CHAPTER IX

FROM THE FRANCO-GERMAN WAR TO THE PRESENT TIME

Among the great advances made in the last few decades of the nineteenth century must be included the successful battle of modern hygiene against infectious diseases. This struggle was introduced by the development of practical hygiene in England and by the perfection of scientific hygiene through the work of Pettenkofer. But a firm basis on which to combat pestilence was not secured until the brilliant discoveries of Koch and his successors pointed out to us the cause of these pestilences, and methods were found to demonstrate in a short time the presence of disease-germs, even among persons who become ill but slightly, or not at all, and who for that reason are very dangerous to those about them.

Since even in time of peace the close quarters in which soldiers live in barracks greatly favour the outbreak of epidemics, the military authorities constantly watched and profited by these advances in the field of disease-prevention; and with the success of efforts to decrease the prevalence of infectious diseases among the soldiers in time of peace, so also in war-times it became possible to check more thoroughly than ever before the dissemination of these diseases. Hence the number of men carried away by epidemics is much smaller in modern wars than used to be the case.

1. THE RUSSO-TURKISH WAR OF 1877–8[304]

The Russo-Turkish War of 1877–8, like all former wars with Turkey, was characterized by severe pestilences, which at both seats of the war, the European as well as the Asiatic, were responsible for large numbers of deaths. Typhus fever, which frequently made its appearance in Russia and in the Balkan Peninsula, was once more the disease which made the greatest havoc. In the years preceding the war it had raged in the form of epidemics in several Russian Governments, and it is probable that the Russian army was already infected with it. Erisman states that cases of typhus fever were observed among the soldiers in the thirty-fifth infantry division when it was being assembled in the Government of Kiev; the disease also revealed its presence among the troops when they were mustered at Kishinev (Bessarabia) before the war broke out. In April and May 1877, when the army was advancing toward the Danube under a steady downpour of rain, the number of sufferers from typhus fever, intermittent fever, and dysentery increased considerably. During the siege of Plevna, which lasted 143 days and terminated in the capitulation of the city on December 10, 1877, the prevalence of disease increased still more. The march across the Balkan Peninsula in the winter of 1877–8 made great demands upon the badly nourished Russian troops. The better conditions anticipated in the Balkan lowlands did not show themselves; on the contrary, here began, from the standpoint of sanitation, the most unfortunate part of the campaign, since the retreating Turks had devastated the entire country. The number of typhus-fever patients in the Russian army, which numbered some 411,000 men, increased to 18,049 in the month of February 1878, and of these 7,522 had spotted fever and 1,540 died. The pestilence continued to rage with unbroken severity until May; in June it began to abate. The total number of fever-patients and deaths in the Russian army during its march to the Danube is indicated by the following table:

_Patients._ _Deaths._ Typhoid fever 25,088 7,207 Gastric fever 38,363 1,615 Typhus fever 32,451 10,081 Relapsing fever 39,337 4,849

The number of men in the army increased from 217,446 in April 1877, to 418,000 in March 1878.

The military lazarets played an important and disastrous rôle in the dissemination of typhus fever, just as they had done in the Napoleonic Wars. ‘The lazaret-system adopted by the Roumanians’, says Niedner,[305] ‘proved utterly inadequate for the Russians. Scarcely a third of the regular division-hospitals and military hospitals were made mobile, and their number, as well as their equipment, was insufficient. The lazarets were supervised by the Hospital Department, and consequently lacked all medical management and were always missing wherever they were needed. The few available lazarets were overcrowded, and being full of dirt and refuse they merely constituted an added danger for the patients and for the inhabitants. Not until after long delay were additional barracks constructed, and these were so badly arranged that they offered very little relief from the condition of overcrowding in the hospitals. Above all, there was a lack of means for disinfection and of clean linen, and this rendered it inevitable that large quantities of infectious material should accumulate in the lazarets, and that convalescents discharged from these hospitals should be more likely to infect other people with whom they came in contact along the military roads.’ The transporting of these convalescents back to Russia began in the first part of the campaign; they not only spread the disease all along the military roads, but large numbers of them conveyed it back to Russia itself, where it appeared in countless localities and soon developed into a widespread epidemic of typhus fever. At the end of the campaign, to be sure, conditions improved; in the spring of the year 1878 a commission appointed for the purpose finally succeeded in establishing certain rules governing sanitation in the lazarets, and in bringing it about that typhus fever patients were everywhere isolated. When the war was over the troops were transported back home across the Black Sea, along the coast of which, in the ports of Réni, Nikolayev, Sebastopol, and Odessa, health-committees had been appointed to see to it that the sick soldiers were congregated by themselves.

Typhoid and typhus fever likewise became very widespread in the Caucasian army. According to Kosloff, typhus fever was not endemic in Armenia, as was probably the case with typhoid fever; the Russian physicians think that it was conveyed thither by the Russians themselves and not by the Turks. The conditions for quartering the Russian troops were as unfavourable as one could possibly imagine; they were housed in dirty Armenian villages, where nobody attended to the removal of refuse, and were badly provisioned and inadequately supplied with clothing; this, coupled with continuous marching and fighting, greatly reduced their power of resistance. In October 1877 the main army was infected with typhus fever, and the overcrowded hospitals merely helped to spread the disease. Conditions were worst of all in the detachment in Erivan. After the troops had gone into winter quarters there, typhus fever broke out with terrible severity and presently the entire government of Erivan was suffering from the pestilence; particularly hard hit were the cities of Erivan, Chorassan, &c., where the troops were very numerous and were exposed to the ravages of the pestilence. The following table indicates the number of men in the Caucasian army that contracted and succumbed to the four diseases mentioned:

_Patients._ _Deaths._ Typhoid fever 24,473 8,908 Gastric fever 9,589 1,044 Typhus fever 15,660 6,506 Relapsing fever 14,576 3,775

The inhabitants of those regions in Asia in which fighting took place were not attacked by typhus fever. The Turkish troops, on the other hand, suffered severely from the disease, though not so severely as the Russian troops; the reason for this was that the former were better nourished and their camps were kept clean. The Turkish prisoners fared no better than the Russian prisoners; of 57,000 prisoners taken, 13,983 succumbed to various fevers, most of them to typhus fever.

2. THE BOER WAR OF 1899–1901

In the war which England waged against the free states, Orange and Transvaal, and which lasted more than two years and necessitated the transportation, on the part of England, of more than 400,000 soldiers to South Africa, infectious diseases, particularly typhoid fever, played a very important rôle. The English army, which averaged 200,000 men, sustained the following losses:[306]

_Died of _Died in battle diseases._ and of wounds._ _Total._ From Feb. 10, 1900, to the end of that year 7,009 4,088 11,097 In the year 1901 4,318 2,337 6,655 —————— ————— —————— Total 11,327 6,425 17,752

Typhoid fever had always been prevalent in South Africa; the first cases in the English army were observed during the hurried march to Bloemfontein along the Modder River, on which the soldiers were dependent for drinking-water, despite the fact that typhoid fever was known to be raging in places further upstream. The Berkefeld and Pasteur filters yielded too little water, for the reason that they soon became clogged; the soldiers used boiled water with reluctance, for the reason that it took so long for it to cool. Another source of infection besides the water was the fine dust that was stirred up by daily wind-storms; this dust, being full of disease-germs, contributed greatly to the dissemination of typhoid fever. Furthermore, the crowding together of soldiers in tents caused many of them to contract the disease by direct communication.[307]

Jameson, the chief of the army’s medical staff, lamented the fact that sanitary officers (hygienists), originally appointed to accompany each division of troops, were dismissed. The regular doctors, who were then called upon to perform their functions, were fully occupied with taking care of the wounded, and were probably not well informed as to hygienic investigations and measures. The results obtained from preventive inoculation, which was practised on some of the soldiers, were in general satisfactory.

In other places the conditions were similar to those along the Modder River; in Paardeberg the available drinking-water was equally bad, and in Bloemfontein there was an explosion-like outbreak of fever. From the beginning of the campaign to the middle of the year 1900 there were 13,057 cases of disease in the army, and of those 3,174 terminated fatally; the total number of cases during the entire war was no less than 42,741.

The English troops that were shut up in Ladysmith from November 1, 1899, to February 27, 1900, were very severely attacked by typhoid fever. In the first part of November the English garrison had consisted of 13,496 men, and by March it had dwindled down to 10,164 men. The number of sick soldiers committed to the lazaret amounted to no less than 10,668, and of these 1,766 had typhoid fever and 1,857 had dysentery; 383 of the former and 117 of the latter died. When the Boers withdrew there were 1,996 patients in the hospital, 708 of them suffering from typhoid fever, 341 from dysentery, and 189 from wounds.[308]

In the Concentration Camps which the English established in the summer of the year 1900 for the accommodation of the women and children in the South African Republics, the pestilences soon gained the upper hand. Lord Roberts had made arrangements to concentrate the families of the Boers in camps; since the farms of the Boers were systematically burned, these camps were supposed to protect their wives and children against starvation, and at the same time the wives and children served as hostages for their husbands and fathers. When the location of these camps was decided upon, not sanitary, but military considerations were taken into account; it was necessary that they should be controlled from a near-by fortress. They soon became overcrowded, the supply of water was inadequate, and there was much uncleanliness. The inhabitants of the camps were mostly women, children, and old men; thus, for example, in October 1901, of the people living in the camps in the Orange Free State, 55 per cent were children under fifteen years of age, 31.9 per cent were women, and 13.1 per cent were men, mostly old men. According to the reports submitted to Parliament the condition of health in the Concentration Camps in Natal and in the Cape Colony was not unfavourable, but in those in Transvaal and Orange it was very bad. The following statistics, covering the time between June and September 1901, relate to the Concentration Camps in the Transvaal:[309]

NUMBER OF INHABITANTS. _Month._ _Men._ _Women._ _Children._ _Total._ June 8,576 16,078 19,811 44,465 July 9,665 20,012 24,462 54,139 August 10,496 22,036 25,983 58,515 September 10,581 22,226 26,599 59,406 —————— Average 54,131

NUMBER OF DEATHS. _Month._ _Men._ _Women._ _Children._ _Total._ _Annual death-rate._ June 26 48 310 384 103·6 July 51 118 748 917 203·2 August 32 185 1,014 1,231 252·5 September 75 165 1,014 1,254 253·3 ————— Average 209·8

In regard to the Orange Free State the following statistics, including the month of October, were compiled:

NUMBER OF INHABITANTS. _Month._ _Men._ _Women._ _Children._ _Total._ June 5,116 9,646 17,953 32,715 July 5,351 11,213 20,132 36,696 August 5,826 13,381 24,415 43,622 September 6,089 14,140 25,118 45,347 October 5,906 14,471 24,929 45,306 —————— Average 40,737

NUMBER OF DEATHS. _Month._ _Men._ _Women._ _Children._ _Total._ _Annual death-rate._ June 32 75 182 289 106·0 July 50 69 369 488 159·5 August 30 82 510 622 171·1 September 43 153 885 1,081 286·0 October 58 133 1,329 1,520 402·6 ————— Average 235·6

All told, no less than 19,600 persons (14,894 children and 4,706 adults) died in the Concentration Camps up to March 1902; that is, about one-fifth of the total number of inhabitants died in a period of about fifteen months. As indicated by the above tables, the children suffered more severely than the adults. The principal causes of the high mortality among the children were measles and pneumonia; since the grownup Boers had never experienced an attack of measles in their childhood, they too, even the very old men, contracted the disease and many of them succumbed to it. The prevalence of pneumonia can be explained on the ground that the temperature fluctuated greatly in the course of the winter, and the nights, in particular, were extremely cold. Whooping-cough, varicella, mumps, and diphtheria were prevalent in all the camps, and typhoid fever, which, as remarked above, is endemic in many parts of South Africa, was very common; so also were diarrhoea and dysentery.

The chief cause of the high mortality in the prison-camps was the fact that such large numbers of men, men whose vitality had been reduced by privations and hardships, were congregated in places which had not been properly prepared to receive them. The unfortunate prisoners often reached the place of detention in a pitiable condition—exhausted and half naked. Furthermore, they were men who had no appreciation of the order that must be observed, when large numbers of people are congregated in one place, in attending to the daily requirements of nature, nor were they willing to be taught. The result was that the ground became filthy; the open spaces in front of the tents were often used in place of the latrines; the contents of slop-jars were simply thrown out in front of the doors, instead of being emptied into receptacles that were deposited here and there for that purpose. The mothers had no idea of nursing, and were unwilling to take medical advice; in order to avoid having to send their children to the hospital, they kept secret the fact that they were sick, thus giving measles, diphtheria, &c., the best possible chance to spread. We read in an English report:[310]

A large share of the high death-rate in them is ascribable to the condition in which the women and children arrive. Often they have been half-starved and are broken down in health. It cannot be wondered at that under these circumstances measles and other diseases are inordinately fatal. The dirty personal habits of the Boers, their use of improper and often disgusting remedies, and their ignorant errors of dietetics in regard to young children, have rendered it extremely difficult to secure favourable results in the treatment of cases of sickness among the Boer children. There appears to be no doubt, as indicated in our previous special article, that the measles which has been prevalent has been of a specially malignant type. Its malignancy has doubtless been intensified by the dirty condition of the Boer children, and by the overcrowding that has been permitted in the camps, as well as by the previous bad health of these children. The present reports afford abundant evidence confirmatory of the conclusion at which we had previously arrived, that dysentery, diarrhoea, and enteric fever in a large proportion of the camps have been prevalent as well as measles.

And in another report we read:[311]

Measles of a particularly malignant type has prevailed. Its fatality has doubtless been increased by the exhausted and semi-starved condition in which many of the Boers and their children have arrived at the camps. It has been impossible to isolate such cases in the camps; and the crude and ignorant and even mischievous methods of domestic treatment adopted by the Boer women have doubtless increased the evil, as have also the personal uncleanliness of the Boers and their fear of fresh air as well as of clean water. But, as previously pointed out, enteric fever and diarrhoea and dysentery have claimed a large toll of victims, and for the excessive amount of these the deficient sanitary control of the camps must be held in a large measure responsible.

With the arrival of the better season, when the Concentration Camps, under the pressure of public opinion, were thoroughly cleansed, the condition of health improved. Hönigsberger,[312] who inspected the camp at Merebank (in Natal) in May 1912, derived a very favourable impression; notwithstanding the fact that the camp lay on low ground near the sea-coast, where the soil was necessarily damp, there was no visible surface water because of an effective system of drainage. The drinking-water facilities were good. Of some 8,000 refugees sheltered there only 110 died between the months of February and May 1902.

3. THE WAR IN SOUTH-WEST AFRICA (1904–7)[313]

In the very first year of the war, typhoid fever broke out with great severity. The disease first made its appearance in the war against the Herero nation in the first part of April 1904; it attacked the eastern division of the army, which was commanded by Major von Glasenapp and numbered twenty-five officers and 509 men, in Onjatu (midway between Windhuk and Waterberg), after the soldiers had been exposed to rainy weather, cold nights, and extreme hardship. On April 6 there were six cases of the disease reported, and by April 16 the number of cases had increased to sixty-six; the division was then transferred to Otjihaenena, where the patients were housed in permanent lazarets and the healthy men were quarantined. Throughout the remaining part of the war, typhoid fever played an important rôle; the total number of deaths in the years 1904–7 was 1,491; of these 689 succumbed to diseases, 439 of them to typhoid fever. The soldiers who fought in the battles against the Hereros were most severely attacked; of a total of 470 deaths 283 were caused by typhoid fever and only twenty-two by other diseases. In the three years’ struggle against the Hottentots some 1,200 soldiers died; 375 of them died of diseases; of the 375 typhoid fever was responsible for 156.

4. THE RUSSO-JAPANESE WAR OF 1904–5

The apprehension that the Russo-Japanese War would be accompanied by severe outbreaks of infectious diseases turned out to be groundless. The chief danger that threatened both armies was typhoid fever, which is endemic in Manchuria, and which, on account of the filthy condition of the Chinese villages, was given an excellent opportunity to spread. In the first place, the soldiers were prevented from being infected by the fact that they were allowed to drink nothing but boiled water, and were always supplied with hot water for tea; in the second place, when they were called upon to remain in one place for a considerable length of time, they were quartered, not in the Chinese villages, but in earth-huts; or, if they were compelled to live in the Chinese villages, these were always thoroughly disinfected beforehand. Whenever it was possible, the Japanese military physicians, before the troops arrived in a village, investigated the place with reference to hygienic conditions and subjected the inhabitants to an examination. Notwithstanding all this, large numbers of soldiers on both sides, in the course of the war, which lasted twenty-one months, contracted typhoid fever, diarrhoea, and dysentery. In both summers, which are very hot in Manchuria, typhoid fever made its appearance, to a greater extent in the second than in the first, since the troops before and after the battle of Mukden remained encamped for a long time in one and the same place.[314] According to the statements of the Russian General Medical Staff,[315] the total number of deaths in the Russian army (excluding the troops at Port Arthur and the fleet) caused by diseases was 7,960, and to these must be added the deaths among the discharged troops; the total number of men in the Russian army was 709,587. Even if these figures are incomplete, nevertheless they distinctly show that epidemic diseases, considering the long duration of the war, were not very prevalent. The reports of foreigners who accompanied the Russian army agree in pronouncing the general condition of health excellent.[316] Spotted fever and anthrax were also observed, but among both the Russians and the Japanese they appeared only sporadically. According to Follenfant,[317] 56,717 cases of infectious diseases occurred among the Russians; of these 25,800 were enterorrhoea, 15,800 were typhoid fever, 8,970 were dysentery, and 4,500 were malaria. Regarding the prevalence of disease in Port Arthur we shall have more to say in the tenth chapter.

Conditions among the Japanese were less favourable, since, on account of their rapid advance, sanitary measures could not be carried out as extensively as was desirable. The total number of men in the Japanese army carried away by diseases was no less than 21,802; 3,956 succumbed to beri-beri, 4,073 to typhoid fever, 1,804 to dysentery, and 11 to typhus fever.[318] All told, 95,572 cases of beri-beri were observed; at first the disease was very common, but later on, when barley was added to the rice, its prevalence decreased. The number of Japanese soldiers killed in battle was very large (47,387), and to these must be added 10,970 who died of wounds.

As to whether or not the war caused typhoid fever and dysentery to spread among the civil inhabitants of Manchuria, as was probably the case, we have no specific information; the appearance of other diseases among the civil inhabitants is improbable, since the troops would certainly have contracted them had they been prevalent.

No information has been given by either Russia or Japan as to whether the soldiers brought diseases back home with them. In Japan, according to the _Year Book of Statistics_,[319] the number of deaths was as follows:

_Typhoid._ _Typhus._ _Cholera._ _Dysentery._ _Beri-beri._ 1903 4,585 9 140 7,172 10,783 1904 5,100 5 51 5,294 9,408 1905 6,291 10 34 8,763 11,703 1906 6,338 5 29 5,173 7,766 1907 5,974 6 1,702 5,872 8,767 1908 5,824 9 297 8,053 10,786

In order to prevent the transplantation of infectious diseases into Japan, very comprehensive measures of precaution were adopted by the Japanese military authorities, as was the case after the war with China. Infected soldiers, and soldiers suspected of being infected, were not allowed to join the transports; in order to find them out, three quarantine stations were established, one in Dairei (near Moji), a second in Ninoshima (near Ujina), and a third at Wadano Misaki (near Kobe). When the transports of troops reached their destination, the men were divided into groups of 60 and sent to disinfection establishments, where they were bathed and their effects were disinfected. The sick were committed to the hospital, and suspicious cases were quartered in barracks under observation. If infected men had been found on a ship, the entire ship, crew, and officers, were disinfected. The disinfection establishments received 828,376 men for examination; of these 429,962 were disinfected.[320]

5. THE OCCUPATION OF TRIPOLI BY THE ITALIANS (1911)

During the battles fought in connexion with the occupation of Tripoli by the Italians, infectious diseases were confined within narrow limits. According to Sforza, the army physician in Tripoli,[321] cholera broke out there in the second half of October 1911, reached its climax in November, and disappeared entirely in the second half of December. The disease was spread chiefly by dates, which had been infected by flies; it first appeared among the native beggars, then spread to the rest of the population, and finally to the Italian soldiers. The pestilence raged only in Tripoli, a fact which Sforza regards as a proof that it was not conveyed thither by the Italians; for had this been the case, cholera would have revealed its presence in Homs, Bengasi, Derna, and Tobruk, in which places thousands of soldiers disembarked, but not a single case of the disease was observed. Typhus fever is endemic in Tripoli; after the Italian occupation twenty cases of that disease were observed among the natives and ten cases among the soldiers. In order to prevent diseases from spreading to Italy, convalescents were not allowed to return home until there was absolutely no danger of their communicating the infection to other persons. The same measures of precaution were used in relation to relapsing fever.

6. THE WAR BETWEEN TURKEY AND THE BALKAN STATES (1912–13)[322]

Regarding the Balkan war definite information is still wanting. Well known, however, is the outbreak of cholera along the Tchatalja lines; but the progress of the disease was soon checked and it did not become very widespread. It first appeared in the camp of the Turks, whither it was borne by troops from Asia, where severe epidemics of it had occurred in Mecca and Tiberias, and where it had made its appearance in several other places. In Constantinople the first case of the disease was reported on November 5, 1912; in the first week of December it had reached its climax, and after January 20 only sporadic cases were observed. The following table indicates the number of persons who contracted and succumbed to cholera in Constantinople:

_Patients._ _Deaths._ Nov. 5–Dec. 2 (1912) 934 441 Dec. 3–Dec. 9 (1912) 540 229 Dec. 10–Dec. 16 (1912) 451 244 Dec. 17–Dec. 23 (1912) 276 158 Dec. 24–Dec. 30 (1912) 141 74 Dec. 31–Feb. 1 (1913) 173 99 ————— ————— Nov. 5, 1912–Feb. 1, 1913 2,515 1,245

Among the Bulgarians cholera did not become very widespread; throughout the entire territory occupied by the Bulgarians, cases of cholera, to be sure, were observed, particularly along the Tchatalja lines. But the Bulgarians fought the pestilence with energetic measures; the troops were given nothing but boiled water, and careful attention was paid to what they ate; the railway dépôts were thoroughly disinfected, as were all places in which large numbers of people congregated. During the armistice the Bulgarians were forbidden all intercourse with the Turks. For the troops transported back home quarantine stations were established. The result of all these precautionary measures was eminently successful. In Bulgaria itself only sporadic outbreaks of cholera occurred, as in Sofia, Stara Zagara, and in the district of Shumla;[323] on January 18, 1913, Bulgaria was entirely free from cholera.

Typhus fever broke out very frequently in all the armies, but detailed information regarding its prevalence has not been published. According to the reports which have thus far been issued, the disease did not appear in the form of epidemics in any of the armies; on the other hand, it is stated that it broke out among the Turkish prisoners in Bulgaria and Servia, as in Tatar-Bazarjik, Ligotin, Zajecar, and Kujazevas.