat Feet in its ultimate stage, with perhaps some bony de¬ 
 formity but without eversion, is not a disability. 
 
 Flat Feet with eversion and notching of the tendo Achilles 
 usually warrants inclusion in the “ B ” class. 
 
 The Boards have seen ploughmen and farmers with marked 
 Flat Feet and splendid physique who are sent down the line 
 1 W.O. letter 121/Medit. 597 (A.M.D. 2), dated 25/5/16. 
 
THE MEMORANDUM 59 
 
 because they cannot march far, and have consequently been 
 compelled to include such men in the “ B ” class. 
 
 Hallux Rigidus unless marked is not a disability. 
 
 Hallux Valgus with Bunions may be a disability, but a case 
 occurred recently where the Board was about to mark a case 
 with Hallux Valgus without bunions “ B.i ” when they were 
 informed that the man was an excellent footballer. It does not 
 do to infer lightly that it is a disability, and all the collateral 
 evidence available is required. 
 
 Pes Cavus is only a disability when quite definite and well 
 marked. Some surgeons take the view that it is very rarely a dis¬ 
 ability, basing their opinion on their experience in civil practice. 
 
 Varicose Veins of the Leg .—The Boards have seen magnificent 
 specimens of men with an enormous development of Varix, who 
 stated that the veins never gave them much trouble when doing 
 severe manual work. Other men, with trifling Varix, complain 
 of swelling when standing or walking. It has been the practice 
 to send these men for a walk or put them on guard, and ascertain 
 definitely what degree of swelling did occur. In general, a 
 moderate degree of Varix is no bar to service. 
 
 A distinction should be made between veins which are dilated 
 and veins which are Varicose. Professional runners and nurses 
 frequently suffer from Varicose veins. 
 
 Many of the cases would be benefited by the use of puttees 
 rolled not too tightly and fastened below. 
 
 22. Myalgia 
 
 This condition gives more difficulty to the Boards than any 
 other disability complained of, and necessitates a searching 
 clinical examination. 
 
 23 . Malaria 
 
 Malaria cases are now treated as other medical conditions, 
 except that cases of Chronic Recurrent Malaria are boarded and 
 may be classed “ B.i” “ B.ii” and “ B.iii” Egypt for a period. 
 
 XVII. INVALIDING BOARDS 
 
 Army Forms in Use in Connection with Classification 
 and Invaliding 
 
 The principal forms used are : 
 
 B. 179, which is employed whenever an N.C.O. or man is recom¬ 
 mended for “ Change to England.” 
 
60 A VISION OF THE POSSIBLE 
 
 A. 45, which is used whenever an Officer is recommended for 
 “ Change to England.” 
 
 A. 45«, which must be filled up before the discharge from hos¬ 
 pital of an Officer who has sustained a wound, accident, 
 or injury in action. 
 
 A. 466, which must be filled up before leaving hospital whenever 
 
 an Officer has sustained a wound, injury or accident, on 
 duty but NOT IN ACTION. 
 
 B. 183. In the case of those of unsound mind who are recom¬ 
 
 mended for “ Change to England.” 
 
 A. 45 (revised). In the case of Nurses, this form will be used. 
 
 In filling up Form B. 179 for cases recommended for transfer 
 to England a number of instructions must be borne in mind : 
 
 The Board is not responsible for the statements made by the 
 Medical Officer. It can, however, amend the diagnosis, and it 
 can express its disagreement with the notes of the M.O. 
 
 A disease cannot both be caused and aggravated by Active 
 Service, because the information is furnished for pension pur¬ 
 poses and the highest grade is granted for causation. 
 
 Pensioners are not to be questioned as to the amount of their 
 actual earnings. 
 
 It has been brought to notice that Medical Boards, when 
 assessing the physical disablement of soldiers about to be in¬ 
 valided, or of pensioners who are being examined for reassess¬ 
 ment of their pensions, are in the habit of making inquiries as 
 to the actual earnings of the pensioners. This is contrary to 
 the present policy. 1 
 
 In no cases are men to be questioned as to the amount of their 
 earnings. 
 
 When the replies to questions 9, 10, and 11 are based on the 
 man’s own statement, the words “ Man’s statement ” should 
 invariably be inserted. 
 
 The Ministry of Pensions has called attention to the glaring 
 discrepancies frequently noticed between the replies to questions 
 13 and 25. 
 
 If the reply to question 21 is in the negative, question 22 
 should invariably be answered, as otherwise further reference and 
 unnecessary delay is involved. 
 
 Assessment of incapacity in reply to question 25 should 
 always be in percentages of disablement in accordance with the 
 1 A.C.I. 1615, dated 27/10/17. 
 
THE MEMORANDUM 
 
 61 
 
 instructions on the form, such terms as “Not applicable,” “The 
 same as on enlistment,” “Not lessened since enlistment,” “Nil 
 due to service,” are not to be used, as they do not help in dealing 
 with the case from the financial point of view. 1 
 
 It is desirable that Medical Boards should recommend institu¬ 
 tional treatment in every case of loss of sight when the man 
 has no useful vision. 
 
 Bronchitis, Pleurisy, Pneumonia, Rheumatic Fever, and 
 Nephritis are only to be regarded as caused by active service if 
 they are due to proved exposure. If necessary this evidence is 
 to be obtained from the O.C. Unit to which the man belongs. 
 Duty at the Base or on L. of C. can but rarely be regarded as 
 either cause or aggravation by service. If the foregoing principles 
 are borne in mind the answer to the question should present no 
 difficulties.® 
 
 With regard to Diphtheria, it is not to be lightly assumed that 
 the liability thereto is as great on active service during an out¬ 
 break as in civil life, and members of Boards will therefore care¬ 
 fully weigh the question before attributing it to active service. 
 
 Officers and Soldiers Invalided for Tuberculosis 
 of the Lung 
 
 1. As it is found that the wording of A.C.I. 1108 of 1917 is 
 liable to be misunderstood, the following will be substituted for 
 the instruction which is hereby cancelled. 
 
 2. Owing to the difficulty of deciding in the case of Officers 
 invalided and soldiers discharged on account of tuberculosis of 
 the lung whether or not the disability is attributable to or aggra¬ 
 vated by military service, and in order that a uniform procedure 
 may be followed by Medical Boards when dealing with such cases, 
 it has been decided that the following principles should be 
 adopted: 
 
 (a) In all cases in which the Officer or soldier has developed 
 the disease during service overseas, it will be considered as attri¬ 
 butable to or aggravated by military service.* 
 
 (b) In other cases, unless the Board are satisfied that phthisis 
 was present previous to the man’s enlistment or (if he did not 
 serve in the ranks) to the Officer’s commission, and that it was 
 
 1 A.C.I. 1475, dated 26/9/17. 
 
 8 D.M.S./G.H.Q./E.E.F. 3721/0S, dated 3/1/18. 
 
 8 A.C.I. 1671, dated 10/11/17. 
 
62 
 
 A VISION OF THE POSSIBLE 
 
 not aggravated by military service, it should also be considered 
 as attributable to or aggravated by military service. 
 
 Military Orthopedic Cases 
 
 Military Orthopaedic cases will be held to include : 
 
 1. Derangements and disabilities of joints, including Anky¬ 
 losis. 
 
 2. Deformities and disabilities of feet, such as Hallux Rigidus, 
 Hallux Valgus, Hammer toes, metatarsalgia, painful heels, flat 
 and claw feet. 
 
 3. All malunited and ununited fractures. All fractures of the 
 femur. 
 
 4. Cases of nerve-lesion requiring operative or other treatment. 
 
 5. Cases requiring tendon transplantation. 
 
 6. Cases requiring surgical appliances. 1 
 
 Military Orthopaedic cases when being invalided to England 
 will be specially labelled in order that they maj r be suitably dis¬ 
 tributed on arrival. (W.O. letter 24/Gen. No./4843 A.M.D. (2), 
 dated 30/8/1917.) 
 
 Jaw and Limb Cases among New Zealand Soldiers 
 
 Bad jaw cases and badly damaged limb cases that can be 
 improved by special treatment which is available in England and 
 not in New Zealand are to be invalided to England in order that 
 they may receive such special treatment. 
 
 Headquarters N.Z.E.F. in Egypt, W. 28, dated 25/5/1918. 
 
 Wounds or Injuries sustained in Action (Officers) 
 
 With reference to Articles 641 to 647 of the Royal Warrant for 
 Pay 1914 will you please arrange for all Officers who sustain 
 wounds or injuries in action to be examined by a Medical Board 
 as soon as it is considered that a true estimate of the wound or 
 injury can be determined. 2 
 
 Proceedings to be prepared on Army Form A 45a and forwarded 
 to this office in duplicate. The instructions on the back of this 
 form must be strictly adhered to. 
 
 These Boards should only be held in hospitals in Cairo. 
 
 1 A.C.I. 1314 of 1917. 
 
 2 D.M.S./G.H.Q./E.E.F. 2250 G, dated 1/6/17. 
 
THE MEMORANDUM 
 
 63 
 
 Sick Leave of Q.A.I.M.N.S. Reserve, T.F.N.S. and V.AJX 
 and Special Probationers employed on Nursing Duties 
 
 The revised A.F. A 45 will be used to report proceedings 
 of Medical Boards on nurses and probationers, but Categories 
 2, 5 (b), 6 (a) and (b), and 7 will be struck out. 1 
 
 XVIII. COMMISSIONS 
 
 Applicants for Commissions will be examined in accordance 
 with the procedure laid down in the regulations for the R.A.M.C., 
 due regard being paid to the following Army Council Instructions : 
 
 1. During the period of the present war, officers acting on 
 general service, who have proved their physical fitness by active 
 service in the field, will not be required to undergo further medical 
 examination when recommended for permanent commissions. 
 
 2. Similarly, Warrant Officers, N.C.O.s, and men on general 
 service recommended for commissions on account of their 
 aptitude for military work in the field, who have proved during 
 their service in the field that they are physically fit to perform 
 the duties which devolve upon a soldier on active service, may 
 be accepted without further medical examination.* 
 
 3. Officers and men will not be recommended who are obviously 
 physically unfit for general service. 
 
 4. In doubtful cases a medical examination may be called for. 
 
 1 A.C.I. 1654, dated 6/11/17. 
 
 * A.C.I. 1922, dated 19/10/16. 
 
CHAPTER V 
 
 BOARDING SYSTEM 
 
 As time passed the functions of the Standing Medical 
 Boards widened. They became Boards of Classifica¬ 
 tion, Boards of Invaliding, the Commissioners of Pen¬ 
 sions referred cases to them for report, applicants for 
 Commissions came under their cognizance, and finally 
 it was decided that the Boards should investigate the 
 physical condition of all prisoners of war who were to 
 be repatriated. The latter function became a most 
 extensive one, as the figures quoted later will indicate; 
 but in addition to these duties, yet another function 
 made its appearance as the war dragged on. People 
 in England, apparently through Members of Parlia¬ 
 ment in many cases, wrote to the War Office stating 
 that a soldier in Egypt was reported to be in a 
 desperate condition. His sight was being ruined by 
 the sun, or his health by the climate, as the case might 
 be. These statements reached Egypt through the 
 usual channel, and a Medical Board was then held on 
 the soldier. Inquiries of this kind took up a good 
 deal of time before the war ended. It will be seen, 
 therefore, that the Standing Medical Boards were now 
 occupied with six distinct functions: Classification, 
 Invaliding, Pensions, Commissions, Repatriations, and 
 Special Inquiries. 
 
 The work had become greatly extended during 1917 
 after the visit of the Inspector of Man Power, when 
 
 64 
 
BOARDING SYSTEM 
 
 65 
 
 substitution was introduced on an extensive scale— 
 that is, the fit men on the Lines of Communication were 
 replaced by the partially unfit—and the pressure on 
 the Boards became very great indeed ; at the end of 
 1917 the D.M.S. estimated that directly or indirectly 
 a division had been added to the Force in the E.E.F. 
 by the work of the Standing Medical Boards. As the 
 development of the man-power problem continued, 
 all the garrison battalions were combed out twice—that 
 is to say, they were examined twice with a view to re¬ 
 classifying their members, and a large number of men 
 in the categories of “ A ” and “ B.i Front Line ” were 
 obtained from them. Furthermore all fresh drafts of 
 garrison battalion personnel from Great Britain were 
 classified on arrival. Of both these proceedings there 
 is a good deal to say. In one garrison battalion 800 
 strong, no less than 400 men (approximately) were 
 classed “ A,” and a further number were classed “ B.i 
 Front Line.” It will be readily understood that so 
 drastic a combing out of the battalion did not excite 
 the enthusiasm of the battalion commander nor of his 
 stall, though they loyally supported the finding of the 
 Board. 
 
 The details given in the table on page 66 tell their 
 own tale. 
 
 In the course of these investigations many perfectly 
 fit men were found who stated that they had never 
 been previously examined, but had been incorporated 
 direct from the Special Reserve. In very many cases 
 no record of previous classification could be found—in 
 fact, it was perfectly evident that no careful scrutiny 
 had been made. When permission was given in 1917 to 
 enter the finding of all Medical Boards, with clinical 
 notes, in the paybook (A.B. 64), these irregularities 
 5 
 
66 
 
 A VISION OF THE POSSIBLE 
 
 RECLASSIFICATION OF A GARRISON BATTALION 
 
 January 23 to March 30, 1818 
 
 Presented for reclassification 
 
 Deferred as stated below .... 
 
 Reclassified, as below ..... 
 
 . 827 
 . 48 
 
 . 779 
 
 Disability. 
 
 Raised to 
 '• A.” 
 
 Raised to 
 “ B.I.F.L.” 
 
 Confirmed 
 “ L. of 0." 
 "BiorB.ii” 
 
 •• BUi." 
 
 Total. 
 
 None .... 
 
 281 
 
 These i 
 “ No A] 
 
 nen were 
 Dparent D 
 
 marked 
 isease ” 
 
 281 
 
 Age .... 
 
 — 
 
 24 
 
 91 
 
 1 
 
 lie 
 
 Feet .... 
 
 21 
 
 6 
 
 20 
 
 — 
 
 47 
 
 Debility 
 
 9 
 
 5 
 
 25 
 
 1 
 
 40 
 
 D.A.H. 
 
 2 
 
 2 
 
 29 
 
 2 
 
 36 
 
 Hernia (and Hy.) . 
 
 5 
 
 — 
 
 28 
 
 — 
 
 33 
 
 Bronchitis 
 
 2 
 
 1 
 
 27 
 
 — 
 
 30 
 
 Vision Def. . 
 
 5 
 
 8 
 
 16 
 
 — 
 
 29 
 
 Organic Disease of Heart 
 
 — 
 
 2 
 
 24 
 
 2 
 
 28 
 
 G.S.W. (old) . 
 
 21 
 
 2 
 
 5 
 
 — 
 
 28 
 
 Miscellaneous 
 
 4 
 
 1 
 
 14 
 
 3 
 
 22 
 
 Varix .... 
 
 9 
 
 1 
 
 5 
 
 — 
 
 15 
 
 Old Injury 
 
 7 
 
 — 
 
 6 
 
 — 
 
 13 
 
 Hearing Def.. 
 
 7 
 
 1 
 
 2 
 
 3 
 
 13 
 
 Poor Physique 
 
 1 
 
 4 
 
 5 
 
 — 
 
 10 
 
 Teeth Def. 
 
 8 
 
 — 
 
 — 
 
 — 
 
 8 
 
 Obesity 
 
 3 
 
 1 
 
 3 
 
 — 
 
 7 
 
 Speech 
 
 1 
 
 — 
 
 6 
 
 — 
 
 7 
 
 Arthritis 
 
 1 
 
 — 
 
 4 
 
 — 
 
 5 
 
 Varicocele 
 
 4 
 
 — 
 
 — 
 
 — 
 
 4 
 
 Epilepsy 
 
 — 
 
 — 
 
 — 
 
 3 
 
 3 
 
 Myalgia 
 
 2 
 
 — 
 
 — 
 
 — 
 
 2 
 
 Neurasthenia 
 
 — 
 
 — 
 
 — 
 
 — 
 
 2 
 
 Rheumatism 
 
 — 
 
 1 
 
 — 
 
 — 
 
 1 
 
 
 393 
 
 59 
 
 312 
 
 15 
 
 779 
 
 Deferred for Consulting Surgeon’s report. . . .12 
 
 ,, ,, ,, Aurist’s report .... 7 
 
 , ,, ,, ,, Oculist’s report . . . .14 
 
 ,, ,, ,, Treatment or Observation . .11 
 
 ,, ,, ,, Physician’s report . . .4 
 
 48 
 
 began to disappear. A standing order was issued that 
 any man about whose category there was any doubt, 
 or whose classification was not entered in his paybook, 
 should be at once brought before a Board. By the 
 
BOARDING SYSTEM 67 
 
 end of the war, the combing out of the garrison bat¬ 
 talions yielded practically no Category “ A ” men. 
 
 One rather theatrical incident throws a sidelight on 
 the man-power problem : 
 
 During the winter of 1917, Military Football Leagues 
 were very active in Cairo and Alexandria, and as the 
 soldiers in Cairo and Alexandria were supposed to be 
 “ B ” Class men, the Inspector of Man Power, through 
 the proper channel, requested that the Standing Medical 
 Board should investigate the physical condition of all the 
 football players in Cairo. The result was as follows : 
 
 Of the 400 footballers, about 270 were known to be 
 “ A ” Class men employed in various administrative 
 units, but 127 men were classed “ B,” and were accord¬ 
 ingly reconsidered and reclassified. Of the 127 men 
 some had recently been classified “ B,” and there was 
 no suggestion that any change should be made. The 
 127 men were divided into Hospital Personnel, and 
 Personnel of other Units. Of the 52 men employed 
 in hospitals, it was decided to re-examine 16, of whom 
 14 were reclassified. Of the 75 belonging to other 
 units, 44 were examined, of whom 35 were classified 
 and 9 deferred. 31 were absent. It became a matter 
 of extreme difficulty to trace the whole of these men 
 and to get them before a Board. 
 
 The general result was as follows : 
 
 Of the 52 men of the Hospital Teams, 16 were re¬ 
 examined, 4 were classed “ A,” and 2 “ B.i Front Line/' 
 
 Of the 75 remaining men, 44 were reclassified, 14 
 were classed “ A," and 5 “ B.i Front Line.” 
 
 When the absent men were finally brought before a 
 Board, the total result was a substantial gain for the 
 “ A ” Class men. The position then taken up is indi¬ 
 cated in the following statement: 
 
68 
 
 A VISION OF THE POSSIBLE 
 
 “ It need hardly be said that the fact of the ‘ B * 
 Class man playing football, or taking other violent 
 exercise, should be made an a 'priori reason for his 
 Medical Officer at once submitting him to a Standing 
 Medical Board.” I do not wish to labour the importance 
 of this incident in itself. Its importance lay in the 
 indication it furnished of the necessity for tightening 
 up the system, and it led to important developments in 
 that direction. 
 
 In addition, during the examination of the garrison 
 battalions previously referred to, two unusually power¬ 
 fully made men presented themselves. I inquired of 
 them what they had the matter with them, and they 
 said they had nothing; when I asked them why 
 they had been classed “ B,” they replied that they had 
 been boarded in England and understood they had been 
 made “ B ” Class men because they were professional 
 footballers. They stated that they had no desire to 
 remain ‘‘ B ” Class men and were quite prepared to do 
 their work at the front. They were accordingly classi¬ 
 fied “ A.” It makes very little difference if a few “ A ” 
 class men be kept at the base for special reasons, 
 but it does make a profound difference if men once get 
 it into their heads that other than military medical 
 considerations enter into the decisions of the Boards, 
 and the examination of the footballers in Cairo had an 
 influence far beyond the intrinsic importance of the 
 investigation itself. 
 
 The methodical examination of all “ B ” Class per¬ 
 sonnel on arrival in Egypt elicited facts of the most 
 far-reaching importance. In general, about one-third 
 of the “ B ” Class personnel who arrived in Egypt 
 were immediately placed in the “ A ” category—that is, 
 the Board regarded them as quite fit for front-line 
 
BOARDING SYSTEM 
 
 69 
 
 service. They were sent to the front line, and I 
 understand that the majority of them did the work 
 quite well. This result was apparently owing to the 
 different standards adopted by Boards in Great Britain 
 and Boards in Egypt, and the difference in standards 
 was in my candid conviction due to two causes : 
 
 1. That in Egypt the Boards were entirely in the 
 hands of whole-time medical officers, and usually officers 
 with temporary commissions. 
 
 2. In England some Boards were said to be conducted 
 by civilian doctors, a number of whom had apparently 
 not served abroad, certainly had not served in Egypt or 
 Mesopotamia, and presumably did not fully understand 
 the conditions, or what a soldier should be prepared to do. 
 
 A perusal of Chapter IX will indicate the divergence 
 of views as regards visual standards alone. We learnt 
 afterwards that the fact that so many men of the “ B ” 
 category were classed “ A ” on arrival in Egypt was 
 attributed in England to the salubrious nature of the 
 climate in Egypt, which apparently produced this 
 startling improvement within a week or two of their 
 arrival in that placid country. 
 
 In closing this chapter it is necessary to remind 
 the reader that the conclusions now presented in crys¬ 
 tallized form were but dimly visible whilst the work was 
 being conducted, and that it was only in the early part 
 of 1918 that order was beginning to be evolved out of 
 the loose system that had grown up. It is difficult now 
 to realize that these recruits arrived in Egypt in many 
 instances without specific information respecting the 
 reasons why they had been classified “ B ”; and that as 
 clinical information was rarely furnished by the British 
 Medical Boards, the whole of the work had to be done 
 over again. It was this circumstance that resulted in 
 
70 
 
 A VISION OF THE POSSIBLE 
 
 the discovery that the standards differed so widely. 
 At first the British classification was accepted without 
 demur, but when scores and then hundreds of the men 
 were returned by the Boards as fit who had been 
 classed as unfit by British Boards, it became evident 
 that there was a serious divergence of views. Presidents 
 of Boards have often felt that the nation would have 
 gained immensely had some of the presidents of the 
 English Boards visited Egypt, and some of the presidents 
 of the Egyptian Boards visited Great Britain, and that 
 the disastrous shortage of men in the British Army 
 at the commencement of 1918 might have been thus 
 minimized. 
 
 CLASSIFICATION BOARD HELD AT TANTA 
 March 10, 1918 
 
 A newly arrived draft of 50 men to the.was examined. These 
 
 men were classified “ B” in England, but their A.B. 64 contained no 
 statement as to their Class or disability. 
 
 Of the 50 men, 49 were present and one was absent in hospital. The 
 following statement shows the changes in classification. 
 
 Disability for which classed 
 “ B ” in England. 
 
 Ko. 
 
 Classed. 
 
 Raised 
 to “ A.” 
 
 Raised to 
 “ B.i F.L." 
 
 Class 
 
 Confirmed. 
 
 Deferred 
 to see 
 Specialists. 
 
 Vision .... 
 
 19 
 
 10 
 
 1 
 
 ._ 
 
 8 
 
 Debility 
 
 8 
 
 5 
 
 1 
 
 2 
 
 — 
 
 Hearing 
 
 2 
 
 2 
 
 — 
 
 — 
 
 — 
 
 Organic Heart Disease . 
 
 3 
 
 “ 
 
 (one lowe 
 
 1 
 
 red “ B.ii 
 
 1 
 
 i”) 
 
 Age .... 
 
 2 
 
 — 
 
 — 
 
 2 
 
 — 
 
 Bronchitis 
 
 2 
 
 — 
 
 1 
 
 1 
 
 — 
 
 Flat Feet 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 G.S.W. (old) . 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Loss of Finger (3rd left) . 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Poor Physique 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 I.D. Knee Joint 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 Kyphosis 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 Fractured Leg 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Varicocele 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Pains in Back 
 
 1 
 
 — 
 
 — 
 
 — 
 
 1 
 
 Old Sprained Ankle 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Piles .... 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 Hernia 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 Myalgia 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 
 49 
 
 22 
 
 9 
 
 7 
 
 10 & 1 
 lowered 
 
BOARDING SYSTEM 
 
 71 
 
 In order that there may be no misapprehension of 
 this point, the results are shown of a number of 
 examinations of men who had just arrived in Egypt 
 classed as Garrison Battalion men. 
 
 The first instance is given on page 70, from which 
 it will be seen that of the 49 men examined, 22 were 
 raised to Class “ A,” and 9 to Category “ B.i Front 
 Line/’ and it will be noticed that of the 31 men so 
 raised, no less than 11 were raised on account of 
 altered visual standards. 
 
 CLASSIFICATION BOARD HELD AT PORT TEWFIK 
 March 17, 1918 
 
 Disability. 
 
 No. 
 
 Classed. 
 
 Raised 
 to "A." 
 
 Raised 
 to "B.i 
 F.L.” 
 
 Class Con¬ 
 firmed. 
 
 Deferred 
 to see 
 Specialist. 
 
 Vision 
 
 
 
 29 
 
 22 
 
 2 
 
 _ 
 
 6 
 
 Debility 
 
 
 
 26 
 
 24 
 
 1 
 
 1 
 
 — 
 
 Hernia 
 
 
 
 16 
 
 1 
 
 2 
 
 12 
 
 1 
 
 G.S.W. (old) 
 
 
 
 13 
 
 6 
 
 3 
 
 4 
 
 — 
 
 Age .... 
 
 
 
 13 
 
 — 
 
 6 
 
 8 
 
 — 
 
 Feet.... 
 
 
 
 10 
 
 3 
 
 4 
 
 2 
 
 1 
 
 Hearing . 
 
 
 
 8 
 
 7 
 
 — 
 
 — 
 
 1 
 
 Old Injury 
 
 
 
 7 
 
 4 
 
 1 
 
 — 
 
 2 
 
 D.A.H. 
 
 
 
 6 
 
 1 
 
 3 
 
 2 
 
 — 
 
 Poor Physique . 
 
 
 
 6 
 
 — 
 
 2 
 
 4 
 
 — 
 
 Varix 
 
 
 
 5 
 
 2 
 
 2 
 
 1 
 
 — 
 
 Myalgia 
 
 
 
 3 
 
 3 
 
 — 
 
 — 
 
 — 
 
 Under size 
 
 
 
 3 
 
 — 
 
 2 
 
 1 
 
 — 
 
 Bronchitis . 
 
 
 
 2 
 
 1 
 
 — 
 
 1 
 
 — 
 
 Neurasthenia 
 
 
 
 2 
 
 — 
 
 2 
 
 — 
 
 — 
 
 Rheumatism 
 
 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Enlarged Thyroid (old history of) 
 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Dyspepsia . 
 
 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — 
 
 Hysteria . 
 
 
 
 1 
 
 — 
 
 I 
 
 — 
 
 — 
 
 Synovitis, Knee . 
 
 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Nephritis . 
 
 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Organic Disease of Heart 
 
 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Piles 
 
 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Hydrocele . 
 
 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Epilepsy . 
 
 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 
 169 
 
 77 
 
 31 
 
 41 
 
 10 
 
 Summary 
 
 Percentage raised to “ A ” . . . . . . 48’4 
 
 „ „ ,, “ B.i F.L.”.19 5 
 
 Total 
 
 67'9 
 
72 
 
 A VISION OF THE POSSIBLE 
 
 Another draft of 159 men, most of whom were new 
 arrivals from England, were examined at Port Tewfik 
 on March 17, 1918, with the result shown on page 71. 
 Again it will be noticed that of the 77 men classed 
 “ A,” 22 were raised on account of vision. 
 
 Again, during the month of March 1918, 69 men 
 were examined who had arrived in Egypt and were 
 stated to have been classified “ B ” in Great Britain. 
 Of the 69 men examined, 49 were classed “ A,” 7 were 
 classed “ B.i Front Line ”—that is, 56 out of a total 
 of 69. The men classed “ A ” were said to be suffering 
 from the following disabilities : 
 
 Hearing ..... 1 
 
 Vision ..... 7 
 
 Feet.1 
 
 Poor Physique ... 2 
 
 Gunshot Wound ... 2 
 
 Miscellaneous .... 5 
 
 No apparent disease . . 31 
 
 49 
 
 The table is set out on page 73. 
 
 I have given these three instances because these 
 drafts were examined at different times and places, 
 and represented different arrivals. The results are 
 tolerably uniform, justifying the general statement 
 made in my report to the D.M.S. that of new arrivals 
 in Egypt sent from Great Britain and allotted to garrison 
 battalions, it may be said in general terms that about 
 one-third are “ A ” class men, about one-third are 
 “ B.L. of C.” and less than one-third are “ B.i Front 
 Line,” 
 
BOARDING SYSTEM 
 
 73 
 
 CLASSIFICATION BOARD, CITADEL 
 March 27, 1918 
 
 Disability. 
 
 No. 
 
 Classed. 
 
 Raised 
 to “ A.” 
 
 Raised to 
 “ B.i F.L.” 
 
 Raised to 
 “ B.i L.C.” 
 
 Confirmed 
 “ B.i L.C.” 
 
 N.A.D. 
 
 31 
 
 31 
 
 The ma 
 stated 
 idea wh 
 
 ority of t 
 that thej 
 y they we 
 “ B.” 
 
 hese men 
 r had no 
 re classed 
 
 Vision .... 
 
 10 
 
 7 
 
 2 
 
 — 
 
 1 
 
 Debility 
 
 5 
 
 
 
 3 
 
 1 (1 
 
 lowered 
 to B.ii 
 L.C.) 
 
 Feet .... 
 
 3 
 
 1 
 
 2 
 
 — 
 
 — 
 
 Poor Physique 
 
 3 
 
 2 
 
 — 
 
 1 
 
 — 
 
 Age .... 
 
 3 
 
 *- 
 
 3 
 
 — 
 
 — 
 
 Hearing 
 
 2 
 
 1 
 
 — 
 
 1 
 
 — 
 
 G.S.W. 
 
 2 
 
 2 
 
 — 
 
 — 
 
 — 
 
 Hernia 
 
 2 
 
 — 
 
 — 
 
 2 
 
 — 
 
 Asthma 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Loss of Finger 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Neurasthenia 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Varix .... 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Rheumatism . 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Stature 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 D.A.H. 
 
 1 
 
 1 
 
 — 
 
 - 
 
 — 
 
 Organic Heart Disease . 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 
 69 
 
 49 
 
 7 
 
 10 
 
 2 (1 
 
 lowered) 
 
 Raised to “ A” . . . . . .71 percent. 
 
 „ ,, “ B.i F.L.”.10 „ „ 
 
 At the conclusion of the war a fresh batch of R.A.M.C. 
 personnel were boarded, who had arrived in Egypt 
 comparatively recently, and rather to the surprise of 
 the Board we found that apparently there had been no 
 material alteration of the British standards. These 
 men had all been classed “ B.i or “ B ii.” The total 
 number of men reclassified was 83, and of these 21 
 were classed “ A,” and 16 “ B.i Front Line.” A 
 number were deferred for further examination; and as 
 many of them were in Category “ B ” for visual reasons, 
 it is practically certain there will be several more “ A ” 
 men amongst them. 
 

 CHAPTER VI 
 
 boarding system ( continued ) 
 
 In the course of the work of the Standing Medical Boards, 
 two other remarkable problems came to light, and 
 came to light solely because of the existence of the 
 Standing Medical Boards, since apparently there was 
 no other mechanism in the R.A.M.C. available for their 
 detection. When the hospital of A1 Hayat, Helouan, 
 was opened, it was intended to be a reception station 
 for all disabled men who were unable to reach England 
 on account of the submarine menace. At or about the 
 time of its opening, however, the submarine campaign 
 became somewhat mitigated, the Spanish Commissioners 
 boarded all steamers, and this hospital, No. 71 General 
 Hospital, was then made largely an Orthopaedic and 
 Convalescent Hospital as it was so well fitted with 
 orthopaedic appliances. As a result, every hospital in 
 Egypt transferred its chronic cases to Helouan, and a 
 most extraordinary collection of clinical material made 
 its appearance. Cases that defied treatment, men 
 who did not particularly want to get well quickly, 
 men who were tired of the war, and a certain sprinkling 
 of malingerers—in fact, all the tail of the army collected 
 at A1 Hayat. The nature of the problem soon became 
 apparent; and the officer commanding the hospital, 
 realizing the position, ordered that every patient who 
 had been in the hospital for one month should be 
 brought before the Standing Medical Board, and the 
 
 74 
 
BOARDING SYSTEM 
 
 75 
 
 Board should then decide whether the man should be 
 invalided, whether he should be classified, or whether 
 further treatment should be continued. Furthermore, 
 in every case inquiry was made as to how long such a 
 man had been in hospital. The ordinary return sent 
 to the D.M.S. from a hospital only indicated the time 
 he had been in that hospital, and an attempt was now 
 made to find out how long a number of these men had 
 been in hospitals altogether. The table which follows 
 indicates the rather remarkable position that had been 
 reached: 
 
 71ST GENERAL HOSPITAL, HELOUAN 
 April 28, 1918 
 
 The following table shows the length of stay in hospital of 106 men 
 who appeared before a Medical Board on the above date : 
 
 1 man had completed a period of 16 months 
 
 1 
 
 1 
 
 1 
 
 36 
 
 40 
 
 17 
 
 8 
 
 I 
 
 12 
 
 8 
 
 7 
 
 6 
 
 5 
 
 4 
 
 3 
 
 2 
 
 The average period in the above cases is 5-2 months. 
 
 Vigorous measures were taken by the Standing 
 Medical Board, and before long the problem was solved. 
 
 When the hospital was broken up again, the evil 
 disappeared from sight; for being distributed through¬ 
 out all the hospitals in the Command, it was not 
 sufficiently remarkable in any one hospital to attract 
 much notice. 
 
 The second problem which arose was due to the 
 prevalence of malaria, and particularly of the benign 
 tertian and recurrent form. Patients suffering from the 
 recurrent benign tertian form were ill usually one to 
 three days every ten to fourteen days, and were 
 
76 
 
 A VISION OF THE POSSIBLE 
 
 tolerably well in between. The usual routine was that 
 when they reached their depot at Kantara they de¬ 
 veloped a shivering fit, were sent into the local hospital, 
 which was always overcrowded, and were then trans¬ 
 ferred to either Cairo or Alexandria, where they arrived 
 afebrile. They were watched carefully by a medical 
 officer for eight to ten days, who, noticing nothing 
 wrong, discharged them either back to Kantara or 
 to a Convalescent Depot. Sooner or later they developed 
 another shivering fit, and were again sent to another 
 hospital, and the round began anew. They were known 
 in the service as “ The Round Trippers.” Some of them 
 had been travelling in this way from eight to fourteen 
 or fifteen months, and had done no work during the 
 whole of that period, since no one saw exactly what 
 was occurring because of the fact that they usually 
 obtained admission into a fresh hospital with each 
 attack. The Standing Medical Board inquired into the 
 matter, reported the facts, and, under instruction, 
 classified these men “ B.ii L. of C. Egypt, for Duty and 
 Treatment.” They were thus placed in a non-malarial 
 region, they were kept under medical supervision, and 
 when attacks came on they were placed in a small 
 detention hospital for two or three days. This method 
 put an end, not only to the problem, but in many 
 instances to the disease, the combination of regular work 
 with treatment producing most beneficial results. One 
 of the Round Trippers gave evidence that he had been 
 an inmate of every hospital in Egypt, but added that 
 he was unable to say which one he preferred. 
 
 When the facts relating to the prevalence of “ A ” 
 men in the Garrison Battalions were realized by the 
 Administrative Medical Officers, steps were taken to 
 adjust the difficulty, and the following certificate was 
 
BOARDING SYSTEM 77 
 
 required every month from the medical officer in charge 
 of the battalion : 
 
 “ I certify that the remaining Class ‘ B ’ personnel (Officers 
 and Other Ranks) who are in or attached to units under my 
 medical charge, and who were due for re-examination during 
 the past month, have been duly re-examined by a Medical Officer, 
 and that I consider their classification should remain unchanged.” 
 
 This meant that the whole battalion was medically 
 inspected once a month, and that any man about whose 
 category there was any doubt was submitted at once 
 to the Standing Medical Board. 
 
 A number of other serious problems came before the 
 Boards, and under instructions from administrative 
 officers all anomalies were reported in detail, and by 
 this means the administration gradually improved in 
 efficiency; in other words, a seventh function had been 
 imposed on the Standing Medical Board—that its 
 members were to act as Medical Intelligence Officers and 
 formally draw attention to any irregularities which came 
 under their notice. 
 
CHAPTER VII 
 
 STATISTICAL RESULTS OF THE WORK 
 
 It must be remembered that when the work of the 
 Standing Medical Boards was begun in 1917, there was 
 little printed or written evidence to guide them. No 
 statistical evidence was available, and most medical 
 officers had their own ideas about fiat feet and the like. 
 By way of preliminary, an analysis was made of 672 
 men who were classified by a Civilian Board—that 
 is, a Board of temporary Military Medical Officers—in 
 May 1917. 
 
 Of these 672 men, 150 were marked “ B ” for defor¬ 
 mities of the feet, as shown in the sub-heading. 
 
 The remainder were classified as follows: 
 
 97 D.A.H. 
 
 53 V.D.H. 
 
 39 G.S.W. 
 
 51 Myalgia and Rheumatism. 
 
 29 Hernia. 
 
 30 Varicocele and Varix. 
 
 80 Debility. 
 
 37 Asthma, Bronchitis, and Emphysema. 
 
 10 Defective Vision. 
 
 15 Defective Hearing. 
 
 81 Miscellaneous. 
 
 78 
 
STATISTICAL RESULTS OF THE WORK 79 
 
 Of the 150 men who were classed for deformities of 
 the feet, no less than— 
 
 82 
 
 were 
 
 for Flat feet. 
 
 24 
 
 33 
 
 33 
 
 Deformities of the feet. 
 
 23 
 
 33 
 
 33 
 
 Hammer toes, etc. 
 
 6 
 
 33 
 
 33 
 
 Injuries to ankles. 
 
 15 
 
 33 
 
 3 3 
 
 Miscellaneous. 
 
 A comparison of this table with subsequent tables 
 will show the extent to which deformities of the feet 
 disappeared, the extent to which myalgia disappeared, 
 and the extent to which D.A.H. disappeared, whilst 
 varicocele disappeared altogether. 
 
 With the foregoing facts recorded as a guide, the 
 work began, and towards the end of October 1917 a 
 classification had been effected of about 9,000 cases. A 
 great many more had been examined, but as I had little 
 clerical assistance it was impossible to keep count of all 
 of them. 
 
 The result was as shown in the table on page 80. 
 
 The following report was drafted by me as the result 
 of the work done up to October 31, 1917 : 
 
 1. Area dealt with .—The following report furnishes an account 
 of the Classification of 8,918 Officers and men, who have been 
 examined between the beginning of March 1917 and October 31, 
 1917. It does not by any means include all the cases boarded 
 in that period, as there were no means of keeping records satis¬ 
 factorily during part of the time, and the absence of clerical 
 assistance made the work difficult. From March until the 
 
80 
 
 A VISION OF THE POSSIBLE 
 
 SUMMARY OF RESULTS—INVALIDING AND CLASSIFICATION 
 BOARD—HELD ON 8,918 CASES DURING 1917, MARCH TO 
 OCTOBER 
 
 Disability. 
 
 Dis¬ 
 
 charged 
 
 from 
 
 Hospitals. 
 
 Invalided 
 
 to 
 
 England. 
 
 Lines of 
 Communi¬ 
 cation. 
 
 Cases at 
 Base 
 Depots. 
 
 Garrison 
 
 Bat¬ 
 
 talions. 
 
 Total. 
 
 Category “ A” . 
 
 191 
 
 _ 
 
 1,961 
 
 592 
 
 700 
 
 3,442 
 
 Deferred Cases . 
 
 121 
 
 — 
 
 249 
 
 146 
 
 203 
 
 719 
 
 Category “ T.B.” 
 
 159 
 
 — 
 
 58 
 
 466 
 
 29 
 
 712 
 
 Age (Debility) 
 
 149 
 
 — 
 
 88 
 
 114 
 
 499 
 
 750 
 
 G.S.W. 
 
 99 
 
 48 
 
 20 
 
 155 
 
 58 
 
 380 
 
 D.A.H. 
 
 58 
 
 4 
 
 83 
 
 57 
 
 63 
 
 265 
 
 Hernia 
 
 31 
 
 — 
 
 81 
 
 80 
 
 71 
 
 263 
 
 Vision (Defective). 
 
 72 
 
 — 
 
 96 
 
 18 
 
 38 
 
 224 
 
 Feet .... 
 
 26 
 
 — 
 
 80 
 
 30 
 
 75 
 
 211 
 
 Malaria 
 
 90 
 
 6 
 
 3 
 
 100 
 
 7 
 
 206 
 
 Debility 
 
 50 
 
 6 
 
 46 
 
 40 
 
 56 
 
 198 
 
 Bronchitis (including 
 
 
 
 
 
 
 
 Asthma, Pleurisy, and 
 
 
 
 
 
 
 
 results of Pneumonia . 
 
 59 
 
 9 
 
 45 
 
 18 
 
 48 
 
 179 
 
 Organic Heart Disease 
 
 
 
 
 
 
 
 (including Dilatation 
 
 
 
 
 
 
 
 and Hypertrophy) 
 
 65 
 
 6 
 
 43 
 
 27 
 
 29 
 
 170 
 
 Miscellaneous 
 
 44 
 
 11 
 
 40 
 
 27 
 
 30 
 
 152 
 
 Deafness 
 
 68 
 
 1 
 
 17 
 
 10 
 
 21 
 
 117 
 
 Poor Physique 
 
 9 
 
 — 
 
 36 
 
 26 
 
 44 
 
 115 
 
 Injuries 
 
 24 
 
 4 
 
 29 
 
 17 
 
 35 
 
 109 
 
 Transfer 
 
 — 
 
 — 
 
 11 
 
 68 
 
 23 
 
 102 
 
 Arthritis (principally of 
 
 
 
 
 
 
 
 knee, frequently due to 
 
 
 
 
 
 
 
 football or displaced 
 
 
 
 
 
 
 
 semilunar cartilages) . 
 
 28 
 
 4 
 
 16 
 
 16 
 
 21 
 
 85 
 
 Varix .... 
 
 16 
 
 — 
 
 11 
 
 17 
 
 22 
 
 66 
 
 Neurasthenia 
 
 21 
 
 7 
 
 8 
 
 14 
 
 7 
 
 57 
 
 Unspecified . 
 
 6 
 
 19 
 
 15 
 
 — 
 
 16 
 
 56 
 
 Mental 
 
 9 
 
 24 
 
 2 
 
 — 
 
 — 
 
 35 
 
 Myalgia 
 
 13 
 
 — 
 
 3 
 
 5 
 
 6 
 
 27 
 
 Bilharzia 
 
 22 
 
 1 
 
 1 
 
 2 
 
 — 
 
 26 
 
 Hysteria 
 
 15 
 
 1 
 
 2 
 
 2 
 
 5 
 
 25 
 
 Dysentery 
 
 9 
 
 7 
 
 2 
 
 3 
 
 3 
 
 24 
 
 Obesity 
 
 1 
 
 — 
 
 8 
 
 3 
 
 10 
 
 22 
 
 Epilepsy 
 
 14 
 
 1 
 
 1 
 
 — 
 
 4 
 
 20 
 
 Gastritis 
 
 7 
 
 12 
 
 — 
 
 — 
 
 1 
 
 20 
 
 Nephritis 
 
 7 
 
 9 
 
 2 
 
 1 
 
 0 
 
 19 
 
 Enteritis (includes simple 
 
 
 
 
 
 
 
 Intestinal Infection) . 
 
 11 
 
 4 
 
 1 
 
 0 
 
 2 
 
 18 
 
 Rheumatism 
 
 3 
 
 4 
 
 2 
 
 6 
 
 3 
 
 18 
 
 Speech 
 
 7 
 
 — 
 
 1 
 
 6 
 
 4 
 
 18 
 
 Tubercle 
 
 — 
 
 15 
 
 — 
 
 — 
 
 2 
 
 17 
 
 Appendicectomy . 
 
 3 
 
 — 
 
 5 
 
 4 
 
 2 
 
 14 
 
 Goitre .... 
 
 2 
 
 3 
 
 5 
 
 3 
 
 1 
 
 14 
 
 Diphtheria . 
 
 4 
 
 — 
 
 — 
 
 5 
 
 — 
 
 9 
 
 Piles .... 
 
 1 
 
 — 
 
 1 
 
 1 
 
 4 
 
 7 
 
 Nervous 
 
 2 
 
 2 
 
 — 
 
 1 
 
 — 
 
 5 
 
 Total .... 
 
 1,416 
 
 208 
 
 3,072 
 
 2,080 
 
 2,142 
 
 8,918 
 
STATISTICAL RESULTS OF THE WORK 81 
 
 early part of June, the Boards were entirely confined to the 
 hospitals in Cairo, but by direction after that date Boards were 
 held systematically at Kantara, Port Said, Ismailia, Suez, El 
 Arish, and Rafa, in addition to the Boards at Cairo. Further¬ 
 more, subsequent to the middle of June, Boards were held at 
 various places in the Delta, namely Bilbeis, Zagazig, Tanta, and 
 Benha. The total number of cases boarded during the period 
 was between twelve and thirteen thousand, including, of course, 
 some who were duplications. 
 
 2. Local and Standing Boards .—After the inspection of the 
 Forces in Egypt by General Lawson, and the discussion respect¬ 
 ing manpower, orders were given to classify all men on the Line 
 of Communication who had not already been classified, or about 
 whom records were not obtainable. A very large number of 
 men were consequently presented to Boards, and it became 
 impossible for the Boards of which Lieutenant-Colonel Eason 
 and I are Presidents to do the whole of the work. The D.M.S. 
 then issued instructions that the A.D.M.S. or the D.D.M.S. of 
 any district might form a Local Board, which had power to 
 classify such men as “ A ” when they regarded them as fit, but 
 they were to refer all doubtful cases to the Boards of which 
 Lieutenant-Colonel Eason and I are Presidents, known as the 
 Standing Medical Boards, for classification. As a very large 
 number of men were classified “ A ” in this way, it will be seen 
 that the 8,918 cases referred to in this report largely represented 
 the residuum left by the investigation of other Boards. 
 
 3. Methods adopted .—The method adopted differed according 
 as the men were: “Unclassified,” “ Lines of Communication,” 
 or “ men from Garrison Battalions,” “ Base Depots” or “ from 
 Hospitals.” Men on the Lines of Communication were examined 
 two at a time, each by one member of the Board, and on comple¬ 
 tion of the examination were inspected by the President and 
 examined or interrogated. Assuming that there was no need to 
 refer such cases for a specialist’s opinion respecting Vision,Hearing, 
 or other condition, it was possible to examine satisfactorily in 
 this way about thirty cases an hour, and, by working ten hours 
 a day, to dispose of 300 in the course of the day. The remaining 
 cases were presented with a clinical report, often by the Medical 
 Officer in charge himself. They were dealt with one at a time, 
 and with the machinery in excellent order could not be dealt 
 with much more rapidly than twenty to twenty-five in the hour. 
 
 6 
 
82 
 
 A VISION OF THE POSSIBLE 
 
 Two hundred represented a good day’s work. The procedure 
 adopted after experience by the D.M.S./E.E.F., Surgeon- 
 General Maher, was that suggested to him by the President of 
 the Classification Board in Alexandria, Lieutenant-Colonel 
 Eason, C.M.G., and myself. The memorandum embodying 
 directions he gave is attached herewith, together with the form 
 ultimately adopted. The great merit of the form used is the 
 use of carbon papers. The roll can be prepared in quadruplicate, 
 the decision of the Board filled in by the Chairman, so that by 
 the end of the day, when the Board rises, the clerical work is 
 practically finished. 
 
 4. Character of the Work .—It is necessary to say something of 
 the character of the boarding conducted under the several 
 headings: 
 
 (a) Cases boarded at the Hospitals in Cairo are usually pre¬ 
 sented with a wealth of clinical information, which makes the 
 decision, in the majority of cases, a comparatively simple matter, 
 and especially in the case of men invalided to England. The 
 clinical work would, in my opinon, be difficult to improve. 
 
 (b) The work done in the Lines of Communication units, 
 dealing as it does largely with healthy men, is comparatively 
 simple, but even here constant reference must be made to an 
 Oculist and Aurist and occasionally to a Surgeon and Heart 
 Specialist; in fact, so constant are the references to Vision and 
 Hearing, that latterly I have arranged that an Oculist and Aurist 
 shall be in attendance during all Boards, apart from the Hospital 
 Boards. 
 
 (c) At the Base Depots the problem is entirely different. The 
 majority of the cases presented are cases marked T.B. and 
 Discharged from Hospitals, or men who have not been boarded 
 before. They constitute the most unsatisfactory part of the 
 work, and are referred to at some length later in this report. 
 
 (d) The combing out of the Garrison Battalions has now been 
 thoroughly done. The clinical work has usually been prepared 
 with some care by the Medical Officers in charge, and the pro¬ 
 cedure has been smooth and certain. 
 
 5. Results .—The results of the examination are set out in the 
 table (see page 80) and show 7 at a glance the principal causes 
 of disability. 
 
 Under the headings defer and transfer are cases which are 
 often duplications. They represent cases w'hich w 7 ere referred 
 
STATISTICAL RESULTS OF THE WORK 83 
 
 for further examination or other causes. Under the heading 
 T.B., too, the cases are practically deferred decisions, but all 
 the defers, transfers, and T.B.s do not reappear in the sub¬ 
 sequent classifications, as in some instances they were classified 
 elsewhere, viz. at Alexandria or by Local Boards. 
 
 (а) Reviewing the results under the several headings: The 
 1,416 cases under the heading discharged from hospitals 
 must have subtracted from them the “A” 191, defer 121, 
 and T.B. 159, leaving 945; these represent the residual cases 
 which entered Hospitals in Cairo and were found unfit for 
 “ A ” work afterwards. 
 
 (б) The small number of men invalided to England will 
 attract notice. Nothing is more striking than the fact that the 
 number of men who will not be fit for any sort of service after 
 five months is very small indeed, and that the necessity' for 
 Hospital Ships is not very great. 
 
 (c) Lines of Communication .—The bulk of these cases were 
 healthy men, and had probably been examined before entrance 
 to the Army. They include A.S.C., A.O.D., R.E., R.A.M.C., 
 and other special units. 
 
 ( d ) The cases at the base depots include T.B. cases dis¬ 
 charged from the Hospitals and transferred to Base Depots, and 
 also drafts sent to the Base Depots on their way to the front, 
 and there arrested by their Medical Officers and brought before 
 a Board. About the T.B. cases more will be said in a special 
 paragraph. 
 
 (e) Garrison Battalions .—While it is true the periodical combing 
 of the Garrison Battalions will yield a certain number of fit men, 
 the number will not be nearly so great in the future. A large 
 proportion of the “ A ” men in the Garrison Battalions were men 
 drawn from the Special Reserve, or men who had never been 
 examined at all, or men who had been for a long term in a 
 Garrison Battalion and had completely recovered from any 
 disability they had suffered from. In spite of the large proportion 
 of men marked “ A ” to which must be added many of the cases 
 marked defer or transfer, it must be remembered that these 
 only represent a moderate proportion of “A” men obtained 
 from the Garrison Battalions. The Local Boards classed many 
 more of the men “ A.” It is doubtful whether in some cases 
 Garrison Battalions did not contain as many “A” as “ B” 
 men. Cases now being classed “B.i” for wounds, D.A.H., and 
 
84 
 
 A VISION OF THE POSSIBLE 
 
 the like, will in some cases become “A.” men, and the future 
 combing out will yield the residuum of such cases, but the 
 numbers, as before indicated, are not likely to be very great. 
 
 6. Clinical Reasons for Classifying Men “ B .”—It will be seen 
 that, apart from gunshot wounds, the principal cause of the 
 “B” Classification was D.A.H., which comes second on the 
 list of Disabilities, and which in many cases probably represents 
 a general physical failure. The question has arisen repeatedly 
 whether some of these cases may have been artificially induced, 
 but there never has been anything to suggest such causation, 
 and circumstances have prevented the necessary investigation 
 being made, though such an investigation had been planned. 
 
 It will be noticed that Hernia comes third on the list. By 
 direction of the D.M.S./E.E.F., all the Hernia cases were classed 
 “ B.i,” and fitted with trusses where operation was declined. 
 The view taken was that if discrimination was exercised, it 
 would result in a procession of men up and down the line, and 
 would not be satisfactory. It was thought better to class 
 them all “ B.i,’' fit them with trusses, and keep them as a poten¬ 
 tial reserve, and if necessary send the whole of them to the front 
 line as a reinforcement. 
 
 The large number of Defective Vision cases, which come fourth 
 in the list, is very instructive, in view of the moderate standard 
 adopted in Egypt on the advice of the Consulting Oculist E.E.F. 
 Were the standard originally fixed officially adhered to, it is no 
 exaggeration to say that hundreds or even thousands of useful 
 men, fit for the front lines, would immediately be relegated 
 to the “ B ” class. 
 
 The Army Council Orders relating to Flat Feet have had their 
 effect, and Deformities of the Feet have now passed from first to 
 fifth place, and are likely to be still lower. 
 
 Deafness, which comes eleventh on the list, occupies a sub¬ 
 ordinate place. The diffusion of knowledge relating to the 
 comparative innocuousness of Otitis Media, and the attention 
 given to this condition by the R.A.M.C. Officers, has rendered 
 it a formidable item no longer. 
 
 It will be noticed that both Neurasthenia (seventeenth) and 
 Hysteria (twenty-second) are low down on the list, and that 
 Shell Shock does not appear at all. The number of genuine 
 cases of Shell Shock which have come under notice are negligible. 
 
 7. Reviewing the causes of Disability, I find it difficult to 
 
STATISTICAL RESULTS OF THE WORK 85 
 
 suggest any method by which the numbers can be still further 
 reduced, except (1) by an investigation into the possibility of 
 artificial inducement of D.A.H., (2) the use of all the Hernia 
 cases, (3) greater care of the feet and the use of the Regimental 
 Bootmaker, and (4) some limitation on the playing of football. 
 
 8. Standards. —If the war continues, and more men are 
 wanted at the Front, it will not be easy to get them by further 
 lowering of standards, apart from the suggestions already made, 
 but the “ B.i ” men in the Garrison Battalions, if given some help 
 with transport, would form a valuable reinforcement from the 
 physical point of view. They are composed in most cases of 
 elderly men, of considerable experience and often of considerable 
 ability. 
 
 9. “ T.B.” 1 —Surveying the work of the Boards, certain 
 changes seem desirable. Undoubtedly the greatest leakage, 
 abuse, and wastage occurs in the class “ T.B.” The “ T.B.” is 
 so made by the Medical Officer of the Hospital with the con¬ 
 currence of the Medical Officer of the unit. He is not to be 
 “ T.B.” unless it is tolerably certain he will be “ A ” within five 
 months. Having been classed “ T.B.” he is sent to a Base 
 Depot, and does miscellaneous fatigues and occasional drills. 
 The experience of the Board has been that when his period of 
 “ T.B.” is up, he shows too often a decided disinclination to 
 shift his position. He does not feel well, he is not at all fit, and 
 the tendency was to extend the period. The Board speedily 
 found in many cases, particularly D.A.H. and Neurasthenia, 
 that at the end of one or two extensions of period he was cer¬ 
 tainly no better than he was at the beginning. The Board 
 accordingly made a clean sweep and classed them all “A” or 
 “ B.” The life of the man in the camp as a “ T.B.” case has 
 been more or less demoralizing under existing conditions. The 
 miscellaneous character of the work, the alternations of activity, 
 and the lack of physical drill, have not conduced to his better¬ 
 ment. I beg to recommend that in future men discharged from 
 hospitals should not be classed “ T.B.” except by a Hospital 
 Board, and that they should never be classed “ T.B.” unless it 
 is almost certain that they will become “ A” within a specific 
 and reasonable time, say two months. If there is lack of cer¬ 
 tainty, they are better placed in a Garrison Battalion, where the 
 regular work, discipline, and mode of life under one medical 
 
 1 “T.B.” meant Temporary Base, but is now replaced by Category D. 
 
86 
 
 A VISION OF THE POSSIBLE 
 
 officer are more conducive to recover} 7 . In my opinion the 
 field of the “ T.B.” case wants more supervision and certainly 
 requires limitation. It might indeed be replaced in part by a 
 Command Depot. 
 
 10. To whatever extent the E.E.F. may grow, it does seem 
 desirable that Boards which have authority to classify men “B ” 
 should be as few as possible, and that the personality of the 
 President should vary as little as possible. There is no objection 
 to giving authority to divers Boards to classify men “A,” 
 because if a mistake is made it so soon rectifies itself. Once, 
 however, a man is classed “ B,” considerable difficulty may be 
 experienced in reclassifying him “ A.” It is for this reason 
 that the three Presidents of Boards have arranged to meet 
 periodically to discuss problems which arise, to keep one another 
 informed of any difficulties, and to mutually respect the classi¬ 
 fications of the Standing Medical Boards presided over by the 
 three medical officers respectively. The beneficial results of this 
 policy have already become abundantly apparent, and the 
 extension of the policy by the creation of a Statistical Depart¬ 
 ment relating to Invaliding and Classification Boards might be 
 of great assistance to the Army in Egypt. 
 
 Towards the end of 1917 the work was well in hand, 
 andtheD.M.S. divided the work between three districts, 
 namely, Alexandria, Delta District (including the 
 canal but excluding Kantara), and Palestine L. of C. 
 
 The next set of figures relate only to the Delta District 
 and refer to the months of October (part), November, 
 and December, the number of cases being 4,587. 
 The reasons for the increase of number are that some 
 clerical help was now available, and the returns were 
 being kept more accurately. Noticeable in this table 
 is the appearance of cases of malaria in vast numbers 
 (due to the fact that the D.M.S. ordered that all malaria 
 cases should be classified “ B ” for a term), the great 
 reduction in the number of D.A.H. cases, and the very 
 low place now occupied by Feet. 
 
Period: Latter Half of October and Months of November and December 1917 
 
 
 O'OMiOOOOt'h* CO *© *Q ^ COCO COCOWNW^^'H'H'H 
 
 HOO^HH 
 
 a ® 
 
 1° 
 
 'f#O’H00ffl«MO lOoecq®^ ( 0(0 MtOOt'O . <N <M 
 
 O —I M —I 4* -H —I —I -< —I 
 
 w 1 
 
 4*|®t>t-COC6e*5© -># 00 N SO "it lOlO M to O t- O | N N 
 
 a 
 
 §; s 
 
 2« 
 
 Is 
 
 o'E 
 
 rH 1C t'0cc>0^ I> H-HCOOCO (M I ^00 lO^-H 
 <N ^ ^ ^ -H | I -H 
 
 ‘O 
 
 <M I lO »0 ^ fO O N t'* I-H CO CO CO OJ 
 
 1 r-H —< r-l rft 
 
 » W 
 
 «!> 
 
 t^COOOOCOOCOO’f >0 000010 05 O 
 
 01^(MOt-CCC0-^>0 'O lO ^ (M CO .—I —< I—< (M rH rH —< r-< 
 
 O CO rH 
 
 o | JO *0 JpH^iO CO CO CO 
 
 io cq CO I 00 
 
 »o - 
 
 *0 <M - 
 
 N H t'* iH o 
 
 * l> *—I f-H . 
 
 <M I CO CO 
 
 CO I Ot'^QOOt^oO 
 CO | Cl CO lo CO CO Tf 
 O <N 
 
 OhO^C5 
 ^ ^ ^ (M --H 
 
 r- «co W5 o t> 
 
 PH (N ^ H M 
 
 OOCCH^HH 
 
 c8 
 
 Mi 
 
 x a 
 
 a-s 
 
 - SJ 
 © o 
 
 . _ bp trf 
 
 C5«0*?« 
 
 >> 
 
 fc'jSW 
 
 ®’| <! 
 
 | >> * 
 
 pO c3 
 
 I . £8 
 i g-S 
 
 i ■£ a 
 
 i © .2 
 
 ; -£q 
 
 w ®* 
 
 1 — a 
 1 o a 9 
 
 ! ® §! 
 
 © -p „ 
 
 * >> A o 
 
 IgJs 
 
 OQ a 
 % ocft 
 
 o 3 - 
 
 %>£s 
 
 |.S,d 
 
 O © ^ o' 
 
 s | S>s 
 
 m “ 1.3 
 
 © V 
 
 > Q, 
 
 41+J s O 
 
 $ a 
 
 is © e 
 
 Q® g I 
 
 g 2 fl< 
 
 :s gp& 
 
 >ofi 
 
 © 
 
 - 
 
 PS 
 
 I 1 
 
 31 
 
 O 3 
 
 © .3 
 
 c8 
 
 cS 
 
 ft 
 
 A 
 
 -Q 
 
 © 
 
 3 
 
 S3 
 
 •_>. • 
 4^ 
 
 a 
 
 © 
 
 . s . 
 a 1 _ 
 £ 
 
 £ © 
 ^ 60 
 
 a £ 
 
 J4 A 
 •« “ 
 ° S 
 
 . A 
 
 © 
 
 ft 
 
 © 
 
 © 
 
 ft 
 
 J> 
 
 A 
 
 > 
 
 3 
 
 .9-1 '» 
 
 =3 3>fr| 
 
 .s t|i 
 
 ss5a 
 
 87 
 
 .S W C8 
 
 u <+■• •-« 
 
 a o g 
 
 j3 © 
 
 <a a -g 
 3®| 
 X g 4 
 
 I 3 
 
 1 u © 
 
 1-3 fc 
 
 SP| 
 
 l| 
 
 .2 « 
 
 © 
 
 3 
 • a< 
 *55 
 
 1.2 >> 
 
 I 4=> -22 
 
 ■’SCLi , 
 
 c8 
 
 -d 
 
 o 
 
 . >> 
 CQ 
 
 Ph 
 
 TJ 
 
 a 
 
 • c3 
 
 o 
 
 ‘ Xi 
 o 
 
 a 
 3 
 . '© 
 s 
 
 • © 
 
 £ 
 
 © 
 
 -.3 
 
 3 
 
 © 
 
 •3 
 
 © 
 
 © 
 
 . 00 
 d 
 
 *3 
 
 js 
 "o 
 «8 d 
 
 • § 
 © 
 
 £ 
 
 -3 
 
 H H 
 
 49 «*s -5 « •- 
 
 ^ © Gm © u 
 
 G> © © o d 
 
 ft Q ^ ft > 
 
 '© x.2 s' £.2 -1 
 
 5 g § S. £ § 
 
 ___ I -1 ^ (D 
 
 j S« >ii “ 5 J S 
 
 ft£ £ ®.bS 
 
 S 3 ^*2 ft 3 3 ft O 
 5 K H Eh fQ W C5 
 
 > ^© © 
 
 _ — ^ 
 
 © 8 S 
 
88 
 
 A VISION OF THE POSSIBLE 
 
 During 1918 some clerical assistance was provided, 
 and consequently greater accuracy was obtained, and 
 the following table represents a copy of the report 
 furnished for the half-year ending June 1918, 13,393 
 cases being dealt with. The results noteworthy in this 
 table are the facts that D.A.H. becomes practically a 
 negligible quantity ; Defective Vision still occupies a 
 high place; Myalgia and Rheumatism are low down 
 on the list; Defective Feet only account for 237 cases 
 out of the 7,134 classified “ B.” It will be noted, too, 
 that D.A.H. cases treated in April, May, and June at 
 the Command Depot, 360 in number, furnished no 
 less than 232 “ A ” Class men; in other words, D.A.H. 
 had to an extent disappeared. Experience has shown 
 that what has been called “ D.A.H.” is usually rapid 
 heart action, due to exhaustion from some temporary 
 cause, and that with suitable treatment and graduated 
 training the disability disappears. 
 
 The extent to which heart diseases gave trouble may 
 be gathered from the following figures : from February 
 to October 1917, the Standing Medical Board classified 
 261 men for D.A.H. and 170 men for V.D.H. During 
 the period from October to December 31, 1917, in the 
 Delta District, the Board classified 107 men for D.A.H. 
 and 61 for V.D.H. During January and February 
 1918, in the same district, the figures were 97 D.A.H., 
 and 64 V.D.H. Comparison of these figures with those 
 obtained subsequently when the heart clinic was fully 
 developed are rather instructive. It is impossible to 
 classify satisfactorily men with heart diseases without 
 ascertaining by proper methods what the heart can 
 stand. 
 
STATISTICAL RESULTS OF THE WORK 89 
 
 STANDING MEDICAL BOARD, DELTA DISTRICT 
 
 Half-year ending June 30, 1918 
 (a) NUMBER OF CASES DEALT WITH 
 
 Class. 
 
 Hospitals, Con¬ 
 valescent Depots, 
 Command Depot. 
 
 Garrison 
 
 Battalions. 
 
 L. of 0. 
 Personnel. 
 
 Total. 
 
 A . 
 
 792 
 
 798 
 
 568 
 
 2,168 
 
 D . 
 
 343 
 
 144 
 
 67 
 
 744 
 
 “ B.i. Front Lino ” 
 
 242 
 
 364 
 
 295 
 
 901 
 
 “ B.i. L. of C." . i 
 
 “ B.ii.” „ . . / 
 
 2,026 
 
 1,294 
 
 685 
 
 4,005 
 
 B.iii.”. 
 
 499 
 
 295 
 
 110 
 
 904 
 
 Invalided . 
 
 1,324 
 
 — 
 
 — 
 
 1,324 
 
 Deferred 
 
 642 
 
 548 
 
 259 
 
 1,449 
 
 Total . 
 
 6,068 
 
 3,443 
 
 1,974 
 
 11,485 
 
 Prisoners of War . 
 
 
 
 1,817 
 
 Extraneous 
 
 • 
 
 . 
 
 • 
 
 91 
 
 Total .......... 
 
 13,393 
 
 (b) CASES CLASSED OTHER THAN “ A ’’—SUMMARIZED 
 ACCORDING TO DISABILITIES 
 
 Disability. 
 
 
 
 Hospitals, 
 
 etc. 
 
 Garrison 
 
 Battalions. 
 
 L. of 0. 
 
 Total. 
 
 G.8.W. 
 
 
 
 1,157 
 
 155 
 
 47 
 
 1,359 
 
 Age .... 
 
 
 
 142 
 
 495 
 
 158 
 
 795 
 
 Debility 
 
 
 
 333 
 
 172 
 
 136 
 
 641 
 
 Miscellaneous 
 
 
 
 331 
 
 95 
 
 54 
 
 480 
 
 Malaria .... 
 
 Bronchitis (including Asthma 
 
 and 
 
 367 
 
 7 
 
 16 
 
 390 
 
 Pleurisy) 
 
 
 
 174 
 
 107 
 
 54 
 
 335 
 
 Organic Heart Disease . 
 
 
 
 141 
 
 114 
 
 76 
 
 331 
 
 Vision (Defective) . 
 
 
 
 111 
 
 98 
 
 102 
 
 311 
 
 D.A.H. 
 
 
 
 108 
 
 93 
 
 54 
 
 255 
 
 Hernia .... 
 
 
 
 69 
 
 113 
 
 63 
 
 245 
 
 Feet (Defective) 
 
 
 
 51 
 
 96 
 
 90 
 
 237 
 
 Injury . , 
 
 
 
 107 
 
 57 
 
 44 
 
 208 
 
 Arthritis 
 
 
 
 102 
 
 36 
 
 24 
 
 162 
 
 Hearing (Defective) 
 
 
 
 55 
 
 70 
 
 24 
 
 149 
 
 Poor Physique 
 
 
 
 13 
 
 85 
 
 41 
 
 139 
 
 Neurasthenia 
 
 
 
 85 
 
 15 
 
 14 
 
 114 
 
 Rheumatism . 
 
 
 
 59 
 
 25 
 
 21 
 
 105 
 
 Varix .... 
 
 
 
 34 
 
 48 
 
 22 
 
 104 
 
 Diphtheria 
 
 
 
 89 
 
 2 
 
 4 
 
 96 
 
 Nephritis . . 
 
 
 
 69 
 
 3 
 
 6 
 
 78 
 
 Mental Disease or Deficiency 
 
 
 
 68 
 
 5 
 
 4 
 
 77 
 
90 
 
 A VISION OF THE POSSIBLE 
 
 (6) CASES CLASSED OTHER THAN “ A ’’—SUMMARIZED 
 ACCORDING TO DISABILITIES [continued) 
 
 Disability. 
 
 
 
 Hospitals, 
 
 etc. 
 
 Garrison 
 
 Battalions. 
 
 L. of 0. 
 
 Total. 
 
 Enteritis (including simple Intestinal 
 Infection) ..... 
 
 63 
 
 5 
 
 3 
 
 71 
 
 Tubercle of Lung . 
 
 
 
 68 
 
 — 
 
 — 
 
 68 
 
 Epilepsy 
 
 
 
 38 
 
 16 
 
 4 
 
 68 
 
 Myalgia 
 
 
 
 39 
 
 9 
 
 2 
 
 60 
 
 Dysentery 
 
 
 
 38 
 
 — 
 
 — 
 
 38 
 
 Neuritis 
 
 
 
 33 
 
 2 
 
 1 
 
 36 
 
 Phthisis 
 
 
 
 30 
 
 — 
 
 — 
 
 30 
 
 Hysteria 
 
 
 
 18 
 
 7 
 
 3 
 
 28 
 
 I.C.T. 
 
 
 
 22 
 
 1 
 
 3 
 
 26 
 
 Appendicectomy 
 
 
 
 19 
 
 2 
 
 5 
 
 26 
 
 Speech (Defective). 
 
 
 
 5 
 
 10 
 
 6 
 
 21 
 
 Bilharzia 
 
 
 
 9 
 
 — 
 
 4 
 
 13 
 
 Arterial Sclerosis . 
 
 
 
 9 
 
 2 
 
 — 
 
 11 
 
 Albuminuria 
 
 
 
 6 
 
 — 
 
 2 
 
 8 
 
 Obesity 
 
 
 
 2 
 
 6 
 
 1 
 
 8 
 
 Int. Derangement Knee . 
 
 
 
 4 
 
 3 
 
 1 
 
 8 
 
 Gastritis 
 
 
 
 6 
 
 — 
 
 1 
 
 7 
 
 Colitis .... 
 
 
 
 6 
 
 — 
 
 — 
 
 6 
 
 Sciatica 
 
 
 
 6 
 
 — 
 
 — 
 
 6 
 
 Rheumatic Fever . 
 
 
 
 5 
 
 — 
 
 — 
 
 5 
 
 Total 
 
 • 
 
 • 
 
 4,091 
 
 1,963 
 
 1,090 
 
 7,134 
 
 (c) ANALYSIS OF 892 CASES INVALIDED DURING APRIL, 
 MAY, AND JUNE 
 
 Disability. 
 
 
 No. of 
 Oases. 
 
 Disability. 
 
 
 No. of 
 Cases. 
 
 G.S.W. 
 
 
 313 
 
 Arthritis 
 
 
 10 
 
 Miscellaneous 
 
 
 101 
 
 Neuritis 
 
 
 10 
 
 Mental 
 
 
 54 
 
 Epilepsy 
 
 
 9 
 
 Tubercle of Lung 
 
 
 50 
 
 Ent. Infection 
 
 
 9 
 
 Debility 
 
 
 37 
 
 Diphtheria 
 
 
 7 
 
 Organic Heart Disease 
 
 
 36 
 
 Arterial Sclerosis . 
 
 
 6 
 
 Bronchitis (including Asthma 
 
 
 Colitis 
 
 
 5 
 
 and Pleurisy) . 
 
 
 31 
 
 Rheumatic Fever 
 
 
 3 
 
 Age (and debility, etc.) 
 
 
 28 
 
 Hysteria 
 
 
 3 
 
 Nephritis . 
 
 
 28 
 
 Gastritis 
 
 
 3 
 
 Malaria 
 
 
 25 
 
 Bilharzia 
 
 
 3 
 
 Phthisis 
 
 
 25 
 
 Myalgia 
 
 
 2 
 
 D.A.H. 
 
 
 21 
 
 Inflammation of Stomach 
 
 2 
 
 Dysentery . 
 
 
 20 
 
 Rheumatism 
 
 
 2 
 
 Vision 
 
 
 16 
 
 Appendicitis 
 
 
 2 
 
 Neurasthenia 
 
 
 15 
 
 
 
 — 
 
 Injury 
 
 
 13 
 
 Total . 
 
 • 
 
 . 892 
 
STATISTICAL RESULTS OF THE WORK 91 
 D.A.H. RETURN 
 
 (d) CASES RETURNED TO DUTY AFTER TRAINING AT COM¬ 
 MAND DEPOT, ABBASSIA, DURING MONTHS OF APRIL, 
 MAY, AND JUNE, 1918 
 
 As Class 
 
 Total 
 
 A” 
 
 
 
 
 
 . 242 
 
 ‘ B.i. Front Line” . 
 
 
 
 
 
 3 
 
 ‘ B.i. L. of C.” 
 
 
 
 
 
 . 60 
 
 ‘ B.ii 
 
 
 
 
 
 35 
 
 “ B.iii „ 
 
 
 
 
 
 . 20 
 
 . 
 
 
 
 
 
 . 360 
 
 (e) TABLE SHOWING THE TOTAL NUMBER OF CASES DEALT 
 
 
 WITH EACH 
 
 MONTH 
 
 
 J anuary . 
 
 • • • 
 
 
 
 1,463 
 
 February . 
 
 
 
 
 1,460 
 
 March 
 
 
 
 
 2,224 
 
 April 
 
 
 
 
 2,673 
 
 May 
 
 
 
 
 2,622 
 
 June 
 
 
 
 
 2,951 
 
 Total for half-year 
 
 
 • 
 
 13,393 
 
 It was suggested early in 1918 that “ A ” Class men 
 should be classified according to occupations for which 
 they were physically fit. For example, some men might 
 be “ A—mounted work ” ; men, for example, with flat 
 feet and similar men might be classed “ A—motor work.” 
 Similarly a man might be classed “ A—motor work ” 
 who had good vision in one eye and was not totally 
 blind in the other, i.e. who could not be a marksman. 
 Finally, however, it was decided that there could be no 
 classification of “A” Class men, but that men might 
 be marked “ B.i. Front Line,” and sub-classified as 
 might be thought fit, which came to very much the 
 same thing. 
 
 The following table indicates the work that was 
 done during the four months ending October 31, 1918 : 
 
92 
 
 A VISION OF THE POSSIBLE 
 
 STANDING MEDICAL BOARD, DELTA DISTRICT 
 
 (<*) CASES DEALT WITH DURING THE MONTHS OF JULY, 
 AUGUST, SEPTEMBER, AND OCTOBER 1918 
 
 Officers. 
 
 Other Banks. 
 
 Class. 
 
 No. 
 
 Hospitals, Con¬ 
 valescent Depots, 
 Command Depot. 
 
 Garrison 
 
 Battalions. 
 
 L. of C. 
 Personnel. 
 
 Totals. 
 
 “A” 
 
 "D” 
 
 “ B.i. Front Line 
 “B.i.L. ofC.” . 
 
 ** B.ii ” „. 
 
 “ B.iii ”. 
 
 Invalided . 
 
 Deferred 
 
 40 
 39 
 
 3 
 
 42 
 
 41 
 38 
 
 119 
 
 8 
 
 375 
 
 338 
 
 148 
 
 460 
 
 659 
 
 304 
 
 1,215 
 
 263 
 
 176 
 
 7 
 
 168 
 
 267 
 
 179 
 
 55 
 
 110 
 
 245 
 
 17 
 
 193 
 
 177 
 
 126 
 
 35 
 
 96 
 
 836 
 
 401 
 
 502 
 
 946 
 
 1,005 
 
 432 
 
 1,334 
 
 477 
 
 Total . 
 
 330 
 
 3,762 
 
 962 
 
 889 
 
 5,933 
 
 Repatriation Boards—Prisoners of War . 
 
 Repatriation Boards—Palestine Jews 
 
 A.45—a and b ....... 
 
 Commissions ........ 
 
 Extraneous ........ 
 
 1,353 
 
 35 
 
 46 
 
 45 
 
 49 
 
 Total .......... 
 
 7,461 
 
 (6) ANALYSIS OF CASES RECOMMENDED FOR INVALIDING 
 
 Disability, 
 
 No. of 
 Cases. 
 
 G.S.W. 
 
 249 
 
 Miscellaneous 
 
 179 
 
 Malaria .... 
 
 152 
 
 Dysentery . . . . 
 
 151 
 
 Tubercle of Lung 
 
 89 
 
 Mental .... 
 
 78 
 
 Debility ; . . . 
 
 75 
 
 Bronchitis (including Pneu¬ 
 
 
 monia, etc.) 
 
 68 
 
 Injury .... 
 
 47 
 
 Phthisis .... 
 
 46 
 
 Neurasthenia 
 
 32 
 
 Organic Heart Disease 
 
 31 
 
 Nephritis .... 
 
 17 
 
 Enteritis .... 
 
 16 
 
 Neuritis .... 
 
 16 
 
 Vision, Defects of . 
 
 12 
 
 Disability. 
 
 Rheumatic Fever . . 10 
 
 Colitis .... 9 
 
 Arthritis .... 8 
 
 Epilepsy .... 7 
 
 Diarrhoea .... 6 
 
 D.A.H.6 
 
 Inflammation of the Stomach 6 
 
 Inflammation of Joints . 5 
 
 Arterial Sclerosis . . 4 
 
 Hysteria .... 4 
 
 Jaundice .... 3 
 
 I.C.T. . ' . . . 2 
 
 Myalgia .... 2 
 
 Relapsing Fever ... 2 
 
 Diphtheria .... 2 
 
 Total .... 1,334 
 
STATISTICAL RESULTS OF THE WORK 93 
 
 D.A.H. RETURN 
 
 (a) CASES RETURNED TO DUTY AFTER TRAINING AT THE 
 COMMAND DEPOT, ABBASSIA 
 
 As Class “A”.182 
 
 ,, ,, “ B.i. Front Line” ...... 4 
 
 „ „ “B.i. L. ofC.”.38 
 
 ,, ,, “ B.ii. ,, ...... 32 
 
 ,, ,, “ B.iii. ,, .6 
 
 261 
 
 (6) CASES CLASSED “ B ’’—SUMMARIZED ACCORDING TO 
 DISABILITIES 
 
 Officers. 
 
 Other Banks. 
 
 Disability. 
 
 No. 
 
 Classed. 
 
 Hospitals, 
 
 etc. 
 
 Garrison 
 
 Battalions. 
 
 L. of 0. 
 Personnel. 
 
 Total. 
 
 Malaria 
 
 22 
 
 416 
 
 33 
 
 9 
 
 479 
 
 Debility 
 
 16 
 
 216 
 
 106 
 
 97 
 
 434 
 
 Age (and debility) 
 
 11 
 
 69 
 
 218 
 
 70 
 
 358 
 
 G.S.W. 
 
 16 
 
 219 
 
 36 
 
 21 
 
 291 
 
 Miscellaneous 
 
 16 
 
 110 
 
 30 
 
 28 
 
 183 
 
 Feet (Defective) . 
 
 — 
 
 41 
 
 27 
 
 58 
 
 126 
 
 Vision (Defective) 
 
 1 
 
 37 
 
 30 
 
 48 
 
 116 
 
 Hernia 
 
 1 
 
 49 
 
 30 
 
 27 
 
 107 
 
 Bronchitis (with Pleurisy) 
 
 4 
 
 57 
 
 29 
 
 15 
 
 105 
 
 Organic Heart Disease . 
 
 5 
 
 47 
 
 15 
 
 36 
 
 103 
 
 Injury .... 
 
 6 
 
 62 
 
 15 
 
 15 
 
 98 
 
 D.A.H. 
 
 2 
 
 21 
 
 18 
 
 27 
 
 68 
 
 Poor Physique 
 
 1 
 
 18 
 
 25 
 
 23 
 
 67 
 
 Neurasthenia 
 
 3 
 
 33 
 
 7 
 
 8 
 
 61 
 
 Hearing (Defective) 
 
 3 
 
 22 
 
 7 
 
 16 
 
 48 
 
 Arthritis 
 
 1 
 
 27 
 
 9 
 
 6 
 
 43 
 
 I.D.K.J. 
 
 3 
 
 19 
 
 1 
 
 4 
 
 27 
 
 Varix .... 
 
 1 
 
 11 
 
 7 
 
 7 
 
 26 
 
 Epilepsy 
 
 — 
 
 21 
 
 — 
 
 3 
 
 24 
 
 Myalgia 
 
 1 
 
 13 
 
 4 
 
 4 
 
 22 
 
 Nephritis 
 
 — 
 
 14 
 
 — 
 
 2 
 
 16 
 
 Appendicectomy . 
 
 2 
 
 9 
 
 1 
 
 3 
 
 15 
 
 Diphtheria . 
 
 1 
 
 12 
 
 — 
 
 — 
 
 13 
 
 I.C.T. 
 
 — 
 
 12 
 
 — 
 
 — 
 
 12 
 
 Enteric Infection . 
 
 4 
 
 6 
 
 1 
 
 — 
 
 10 
 
 Dysentery . . . 
 
 1 
 
 9 
 
 — 
 
 — 
 
 10 
 
 Rheumatism 
 
 2 
 
 — 
 
 6 
 
 1 
 
 9 
 
 Speech (Defective) 
 
 — 
 
 2 
 
 1 
 
 3 
 
 6 
 
 Arterial Sclerosis . 
 
 3 
 
 2 
 
 1 
 
 — 
 
 6 
 
 Hysteria 
 
 — 
 
 2 
 
 2 
 
 — 
 
 4 
 
 Psoriasis 
 
 — 
 
 3 
 
 — 
 
 — 
 
 3 
 
 Neuritis 
 
 — 
 
 3 
 
 — 
 
 — 
 
 3 
 
 Sciatica 
 
 — 
 
 2 
 
 — 
 
 — 
 
 2 
 
 Totals 
 
 124 
 
 1,571 
 
 659 
 
 531 
 
 2,885 
 
 Number of men whose category was lowered from “ A ” to “ B ” 838 
 ,, ,, ,, ,, ,, ,, raised from “ B ” to •“ A ” . 301 
 
94 
 
 A VISION OF THE POSSIBLE 
 
 Conspicuous features, however, are the steady increase 
 in the malaria cases as they were classified for Base 
 work, and the practical disappearance of the D.A.H. 
 cases. 
 
 One of the most remarkable circumstances which 
 came under my notice resulted from the application 
 of the systematic methods of the Standing Board to 
 the Base Camp at Kantara. The Base Camp was filled 
 with men discharged from hospitals, and graded “ T.B.” 
 (Temporary Base). These men were supposed to be 
 examined once a week by a medical officer, and were 
 ultimately classified “A ” or “ B.” The tendency of 
 the Board was to extend the period if they were not 
 progressing favourably; and when the Standing Medical 
 Board took over, the members found the camp filled 
 with many hundreds of more or less demoralized men, 
 who were sometimes doing a fatigue and some¬ 
 times a parade. Feeling their way, the members of 
 the Board extended their periods once or twice in a 
 certain number of cases and found that at the end 
 of the extension many men were no better, and in some 
 cases w T ere even worse than before; they were accord¬ 
 ingly either classified “ A,” or transferred to one of the 
 “ B ” categories and put to garrison work, and in a 
 few weeks the camp was emptied. Only those who 
 are used to Army Medical work realize the way in which 
 men can be demoralized by too much, and injudicious, 
 kindness. The discharge of these men to work put an 
 end to the trouble in the camp, and in' most cases 
 effected amelioration of the men’s physical condition. 
 
< w 
 
 O QQ 
 
 pq w 
 
 rC 
 
 o .5 
 
 *0 §•§ 
 
 Eu s.E 
 
 ■3w 
 
 c3 Qj **-< 
 h O ~ & 
 
 mu 
 
 3 © 
 
 le 
 
 a ^ 
 3 £» 
 
 « 
 
 fc fc 
 
 tno 
 
 S 8 
 
 © 
 
 -O 
 
 a 
 
 33 
 
 a 
 
 © 
 
 a 
 
 a 
 
 © 
 
 T3 
 
 O) 
 
 2-5 
 
 95 
 
 THE CLASSIFICATION FORM ADOPTED. 
 
CHAPTER VIII 
 
 REPATRIATION BOARDS 
 
 The Repatriation Boards were of several classes. In 
 those conducted on Germans, the procedure was strictly 
 defined by the Anglo-German agreement, and the dis¬ 
 abilities for which repatriation or internment in 
 Switzerland might be requisite are laid down with 
 meticulous precision. In the case of the Bulgarians, and 
 still more so in the case of Ottoman Turks, greater lati¬ 
 tude was given. The practice adopted was to classify 
 these men in the same manner as English soldiers. 
 As a matter of fact, 1,300 invalid Turks were wanted 
 for repatriation, but out of some thousands of Ottoman 
 Turks examined only a percentage were in such a poor 
 condition that repatriation could be recommended, and 
 it might have even become necessary to send partially 
 fit men back to Turkey, in order to secure the release 
 of our own men who were imprisoned: In order that 
 the military authorities might know exactly what 
 they were doing, and whom they were returning, it 
 was laid down that a disability of 40 to 50 per cent., 
 which was likely to be permanent, warranted classifi¬ 
 cation “ B iii. L. of C.” and that 50 per cent, disability 
 or more warranted discharge from the service ; accord¬ 
 ingly all “ B iii. L. of C.” and all “ C ” cases were 
 recommended for repatriation. 
 
 The feature of the work amongst the Turks waa 
 
 96 
 
REPATRIATION BOARDS 
 
 97 
 
 the extraordinary prevalence of pellagra, a condition 
 which was so serious that the Commander-in-Chief, 
 E.E.F., ordered special inquiry to be made. The 
 report of the commission will doubtless make its 
 appearance in due course, but one outstanding fact in 
 connection with pellagra may be worth mention. 
 There was, during the war, an Armenian Refugee Camp 
 at Port Said. At this camp pellagra made its appear¬ 
 ance. The lady doctor in charge of the camp insisted 
 that the Calories in the Dietary should be increased; 
 this was done, and in the course of six months the 
 pellagra disappeared and did not recur. The instance 
 is probably classic, for never anywhere else has it been 
 possible to test the effect of an alteration of diet on 
 people living in the same position, in the same climate, 
 with the same occupation, and in people of the same 
 race. The only altered condition, as far as we know, 
 was in the diet. 
 
 Unfortunately with pellagra came an epidemic of 
 destructive ophthalmia, which caused a large amount of 
 blindness. Once the cornea of a pellagraic lurk became 
 ulcerated, the eye was not long in being lost. The 
 ophthalmia was not gonorrhoeal, but was of the Koch- 
 Weeks type. The most strenuous efforts were made 
 to grapple with the difficulty by the Consulting Oculist 
 and his staff, and it was ultimately got under. Interest 
 is likely to centre in the fact that a similar outbreak 
 occurred in Napoleon’s Army at the beginning of the 
 nineteenth century, and yet in the four years in Egypt 
 only one eye of a British soldier has been lost from 
 ophthalmia, a circumstance attributed by some army 
 surgeons to the abolition of the roller towel. 
 
 The classification of the lurks furnished a good deal 
 of clinical information of interest. Heart cases, whether 
 7 
 
98 
 
 A VISION OF THE POSSIBLE 
 
 organic or functional, appeared to be rare, whilst tubercle 
 of the lung, with or without pellagra, appeared to be 
 very common indeed. There is no doubt that one of 
 the reasons for the extensive spread of pellagra in the 
 Turkish Army was the fact that the Turkish Medical 
 Officers themselves did not recognize the disease; a 
 circumstance not very remarkable, for until the char¬ 
 acteristic signs were pointed out, few medical officers 
 recognized pellagra in its earliest stages. There is 
 no doubt its existence amongst the Turkish prisoners 
 has furnished an invaluable opportunity for the investi¬ 
 gation of this scourge, and it has thrown a flood of 
 light on the tradition of Egyptian ophthalmia, which 
 had become quite discredited from recent favourable 
 experiences in the British Army. In thirty years of 
 ophthalmic practice, I have never seen anything 
 approaching the destruction wrought by this disease 
 in spite of the most determined efforts made to stop 
 it. Like trachoma in Egypt, it is probably a direct 
 product of the habits of the people. 
 
 Of the Turkish prisoners of war about 3,000 were 
 presented for Boarding, and of these 1,783 were adjudged 
 “ B.iii. L. of C.” or Fit for Discharge, and were recom¬ 
 mended for repatriation. It is noteworthy that of 
 these Ottoman Turks recommended for repatriation, 
 no less than 117 were recommended on account of total 
 blindness due to ophthalmia, apart from a large number 
 of others whose vision in one eye had been completely 
 lost, or whose vision in both eyes had been extensively 
 damaged. 
 
CHAPTER IX 
 
 STANDARDS OF VISION 
 
 The variations and mode of thought respecting stan¬ 
 dards of vision have been so numerous and the practical 
 consequences during the war have been so serious that 
 I propose to devote some little attention to them, and 
 to indicate how grave may be the consequences of 
 adopting artificial standards without sufficient scientific 
 evidence. I set aside for the present consideration of 
 the vision of officers and limit myself entirely to a dis¬ 
 cussion of the vision of the men. 
 
 Before the war recruits were supposed to possess 
 vision of 6/24 in each eye without glasses, or 6/6 in 
 one eye and 6/36 in the other. The foregoing was the 
 standard test of vision for all arms of the service includ¬ 
 ing militia, yeomanry, and volunteers, with the excep¬ 
 tion of a corps of Army schoolmasters for which a 
 candidate was accepted if the examiner considered that 
 his vision was good. 
 
 Who devised these standards I do not know, and I 
 find it difficult in the light of modern knowledge to 
 understand the advocacy of such a standard. 
 
 A vision of 6/24 in each eye without glasses is for 
 ordinary purposes very good vision, assuming there is 
 no ocular disease, but the adoption of such a standard 
 implies the rejection of all myopes of low degree and of a 
 number of men suffering from other errors of refraction; 
 
 99 
 
100 A VISION OF THE POSSIBLE 
 
 in fact, such a standard if adopted would have excluded 
 thousands of men from the front line in the E.E.F. 
 who did their work very well. 
 
 It was quite evident that this pre-war standard was 
 impossible, and the Army Council issued a second 
 order: 
 
 If a man’s vision is 6/24 in one eye without glasses, and his 
 right eye can be brought up to 6/12 with glasses, he will be con¬ 
 sidered fit for Category “ A ” (Army Council Instruction No. 
 211, dated 4/2/1917). 
 
 This standard excluded all left-eyed men and all low 
 myopes and soldiers possessing some other errors of 
 refraction, and consequently when the nation's man¬ 
 power began to run out the D.M.S./E.E.F., after con¬ 
 sultation with the Consulting Oculist, E.E.F., fixed the 
 standard for men already in the service as 6/24 in the 
 right eye with or without glasses, providing he was 
 not blind in the left eye; blindness was defined as 
 inability to count fingers at three feet. The minimum 
 standard was fixed by the Army Council at 6/60 in one 
 eye without glasses, that of the other eye being less 
 or nil. 
 
 The Egyptian standard worked very smoothly, and 
 by its adoption hundreds of men were sent to the 
 front line and did very well indeed. An attempt was 
 made to amend this regulation by making it apply to 
 the left eye, i.e. to read “ that vision of 6/24 in either 
 eye with or without glasses, provided the other eye 
 was not blind,” but the authorities pointed out that 
 it was impracticable to give instruction in musketry 
 in Egypt to left-eyed men, and accordingly such men 
 were passed into the front line “ it. A.M.C.” or “ A.S.C.,” 
 etc., if otherwise fit. 
 
STANDARDS OF VISION 
 
 101 
 
 When many hundreds of men had been so classified, 
 the D.M.S. cancelled the order and reverted to the 
 standard previously alluded to, on the grounds that 
 he could not modify an Army Council instruction. At 
 this juncture, however, the Army Council issued another 
 instruction, which was as follows : 
 
 If a recruit can read, without glasses, not less than 6/12 with 
 each eye, he may be accepted for Category “A” without examina¬ 
 tion by an ophthalmic specialist. 
 
 If the vision is below this standard, the recruit shall be sent for 
 examination to an ophthalmic specialist. 
 
 Instructions to Ophthalmic Specialists. Category “ A.” —A re¬ 
 cruit will be considered fit for Category “ A ” if his vision with¬ 
 out the aid of glasses is not less than 6/60 with one eye (R. or L.) 
 and not less than 2/60 with the other, provided that, with the aid 
 of glasses if necessary, his vision is not less than 6/12 with one 
 eye and that both eyes have good field of vision as tested by 
 hand movements. 
 
 Category “ B.” —“B.i.” A xecruit whose vision is not equal 
 to the standard laid down for Category “ A ” will be considered 
 fit for Category “ B.i.” if his vision without the aid of glasses 
 is not less than 3/60 with the better or only eye, provided that 
 with the aid of glasses his vision is not less than 6/18 with one eye. 
 
 B.ii. A recruit whose vision is not equal to the standard laid 
 down for Category “B.i” will be considered fit for Category 
 “ B.ii ” if his best obtainable vision with the better or only 
 eye (with or without glasses) is not less than 6/60. 
 
 Men in the Labour Corps whose best obtainable vision, aided 
 if necessary with glasses, is less than 6/24 with the better or only 
 eye will be considered unfit for dangerous employment such as 
 dock labour, railway shunting, etc. 
 
 B.iii. The standard of vision for clerks will be the same as 
 for “ B.i,” while that for other occupations referred to in para. 6 
 “B.iii” of A.C.I. 1606 of 1917, viz. storemen, batmen, cooks, 
 orderlies, sanitary orderlies, or skilled tradesmen, will be the 
 same as for “ B.ii.” 
 
 Note. —(1) A man may be passed into Category “ B.i, B.ii, or 
 B.iii if one of his eyes has been lost or is completely blind, pro¬ 
 vided that the remaining or better eye is up to the required 
 
102 A VISION OF THE POSSIBLE 
 
 standard and has a good field of vision as tested by hand move¬ 
 ments. 
 
 (2) No man will be accepted for any form of military service 
 with a lower standard of vision than that laid down for “ B.ii.” 
 
 Serving Soldiers 
 
 In retesting the vision of serving soldiers the standard will be 
 the same as for recruits, but men who have been found capable 
 of carrying out their duties efficiently need not necessarily be 
 placed in a lower category on account of their eyesight not 
 being equal to the standard laid down for the category in which 
 they are serving. 
 
 This standard was undoubtedly better than that 
 adopted according to previous Army Council instruc¬ 
 tions from the point of view of obtaining “ A ” Class 
 men, but it was far inferior to that laid down by the 
 Consulting Oculist, E.E.F., which had worked exceed¬ 
 ingly well, and its very artificiality raised doubts re¬ 
 specting its practicability. 
 
 It has been the fortune of the writer to act as Con¬ 
 sulting Oculist to a number of Steamship Companies 
 and to the Pilot Service in Melbourne, and to investi¬ 
 gate the condition of vision of the pilot who was re¬ 
 sponsible for the loss of the P. & 0. steamer Australia 
 in 1904. In the course of these investigations he has 
 taken a great deal of trouble to find precisely what men 
 with 6/24 vision can or cannot see. He rendered him¬ 
 self artificially myopic with glasses both when at sea 
 and on land, and found that with a 6/24 vision, all 
 ordinary operations can be carried out without difficulty, 
 navigation can be undertaken in fine weather, and 
 objects can be seen, distances judged, though details 
 are not so clear as they usually are. Where the man of 
 6/24 vision or even 6/12 vision comes to grief as an 
 engine-driver or as a mariner is that with these defects 
 
STANDARDS OF VISION 
 
 103 
 
 of vision there is a marked degree of colour blindness, 
 as has been clearly shown by Sir William Abney; but 
 as the majority of soldiers do not have to discriminate 
 between coloured lights at night, the futility of setting 
 a high standard is apparent. The facts relating to 
 these investigations were placed before the British 
 Association for the Advancement of Science at its 
 meeting in Melbourne in 1914. It is, however, necessary 
 to labour the question, since no less an authority than 
 the late Director-General of Army Medical Services, 
 Sir Alfred Keogh, in a War Office memo, dated 
 August 14, 1916, says : 
 
 With reference to the scheme for the issue of spectacles to 
 troops, I am directed to inform you that in many cases it would 
 appear that soldiers are ordered glasses quite unnecessarily. I 
 am accordingly to submit the following remarks for the guidance 
 of all concerned, and to point out that the conclusions arrived 
 at are the result of the experiences gained by ophthalmic sur¬ 
 geons at the front in France, after the examination of many 
 thousands of men sent down from the firing-line complaining of 
 defective vision. 
 
 So far as infantry are concerned, this is at present chiefly 
 a war of “bombs” and hand and rifle grenades, and a high 
 standard of marksmanship in every individual infantry-man is 
 not essential; some good marksmen are required as snipers, 
 but the company officer always has a sufficient number of men 
 under his command for that purpose. It should also be borne 
 in mind that battalions are as a rule only nine or ten days in 
 the trenches, and are then five or six days back behind the firing- 
 line “ resting.” As regards artillery, and the requirements of 
 vision of gunners, shooting is always done by map and telephone. 
 
 A soldier will not wear glasses unless the benefit which accrues 
 from their wear is very obvious and apparent to himself. 
 
 In a large number of cases complaining of their sight (quite 
 40 per cent, of those tested at the ophthalmic centres at the 
 front in France) it has been found that glasses are quite un¬ 
 necessary. 
 
 It should, however, be remembered that many soldiers of the 
 
104 
 
 A VISION OF THE POSSIBLE 
 
 New Armies have become so accustomed to use glasses in civil 
 life that they are at a very serious disadvantage without them. 
 
 The following classes of cases are not, as a rule, ordered glasses : 
 
 (a) Slight degrees of myopia, under one dioptre. 
 
 (b) Slight degrees of hypermetropia, two dioptres and 
 
 under, in men under thirty. 
 
 (c) Some cases of moderate degrees of astigmatism. Even 
 
 though astigmatism is shown by retinoscopy, and 
 occasional headache is complained of, glasses are not 
 considered necessary in all such cases; each case 
 must be judged on its merits .—(Extract from W.O. 
 Letter 24, General No. 4906 ( A.M.D . 3), dated 1587, 
 14/8/1916.) 
 
 It may be laid down, then, with certitude that anyone 
 who has 6/24 vision with one eye, with or without glasses, 
 can do all the ordinary work a soldier can do without 
 any difficulty, but there now arises, however, a further 
 question. If it is permitted to obtain this vision with 
 glasses, as it is in terms of the most recent A.C.I., what 
 does it matter what the man sees without glasses ? 
 There is no reason why he should not have a second 
 pair of glasses, and if he loses both he is no worse 
 off than a man with a sprained ankle. The official 
 discrimination between visions of 2/60, 3/60, and 
 6/60 is in my judgment artificial and not sound. 
 Those who are conducting investigations into the 
 acuity of vision are aware how rough the calculations 
 are. Visual acuity as measured with types depends 
 on the way in which letters are painted—that is, on 
 contrast with the background, on the illumination, and 
 on the size of the pupil; only those who have looked 
 into the matter closely are aware of the extraordinary 
 variations that can be produced by such factors, and 
 the setting of such minimum standards without glasses 
 
STANDARDS OF VISION 
 
 105 
 
 is in my judgment quite futile and harmful. The 
 standard I should like to have seen adopted was that 
 adopted by the D.M.S. in 1917, modified to read 6/24 
 in either eye with or without glasses, provided the other 
 eye is not blind. There is not the slightest doubt that 
 the adoption of these sensible standards of vision would 
 have saved the British Army thousands of men who 
 are otherwise perfectly sound. 
 
 Trachoma .—The Army Council decided that cases of 
 trachoma were to be invalided out of the Army at once, 
 and this decision gave a good deal of trouble, for men 
 arrived in Egypt who had been taken into the Army 
 in England with trachoma, and under this decision had 
 to be sent straight back to England and discharged from 
 the Army. There were certainly not very many cases, 
 but there were a few. Experience in Egypt, however, 
 has shown that people with the habits of the English 
 soldier are not at all likely to be infected with trachoma, 
 and infection was very rare in the British Army—in 
 fact, experience in Egypt has shown that infection with 
 trachoma is usually a direct result of the habits of 
 people. A vast number of the Egyptian population and 
 a large number of the Turks suffer from it, and not¬ 
 withstanding this I doubt whether one hundred 
 British soldiers have been infected with trachoma. 
 It is really a negligible disease, and it is time that the 
 truth respecting its contagious character should be 
 known. 
 
 All over the world nations have been legislating to 
 prevent the introduction of patients suffering from 
 trachoma, fearing that, with their entry, the disease 
 would spread to the local inhabitants. The experiences 
 in Egypt has shown that, with an Anglo-Saxon popu¬ 
 lation, the risk is negligible. The spread of trachoma 
 
106 
 
 A VISION OF THE POSSIBLE 
 
 depends not so much on the presence of patients suffer¬ 
 ing from trachoma as on the habits of the people. 
 
 The following report on the ophthalmic work done in 
 Egypt during 1915 was forwarded by me through the 
 War Office to The British Journal of Ophthalmology : 
 
 REPORT ON OPHTHALMIC CASES IN EGYPT, 1915 
 
 There appeared in the August number of The British Journal 
 of Ophthalmology 1917, valuable reports on the ophthalmic 
 work done in Egypt in 1915-1916 by Lieutenant-Colonel 
 Eason, C.M.G., Consulting Oculist, E.E.F., and by Major 
 Lockhart Gibson, A.A.M.C., who was at Mudros in the latter 
 part of 1915 and in Egypt for part of 1916. Both of these 
 reports relate to the period when the work in Egypt was well 
 organized, when appliances were freely obtainable, and when 
 medical assistance was abundant. 
 
 1. I propose to complete the story by describing the oph¬ 
 thalmic work in Egypt during the period of improvisation, 
 viz. from the beginning of 1915 until November of the same 
 jmar when I was invalided out of Egypt. The actual work 
 began on January 24, 1915, at the 1st Australian General 
 Hospital, Heliopolis, where an Ophthalmic and Aural Depart¬ 
 ment was opened, and to which patients speedily found their 
 way. As there was no Ophthalmic or Aural Surgeon available 
 in Egypt at the time, I was appointed Consulting Oculist (and 
 Aurist) to the Force in Egypt, and the greater part of the work 
 was done at Heliopolis. As the year passed by oculists began 
 to arrive in Egypt, and decentralization was gradually effected. 
 The Staff at Heliopolis usually consisted of two or three 
 assistant surgeons, one medical student, and two nurses in 
 the Out-Patient Department, with the use of a ward of 100 beds. 
 The assistant surgeons were mainly Captain Morlet, Captain 
 Stevens, Captain MacLellan, Captain Burke, and Captain Rosen- 
 field, A.A.M.C., with Mr. Cook and Mr. Wharton medical students. 
 The clinic was available, and utilized freely by British and 
 New Zealanders as well as Australian troops. In passing, it 
 may be said that the work was very extensive and heavy, and 
 that there was a considerable amount of operative work after 
 the Dardanelles landing. 
 
STANDARDS OF VISION 
 
 107 
 
 2. As regards the nature of the diseases treated, the results 
 were a surprise to those who, like myself, possessed no previous 
 experience of military work. Of the ophthalmic cases, half were 
 cases of ophthalmia, principally of the Koch-Weeks variety, 
 with a smaller percentage of diplo-bacillary cases. There were 
 only five cases of gonorrheal ophthalmia during the whole 
 period ; a most remarkable circumstance when the frequency 
 of venereal disease is considered. Errors of refraction com¬ 
 prised nearly 40 per cent, of the cases,so that the cases of ophthal¬ 
 mia and refraction constituted the greater portion of the work, 
 90 per cent, in all. There were very few cases of trachoma, 
 and nearly all of them came from Australia. It is not a little 
 remarkable that, in a country where trachoma is so exceedingly 
 prevalent as Egypt, practically none of the soldiers con¬ 
 tracted it. The circumstance throws a flood of light on the 
 supposed contagious nature of trachoma amongst Europeans, 
 and incidentally on the legislation adopted in the various coun¬ 
 tries with regard to persons suffering from trachoma. 
 
 3. After the landing at the Dardanelles, a fair number of 
 injuries made their appearance, and a considerable number of 
 eyes were excised. A few operations were performed for cataract 
 and the removal of foreign bodies, and in a number of cases 
 projectiles were removed from the orbit. One death occured 
 after the removal of a projectile from the apex of the orbit, 
 and after death a second bullet was found in the brain. Many 
 of the eyes which were excised had not been directly injured, in 
 some cases the projectiles had not passed within an inch of 
 them, nevertheless the internal coats were torn, and the eyes 
 hopelessly disorganised. Whether this arises from the velocity 
 of entry of the projectile or from its rotation, we were unable to 
 decide, but the cases were fairly frequent, and the conclusion 
 certain. 
 
 4. Removal of Foreign Bodies .—The majority of the foreign 
 bodies in the interior of the eye were non-magnetic, and the eyes 
 were hopelessly disorganized. The large magnet at Mansourah, 
 which is under the control of the Public Health Department, 
 Egypt, was placed at our disposal, but few cases made their 
 appearance in which its use was necessary or of service. 
 
 5. Shell Shock .—Of genuine shell shock, i.e. shell concussion, 
 we saw a few cases. Men who showed no sign of external 
 injury complained of defective vision in one eye and showed 
 
108 
 
 A VISION OF THE POSSIBLE 
 
 haemorrhages into the retina. Whether these were due to 
 direct concussion or, as Dr. Mott suggests, due to gassing, I do 
 not know. They were not common, but there were a few definite 
 cases. The remaining cases of so-called shell shock were, when 
 genuine, obviously cases of hysteria, and there were very few 
 of them. A common type of case was the man who screamed 
 at the light, turned his face to the pillow, closing his eyes 
 violently, and of these cases nothing more need be said than 
 that their recovery was usually a matter of a day or two. 
 
 6. Malingering .—A fair number of malingerers made their 
 appearance at first, and gave a great deal of trouble by reason 
 of the elaborate examination that such cases necessitated. As 
 soon, however, as they realized that an expert department had 
 been created in Egypt, the numbers fell off, and these cases 
 ceased to be of any great importance. There is, however,a type 
 of case much more difficult to handle than the true malingerer— 
 the man with a tendency to neurasthenia or hysteria, who 
 exaggerates his symptoms, and who is subconsciously endeavour¬ 
 ing to prove that he is really worse than the medical officer thinks 
 he is. This singular nervous mixture is sometimes very difficult 
 to deal with. There is no sharp line to be drawn between the 
 element of fraud and the element of nervous demoralization. 
 However difficult the problem may be, I am quite convinced 
 that the only mode of treatment which is effective is that based 
 on the absence of morbid sympathy, and based directly on the 
 induction of a normal morality. In these cases the sympathetic 
 lady visitor is apt to be highly dangerous. In such cases, when 
 a complete examination of the eyes showed that there was no 
 disease of fundus or media, and the error of refraction was 
 simple, we disregarded altogether the man’s statement respecting 
 his accuracy of vision and discharged him to duty after a reason¬ 
 able rest, and I think I can say with confidence that in not one 
 single instance was a mistake made. 
 
 7. It must be remembered that in the early part of 1915 
 the issue of spectacles to the men had not been authorized, and 
 arrangements were made at first whereby the men could purchase 
 their own glasses at reasonable rates with opticians in Cairo. 
 Later on, the War Office authorized the issue of spherical glasses. 
 By this time, all concerned had become aware of the fact that 
 it is useless to order glasses for men in the field unless their vision 
 is considerably improved by their use. It also became obvious 
 
STANDARDS OF VISION 
 
 109 
 
 to those who watched the work that high-standard vision is not 
 required from modern soldiers. Those who have rendered them¬ 
 selves artificially myopic, as I have done, for the purpose of 
 investigation will be surprised to find how much they can see 
 in the way of common objects with a vision of 6/24ths. I 
 published an account of the investigation of the kind I made in 
 connection with the visit of the British Association for the 
 Advancement of Sciences to Australia in 1914. So far as 
 mariners at sea are concerned, the real danger of defective vision, 
 that is a vision of anything below 6/12ths, is the reduction of 
 the colour sense which follows. 6/12th-form vision would not 
 materially interfere with the activities of people in most occupa¬ 
 tions, but 6/12th vision and less for pilots or engine drivers 
 may be a very serious matter, because of the great reduction of 
 colour perception with which it is associated. In the case of 
 the ordinary soldier this condition does not arise, and there is no 
 doubt that standards of visual acuity set in the past have erred 
 on the side of stringency. 
 
 8. One-eyed Men .—It was decided in 1915 to invalid men 
 with only one eye out of the country, because of the supposed 
 risk to the other eye from ophthalmia. We have since learned 
 that the risk of losing an eye from ophthalmia in Egypt is 
 negligible. The policy of sending one-eyed men to the front 
 was dealt with by the Army Council subsequently, but a one- 
 eyed man runs very little more risk of losing his eye in Egypt 
 than he does in England, apart from the risk of active service. 
 He may, it is true, get odd attacks of irritation from the dust, 
 but of serious ophthalmia there is very little risk. One remark¬ 
 able case came under notice. An Australian who had lost one 
 eye from detachment of the retina determined to go to the 
 Dardanelles. He eluded authority and got to the Dardanelles, 
 was injured in the blind eye and returned to Heliopolis to have 
 it excised. 
 
 Summing up the work, it is obvious that the business of an 
 oculist in a war zone does not include the fine work he is accus¬ 
 tomed to in civil practice. The greater part of his time is taken 
 up with the treatment of ophthalmia and the cases of errors of 
 refraction, but there is imposed upon him a far greater responsi¬ 
 bility than appears in these activities. It is his business to dis¬ 
 criminate between the cases which are fit and which are unfit 
 for duty and to see that the cases of hysteria and fraud are 
 
110 
 
 A VISION OF THE POSSIBLE 
 
 kept in the lines, and that trivial cases are treated at the Front. It 
 is his business to return those who do reach the Base as rapidly as 
 possible. In order to be useful and effect this result, he has to 
 superadd to the expert knowledge gained in civil practice an 
 entirely new and military objective, which calls into being a 
 series of judgments which take time in acquisition, and are 
 exceedingly valuable when once acquired. 
 
CHAPTER X 
 
 THE BATTLE OP MARCH 21, 1918 
 
 The previous chapters relating to Standing Medical 
 Boards will have given an insight into the many and 
 complicated problems that are at issue and will have 
 contained a hint, but a hint only, of the far-reaching 
 and national importance of the work done. In Field- 
 Marshal Douglas Haig’s report of the battle of March 21, 
 1918, when the 5th British Army was badly defeated 
 in France—probably the greatest British defeat in 
 history, though now happily redeemed—he points out 
 that the British line was being held by one British 
 division for about 7,000 yards, whereas the Germans 
 had massed several divisions on the same line, with 
 a general numerical superiority of three to one. I 
 have seen it publicly stated, and it was certainly 
 rumoured in Egypt two months before the battle took 
 place, that the British Army was short of men, and the 
 shortage was considered to be 800,000 men; that is to 
 say, there were 800,000 men less than had been estimated 
 to be available. It was supposed to be partly due to 
 the unexpected losses of 1917, but I think there was 
 another and more cogent reason for a portion of such 
 shortage as may have existed. 
 
 The following article in The British Medical Journal 
 of September 26, 1918, will illustrate : 
 
 A PHYSICAL CENSUS AND ITS LESSON 
 
 Almost exactly a year ago we gave a short account of the 
 lines along which the reorganized Medical Department of the 
 
 111 
 
112 
 
 A VISION OF THE POSSIBLE 
 
 Ministry of National Service would work. It seemed to us then 
 that the plan which we sketched in broad terms had been ably 
 constructed and showed a proper appreciation of the medical 
 position and of the part which medical boards should play in 
 the examination of recruits, and we ventured the opinion that 
 the work of medical examination under the new scheme ought 
 to remove all legitimate causes of grievance. We are now able 
 to give some indication of the results of the physical examinations 
 undertaken during the first eight months of the present year, 
 and of the message they convey as to the physical fitness of the 
 British stock. 
 
 Between January 1 and August 31, 1918, the number of 
 medical examinations conducted by National Service Medical 
 Boards in Great Britain amounted to 2,080,709. During this 
 period 28,035 applications (that is, 1'34 per cent, of the examina¬ 
 tions) were made to appeal tribunals for medical re-examination, 
 and of these applications less than a half were held by the 
 tribunals to rest on grounds sufficiently substantial to justify 
 the granting of leave for re-examination. Further, of the 
 applicants who were granted leave to be examined by the medical 
 assessors of the Local Medical Board, the grading of 50 per cent, 
 was unchanged. 
 
 In other words, in less than 4 per cent, of this enormous number 
 of medical examinations there was reason to believe (so far as 
 the evidence afforded by the organization of appeal tribunals 
 goes) that the grading by the National Service Medical Board 
 did not correctly represent the degree of medical fitness of the 
 individual. This result may be expressed by the general state¬ 
 ment that a National Service Medical Board, working full time 
 and examining twenty-five men per session of two and a half 
 hours, graded one man per week incorrectly. 
 
 In order to realize the vast amount of work that has been 
 done in this direction by the medical profession since the begin¬ 
 ning of this year, it should be remembered that the administra¬ 
 tive machinery was not created until November 1917, and that 
 the examinations have been carried out during a period in which 
 unprecedented strain was thrown upon the profession to meet 
 the heavy and persistent demands of the fighting forces for 
 medical personnel. Moreover, the work has been done in a 
 country to which the whole idea of conscription was novel and 
 distasteful. The working of the administrative machinery of a 
 
THE BATTLE OF MARCH 21, 1918 113 
 
 compulsory Military Service Act in its application to the individual 
 had never been envisaged, and the difficulties arising from the 
 consequent mental attitude of the population were much intensi¬ 
 fied by the raising of the general military service age to fifty-one 
 in April, which greatly increased the perplexity of the domestic, 
 occupational, and medical problems, and appeared to threaten 
 the whole fabric of the national structure. The problems of 
 grading had never been thought out, while the details of the 
 procedure, and to a less extent the methods of examination, 
 were new and unfamiliar. That in such circumstances the 
 average error should be represented by a fractional percentage 
 constitutes a record of which our profession has every right to 
 be proud, as well as those responsible for the creation and ad¬ 
 ministration of the machinery necessary to perform this work 
 upon an organized basis. 
 
 There is another and more important aspect of this work. Of 
 the two million men examined, not more than 36 or 37 per cent, 
 were placed in Grade “I”—that is, approximately only one in 
 every three had attained the normal standard of health and 
 strength, and was capable of enduring physical exertion suitable 
 to his age ; the remainder—more than a million and a quarter— 
 did not reach this standard. The suggestion has been made 
 that the low proportion of fit men among those examined during 
 this period is due to the fact that only the leavings of the popula¬ 
 tion were under review. Analysis of the records available, 
 however, shows that this is not the case, and that as a fact the 
 men examined constituted a fair sample of the male population 
 between the ages of 18 and 43 and a smaller proportion of the 
 more fit between 43 and 51. We are told, further, that the 
 experience of the Boards medically examining women for 
 national work corresponds broadly to that of the National 
 Service Medical Boards examining men. Such evidence points 
 only too clearly to a deplorably low state of national health. 
 
 While it has not yet been possible to work out the details'of 
 this great mass of medical examinations, the preliminary results 
 indicate that preventable disease is responsible for the bulk of 
 these physical disabilities, and demonstrate the ravages which 
 industrial life has made upon our real national capital—the 
 health and vigour of the population. Too little food, too long 
 hours of work, too little sleep, too little fresh air, too little play, 
 too little comfort in the home, are evidently the chief factors 
 8 
 
114 A VISION OF THE POSSIBLE 
 
 concerned in producing this mass of physical inefficiency with 
 all its concomitant human misery and direct loss to the country. 
 To take effective measures on the broadest lines to remedy this 
 condition of things is a most urgent duty. It is not necessary 
 to wait for the end of the war. The war has revealed the defect, 
 but it has also led to the suggestion of remedies, as may be read 
 in the reports of the Health of Munition Workers Committee. 
 It was mainly for this reason that it seemed well from time to 
 time to devote a good deal of our scanty space to these reports. 
 They were written to meet an emergency, but contained much 
 of permanent value in relation on the one hand to hours of work 
 and industrial fatigue, and on the other to what is commonly 
 called welfare work—that is to say, the application of sound 
 medical and hygienic principles to the care of the health of 
 workers. The State in the future may do something, especially 
 in relation to the last of the evil influences enumerated above, 
 for it seems to be acknowledged that the capital necessary for 
 proper housing cannot be provided by private enterprise ; but 
 the remedy for the other evils must be sought in a closer and 
 more friendly understanding between employers and employed. 
 Dr. Rhoda Adamson’s article published last week (p. 309) 
 shows that it is by no means hopeless to expect employers to 
 respond to a reasoned appeal. Although real improvement can 
 hardly be expected for one or two generations, the foundations 
 of a better national physique can be laid at once. 
 
 This leading article in The British Medical Journal 
 appears to me to be remarkable. In the first place, if 
 only one man in every three was regarded as fit for 
 general service, there was not much reason for appealing 
 from the decision of the Boards, and it is difficult to 
 understand any jubilation about the success of this 
 Boarding system when two-thirds of those examined 
 were placed lower than Grade “ I.” 
 
 The inference drawn by the writer, too, that the 
 physical conditions in Great Britain show evidence of 
 serious deterioration depends entirely on what stan¬ 
 dards those Boards adopted. 1 We have already shown 
 
 1 Chapter v. 
 
THE BATTLE OF MARCH 21, 1918 115 
 
 in earlier chapters our estimate of the physical con¬ 
 dition of the men who were not Grade “ \ ” who reached 
 Egypt, and were allotted to Garrison Battalions. Had 
 the visual standards in Great Britain been those 
 adopted in Egypt by the D.M.S. on the advice of the 
 Consulting Oculist in 1917, and had all cases of otorrhcea 
 which were not deaf been placed in Grade “ I,” if they 
 were otherwise physically fit, it is quite safe to con¬ 
 jecture from the Egyptian experience that many 
 thousands of men would have been added to 
 Grade “ I ” in Great Britian. If the remaining Egyptian 
 standards had been adopted—and be it remembered 
 that when tested they were found to be satisfactory 
 under the most severe conditions in the desert—it is 
 possible that a far larger percentage of Grade “ I ” 
 men would have been obtained from the recruits 
 examined in Great Britain, and in that event the 
 British Army might not have been defeated on March 21, 
 because its reserves might have been, and probably would 
 have been, ample. Two hundred thousand men would 
 have made all the difference. I submit, then, with 
 proper respect, that it is a matter for national considera¬ 
 tion whether a proper inquiry should not be made to 
 determine whether the defeat of March 21 was not 
 primarily due to the standards adopted by the medical 
 Boards in Great Britain, and if so, who was responsible 
 for the fixation of those standards. Were they 
 medical officers who had served abroad and were 
 acquainted with war conditions, or were they medical 
 officers who had served at home and were not so fully 
 aware \ 
 
 There seems to me to be on the evidence furnished in 
 Egypt an a priori case for judicial inquiry. 
 
 It is, perhaps, not amiss at this stage to remind readers 
 
116 
 
 A VISION OF THE POSSIBLE 
 
 of the essential difference between the conditions in 
 France as they are reported to have existed, and the 
 conditions in Egypt as they are known to me, so far as 
 hardship is concerned. There seems little doubt that 
 in France a soldier is more likely to suffer from gunshot 
 wound, and that the work in muddy trenches in Flanders 
 was very trying, but when he was out of the trenches 
 the conditions were not so 'severe, and leave to England 
 was always possible. In Egypt there was no mud, but 
 there was intense heat, months and months were spent 
 in the desert, and leave to England was impossible; 
 and whilst the risk from gunshot wound was not so 
 great as in France, though quite great enough, the 
 risk from dysentery, malaria, and the like was very 
 serious, as the last acts of the campaign show. Any 
 man who went through four years’ campaigning in Egypt 
 and Palestine, and came out unscathed at the end of it, 
 could regard himself as fortunate. 
 
SECTION III 
 
 THE MANAGEMENT OF VENEREAL DISEASE 
 
 CHAPTER XI 
 
 THE PROBLEM OF VENEREAL DISEASE 
 
 The damage done during the war by venereal disease 
 has been enormous, and some indication of the gravity 
 of the problem and its difficulties will be afforded to 
 anyone who will glance through the references to the 
 matter in a book published by Lieutenant Deane and 
 myself called The Work of the Australian Army Medical 
 Corps in Egypt in igiy-iy. The matter is also dealt 
 with in my own work, The Twin Ideals. 
 
 In Egypt the matter has undergone three phases : 
 
 When I was A.D.IvI.S. to the Australian Force in 
 1915, the most active efforts were made both in the 
 moral and prophylactic direction, and the work done 
 is referred to in the chapters referred tp. When I ceased 
 to be connected with that Force, and was invalided 
 to England in November 1915, for some time no one 
 took my place. During this interregnum the troops 
 returned from the Dardanelles and the conditions in 
 Egypt were such as to force the appointment of a 
 military and civilian committee, known as the Cairo 
 Purification Committee, presided over by the Inspector- 
 General of Communications, E.E.F. This committee 
 
 in 
 
118 
 
 A VISION OF THE POSSIBLE 
 
 took extensive evidence from medical officers, chaplains, 
 and others, and elicited the remarkable information that 
 in April 1916, in one section of the forces, the admis¬ 
 sions for venereal disease were at the annual ratio of 
 25 per cent. (The figure was really higher.) When it is 
 remembered that there may be a good deal of conceal¬ 
 ment of venereal disease, some idea of its incidence 
 may be gained. The average annual rate in this 
 month for the whole Force was about 12 per cent. 
 As usual, once attention was directed to the matter, 
 it began to decline. The committee recommended 
 that a number of steps should be taken, including 
 the appointment of ablution tents to which men could 
 repair immediately after exposure. The disease steadily 
 fell in frequency, and at the end of 1917 had attained 
 small proportions. Again attention rather slackened, 
 the troops advanced into Palestine, and another serious 
 outbreak took place. Again the military authorities 
 made careful inquiries, and loosed a campaign both 
 on the moral and prophylactic side which had the effect 
 of again holding the disease in check. Like some 
 other medical arrangements in Egypt, the control of 
 venereal disease resembled the movements of an 
 accordion. 
 
 In addition a remarkable piece of evidence has been 
 obtained. At the outbreak of war, Lieutenant-Colonel 
 Elgood, C.M.G., was appointed Base Commandant at 
 Port Said, and did the heavy work attached to that 
 position until the end of the war. As he frankly 
 admitted, at the outset he had no practical knowledge 
 of the ravages of the disease, and the mode of con¬ 
 trolling it. He set to work and made a determined 
 attempt to control the disease, which is described in 
 the following statement: 
 
THE PROBLEM OF VENEREAL DISEASE 119 
 
 PORT SAID UNDER MARTIAL LAW 
 
 A declaration of martial law restricts the liberty of the 
 inhabitants of the country on which it is imposed. Business is 
 impeded ; travelling is interfered with ; private property is 
 requisitioned ; and in a word normal existence is often sacri¬ 
 ficed to the military exigencies. On the other hand, it becomes 
 practicable to remedy, or at least to palliate various abuses 
 neglected by the Civil Administration; particularly when the 
 abuse affects the health and well-being of the troops. Handi¬ 
 capped by the existence of capitulations, no less than by the 
 apathy of the inhabitants of Egypt, the Anglo-Egyptian Govern¬ 
 ment constantly has found itself powerless to reform the abuses 
 which touch neither the person nor the pocket of the resident 
 of the country. The notorious immorality of Port Said is a 
 typical case in point; and it may be of interest, therefore, to 
 describe briefly the measures initiated under martial law to 
 remove this stigma. 
 
 I shall frequently have to speak as if the experiences were 
 purely personal, but I claim no credit for any improvement 
 effected (indeed at times I am reminded painfully of how much 
 has been left undone), and I use the personal pronoun only to 
 undertake the responsibility for the many errors of judgment 
 which have been committed. 
 
 Such expressions as a “ sink of iniquity ” or “ the finest 
 example of hell on earth ” have been applied frequently and 
 with some justice to Port Said. No doubt, within recent years, 
 the more blatant sores have been removed by the Civil Govern¬ 
 ment. For example, the gambling dens opened to the public 
 disappeared some time before the war; but very little change 
 for the better had taken place in the underworld. The Port, 
 still remained a .centre of the White Slave Traffic. Unfortunate 
 girls would remain here a few weeks or months, and then be 
 transferred (or exchanged with other women) to the Far East. 
 The transaction was purely commercial, and the girls were 
 treated as so much merchandise. 
 
 The civil police harassed this traffic in human flesh to the 
 best of their ability ; but it required the perusal of letters 
 (possibly only through the censorship established in the early 
 days of the war) which were exchanged between the procureurs 
 to realize the horrors of this terrible commerce. Hotels of ill 
 
120 
 
 A VISION OF THE POSSIBLE 
 
 fame and brothels abounded iu the European Quarter of the 
 town. In these dens, every form of vice known to the modern 
 world was practised. The women in the first place ^ere 
 subjected to no medical examinatioft, and undoubtedly many 
 must have been infected with venereal disease. Pimps and 
 touts, employed by the hotels and brothels, hung about the 
 main streets and the entrances of the residential hotels. It was 
 very difficult indeed to walk out after dark without being 
 acoosted by more than one of these gentry ; and chaplains have 
 oomplained indignantly to me that even their cloth did not 
 afford protection from the unwelcome attentions of pimps. 
 Indecent and vilely obscene photographs were procurable in 
 many shops at small cost, and were sold publicly without risk to 
 the vendor. Such, briefly, were the morals of Port Said in the 
 autumn of 1914. 
 
 On the declaration of martial law in November 1914,1 pressed 
 upon the civil police the necessity of exercising more control 
 over the public women in the European Quarter. Apart from 
 any consideration of decency, it was clear that troops presently 
 would occupy the town, and in consequence that measures must 
 be taken with reference to these women. The Commandant, 
 Suez Canal Police, acted with promptitude. He closed the 
 brothels, and ejected their inhabitants. The hotels were less 
 easy to deal with. The managements protested vigorously 
 against our action, appealing in certain instances to their con¬ 
 sular authorities for protection. The consuls, however, paid no 
 attention to the outcry, and the hotels were closed. 
 
 The next problem confronting us was the disposal of the 
 women. About half their number decided to leave Port Said, 
 the remainder (say forty) refused to budge. After some con¬ 
 sideration the solution was found, and the women were housed, 
 with their own consent, in the Arab Quarter, where a district 
 was set apart for their convenience. This decision solved a 
 second difficulty incidentally ; for Port Said is divided sharply 
 into two quarters, the European and the Arab. No objection 
 was raised by the inhabitants of the second to our decision; 
 and since all native prostitutes by law were bound to reside in 
 the Arab Quarter, by including in that regulation prostitutes of 
 a European origin it became possible to exercise not only 
 police but also medical control over both classes of public 
 women. Under the direction of the Public Health Department, 
 
THE PROBLEM OF VENEREAL DISEASE 121 
 
 Egyptian Government, a weekly examination of licensed women 
 is made. Those found free from the disease received a card 
 marked “ Same ” ; those infected were sent for treatment to 
 hospital. Incidentally it may be remarked that the term 
 “ Saine ” is a little misleading. It would be more correct to 
 substitute for “ Saine” the word “ Examinee” ; and in these 
 circumstances, no man consorting with a licensed prostitute 
 could complain that he had been deceived. 
 
 While these measures were being undertaken, Indian troops 
 arrived on the Canal. Port Said held a brigade, and the Arab 
 Quarter was placed “ Out of Bounds.” This order had no con¬ 
 nection with prostitution, but was issued in consequence of 
 some doubt being felt at that moment whether reliance could be 
 placed on the loyalty of the Egyptian residents of Port Said. It 
 was decided, therefore, that the Indian-Moslem troops should 
 not be exposed more than was necessary to possible elements of 
 disloyalty. In any case, I confess that I felt no uneasiness in 
 troops consorting with women of the Arab Quarter : for at that 
 period I was under the illusion that,given a satisfactory medical 
 examination of the women, no reasonable risk of venereal disease 
 infection existed. Twelve months later, however, the Indian 
 Expeditionary Force was merged into the Egyptian Expedi¬ 
 tionary Force. Port Said became the Head-quarters of an 
 Army Corps as well as a Base. A division of infantry and of 
 course a number of Base troops were quartered in the Area. 
 The Arab Quarter remained “ Out of Bounds ” ; but with the 
 limited force of military police at my disposal, I was totally 
 unable to enforce my own orders at first. Again, however, I 
 was not greatly concerned ; and it was not until the middle of 
 1916 that I became vaguely aware of the insufficiency of the 
 medical-examination system. But it was apparent to me 
 about that period that the incidence of venereal disease among 
 troops in No. Ill Section, Canal Defence (t.e. Port Said to 
 Kantara) was relatively high ; and, unless I had misread the 
 signs, was growing higher. I ascribed that fact to the inclina¬ 
 tion of the troops to spend their short leaves in Cairo rather 
 than at Port Said, where I felt confidence in the medical examina¬ 
 tion. That assurance, however, was rudely shaken by the 
 establishment of the fact that individual soldiers would visit a 
 particular brothel whose inmates were under medical inspection, 
 and yet contract the disease. I made it my business to invite 
 
122 
 
 A VISION OF THE POSSIBLE 
 
 patients to give me the names of the women, and house, with 
 whom they had associated. In many instances I obtained the 
 woman’s card. The Public Health Department was requested 
 then to make a special examination, and further to take a micro¬ 
 scopic slide. In every case, without exception, the result both 
 medical and microscopic was negative. Either all these soldiers, 
 therefore, were lying deliberately, or certain dependence cannot 
 be placed upon medical examination. 
 
 The Commander-in-Chief at this period spared no pains to 
 impress upon all ranks the importance of diminishing the incid¬ 
 ence of venereal disease in the E.E.F. He directed the publica¬ 
 tion of several memoranda dealing with the subject, wherein he 
 desired all commanders to draw the attention of their men to the 
 ethical side of the question, and the effect which the disablement 
 of men otherwise fit must produce upon the fortunes of the war. 
 How far these appeals of the Commander-in-Chief were successful 
 or not is difficult to estimate. In my own case I assembled all 
 officers of the Base, and expounded the views of the chief ; but I 
 do not think that I enlisted the sympathies of my audience. 
 Senior officers suggested that I should do better to place the 
 Arab Quarter in bounds, and concentrate my efforts upon 
 improving the weekly medical examination of the women; but 
 apart from an increasing distrust of the value of such inspection 
 or examination, I was well aware that the Arab Quarter panders 
 to other and more depraved methods of sexual gratification. 
 To attempt the moral regeneration of the Quarter was beyond 
 my own powers ; but it was my duty apart from all question of 
 reducing venereal disease to protect young soldiers from con¬ 
 tamination with such perverse forms of vice. 
 
 It has been said that the Commander-in-Chief directed that 
 in any consideration of the problem insistence must be laid 
 invariably upon its ethical side. His belief in the latter as a 
 factor was demonstrated by his forming a Purification Com¬ 
 mittee in Cairo with sub-committees in other towns. The 
 Chairman of the Cairo Committee was the Inspector-General 
 Lines of Communication, and I venture to think that the report 
 signed by the majority of his committee is an extremely sane 
 and moderate pronouncement. The Port Said sub-committee 
 proved a useful consultative body. I learnt personally much 
 from some of its members. The medical representatives con¬ 
 firmed my own doubts as to the complete efficacy of the medical 
 
THE PROBLEM OF VENEREAL DISEASE 123 
 
 examination, whilst establishing the fact also that without 
 some such control matters would be much worse. One lay 
 member argued that once the decision had been taken to define 
 the quarter wherein prostitutes were authorized to carry on their 
 calling, that principle should be applied also to all women in 
 Port Said who were convicted of immorality. I was unable to 
 accept such a proposal, even if it had been in my power to cany 
 it out. I could not forget that our action in Port Said had been 
 directed chiefly against the person of the woman; and to in¬ 
 carcerate one in the Arab Quarter because she had made an 
 occasional slip of virtue was to condemn her in fact to social 
 damnation from which there was no escape. 
 
 As elsewhere, indeed, there exists in the town a number of 
 women who are prepared to become the temporary mistresses 
 of men willing to pay for the privilege of supporting them. 
 Thus the artistes attached to the music halls may be included 
 fairly in this category. There are others also, such as semp¬ 
 stresses, who supplement their scanty wages by gratifying the 
 sexual desire of some chance man. But in such instances it is 
 the man who hunts the prey, and not, as in the case of the pro¬ 
 fessional prostitute, the converse. That fact, therefore, was an 
 additional argument in my judgment against any action with 
 regard to this class. 
 
 It was'elicited meanwhile that various conveniences admitting 
 of illicit intercourse between troops and women had sprung up 
 in the town. The hotels of ill fame which had flourished in the 
 past were being replaced, in fact, by less pretentious, but equally 
 vicious establishments, wherein rooms were let for an hour or 
 two. There appeared to be no reason why these houses should 
 be tolerated in the European Quarter, and the civil police took 
 immediate steps to close them. No doubt, others are still open ; 
 but the owners can take no risk to advertise their use, and the 
 trade is attended with some risk. 
 
 A second member, an old resident of Port Said, called attention 
 to the number of touts and pimps infesting the town. In his 
 view, owing to the compulsory extinction of all artificial lights, 
 troops would be unable to find their way to the Arab Quarter 
 after dark, if it were not for the guidance of a tout. His argu¬ 
 ment seemed reasonable, and instructions were issued to the 
 military police to arrest pimps who were observed to be practis¬ 
 ing their trade. Apart from the question of the Arab Quarter, 
 
124 
 
 A VISION OF THE POSSIBLE 
 
 I felt considerable sympathy with many officers who had tom- 
 plained from time to time to me of the annoyance caused by 
 these gentry. The difficulty in the past had been to devise a 
 procedure whereby pimps detected in flagrante delictu could be 
 punished. The civil law was powerless ; but the institution of 
 Summary Military Courts about this period offered the desired 
 means. Later, it transpired that such Courts also were incom¬ 
 petent to punish pimps, and in consequence, though with great 
 reluctance, I had to abandon any further proceedings. Fortu¬ 
 nately I did not become aware of the illegality until several 
 offenders had been found guilty and punished. The pimp not 
 only has been frightened, and is practising his profession with 
 greater caution; but by some administrative measures, I am 
 glad to believe that his activities are now greatly hampered. 
 
 It need hardly be said that a flourishing trade in the past at 
 Port Said was that connected with the sale of liquor. In the 
 early stages of the military occupation of the town, soldiers 
 arrested for being drunk frequently alleged in excuse that the 
 alcohol was drugged ; but vile as the liquor may have been, I 
 do not believe that to be the case; for of the many samples 
 taken and dispatched to Cairo for analysis, no sample was 
 returned as such, though very many were declared entirely unfit 
 for human consumption. 
 
 Drunkenness, however, continued to increase, and early in 
 1916 it was apparent that drastic measures must be taken. 
 Many of the units then encamped at Port Said had disembarked 
 directly from the Dardanelles. Some of the troops, after six 
 months’ arduous trench work, imagined that at Port Said they 
 would have full licence, and the owners of the various bars 
 and restaurants assuredly did their best to foster that belief. 
 
 A Proclamation under martial law had been issued shortly 
 before placing the control of the sale of alcohol in the hands 
 of each local commander. The effects of this Proclamation 
 have been far-reaching ; no more widely than at Port Said. 
 I am not a supporter of total prohibition; but I spent too 
 many years in the old army to fail to appreciate the pernicious 
 result which unrestricted opportunities of obtaining alcohol 
 have upon men who have not attained maturity. In Egypt 
 it is an unfortunate fact that licence to sell liquor is relatively 
 easy to obtain, and Lord Cromer and many experienced Anglo- 
 Egyptian Administrators have deplored the quantity of alcohol 
 
THE PROBLEM OF VENEREAL DISEASE 125 
 
 imported into this once so temperate country. From both the 
 military and the civil points of view, therefore, I had no hesita¬ 
 tion in availing myself of the powers conferred by the Proclama¬ 
 tion, and I restricted the sale of alcohol to the hours of 1 p.m. 
 to 3 p.m., and 6 p.m. to 9 p.m. Drunkenness showed, at once, 
 a sensible reduction; but while all respectable houses of enter¬ 
 tainment obeyed loyally the regulations, less reputable establish¬ 
 ments sought, and still seek, every opportunity to evade them. 
 In the circumstances, it is not easy to obtain proof of any offence, 
 but I have overcome the difficulty to a certain extent by placing 
 ‘‘ Out of Bounds ” any bar or restaurant wherein a naval rating 
 or soldier is perceived to show signs of intoxication. The same 
 penalty is exacted if the Medical Officer of Health, Port Said, 
 reports that the sanitation or cleanliness of a bar or restaurant 
 is deficient; but in such a case, the owner is given fourteen 
 days’ grace to comply with the Health Department’s conditions. 
 
 Some little time elapsed before the Naval and Military 
 Authorities of all Allied Nations agreed that the order “ Out of 
 Bounds ” affixed to the establishment would be respected 
 equally by them; but eventually the point was conceded. 
 The concurrence of all authorities was important, for since 
 many months most of the Allies have been represented at Port 
 Said by permanent detachments of sailors and soldiers. 
 
 The connection between venereal disease and restrictions 
 upon the sale of alcohol may appear to be slight; but as I hope 
 to demonstrate later, the second exercises considerable influence 
 upon the first. I have taken the pains, therefore, to describe 
 at some length our measures at Port Said to limit drink. I 
 have reason to believe that the regulations are considered to be 
 too drastic by many people. At least scarcely a week passes 
 ■without some individual whose position entitles him to respect 
 approaching me with the suggestion that the general sobriety 
 of their troops and their excellent behaviour in the town deserve 
 better recompense. The more respectable civilian residents also 
 feel that their comfort and pleasure are seriously curtailed by 
 these restrictions. I concede willingly the truth of these argu¬ 
 ments : but none the less I do not see my way to relax any of 
 the measures taken. 
 
 Notwithstanding that the Arab Quarter is picqueted and 
 patrolled by the military police, as far as the slender resources 
 of the Port Said base allow, it requires no great ingenuity on 
 
126 
 
 A VISION OF THE POSSIBLE 
 
 the part of any soldiers caring to run the risk to enter and leave 
 the quarter undetected. Nor is it possible for the civil police 
 to prevent the native public women plying their trade on the 
 sea beach. In fact, I had been aware for some time that both 
 of these practices are common. 
 
 Fortunately, however, at this stage, I came into contact with 
 Colonel Sir James Barrett, K.B.E., R.A.M.C., and of Miss E. 
 Rout, New Zealand Voluntary Sisterhood. The first suggested 
 that the solution of the problem would not be found in police 
 measures or in medical examination, but in prophylaxis ; while 
 the second in correspondence relating her own experiences 
 gained in England encouraged me to advocate this remedy. 
 It must be confessed that the men and women of Australasia regard 
 this distasteful subject with greater frankness and with less 
 timidity than Great Britain does. If the figures which from 
 time to time have been shown to me are correct, Australia and 
 New Zealand have good reason to feel anger at the conven¬ 
 tionality which forbids in England any discussion upon venereal 
 disease. 
 
 Figures and facts have produced in me the conviction that 
 in these abnormal days we must rely upon prophylaxis to fight 
 this insidious malady. I have no intention of surrendering any 
 of the police or medical measures which I have attempted to 
 describe in the preceding pages ; and the fact that troops are 
 forbidden to frequent the prostitutes’ quarter, and yet in their 
 camp are provided with prophylactic treatment, is an anomaly 
 which does not deter me from advocating the employment of 
 the latter. So, too, in the twentieth century a.d. is war an 
 anomaly. Yet the entire civilized world at this moment is en¬ 
 tangled in the paradox : and, reckless of sacrifice of blood and 
 money, men are determined ruthlessly to pursue war to its bitter 
 end. If men in spite of orders to the contrary, and in spite of 
 punishment in event of detection, persist in consorting with loose 
 women, I maintain that it becomes the primary duty of all 
 thoughtful persons to take what steps they can to protect the 
 wives, or the girls who will become the wives, left at home from 
 risk of later infection at the hands of their men. 
 
 In August of this year, a permanent Camp of Rest was formed 
 at Port Said for the Mounted Corps, E.E.F. A large proportion 
 of the men belonged to the Australian Imperial Force. These 
 troops have been fighting and marching for more than twelve 
 
THE PROBLEM OF VENEREAL DISEASE 127 
 
 months ; many have had no leave during that period, and no 
 relief from the wearing monotony of the desert. If any troops 
 would be likely to indulge in excesses, it would be men who have 
 endured such conditions. Up to date, 9,282 all ranks have 
 stayed in this camp, some for a period of eight days, others for 
 fourteen, and individuals much longer. Venereal-disease infec¬ 
 tions have been carefully noted. They number thirteen in all, 
 whether the malady shows itself in camp, or on the return of the 
 man to his unit. It is not possible to guarantee the absolute 
 accuracy of the number of the venereal-disease infections, but 
 very great care was taken to keep count of them. 
 
 I have reason to believe that the majority, if not all, of the 
 infected failed to make use of the prophylactic treatment pro¬ 
 vided, owing to their being under the influence of drink. Well 
 may each of these unfortunates ask, as did the Roman poet, 
 Quo me, Bacche, rapis tui Plenum? 
 
 It may be of some interest to describe briefly the prophylaxis 
 practised in-this camp. There are three conditions, viz. ? 
 
 (a) Thorough washing externally with 1 in 1,000 perchloride. 
 
 (b) Irrigation of the anterior urethra with pot. permanganate, 
 
 1 in 3,000. The apparatus used consists of an 
 elevated glass container with rubber tubing, clip, 
 and glass Y-piece nozzle. 
 
 (c) Calomel ointment applied, and bandages furnished to 
 
 keep the ointment from soiling the clothes. 
 
 The numbers availing themselves. of prophylaxis have been 
 4,580, or approximately 50 per cent, of the men attending 
 the camp. It seems reasonable that possibly one-third have 
 made use of the treatment on more than one occasion: or in 
 other words, that (say) one-third only of the total visitors at the 
 camp have had sexual relations with women during their stay at 
 Port Said. A legitimate deduction therefore from that hypo¬ 
 thesis appears to be this : some men are deterred from visiting 
 the Arab Quarter in consequence of the locality being “ Out of 
 Bounds.” 
 
 The figure of 4,580 is certain: for in this case there has been 
 no difficulty in counting (names are' not taken) the number of 
 men daily using the prophylactic tent. To my mind, the fact 
 
128 
 
 A VISION OF THE POSSIBLE 
 
 that less than half of the 9,000 all ranks availed themselves of 
 treatment affords ample justification for the restriction placed 
 upon the Arab Quarter. I argue this. It is clear that few of the 
 remaining 50 per cent, had intercourse with women, and yet did 
 not visit the tent, or inevitably in existing circumstances the 
 venereal-disease infections would have exhibited a very much 
 larger incidence. If therefore we make a liberal allowance for 
 men who have remained continent during their period of rest 
 from some ethical or even sesthetic motive (for the surroundings 
 of the Arab Quarter repel the fastidious), there must remain a 
 residue quite unswayed bj r any such argument. But in all 
 bodies of soldiers there exist individuals who regard an un¬ 
 blemished defaulter sheet as their most prized possession. 
 
 Unlike ethical motives, which tend to lose force with every 
 month the soldier is kept from home, the desire to retain at all 
 costs a “ Clean Sheet ” grows stronger as the soldier’s period of 
 service in the field is prolonged. Such men will not imperil 
 their record by any conflict with the military police; and they 
 respect the latter’s orders. What is the number of men to whom 
 such a consideration applies cannot be estimated. Nor am I 
 personally concerned with any speculation of this nature. I am 
 satisfied that the consideration exists ; and even if it were 
 demonstrated that as a consequence twenty men only were 
 deterred from visiting the Arab Quarter, I would think still 
 that the restriction was justified. 
 
 Signed: P. G. Elgood, Lieutenant-Colonel. 
 
 Base Commandant. 
 
 Port Said, 
 
 December 31, 19*17. 
 
 This report is to me one of the most valuable docu¬ 
 ments in existence, because I know from personal 
 experience the thoroughness with which these measures 
 were adopted. Furthermore, at the time when he 
 thought his sentries were efficient, I became aware that 
 they were being eluded by the ingenuity of the women 
 and those who wished to have intercourse with them; 
 in fact, I do not know of a more impressive instance 
 of the impossibility of wholly suppressing this traffic 
 
THE PROBLEM OF VENEREAL DISEASE 129 
 
 by the use of force. When I acquainted Colonel 
 Elgood with what was going on, he discussed the matter 
 very earnestly with me, and asked whether I would 
 suggest that he should relax any of the disciplinary 
 measures he had taken. I replied that were I in his 
 place I would not relax in the least, but I would add 
 prophylaxis, and make every effort to supply the 
 social wants of the men. It only remains to add that 
 when the typhus epidemic broke out in 1918, and 
 Arab Town was placed out of bounds, the soldiers no 
 longer reported at the ablution tent, as they thought 
 they would be punished for having got into Arab 
 town—in other words, that the fact of their reporting 
 indicated that they had been there—with the result 
 that venereal disease immediately increased. 
 
 In conclusion let me ask any dispassionate reader 
 whether, instead of this administration by oscillations 
 and meetings of committees it would not have been 
 better to have created a new appointment, and to have 
 appointed an A.D.M.S. or Consultant, whose sole 
 business would have been to investigate and advise 
 on the subject of the control of venereal disease. Such 
 an officer would have been constantly travelling, he 
 would have met the officials in the different districts, 
 would have become aware of the difficulties of the 
 problem, and would probably have steadied the 
 administration and minimized the damage. 
 
 But such an appointment would have been an inno¬ 
 vation, and difficult to make. It would have been 
 necessary to persuade not only the Medical Staff, but 
 the Finance Committees of the War Office, that a service 
 which had never before had such an officer now required 
 one. It would have been quite easy, however, to 
 take an officer out of the hospital and give him the 
 9 
 
130 
 
 A VISION OF THE POSSIBLE 
 
 work to do, provided he was not given definite rank, 
 status, and pay. The delay in making these necessary 
 appointments in war-time arises from the cumbrous 
 nature of the official machinery rather than from the 
 desires of the administrative officers themselves. 1 
 
 1 A supplementary account of the management of venereal diseases in 
 Egypt appears in The British Medical Journal, February 1, 1919. 
 
SECTION IV 
 
 THE RELATIONSHIP OF THE RED CROSS TO 
 THE ARMY MEDICAL SERVICES 
 
 CHAPTER XII 
 
 THE R.A.M.C. AND THE RED CROSS 
 
 During the war the British Red Cross Society has 
 been of considerable service. It has, I understand, 
 collected from one source or another some fourteen 
 millions of money, and has expended it for the benefit 
 of sick and wounded soldiers. 
 
 It may be as well to inquire what is its organization, 
 what are its functions, and what is its relation with the 
 R.A.M.C. In the book published by Lieutenant Deane 
 and myself called The Work of the Australian Army 
 Medical Corps in Egypt, extensive reference is made 
 to this subject, but some recapitulation is desirable. 
 
 Its government is unusual. It is managed by a 
 Committee in London, self-appointed and filling up 
 vacancies by co-option, the representative principle 
 being wholly absent. This Committee appoints Com¬ 
 missioners in various parts of the world who are to all 
 intents and purposes autocrats, subject only to the 
 Central Council in London. Advisory Committees are 
 appointed, however, by these Commissioners who 
 possess no powers of administration or control, who are 
 
 131 
 
132 
 
 A VISION OF THE POSSIBLE 
 
 not consulted respecting expenditure, respecting appoint¬ 
 ments, and only occasionally respecting policy. The 
 Committees serve the purpose, however, of reassuring 
 the public respecting the proper working of the Red 
 Cross system and do assist in diffusing a certain amount 
 of interest and information. They are also of very 
 great service when appeals for funds are made. If, then, 
 application be made to the Red Cross Commissioners for 
 assistance by officers commanding hospitals, it rests 
 with the Commissioner to assent or refuse, as the case 
 may be; and though in general they work in friendly 
 association with the officers administering the R.A.M.C., 
 the fact remains that there are two sources of supplies 
 and two independent controls, viz. the Military and 
 the Red Cross. As regards the functions of the Red 
 Cross, they have been well expressed by Sir Henry 
 MacMahon, who, when High Commissioner in Egypt, 
 described them as follows : 
 
 Government supplies all the necessities for the care, treatment, 
 and transport of the sick and wounded, while the Red Cross 
 supplements these necessities by everything that can in any way 
 go to the comfort and well-being of the sick and wounded soldiers. 
 The distinction between necessities and comforts is sometimes 
 so indefinite that the Red Cross, wherever possible, endeavours 
 to have both ready to hand for use when needed. 
 
 And later : 
 
 A word must be said here about the work of the Red Cross 
 Stores. The object of the Red Cross has never been to supply 
 in any large quantities the goods which the War Office sends to 
 the wounded, but it does its best to provide the troops with such 
 things as the War Office does not supply at all or cannot supply 
 at a given time. A State Department, bound as it rightly is by 
 hard-and-fast rules, cannot work as quickly as a private body 
 with more elastic regulations ; moreover, the supplies of any 
 department may change at times, hence it happens that the 
 
THE R.A.M.C. AND THE RED CROSS 133 
 
 British Red Cross occasionally supply certain things more than 
 the War Office can, or it may supplement the War Office supplies, 
 and it does so until the War Office steps in again. Further, 
 the Red Cross supplies many things or small luxuries which the 
 authorities cannot possibly supply, and these are j ust the things 
 which are most appreciated by the sick and wounded. 
 
 The Red Cross, apart from furnishing supplies, did 
 considerable service in establishing bureaus for inquiries 
 relating to the sick and wounded. It further partially 
 arranged convalescent outings, and gave a certain 
 amount of personal attention to the soldier; but over 
 and above these desirable activities, it showed a tendency 
 to undertake functions which belong to the Army Medical 
 Service, as, for example, the organization and adminis¬ 
 tration of hospitals, and motor ambulances. In the 
 book published by Lieutenant Deane and myself, The 
 A.A.M.C. in Egypt, this aspect of the matter has been 
 discussed, and there is no need to refer to it again at 
 length. There are, however, so many activities which 
 might be accomplished by those who possess vision that 
 a well-staffed Red Cross will always be of service, but it 
 must be administered by highly educated men endowed 
 with scientific imagination. 
 
 The personnel of the American Red Cross was arranged 
 on a different plan from that of the British Red Cross. 
 It included medical officers and nurses and was admin¬ 
 istered by an educationalist, but the special function 
 of the American Red Cross in Egypt was, by arrange¬ 
 ment with the British Government, to take over the 
 medical care of the destitute population in Palestine, and 
 it was accordingly organized for that special purpose. 
 
 The Chief Commissioner of the British Red Cross in 
 Egypt was attached to the Staff of the Commander-in- 
 Chief, and consequently the Red Cross was theoretically 
 
134 
 
 A VISION OF THE POSSIBLE 
 
 in some measure under discipline, though practically it 
 was not, for as one Commander-in-Chief said to me, 
 “ If I were to find out that the finances of the Red 
 Cross had been wrongly handled by a military officer 
 who happened to be doing work for the Red Cross, I 
 do not think that it would be directly my business to 
 interfere.” 
 
 It will therefore be seen that the British Red Cross 
 is largely an amateur organization, built up on volun¬ 
 tary lines, managed by an autocratic committee, and con¬ 
 spicuous by the complete absence of the representative 
 principle. Let us ask ourselves, why should the Red 
 Cross undertake any single function which the Army 
 Medical Service can discharge ? In 1914-15 there 
 was a very good reason why it should, as the Army 
 Medical Service was not equal to the task imposed on 
 it; but when the Army Medical Service established 
 hospitals, built hospital trains, hospital ships and the like, 
 why should the Red Cross have continued to administer 
 anything the Army could accomplish ? Surely the pur¬ 
 pose should have been to provide the extra comforts 
 which the Government does not think necessary or 
 right to provide. There is something to me entirely 
 wrong in the administration of hospitals by two systems; 
 the point was exemplified acutely by a Red Cross Com¬ 
 missioner in Cairo, who spoke with pride of the Red 
 Cross Hospital at Ghizeh, to which he stated the men 
 preferred to come because the discipline was easier than 
 at the Army hospitals in Cairo, and the food was better. 
 From this position, then, there is no escape: either the 
 Army hospitals were wrongly administered, or the Red 
 Cross hospital was; but invidious distinctions of this 
 kind are not good for the service. 
 
 The Japanese have long since dealt with this par- 
 
THE R.A.M.C. AND THE RED CROSS 135 
 
 ticular phase of the problem, and those who wish to 
 assist the Japanese Army do so by supplementing the 
 work of the Army Medical Service. 
 
 An interesting work has been published by an 
 American who was in Germany during a part of the 
 war, called Lessons from the Enemy, by McDill, in which 
 full details are given of the colossal work of the German 
 Red Cross, and of the way in which vast numbers of 
 nurses and other medical workers were trained in times 
 of peace. 
 
 Surely a proper solution of the relationship is 
 that the Red Cross should continue as a voluntary 
 organization in times of peace, but on a representative 
 basis and containing in its governing body liaison 
 officers from the army, who should help and guide it, 
 that when war is declared the whole should be incor¬ 
 porated in the Army Medical Service, and the Chief 
 Commissioner become a member of the Staff of the 
 Director of Medical Services. To put it quite plainly, 
 the Red Cross as it exists in England is a relic of the 
 voluntary and amateur spirit which has been present 
 throughout the empire, and which has many advan¬ 
 tages as well as most serious disadvantages. I think 
 the feeling of the majority of medical officers who have 
 served through the war may be expressed much as 
 follows : whether it is really worth while to continue 
 as a voluntary association an organization which with 
 all the advertisement, with all the emotional appeals, 
 and with all the efforts used to raise funds, in England 
 and Overseas, has only raised funds equal to two days' 
 expenditure during the war. 
 
 If the various activities represented by the Red Cross 
 over and above those undertaken by the Army Medical 
 Service are considered right and proper, if the extra 
 
136 
 
 A VISION OF THE POSSIBLE 
 
 supplies over those the soldiers officially receive are 
 passed as right and proper, would it not be better to 
 nationalize it ? Would it not be better to let this relic 
 of the voluntary system drop into its proper place 
 and become an organic part of the life of the nation ? 
 At present a wholly disproportionate estimate is apt 
 to be made of the extent and value of the service 
 rendered. 
 
 A book was recently published, called The R.A.M.C. 
 in Egypt, by “ Sergeant-Major,” and at the end 
 of the book the following quotation is made from 
 an utterance by Sir Courtauld Thompson, Chief Com¬ 
 missioner for the Red Cross in Egypt: 
 
 It is due, however, to the officers and men of the official organi¬ 
 zation (R.A.M.C.)—such a statement can in no way detract 
 from the praise due to the voluntary societies—to record here 
 exactly what proportion the work of the societies bears to the 
 whole volume of achievement which is to be placed to the credit 
 of the British Medical Service in Egypt. This may be accurately 
 set down as about 3 per cent. The estimate is not “ official.’ 5 
 The figure indeed is quoted from a speech delivered by Sir Court¬ 
 auld Thompson, the Chief Commissioner of the Red Cross com¬ 
 bined organizations in Egypt; and may therefore be taken as 
 unimpeachable. At first such a figure applied to the work of 
 these societies may appear disappointingly astonishingly small. 
 It is not, however, really so. A percentage is only a relative 
 term. We are not dealing in this case with 3 per cent, of a 
 molehill, but of a mountain; and in that degree of estimation 
 the work of the Red Cross Society can only be regarded as 
 magnificent from whatever standpoint it is viewed. 
 
 At this meeting someone said that the R.A.M.C. did 
 97 per cent, of the work and got 3 per cent, of the 
 advertisement, whereas the Red Cross got 97 per cent, 
 of the advertisement and did 3 per cent, of the work. 
 
 I take it that if the system were placed on a national 
 
THE R.A.M.C. AND THE RED CROSS 137 
 
 basis, neither party would wish to get any advertise¬ 
 ment other than that accruing to all men who try to 
 render loyal service to their country in time of need. 
 Nothing is more certain to my mind than the necessity 
 for a careful, dispassionate, and sympathetic revision 
 of the relationship of the R.A.M.C. to the Red Cross, 
 and in making the necessary investigation much will 
 be obtained from a study of the corresponding institu¬ 
 tions in Japan and in Germany. 
 
SECTION Y 
 
 THE REORGANIZATION OF THE R.A.M.C. 
 
 CHAPTER XIII 
 
 WHAT IS THE ORGANIZATION OF THE R.A.M.C. ? 
 
 The R.A.M.C. organization before the war appears to 
 have been, like the British Army itself, conducted on a 
 limited scale, both with regard to numbers and to 
 scope of work. It contained apparently about 1,000 
 officers distributed in various parts of the world—that 
 is, a smaller number of officers than have been employed 
 in the Egyptian campaign alone. 
 
 In Egypt there has been a Director of Medical Services 
 (D.M.S.), whose position is always close to the General 
 Officer Commanding-in-Chief, whether the General 
 Head-quarters (G.H.Q.) happened to be in Cairo, at 
 Ismailia, or in the forward areas, and his authority in 
 all matters medical is practically absolute. He is 
 responsible to the Commander-in-Chief and to the 
 Director-General of Medical Services, who again is 
 attached to the Army Council in London, the Army 
 Council being the supreme governing body of the Army 
 under the Secretary of State for War. In addition 
 the E.E.F. has been divided into three sub-commands, 
 namely : Alexandria and the Western Desert, Cairo 
 and the Delta District, and what is known as Palestine 
 Lines of Communication (L. of C.). Each of these 
 sub-commands is presided over by an Assistant Director 
 
 138 
 
ORGANIZATION OF THE R.A.M.C. 139 
 
 of Medical Services (A.D.M.S.), who is associated in 
 like manner with the General Officer Commanding the 
 District, to whom he is responsible as well as to the 
 Director of Medical Services, G.H.Q., E.E.F. 
 
 These three districts have varied a little from time 
 to time in geographical extent, but roughly comprise 
 the following areas : 
 
 A.D.M.S. Alexandria had for his sphere of influence 
 Alexandria and the North-western Desert as far as the 
 frontier of Tripoli. 
 
 The Delta District included Cairo and the whole of 
 Egypt proper west of the Canal, including Suez, Ismailia, 
 and Port Said, but not Kantara. 
 
 Palestine L. of C. included the whole of the extra¬ 
 ordinary Lines of Communication which ran from 
 Kantara at first to El Arish, then to Gaza, subsequently 
 to Jerusalem, and finally to Aleppo, probably one of 
 the most extended and remarkable Lines of Communi¬ 
 cation ever constructed. 
 
 The peculiarity, however, of the Army Medical Service 
 is that the Director-General of Medical Services is not 
 a member of the Army Council. He is a subordinate 
 officer to the Adjutant-General, and only has access to 
 the Head of the Administration by courtesy; and in 
 like manner the D.M.S./E.E.F. is under the control of 
 the D.A.G./E.E.F., and consequently usually approaches 
 the Commander-in-Chief through that channel. Again, 
 in like manner each of the A.D.sM.S. is under the 
 control of the particular D.A.G. of the Command, and 
 usually approaches the Commander of the District 
 through him. The reasons for this arrangement and 
 the desirability of altering it will be discussed later. 
 
 The Adjutant-General and his deputies deal largely 
 with personnel, and are usually referred to as con- 
 
140 
 
 A VISION OF THE POSSIBLE 
 
 stituting the “A” Branch of the Army. It then 
 follows that there are two ways of communication 
 between the D.M.S. and his A.D.sM.S. or between the 
 Director-General of Medical Services in London and 
 the D.M.S./E.E.F.: they can communicate direct (and 
 frequently do) in purely medical matters, or the com¬ 
 munication may reach them through the “A” branch. 
 The variations in the relative number of communica¬ 
 tions received by the two channels bear a fairly close 
 ratio to the strength of the occupant of the office of 
 D.M.S. or D.A.G. as the case may be. 
 
 The District of an A.D.M.S., let us say the Delta 
 District, has its head-quarters at Cairo, and under the 
 administration of the A.D.M.S. of this district is placed 
 a large number of most extensive base hospitals, con¬ 
 valescent depots, and the like, the medical arrangements 
 of a large number of camps and garrison battalions dis¬ 
 tributed throughout the provinces; in other words, the 
 welfare of many tens of thousands of troops. The Staff 
 employed to effect this administration was 1 A.D.M.S. 
 and 6 Medical Officers in the Head Office, including an 
 A.D.M.S. Sanitary—that is, 7 medical officers who were 
 removed altogether from clinical work. In addition 
 there were a number of senior medical officers (S.M.O.s) 
 in camps and barracks who combined clinical work with 
 administrative work. The total number of medical 
 officers employed in these three commands was : 
 
 Alexandria .—An A.D.M.S. and 3 assistants (apart 
 from S.M.O.s). 
 
 Cairo .—An A.D.M.S. and 6 assistants (apart from 
 S.M.O.s). 
 
 Palestine L. oj C .—An A.D.M.S. and 3 assistants 
 (apart from S.M.O.s). 
 
 G.H.Q. —A.D.M.S. and 3 assistants. 
 
ORGANIZATION OF THE R.A.M.C. 141 
 
 The general disposal of these medical officers was 
 one A.D.M.S. Sanitary, one D.A.D.M.S. Administrative, 
 and the others practically the same as the D.A.D.M.S. 
 Administrative without the title. Five officers in 
 Egypt were employed superintending hospital ships, 
 hospital trains, and hospital supplies. 
 
 The Palestine L. of C. included not only Base 
 Hospitals, but also Stationary Hospitals, Casualty Clear¬ 
 ing Stations (C.C.S.s), and Field Ambulances. Beyond 
 the C.C.S.s the Administrative Services were controlled 
 by the D.D.M.S. of an Army Corps, also with an assis¬ 
 tant, in addition to Divisional A.D.sM.S. also with 
 assistants. It will, therefore, be seen that the number 
 of medical officers withdrawn from clinical work and 
 devoting themselves to entirely administrative work 
 was considerable, and, what was more serious, some 
 of these officers were men of considerable clinical 
 ability. 
 
 The hospital administration was comparatively simple. 
 The hospital was commanded in almost every instance 
 by a lieutenant-colonel or colonel, who was a regular 
 R.A.M.C. officer. He had a registrar, who in some 
 instances was a major, and a medical and a surgical 
 divisional officer with the official rank of major, who 
 conducted the administration of the medical and surgical 
 sides of the hospital, who was practically certain to be 
 a regular R.A.M.C. officer if such was available, but 
 in other cases these offices were filled by distinguished 
 clinicians. In addition a surgical specialist was available 
 in some cases; and as the years rolled by, an aurist, 
 oculist, bacteriologist, X-ray specialist, and a dentist 
 were gradually added to the Staff. The whole of these 
 specialists were not present in every hospital, but some 
 of them were present at every hospital, and all of them 
 
142 
 
 A VISION OF THE POSSIBLE 
 
 in the District. In some cases the position of Com¬ 
 manding Officer was occupied by a major—almost 
 invariably a regular R.A.M.C. officer or a Territorial. 
 These positions were, in practice, rarely offered to 
 clinicians, whatever their standing, or whatever their 
 experience, whilst regular officers were available. 
 
 The non-commissioned officers and men in the first 
 instance contained a fair sprinkling of trained men, but 
 as the wastage of war proceeded the “ A ” Class men were 
 transferred to the infantry and their positions filled by 
 “ B ” Class men who required training. This sub¬ 
 stitution took place in 1917, and gave a great deal of 
 trouble until it was completed. So difficult, however, 
 did the conduct of affairs become in 1918 that some 
 hundreds of the “A” Class men had to be withdrawn 
 from the infantry and restored to the medical service. 
 The difficulty was to obtain recognition of the fact that 
 certain R.A.M.C. men belonged to highly skilled occu¬ 
 pations and could not easily be replaced. 
 
 Such, then, was the mechanism as it appeared in 
 Egypt, and any communication made by an officer 
 passed in the ordinary way through his officer com¬ 
 manding to the A.D.M.S. and through him to the 
 D.M.S. and ultimately, if it became necessary, to the 
 Director-General in London. 
 
 So far as pay was concerned, it was made on the 
 familiar scale laid down, but extra pay was available 
 to those who commanded hospitals, to the divisional 
 officers, and to some specialists, namely, oculists, 
 pathologists, and surgical specialists. Beyond this 
 the Army Authorities would not go; and no matter 
 what extra work an aurist, for example, did, he was 
 not officially a specialist, he received no extra pay, 
 nor did he obtain any recognition or promotion. 
 
ORGANIZATION OF THE R.A.M.C. 143 
 
 It follows, therefore, that the position of a full colonel 
 commanding a hospital of, say, 2,000 beds was a highly 
 lucrative one, and the position of a captain occupying 
 a divisional office was a superior one to that of a major 
 who was a specialist. 
 
 Numerous cases of the kind were due, as I shall show 
 later, to what I believe to be the convenient but rigid 
 attitude adopted, for the system adopted throughout 
 the R.A.M.C. is that promotion and increase of pay 
 depend not on clinical merit, but on the administrative 
 office held; that is to say, a clinician of the first order 
 who was a captain could only secure promotion to 
 the rank of major by obtaining a registrar's office or a 
 divisional or some other post in which he would not be 
 doing the same amount of clinical work, if any. There 
 was, however, no means whatsoever of raising his rank 
 or pay and continuing him in the work at which he had 
 been successful. 
 
 In the service in Egypt, for the greater part of the 
 time, there was what appeared to me to be a serious 
 fault in the organization. Each D.M.S. or A.D.M.S. 
 had associated with him a Staff Officer who was almost 
 invariably much his junior. Owing to the mass of office 
 work which centres in these administrative positions, 
 neither the Chief nor the Staff Officer left the office for 
 days together: they consequently did not come in 
 contact with those who were doing the work, they were 
 not aware of the atmosphere in different districts—in 
 other words, they were imperfectly informed. As the 
 line extended into Palestine these difficulties became 
 more and more pronounced, and yet those conducting 
 the work one or two hundred miles away occasionally 
 received orders relating to their special work without any 
 previous consultation whatsoever. As will be indicated 
 
144 
 
 A VISION OF THE POSSIBLE 
 
 in the next chapter, the A.D.M.S. Force in Egypt met 
 this difficulty in part by unofficially employing his 
 Consultants as friendly inspectors. It seems to me, 
 however, that there is only one possible way of building 
 up a sound administration, namely, that each Adminis¬ 
 trative Head should have attached to him an officer of 
 very nearly his own standard of rank, that either the 
 Chief or his second should always be in the office, and also 
 that either the Chief or his second should be constantly 
 travelling. The tendency as one grows older is to become 
 an office “ wallah,” but an office “ wallah ” is not usually 
 a good administrator. 
 
 The system is not a little remarkable, since in the 
 combatant branches of the service the sound policy 
 was almost invariably followed. When friendly repre¬ 
 sentations were made to administrative officers on the 
 subject, the reply usually was that no senior officers 
 were available to act as understudies. Personally, I 
 should not have hesitated to have taken senior officers 
 out of some other position, when so important an end 
 was in sight. 
 
 Such, then, was the mechanism, and an admirable 
 mechanism from some points of view, but it needs 
 very little knowledge of the world to see that in such a 
 hierarchy one obstructionist can create havoc, and can 
 damp the enthusiasm of young energetic men and can 
 force them to become time-servers or break their 
 hearts. As one D.M.S., a man of great ability and moral 
 worth, said to me, it is possible in the service for a senior 
 to completely break the spirit of a junior officer without 
 infringing a single rule. I have often thought myself 
 that had I as a young man joined the service, I should 
 either have had a conflict and, like Cassio, been “ re¬ 
 moved ” at some period of my career, or I should have 
 
ORGANIZATION OF THE R.A.M.C. 145 
 
 had intellectual enthusiasms more or less completely 
 blotted out. 
 
 It is the purpose of this section of the work to indicate 
 how this organic mechanism can be retained with its 
 many advantages and shorn completely of its soul¬ 
 killing tendencies. 
 
 10 
 
CHAPTER XIV 
 
 CONSULTANTS AND PRESIDENTS OF STANDING 
 MEDICAL BOARDS 
 
 Consultants .—It seems that before the war oculists, 
 aurists, and other specialists were not much in demand 
 in the R.A.M.C., because in general those admitted to 
 the service of the Army were not supposed to have 
 special defects, and if they developed them during 
 service they were discharged from the Army. It 
 was, in fact, an eclectic army, composed for the most 
 part of fit men. At the same time a scrutiny of the 
 regulations of enlistment will probably show that these 
 conditions were not observed at all strictly, and that 
 some of the standards were little short of ridiculous. 
 It has, for example, fallen to the lot of some of those 
 who have been at work in Egypt to find that the vision 
 of generals was of such a nature that they could not 
 have properly gained admission had the standards 
 been observed, and the inference may be that the 
 standards were used in a more or less elastic manner, 
 according to the nature of the candidate. Furthermore 
 if the strict enforcement of such standards was adopted, 
 it must have made recruiting difficult, as it must have 
 excluded a large number of desirable people. 
 
 The matter is mentioned here with the object of 
 drawing attention to the fact that the R.A.M.C. regu¬ 
 lations, as a whole, were based on the supposition that 
 the officers were dealing with fit men, and that conse- 
 
 146 
 
STANDING MEDICAL BOARDS 
 
 147 
 
 quently oculists, aurists, dentists, and other specialists 
 were not requisite to any great extent. This, however, 
 has been a national war in which every human being 
 who could be in the service was required, and conse¬ 
 quently the standards of physical efficiency have been 
 revised from time to time. They had not, however, 
 in my judgment been revised with sufficient thorough¬ 
 ness until the matter was taken in hand in Egypt. 
 For a time in Egypt, so far as visual standards were 
 concerned, local arrangements provided for standards 
 far below those fixed by the Army standards, but 
 which were nevertheless in the judgment of the Con¬ 
 sulting Oculist and the D.M.S. adequate, and indeed 
 proved so in practice. Similarly, the Consulting 
 Aurist retained in Egypt the whole of the men suffering 
 from chronic otorrhcea and their retention proved 
 thoroughly satisfactory. Had all men whose vision 
 was below the recruiting standard, and had all men 
 suffering from chronic otorrhqea been withdrawn from 
 the fighting line, the position of the General Officer 
 Commanding would have been serious, as the number, 
 as far as could be estimated, was many thousands. In 
 consequence of the legacies from the R.A.M.C. Peace 
 Establishment, this problem of adjustment of old stan¬ 
 dards to new conditions was incessant, and it was not 
 completed when the war terminated. 
 
 When war broke out there were no Consultants, but 
 during 1915 several Consulting Surgeons passed in and 
 out of Egypt, one Consulting Surgeon remained, and I 
 myself was appointed Consulting Oculist and inciden¬ 
 tally Aurist to the Force in Egypt. When the military 
 organization settled down after the evacuation of the 
 Dardanelles, and with the departure of some of the 
 troops for France, the position was as follows : 
 
148 
 
 A VISION OF THE POSSIBLE 
 
 There was a Consulting Surgeon and a Consulting 
 Physician in Alexandria, a Consulting Surgeon in 
 Cairo, there was a Consulting Oculist for the E.E.F., 
 and also a Consulting Aurist for the E.E.F., but 
 beyond this there were no Consultants. Their powers 
 were defined in terms of a War Office memorandum, 
 and were powers of such a nature that had they been 
 acted upon the service would have been in an uproar 
 in a week; but being sensible men, and having the 
 confidence of the D.M.S., they never attempted to use 
 them. During 1916 and 1917 other appointments 
 were made. A Consulting Dentist to the E.E.F. was 
 appointed, whose task was indeed a formidable and 
 valuable one ; a Consulting Surgeon was appointed to 
 the Delta District, and a Consulting Neurologist to 
 Egypt. 
 
 During 1917 and 1918 two more Consulting Physicians 
 were appointed, one for the Delta District and one 
 for the Palestine L. of C. The appointment for the 
 Delta District was made just before the war ceased, 
 so that -with the exception of a few weeks in 1917, 
 during which a Consulting Physician—Delta District— 
 held office, the Delta District was without the 
 services of a Consulting Physician during the whole of 
 the war. 
 
 In 1918 for the first time, the duties and functions 
 of these officers were defined. The A.D.M.S. of the 
 Force in Egypt met them and obtained a definition 
 of their functions. He then called them together once 
 a week, placing them all on the same footing. At 
 these weekly conferences each member was invited to 
 report on any matter relating to his work he thought 
 fit, whether administrative or purely clinical, and 
 the matter was discussed with the A.D.M.S. in the 
 
STANDING MEDIOAL BOARDS 
 
 149 
 
 presence of the other Consultants. The practice was 
 continued by other A.D.sM.S. of the Force in Egypt, 
 and the force of Consultants gradually developed into 
 a body of friendly inspectors, who acted to the 
 A.D.M.S. as a Military Medical Intelligence Department. 
 Presently hard-working medical officers discovered 
 that the Consultants as a body were there to help them, 
 brought matters under their notice, with the result that 
 friendly and rapid adjustment of their difficulties was 
 frequently effected. This most successful system, begun 
 late in the war, was brought under the notice, in some 
 way, of the Commander-in-Chief, who inaugurated a 
 similar system as regards the D.M.S. At first these 
 meetings were limited to surgeons and physicians, the 
 other specialists being excluded. As a result of this 
 action a most invidious distinction was made between 
 the different branches of medicine, but, as pointed 
 out on page 150, rectification was subsequently 
 effected. 
 
 The War Office ruled in effect at the end of the war 
 that Consulting Physicians and Surgeons should hold the 
 rank of colonel, that the Consulting Oculist and Aurist, 
 who are also Presidents of Boards, should hold the rank 
 of lieutenant-colonel, that the Consulting Neurologist 
 should be a major, and that the Consulting Dentist 
 should be a major or a captain. This curious classifi¬ 
 cation of ranks and this exclusion of specialists from 
 discussions indicates the survival of what always appears 
 to me to be an archaic belief. I have never been con¬ 
 nected with a medical school or university in which 
 the view was not taken that all divisions of medical 
 knowledge were equal in importance, and on scientific 
 grounds any other attitude would be difficult to justify. 
 If, however, in the Army it is necessary to' take the 
 
150 
 
 A VISION OF THE POSSIBLE 
 
 view that the requirements of the soldier came first, 
 and that discrimination should be made, then it seems 
 to me that the Consulting Dentist should come first, as 
 within the territory of his administration there were 
 nearly seventy dentists whose services were absolutely 
 necessary for the supply of soldiers; next comes the 
 Consulting Oculist and Aurist; whilst at the bottom 
 of the list I should place the Consulting Physicians 
 and Surgeons, who are not so indispensable, since every 
 medical officer knows something about medicine and 
 surgery. It is true, however, that subsequently this 
 anomaly was corrected so far as meetings were con¬ 
 cerned, and all Consultants were placed on the same 
 footing as regards meetings, but the anomalies in 
 rank continued. 
 
 I know of few instances which throw a more vivid 
 sidelight on the mode of thought of those who direct 
 the organization of the R.A.M.C. than that just 
 narrated. 
 
 It should be understood that Consultants have no 
 administrative powers in theory, and they never issue 
 a direct order even in clinical matters, but they advise 
 the A.D.M.S. or D.M.S. as the case may be, and he 
 takes action or not as he thinks fit after discussion. 
 When it was possible to deal with a D.M.S. or with 
 A.D.sM.S. who were willing to meet the Consultants 
 and willing to be advised, the system worked well; 
 but in the few cases in which these officers did not wish 
 to meet the Consultants or to be advised, in which they, 
 so to speak, regarded themselves as omniscient, the 
 system worked very badly, and these officers felt as if 
 they were simply window-dressers kept for the purpose 
 of impressing the public. Yet as the years rolled by, 
 complaints in Parliament and the like caused reference 
 
STANDING MEDICAL BOARDS 
 
 151 
 
 to be made to Egypt, the answers to which required 
 special knowledge which not even an omniscient 
 D.M.S. possessed. It was then that the political value 
 of these appointments became apparent. 
 
 The position of these Consultants throws a flood of 
 light on the rigidity of the service. They are not pro¬ 
 vided for in any regulation, they did not exist in 
 pre-war days, and consequently there was no estab¬ 
 lishment in which they appeared. They had little 
 clerical assistance, there was a chronic difficulty with 
 motor-cars and conveniences, and their travelling 
 allowance was on the same scale as that of any other 
 officer, notwithstanding the fact that their expenses 
 were far heavier. 
 
 Summarizing, then, it will be understood that at the 
 end of the war the following Consultants were attached 
 to the Staff of the D.M.S./E.E.F. : 
 
 3 Consulting Physicians; 
 
 3 Consulting Surgeons 
 
 (Who were attached respectively to Alexandria, 
 the Delta District, and Palestine Com¬ 
 mands) ; 
 
 1 Consulting Oculist; 
 
 1 Consulting Aurist; 
 
 1 Consulting Dentist; 
 
 1 Consulting Neurologist; and 
 
 1 X-ray Specialist. 
 
 I think it would have been wiser to have appointed 
 one Chief Consulting Physician and one Chief Con¬ 
 sulting Surgeon to advise the D.M.S., and to have 
 appointed other surgical and medical Consultants to 
 the areas referred to. One officer can direct, three 
 cannot! 
 
152 
 
 A VISION OF THE POSSIBLE 
 
 Presidents of Boards .—Towards the end of the war, 
 another office became of vast importance, the office 
 of President of the Standing Medical Board. This 
 work was begun early in 1917, when it became evident 
 that the man-power of the empire was becoming 
 exhausted, and that what there was had to be used to 
 the best advantage. I was appointed President of the 
 Standing Medical Boards in the E.E.F., excepting 
 Alexandria, which some months later was placed in 
 charge of the Consulting Oculist. In these capacities 
 we had to work out a proper business system, to 
 establish proper physical standards, and, by being as 
 human as possible, to make an unpopular and difficult 
 system work. Ultimately, at the end of 1917 when 
 the system was in working order, it was divided into 
 three and then into four parts, and Presidents were 
 appointed for the Standing Medical Boards, Palestine 
 L. of C.,the Canal Zone, the Alexandria District, and 
 the Delta District respectively. 
 
 Theoretically these Presidents did not exist, as 
 their functions had not been contemplated in times of 
 peace; and consequently difficulties arose concerning 
 clerical assistance, typewriters, travelling expenses, and 
 promotions. So it came about that I personally had 
 to employ a civilian stenographer, to purchase my 
 own typewriter, and to a large extent to pay my own 
 travelling expenses. I do not grudge these things 
 personally—either the work had to be done in this 
 way or not at all—but I quote the instance as illus¬ 
 trating the inflexibility of the service. 
 
 The attitude of the R.A.M.C. officer brought up in 
 the old school was one of courteous and sometimes even 
 genial toleration for an incubus in the form of a Con¬ 
 sultant or a President of Boards. Those, however, who 
 
STANDING MEDICAL BOARDS 
 
 153 
 
 were administering the service presently found out their 
 great value, particularly as War Office inquiries began 
 to appear in Egypt which required precise and accurate 
 answers, and towards the end of the war the Standing 
 Medical Board was firmly established in spite of attacks. 
 Before, however, disposing of the subject for the time 
 being, it may be worth while to point out the extreme 
 difficulty men accustomed to civil administration find 
 in understanding any delay in rapidly grasping these 
 altered conditions and in dealing with such matters in 
 an ordered and sensible way. 
 
 The older type of R.A.M.C. officer who commanded 
 a hospital had difficulty in understanding that with one 
 President for many Boards uniform standards must 
 make their appearance, and that the knowledge gained 
 by the difficulties of one Board was carried on to the 
 next. He further did not appreciate the fact that an 
 order relating to classification or invaliding conveyed 
 by the D.M.S. to the President of a Board was easily 
 carried out, whilst an order sent to multiple Boards 
 was more liable to end in confusion. Furthermore, an 
 officer of the old type commanding a hospital found 
 it difficult to contemplate any system by which he was 
 not absolutely supreme in all matters within his own 
 hospital, and he consequently viewed the Consultants 
 and Presidents of Boards as innovations who might be 
 personally pleasant enough, but who did not belong 
 to the scheme of affairs in which he had been brought up. 
 
CHAPTER XV 
 
 EDUCATION, CHANGES OF PERSONNEL, AND PROMOTION 
 
 Education of Medical Officers 
 
 In my judgment, one of the greatest failures of the 
 service has been the failure to train newly arrived 
 medical officers. As junior medical officers made their 
 appearance in Egypt, they were posted to various 
 positions and there allowed to pick up what information 
 they could. It might be they were sent to a Field 
 Ambulance, they might have been posted to a Battalion, 
 they might be sent to a Base Hospital; but of the general 
 organization of the medical service, of the reason for 
 the existence of the various returns, they were entirely 
 ignorant, and being so became resentful of the amount 
 of clerical work imposed on them. Had they been 
 taken into confidence, and had they been invited to 
 round-table discussions with senior officers, they would 
 have learned more rapidly and their enthusiasm would 
 have been preserved; but though repeated informal 
 recommendations were made by the Consultants that 
 this should be done, it never was done to any consider¬ 
 able extent. The nearest approach to it was a series 
 of clinical meetings held in Cairo and Alexandria during 
 the winter of 1916, and presided over in many instances 
 by the D.M.S. of the time, whose genial attitude did 
 much to help. 
 
 The usual arrangement in Egypt was that there 
 were nine officers in a Field Ambulance, whereas in the 
 
 154 
 
EDUCATION, PERSONNEL, AND PROMOTION 155 
 
 judgment of nearly all concerned three medical officers 
 are quite sufficient. Nearly the whole of the work of 
 a Field Ambulance could be done by sergeant-majors. 
 The explanation given was that the surplus were 
 required for regimental reinforcements in the event 
 of casualties, an arrangement the soundness of which 
 did not commend itself to the j udgment of most of the 
 medical officers. Nothing seems more certain than 
 the importance of the work of a battalion medical officer, 
 not because his work is purely medical, but it is 
 requisite that he should possess sound medical 
 knowledge, with excellent medical judgment, and that 
 few young men possess. The general verdict was that 
 the battalion medical officer should be a medical man 
 who has been in practice for some time, and about 
 thirty to thirty-five years of age, that young men 
 should be employed in the Field Ambulances and the 
 older men farther back. Yet newly joined medical 
 officers were thrown now into this and then into that 
 position without preparation or adequate training of the 
 kind, and the result, as might have been expected, was 
 a great deal of what is known popularly as “ grouse.” 
 
 Something, however, must be said about the civilian 
 medical officer. The ordinary civilian doctor entering 
 the Army, without any special training or instruction, 
 was often a source of very great trouble, not only to 
 the regular R.A.M.C. officer, but also to the temporary 
 officer who had acquired a knowledge of military ways. 
 The training of the average medical man is intense 
 but narrow; all his energies are concentrated on one 
 problem, doing the best for the sick man professionally. 
 He consequently speculates on remote risks his 
 patient may undergo, and warns him from doing this, 
 and that. His job is to conserve the comfort and the 
 
156 
 
 A VISION OF THE POSSIBLE 
 
 well-being of the man who is employing him, and 
 with obligation to the State he is not concerned. In 
 the Army, on the other hand, everything must be done 
 for the good of the service. It is true that the comfort 
 and well-being of the soldier is studied, and studied 
 thoroughly, but always with a specific end in view. The 
 actual clinical proceedings differ very greatly in accord¬ 
 ance with the spirit in which they are approached, and 
 in common with many other officers I arrived at the 
 definite conclusion that I would not allow a purely 
 civilian doctor to have anything to do with the soldier 
 so long as he was in the service. The civilian doctor 
 is almost certain to desoldierize him by his policy of 
 advising the avoidance of all risks, and by his 
 adoption of what are really obsolete physical standards. 
 When the soldier is discharged from the Army and 
 requires medical and surgical attention, then the 
 civilian doctor may be given a perfectly free hand; but 
 I voice the conviction of many temporary officers, 
 that they would not have permitted any medical prac¬ 
 titioner to sit on any Medical Board if he had not 
 actually served in the field himself, because in the 
 majority of cases he does not fully understand the 
 problem, and he does much harm with the best of 
 intentions. 
 
 Many of the difficulties just alluded to are produced 
 by what was well called the theory of omniscience. 
 Once an administrator takes up the comfortable atti¬ 
 tude that if an officer is a medical practitioner he can 
 do any work that comes before him, and that he is 
 dealing with medical officers as interchangeable units, 
 then it is certain trouble will ensue in many directions; 
 and if an administrator imagines that he is omniscient 
 and capable of judging details in all branches of 
 
EDUCATION, PERSONNEL, AND PROMOTION 157 
 
 knowledge, then he is certain to get into difficulty, at 
 all events from the scientific point of view. It seemed 
 to those of us concerned that the proper course would 
 have been to have taken a careful census of all 
 the medical officers in the field, and to have made all 
 possible inquiries from Consultants and senior officers 
 in the field respecting their capacities. It would thus 
 have been possible to place them in the positions in 
 which their services would be most valuable. 
 
 Change of Personnel 
 
 During the four years I have served in Egypt, I 
 found myself under the control of no less than ten 
 Directors of Medical Services, eight of them direct, and 
 two indirect—that is to say, one was a subordinate 
 D.M.S. and the other principal D.M.S. It is true that 
 one of them only held office for a few days, and another 
 only for a few weeks, but the passage of chiefs 
 reminded one of the procession of ghosts in Macbeth , 
 and the changes in subordinate commands were on a 
 similar scale. Now everyone is aware of the difficulty 
 in war-time of securing continuity as in times of peace, 
 but these constant changes served no good purpose. 
 Egypt was saved in 1915 from a disaster similar to that 
 which took place in Mesopotamia, and all the peculiar 
 difficulties incidental to the country were met and sur¬ 
 mounted, hospitals being built up in a certain fashion. 
 After the evacuation of the Dardanelles, there was a 
 reduction in the size and strength of the hospitals, and 
 from that time to the end of the war the hospital accom¬ 
 modation in Egypt resembled the movements of an 
 a-ccordion. Came there a slack period, as there did 
 almost every winter, the tendency was to shut up the 
 hospitals; came there a heavy season, the tendency was 
 
158 
 
 A VISION OF THE POSSIBLE 
 
 the reverse; and owing to these constant changes, at 
 the end of the war the position was distinctly dangerous. 
 The number of changes of subordinate commands in 
 Egypt must have been very large, and apparently 
 larger than was absolutely necessary. But something 
 even more serious developed as time went on. 
 
 The D.M.S. centralized authority in his own office. 
 He apparently believed that the forward area was more 
 important than the base, whereas I think most officers 
 would be of the opinion that you might as well compare 
 the importance of the arm and leg of a human being 
 —he needs both. As a result, he (or someone under his 
 authority) began to move medical officers from Base 
 and Stationary Hospitals at the Base to forward areas, 
 without consulting the A.D.sM.S. of the Districts or the 
 Officer Commanding the Hospital; and thus specialists 
 were taken from their work and were given work that 
 specialists ought not to do, and work at the Base was 
 sometimes thrown into confusion. 
 
 One of the most notable instances of the confusion 
 which can be caused in this way is furnished by the 
 following incident. 
 
 An Aural Specialist had just been placed in charge 
 of a very large clinic, a clinic which was serving the 
 needs of a large Base Hospital, and of a soldiers’ camp. 
 He was appointed for the purpose of relieving the aurist 
 who was absent on leave in England. The arrange¬ 
 ment for his appointment was made by the D.M.S. after 
 consultation with me. I left for another city leaving 
 everything in order. Some two or three weeks later 
 I received a pathetic letter from this officer to say 
 that he had been suddenly sent up the line to a Field 
 Ambulance or C.C.S. (I do not remember which), 
 and would I let him know whether he had done any- 
 
EDUCATION, PERSONNEL, AND PROMOTION 159 
 
 thing wrong. Meanwhile the work at the Base Hospital 
 was in difficulties. 
 
 The A.D.M.S. of the District thought that I must 
 have advised the D.M.S. to take this step, the D.M.S. 
 personally was unaware how it happened, and the 
 Officer Commanding the Hospital did not understand 
 what had occurred; if the specialist had not written 
 the personal letter to me I should have been entirely 
 unaware of the confusion which had followed. If on 
 the other hand the order had reached the A.D.M.S. 
 District, and he had been asked to send someone to 
 the Casualty Clearing Station or Field Ambulance as 
 the case may be, he would naturally have consulted me 
 before damaging what he knew to be an indispen¬ 
 sable clinic, and some reasonable adjustment of the 
 difficulty would have been found. 
 
 On representation being made of the impossibility 
 of conducting business in this way, an alternative being 
 requisite, an A.D.M.S. suggested that if so many 
 medical officers of a certain character were required 
 in forward areas, and the fact were communicated 
 to him, he would send them on and do the work 
 with the minimum of staff. The reply was that the 
 worst men were usually sent forward, and the practice 
 to a large extent continued, mitigated, however, by 
 the policy adopted of leaving specialists alone. To 
 me it was a sad confession of the inefficiency of the 
 administration. If it was true that Officers Com¬ 
 manding Hospitals sent away their worst men, it 
 should have been a comparatively simple matter to 
 deal with them and rectify this evil, but to cause 
 wholesale disturbance instead of dealing with the evil 
 seemed to most officers to be a mechanical way of 
 endeavouring to solve a human problem. 
 
160 
 
 A VISION OF THE POSSIBLE 
 
 Promotion 
 
 In the R.A.M.C. there was no such thing as promotion 
 for service in the class in which an officer was appointed; 
 such has been the experience of the war. If a captain 
 was made a Consulting Surgeon, as was the case, he 
 became a lieutenant-colonel, and then a colonel. If a 
 captain was made a Consulting Dentist, as was the case, 
 he remained a captain, because the position of Con¬ 
 sulting Dentist did not carry any definite rank. If a 
 captain in a hospital did magnificent clinical work, he 
 could not obtain higher rank except by becoming 
 Registrar or Divisional Officer—that is to say, by 
 giving up part of his clinical work and taking up 
 administrative work; in other words, excellence in a 
 special department of knowledge could onlybe recognized 
 by asking him to do something for which he might 
 not be fit, mentally and by training. 
 
 The reason for this system will be readily under¬ 
 stood. It avoids intellectual and moral effort. It is 
 possible to promote a man in this way irrespective of 
 the value of his special services in his new post and in 
 a way that cannot be challenged—that is, an excellent 
 official reason can be given for it. If, on the other 
 hand, it became necessary to promote a man for his own 
 knowledge and lift him above the men around him, it 
 would require careful adjudication and plenty of moral 
 fibre to answer the criticisms of the disappointed; and 
 yet, as I shall show later on, I know of a great service 
 in which this is done, and done successfully. To me, 
 the faulty mainspring of the R.A.M.C. lies in the 
 moral abasement indicated by this attitude. 
 
 As a matter of fact, when a R.A.M.C. officer ceases 
 to be a major and becomes a lieutenant-colonel, he passes 
 
EDUCATION, PERSONNEL, AND PROMOTION 161 
 
 away from clinical work altogether and becomes an ad¬ 
 ministrator. It does not matter what his inclinations may 
 be, or what his ability may be, he must either become 
 an administrator or lose his chance of reward; and the 
 result is that the majority of men, seeing that promotion 
 lies one way only, begin to get out of touch with clinical 
 work, and presently do not quite understand the drift 
 of modern thought. It was largely in consequence of 
 this attitude that the service was so long in properly 
 defining the positions of Consultants and Presidents of 
 Boards. Accustomed to regard the Officer Commanding 
 as omniscient, they failed to realize that in medicine 
 to-day no human being—scarcely even a god—could 
 hope to be omniscient, but he can hope to possess such 
 an insight into, and such a knowledge of, scientific 
 thought that he knows exactly where to turn for 
 helpful and intelligent advice. 
 
 The Sanitary Department of the R.A.M.C., or, as I 
 should prefer to have it called, the Prophylactic De¬ 
 partment, is in my opinion one of the most important 
 departments, but it is the Cinderella of the service. He 
 who takes it may get the satisfaction of doing splendid 
 work, but he will receive neither the promotion nor the 
 rewards which are given to the administrative service. 
 The prevention of disease is never dramatic, people fail 
 to visualize that which has not occurred, and the 
 A.D.M.S. Sanitary in the service at present occupies 
 an indifferent third position (and the clinical element 
 may be placed as a bad second). A noteworthy case 
 existed in Egypt where a Professor of Sanitary Science 
 ultimately at his own wish was placed in command of 
 a Field Ambulance for reasons that are indicated in 
 the foregoing. 
 
 11 
 
CHAPTER XVI 
 
 SUMMARY 
 
 In the foregoing sketch I have endeavoured to show 
 some of the sources of strength and weakness of the 
 Army Medical Administration, and I propose in this 
 chapter to indicate what I believe to be the changes 
 necessary in order to conserve that which is sound and 
 eliminate that which is hurtful. 
 
 The problem which lies before us is much more simple 
 than any problem that has been presented to the nation 
 before, since thousands of civilian medical men have 
 passed through the R.A.M.C., and have become inti¬ 
 mately acquainted with its best and its worst features. 
 The administration is no longer a mystery to them, 
 and its strength and weakness are an open book. They 
 understand perfectly that, whilst a good administrator 
 in the R.A.M.C. would probably be a good administrator 
 elsewhere, yet compared with the difficulties of civilian 
 administration, administration in the Army Medical 
 Service is fairly easy, since it is in the main adminis¬ 
 tration by regulation. They also see how easily men 
 fall away from ideals, and become the servant of a 
 machine, regarding these regulations as sacrosanct, 
 instead of regarding them as a convenient record of the 
 practice that has usually been found to be serviceable, 
 which may be modified at times, and in emergency must 
 be broken. Never has there been a service in which 
 
 162 
 
SUMMARY 
 
 163 
 
 the theory of legal fiction is more obvious. The King's 
 Regulations may not be broken, but in practice in war¬ 
 time they have to be broken, though undoubtedly they 
 are observed as far as it is possible to observe them. 
 The process of amendment is so slow and difficult, 
 owing to the centralization of the machine in London, 
 that it is requisite at times that someone should 
 have the courage to do what is right. 
 
 The “ Office Wallah ” Method 
 The first and fundamental weakness in the adminis¬ 
 tration is to me the tendency to become an “ office 
 wallah ” and to endeavour to manage a large body of 
 highly individualistic, capable men by writing letters 
 to them; letters written often by a man who knows 
 less respecting some special subject than does the 
 recipient. The first and obvious change in principle 
 is that superiors should fully and in conference discuss 
 important items with their subordinates, retaining if 
 necessary the right to take action if they think fit. 
 They should endeavour to come to an agreement 
 with those officers who are to carry out the policy agreed 
 to, and the letter should be written, as in civil life, as 
 embodying the spirit of the agreement reached. I 
 never could have imagined, had I not been in the 
 service, that I should receive a letter written at a 
 distance of 200 miles, giving me instructions regarding 
 expert action in my own department without any 
 previous consultation of any description whatever. 
 As a matter of fact had I obeyed the order, adminis¬ 
 tration would have become difficult. I need hardly 
 say that I represented with proper respect the deadlock 
 which faced us, and managed to obtain some amend¬ 
 ment. Experience of the kind was not very frequent, 
 
164 
 
 A VISION OF THE POSSIBLE 
 
 and all the temporary officers made up their minds 
 during the term of the war to do their best to try to 
 make the machine work somehow or someway, but 
 most of them felt that when the war was over the time 
 would come to try to introduce a more reasonable 
 system, and one more in accord with the scientific 
 spirit of the time. 
 
 In my judgment, no administration will be sound in 
 which every administrative officer is not provided with 
 an understudy of nearly the same rank as himself, so 
 that one or the other may be constantly travelling 
 throughout the command. When it is recollected that in 
 the E.E.F. the distance from one end of the command to 
 the other reached 700 miles (approx.), the futility of the 
 “ office wallah” method of administration will become 
 obvious. 
 
 Proper Rank for Clinicians 
 
 A fundamental fault of the R.A.M.C. organization 
 is that in its higher branches its officers cease to be 
 medical men, and do not become soldiers ; they become 
 what are called administrators. 
 
 When an officer is promoted beyond the rank of 
 major and becomes a lieutenant-colonel, his work 
 becomes purely administrative; and unless his character 
 and mental constitution are remarkable, sooner or later 
 he is apt to lose touch, first with the practice of medicine, 
 and then with scientific interest in medicine. He may 
 become a very good administrator, though, as I have 
 previously mentioned, administrators do not require 
 any extraordinary ability. There is surely another 
 way of dealing with the matter. In my opinion there 
 should be three avenues to promotion : 
 
 (a) As at present through administrative work, for 
 those whose inclinations take them in that direction, 
 
SUMMARY 
 
 165 
 
 but ( b) it should always be possible to rise by clinical 
 work alone, and to reach in time of peace as in time of 
 war a position of Consultant in some branch of know¬ 
 ledge with a rank equal, or nearly equal, to that of the 
 administrator, (c) It should also be possible, by devot¬ 
 ing life’s energies to preventive medicine, to rise to a 
 similar position with similar rank in that department of 
 knowledge. 
 
 If, then, such a principle were adopted, a large com¬ 
 mand in time of peace would consist of: a Director of 
 Medical Services, with a Staff consisting of a Consult¬ 
 ing Physician, Consulting Surgeon, Consulting Oculist 
 and Aurist, Consulting Dentist, Consulting Preventive 
 or Prophylactic officer, or Sanitarian. He would consult 
 these officers in all matters relating to their special 
 functions, and if he found it necessary to over-ride their 
 advice, would minute his reasons for doing so. As a 
 matter of fact such a Staff sitting together as a Council 
 would rarely end in disagreement. The practical diffi¬ 
 culty that would lie in the way of clinical development 
 of such men is the lack of opportunities of practice 
 when dealing with a fairly healthy Army. 
 
 Civilian Advisory Boards 
 
 There is something to be said for this argument, which 
 has, however, been long since met in Germany, where 
 the medical officer of the Army is attached for con¬ 
 siderable periods to civilian hospitals, laboratories, and 
 the like. In order to secure the necessary nexus it is 
 desirable that not only in the Chief Command, but in all 
 Subordinate Commands a small civilian medical com¬ 
 mittee, partly nominated by the Army and partly 
 nominated by the local Medical Association itself, 
 should be associated with the directors as an advisory 
 
166 
 
 A VISION OF THE POSSIBLE 
 
 body. Whether this advisory committee should be 
 paid or not is a matter for discussion. Personally, I 
 should prefer to see it a body of honorary members, 
 and the reward made one of honour only. There are 
 many distinguished members of the profession who 
 would gladly give their services in such a national con¬ 
 cern. This method has always appeared to me to make 
 such committees much more effective, and such at all 
 events has been my own personal experience. I have 
 served on many Government committees, I have never 
 received any Government fee or allowance, and I have 
 felt the independent atmosphere has been enhanced 
 by the fact that I was under no obligation to anyone 
 in the service. 
 
 Promotion 
 
 Let us, then, suppose that the organization is as I 
 have sketched it. How is promotion to be effected ? 
 And there we reach the crux of the problem. Promotion 
 in Egypt has not been effected at all except by appoint¬ 
 ment to administrative positions which carried rank; 
 in other words, by moving men from something they 
 could do, in some cases to do something for which they 
 were not suitable, in order to give them rank, and all 
 promotions have been effected on the ipse dixit of one 
 man. This system appears to me to be absolutely 
 wrong. Sooner or later a subordinate may offend the 
 Chief, or he may come in contact with the Chief, the 
 two men being mutually incompatible, and trouble 
 must ensue unless the Chief is a man of extraordinary 
 tact and judgment. In a Government Department in 
 Australia a system has been evolved which goes far 
 towards meeting this difficulty of providing a stimulus 
 of just promotions. Promotions are effected by a Board 
 
SUMMARY 
 
 167 
 
 of three; one member is appointed by the'Secretary of 
 State ( i.e . Minister), one by the Public Service Commis¬ 
 sioner, and one by the class from which members are 
 to be promoted. The record of the officer is examined, 
 not only with respect to the work he has done in the 
 service, but with respect to the part he has played in 
 the life of the community; in other words, a broad 
 survey of his character is made. If this method of pro¬ 
 motion were adopted, and if the changes indicated 
 above were made, I can imagine an Army Medical 
 Service which would attract some of the finest brain 
 and character in the country and from which work 
 of the first order might be expected. The necessary 
 flexibility would be obtained, the closer association of 
 the civilian and military elements would be conserved, 
 and we should have a mobile service which responded 
 more or less accurately to every advance in human 
 knowledge. 
 
 Should the A.M.S. be under the “ A ” Branch ? 
 
 It will be remembered that the Medical Service is 
 placed under the control of the Adjutant-General and 
 his deputies throughout the service. An attempt was 
 made after the South African War to abolish this 
 arrangement and to place the Director-General and the 
 Directors of Medical Services on the same footing as the 
 Adjutant-General or the Quartermaster-General; that 
 is, the Director-General would become a member of the 
 Army Council, and the Directors of Medical Services 
 would have direct access to the Commander-in-Chief. 
 The proposal, however, was not adopted, notwithstand¬ 
 ing the advocacy of Sir Alfred Keogh. 
 
 I have now had opportunities for four years of watch¬ 
 ing the system, and I feel less positive than I did of 
 
168 
 
 A VISION OF THE POSSIBLE 
 
 the desirability of effecting the change. The real 
 difficulty, which is rarely, if ever, expressed in writing, 
 is that the education of the ordinary medical man 
 requires to be broader if he is to take up such a 
 position. Whilst amongst the Directors of Medical 
 Services there have been many of broad outlook, capable 
 of holding their own in association with other men, 
 there have been a sufficient number of men who did not 
 possess the qualities to warrant making so radical a 
 change. The circumstances of the war have deepened 
 the conviction formed by me in civil life that medical 
 education must be modified in some way so as to give 
 medical men a wider outlook and a better conception 
 of their relationship to society, a theme on which I heard 
 the President of the United States speak with great 
 vigour in 1912. 
 
 Personally I think it would be better that the Director- 
 General should be a member of the Army Council, and 
 that the Directors of Medical Services should have 
 direct access to the Commander-in-Chief; but if such 
 a step be taken, great care will have to be exercised 
 respecting the appointments. It will not be sufficient 
 to appoint an officer who is a good medical practitioner, 
 he must be a cultivated man of science as well. 
 
 Medical Officers should do Medical Work 
 
 On minor matters, such as the misapplication of the 
 abilities of medical men by allotting clerical work and 
 very ordinary administrative duties to them, Lieut. 
 Deane and I have already written at some length in The 
 Australian Army Medical Corps in Egypt. There is no 
 doubt that many of the functions discharged in the 
 Army by the medical officer could be better discharged 
 by a sergeant-major, or a lieutenant-quartermaster. 
 
SUMMARY 
 
 169 
 
 The more the expert knowledge of medical men is 
 utilised and the less they are employed for work that 
 other people can do, the more efficient the service is 
 likely to be. 
 
 Education 
 
 Reference has been made in the course of this work 
 to the necessity for providing instruction for the 
 newly joined medical officer. The matter is of very 
 great importance. For example, much trouble and 
 expense were caused by the fact that medical officers, 
 in passing men down the line, either would or could not 
 pass on clinical information with them. The result was 
 that when the patients arrived at the base or at the 
 halting place, all the work had to be done again. There 
 were instances of two or even three X-ray photographs 
 being taken of the same physical condition for the same 
 purpose, simply because information was not passed on 
 through the proper channel. If, however, no senior 
 officer took the trouble to explain to the junior officer 
 what this channel was, and why it was important that 
 this information should be passed on, there was little 
 wonder that there was some neglect. Probably the 
 hardest part of administration in the Army is securing 
 the rapid passage through the proper channels of the 
 necessary clinical information. 
 
 The Nature or Military Medical Work 
 
 The public generally pictures the Army Medical 
 Service as a collection of enthusiastic medical men 
 doing their best for sick and wounded soldiers. As far 
 as I can hazard a guess, this really represents one-third 
 of their work. It is of course a necessary part of their 
 
170 
 
 A VISION OF THE POSSIBLE 
 
 work, and from my experience it is done very thoroughly 
 and conscientiously. But the military medical problem 
 differs wholly from the civil medical problem, and quite 
 another third of the military activities is, or should 
 be, devoted to the prevention of disease, whilst the 
 remaining third resolves itself into attempts to properly 
 dispose of the sick or wounded soldier, to decide when 
 he is fit to work, where he is fit to work, and what work 
 can be given him to do. The medical practitioner in 
 civil life is not concerned at all seriously with this prin¬ 
 ciple, or with the problem of the prevention of disease in 
 the main. At conferences of Consultants held in Egypt, 
 some of the more newly appointed Consultants took the 
 view that they were in Egypt for clinical purposes 
 only, and that they had nothing to do with adminis¬ 
 tration, yet during the discussion I think it is a fair thing 
 to say that very rarely did one of them utter a 'dozen 
 sentences without trenching on the province of adminis¬ 
 tration. Medical administration and clinical medicine 
 are intimately associated, because treatment includes 
 the proper placing and disposition of the sick man. 
 If it has taken those of us who have been in the service 
 many months or years to become thoroughly acquainted 
 with these elementary principles, what chance has the 
 newly joined medical officer of understanding them un¬ 
 less there is some systematic instruction in the matter ? 
 Furthermore, orders, amendments of orders, and 
 circulars are issued in profusion. One of the ablest 
 medical administrators I have ever met told me he 
 was satisfied if he could get some attention paid by 
 medical officers to the third issue of the same order. 
 Civilian medical practitioners are not in the habit of 
 taking orders. They frequently do not read them, or 
 reading them do not grasp them, and in my judg- 
 
SUMMARY 171 
 
 ment tli3 position could have been improved by two 
 methods : 
 
 1st. The method of conferences, and 
 
 2nd. A systematic and periodical codification of 
 orders, their publication in printed form, and their 
 issue to every medical officer in the Army. Their 
 number is so great and the complications are so be¬ 
 wildering that is almost impossible to carry them in 
 memory. 
 
 Redress of Grievances 
 
 A proper method of redress should be devised for an 
 officer who finds himself aggrieved by action taken in the 
 service. Now just as promotion should not be dependent 
 on the ipse dixit of one man, in like manner serious 
 differences should not be left to the unchecked judg¬ 
 ment of one man, and there should be a Board of 
 Reference for serious complaints. The position is re¬ 
 markable. From a sense of loyalty few officers care to 
 complain about a senior. If they do complain it is more 
 than likely that the senior will get into trouble if he is 
 in the wrong, but it is probable that the junior will be 
 punished whether the senior is in the right or not; in 
 fact, the old Japanese principle is applied, though it is 
 not supposed to be. In the tales of Old Japan it is 
 narrated that a village headman whose village was being 
 maltreated by their immediate lord, appealed to the 
 overlord in the Feudal Hierarchy. The proceeding was 
 quite constitutional and recognized. Complaint having 
 been made, the overlord was compelled to redress the 
 grievance, but he who complained forfeited his life to his 
 immediate lord, unless pardoned as an act of grace. 
 
 It seems to me that a good deal of this principle holds 
 good in the R.A.M.C., and it is not right that it should 
 
174 
 
 A VISION OF THE POSSIBLE 
 
 Hqw can Reform be effected ? 
 
 By what means, then, can such changes be effected ? 
 I see nothing for it but a properly constituted Royal 
 Commission, with power to call for evidence and to 
 protect those who give evidence, so that the speaking 
 may be plain. But the Commission should be carefully 
 appointed, and so far as the medical personnel on that 
 Commission are concerned, I should recommend certain 
 limitations and reservations. I should suggest that 
 a certain number of the seats in the Commission were 
 filled not by Government nominees, but by officers 
 elected by those medical officers who had served 
 abroad, in Egypt, Mesopotamia, and in East Africa, 
 for substantial periods of time. These medical prac¬ 
 titioners have been abroad, away from their families 
 and practices, communication with their friends has 
 been difficult, and they alone know exactly where the 
 administrative shoe pinches. 
 
 I hope from the foregoing chapters I have given clear 
 indication of my appreciation of the essential sound¬ 
 ness of the work done by the R.A.M.C. during the war, 
 and at the same time of its limitations. I believe that 
 all that is sound in it can be retained and by the 
 adoption of the changes indicated it can be made a 
 flexible, mobile institution, capable of greatness, capable 
 indeed of leading the nation not only in matters 
 relating to military science, but also in civil medicine 
 and surgery. 
 
 Is it not obvious that the criticisms amount to the 
 statement that the service shows much individual 
 excellence with defective organization ?—a criticism 
 which applies more or less to the various institutions 
 of the Empire. Anglo-Saxons possess the faults of 
 
SUMMARY 
 
 175 
 
 their qualities and tend to become intellectual anar¬ 
 chists. The day has passed, however, when individuals 
 acting as such can do great things, and the future lies 
 to the intelligent who can combine loyally in team 
 work. 
 
174 
 
 A VISION OF THE POSSIBLE 
 
 Hqw can Reform be effected ? 
 
 By what means, then, can such changes be effected ? 
 I see nothing for it but a properly constituted Royal 
 Commission, with power to call for evidence and to 
 protect those who give evidence, so that the speaking 
 may be plain. But the Commission should be carefully 
 appointed, and so far as the medical personnel on that 
 Commission are concerned, I should recommend certain 
 limitations and reservations. I should suggest that 
 a certain number of the seats in the Commission were 
 filled not by Government nominees, but by officers 
 elected by those medical officers who had served 
 abroad, in Egypt, Mesopotamia, and in East Africa, 
 for substantial periods of time. These medical prac¬ 
 titioners have been abroad, away from their families 
 and practices, communication with their friends has 
 been difficult, and they alone know exactly where the 
 administrative shoe pinches. 
 
 I hope from the foregoing chapters I have given clear 
 indication of my appreciation of the essential sound¬ 
 ness of the work done by the R.A.M.C. during the war, 
 and at the same time of its limitations. I believe that 
 all that is sound in it can be retained and by the 
 adoption of the changes indicated it can be made a 
 flexible, mobile institution, capable of greatness, capable 
 indeed of leading the nation not only in matters 
 relating to military science, but also in civil medicine 
 and surgery. 
 
 Is it not obvious that the criticisms amount to the 
 statement that the service shows much individual 
 excellence with defective organization ?—a criticism 
 which applies more or less to the various institutions 
 of the Empire. Anglo-Saxons possess the faults of 
 
SUMMARY 
 
 175 
 
 their qualities and tend to become intellectual anar¬ 
 chists. The day has passed, however, when individuals 
 acting as such can do great things, and the future lies 
 to the intelligent who can combine loyally in team 
 work. 
 
CHAPTER XVII 
 
 CONCLUSION 
 
 In the foregoing chapters the organization of the 
 R.A.M.C. has been sketched. The writer’s personal 
 experience of phases of its work has been detailed, and 
 he has endeavoured to indicate its strength and with 
 equal clarity its serious shortcomings. A fitting con¬ 
 clusion may be reached in the endeavour to indicate 
 the principles on which inquiry should properly be 
 made. Let us ask ourselves, What is the national 
 purpose of having a Royal Army Medical Corps ? 
 
 The obvious and superficial answer is that the nation 
 requires a permanent Army and consequently needs 
 a medical service to care for the health of the soldier 
 in peace and war. The experience of wars shows us 
 that the R.A.M.C. is quite inadequate to deal with 
 this requisite in time of war without calling in the 
 aid of the civil medical service, since in its ranks it 
 contains neither the number of officers nor the special 
 knowledge necessary for the satisfactory handling of 
 even a moderate military undertaking. A Royal Com¬ 
 mission would therefore inquire whether the arrange¬ 
 ments necessary for calling in this civilian aid were 
 adequate, and whether the brains and ability so called 
 in were disposed to the best advantage. 
 
 But it is obvious that further pertinent questions 
 must at once obtrude themselves. Wars are infrequent, 
 and for years this body of R.A.M.C. officers existed 
 
 176 
 
CONCLUSION 
 
 177 
 
 under peace conditions and is apparently not over¬ 
 worked. Have proper attempts been made to utilize 
 fully the services of the able men in the service for 
 the benefit of the nation ? Has research been en¬ 
 couraged and duly rewarded by promotion which did 
 not involve cessation of research ? Has the study and 
 practice of preventive medicine been encouraged by 
 suitable and similar promotions ? Has clinical ex¬ 
 cellence been regarded as a reason for promotion plus 
 retention of clinical work ? 
 
 If these and similar activities have not been encour¬ 
 aged, may not the nation well ask whether it is getting 
 a proper return for its expenditure ? Should not the 
 R.A.M.C. be employed for such national purposes, and 
 make its mark felt in all these spheres of activity ? 
 Have these aspects of the problem been clearly and 
 publicly presented ? 
 
 From the Crimean War to the Boer War and thence 
 to 1914 the R.A.M.C. has lived in profound peace. 
 What has been the output for the benefit of the 
 nation, and if the result be disappointing whose fault 
 is it ? I am well aware that after such inquiries as 
 those effected by the Mesopotamian and Dardanelles 
 Commissions there is always a public tendency to try 
 to fix the responsibility on some one officer. Now it is 
 true there are in all services inefficient men, but in 
 general no one wishes to be a failure, and most men 
 do their best. Is not the truth largely that the nation 
 by its indifference and penuriousness forces the de¬ 
 velopment of a bad system in the meshes of which 
 even an able man is helpless ? If this prove to be the 
 case, as I feel sure it will, why not concentrate some 
 critical attention on this system, overhaul it root and 
 branch, and honestly face proper reconstruction ? 
 
 12 
 
178 
 
 A VISION OF THE POSSIBLE 
 
 If this view be entertained, the following features 
 of the system amongst others will require special 
 attention : 
 
 (1) Should Directors of Services be regarded as 
 
 omniscient, or should they require Staffs of 
 special advisers ? 
 
 (2) Should the medical officers of the same rack be 
 regarded as interchangeable, and of equal value, 
 or should special knowledge and ability be 
 labelled ? 
 
 (3) Should promotion for clinical excellence, for 
 
 clinical ability or distinction in preventive 
 medicine, be obtainable only by cessation in part 
 or in toto of the special work in which excellence 
 has been demonstrated—in other words, by 
 taking to administration % 
 
 (4) Should promotion be effected on the recom¬ 
 
 mendation of one man, or should the value of 
 all officers be carefully and periodically reviewed 
 by a Board on which civilians are represented ? 
 
 (5) Should not every command be associated with a 
 
 Civilian Medical Board, since whenever war 
 breaks out civilian medical men are required 
 to enable the R.A.M.C. to do its work ? 
 
 (6) Is it desirable that the “ office wallah ” type of 
 
 administration should be further encouraged ? 
 
 (7) What status and functions should be assigned to 
 Consultants, Specialists, and Presidents of Boards ? 
 
 (8) Should medical officers be required normally to 
 perform non-medical and clerical duties ? 
 
 (9) Should some system of military medical educa¬ 
 tion be provided for newly joined civilian officers, 
 and should not the system of conferences be 
 widely extended ? 
 
CONCLUSION 
 
 179 
 
 (10) Should not a proper system and tribunal be 
 instituted for the redress of supposed injustice, 
 or is the mediaeval Japanese system to be 
 endowed with immortality ? 
 
 The above list is not, and is not intended to be, 
 complete, but is furnished as an indication of the 
 questions which every thoughtful medical officer, regular 
 or temporary, is likely to put, and to which the nation 
 may rightly require plain answers. 
 
 A scrutiny of these questions will reduce their 
 number in substance, so that they may be put as follows : 
 
 For what national purpose does the R.A.M.C. exist ? 
 How is it governed ? and what type of medical service 
 within it is rewarded % 
 
 The problem discussed is very serious, since on its 
 satisfactory solution so much depends which is vital to 
 the nation. The answers of a Royal Commission may 
 be far from those which I have indicated, but whether 
 that prove to be so or not it is important that the issue 
 should not be evaded or camouflaged; in other words, 
 that an honest answer should be given to plain inquiry. 
 
 Such inquiry depends on the action of those eminent 
 medical men who have unostentatiously made huge 
 sacrifices during the war, who have been very sensible 
 of the defects described, but whose loyalty has caused 
 them to make the best of it. They are returning to 
 attenuated or non-existent practices, often with no 
 thanks or recognition beyond the sense of duty done, and 
 they are at the least entitled to ask that proper weight 
 be given to such representations as they may make. 
 
 They may well ask that their reward shall be a 
 betterment of the service in the interest of the nation, 
 in the interest of its officers, and indeed in the interest 
 of the science of medicine. 
 
INDEX 
 
 Abney, Sir Wm., 103 
 Armenian Refugee Camp, 97 
 
 — Pellagra in, 97 
 Aural Diseases, 1 et seq. 
 
 Aurist, Consulting, 1 et seq., 147 
 Aurists Functions of, 8, 12, 22 
 Australia, Wreck of the, 102 
 
 Battle of March 21, 1918, 111 et seq. 
 Boards, Medical, 25 et seq. 
 
 -Function of, 65 
 
 -Report on, 79 et seq. 
 
 British Association, 102, 109 
 British Medical Journal, 111 et seq., 
 130 
 
 Bulgarian Prisoners, 97 
 Burke, Captain, 3, 106 
 
 Cairo Purification Committee, 117 
 Civilian Advisory Boards, 165 
 
 — Officer, The, 155 
 Classification Form, 95 
 Commissioners, The Spanish, 25 
 Cook, Mr., 3, 106 
 Concussion Deafness, 6 
 Conference (Aural), 21 
 Consultants, 147 et seq. 
 
 — Various Ranks of, 149 
 
 — List of, 151 
 
 D.A.H., 23, 88, 91, 93 
 Deane, Lieut. P. E., 133, 168 
 Desert Hardships, 116 
 
 Ear Disease not a Disability, 8 
 
 Eason, Lieut.-Col., 26, 106 
 Education, Military, 154, 169 
 Elgood, Lieut.-Col., 118 et seq. 
 
 Epil psy, 56 
 Eye, Loss of an, 109 
 
 Footballers, Examination of, 67, 68 
 
 Garrison Battalions, Counting of, 65 
 German Prisoners, 96 
 Gibson, Dr. Lockhart, 106 
 Grievances, Redress of, 171 
 
 Hearing, Standards of, 53 
 Heart Specialists, 23 
 Hernia, 54 
 
 Instructions to Aurists, 18, 20 
 Instruments, 23, 24 
 Invaliding, Causes of, 90, 92 
 
 Keogh, Sir Alfred, 103, 166 
 
 Laryngology, Journal of, 3 
 Locomotive System, 57 
 Love, Major Kerr, 13 
 
 MacLellan, Capt., 3, 106 
 MacMahon, Sir Henry, 132 
 Malaria, 75 
 Malingering, 6, 108 
 Man Power, Inspector of, 65 
 McDill, Dr., 135 
 Memorandum, Initial, 27 
 — Final, 31 et seq. 
 
 181 
 
INDEX 
 
 182 
 
 Military Medical Work, Nature of, 
 169 
 
 -Popular Misapprehension of, 
 
 169 
 
 Morlet, Capt., 3, 106 
 
 Napoleon in Egypt, 98 
 Nose, Diseases of the, 1 et seq. 
 
 Oculist, Consulting, 1, 97, 100, 115, 
 147 
 
 Oculists, Function of, 110 
 “ Office Wallah,” The, 144, 163 
 Ophthalmia, 97 et seq. 
 
 Organization of the R.A.M.C., 
 138 et seq. 
 
 Otitis Externa, 6 
 Otorrhcea, 1 et seq. 
 
 Pay Book (A.B. 64), 65 
 Pellagra, 96 
 Personnel, 157 et seq. 
 
 Port Said, V.D. at, 119 et seq. 
 Presidents of Boards, 147 et seq. 
 Promotion, 154 et seq., 167 
 Pulmonary System, 56 
 
 Reconstruction of the R.A.M.C., 172 
 Red Cross, The, 131 et seq. 
 
 Red Cross, The American, 133 
 Repatriation Boards, 96 et seq. 
 Report on Ophthalmic Work, 106 
 et seq. 
 
 Results of Boards: 
 
 Difference between British and 
 Egyptian results, 69, 72, 73 
 Rosenfield, Capt., 3, 106 
 Royal Commission, Wanted a, 115, 
 174 
 
 Sanitary (Prophylactic) Service, 
 The, 161, 173 
 Shell Shock, 12, 107 
 Statistics, Diseases Ear, Nose, and 
 Throat, 4, 9, 15 
 
 — Boards, 66, 70, 71, 72, 73, 75, 78, 
 79, 80, 87, 89, 90, 91, 92, 93 
 Stay in Hospitals, Undue, 75 
 Stevens, Capt., 3, 106, 
 
 Submarines, 25 
 
 Teeth, 53 
 
 “ T.B.,” The difficulty of, 85 
 Throat, Disease of, 1 et seq. 
 Thompson, Sir Courtauld, 136 
 Trachoma, 52, 105 
 Trippers, The Round, 76 
 Turkish Prisoners, 96 
 Typhus, 129 
 
 Vascular System, 56 
 Venereal Diseases, 23, 117 et seq. 
 Vision, Standards of, 99 et seq. 
 
 Watson, Capt., 6 
 Wharton, Mr., 3, 106 
 
 Printed by Hatell, Watson & Viney, Li., London end Aylesbury. 
 

 

 
 
sauBjqn ^pSjaAiun 0>ina