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.