KEEPING THE BRITISH SOLDIER FIT.
The history of war has always been a history of epidemics. The fact
that in an army men are crowded together makes it easy for all
communicable diseases, once introduced, to spread with great rapidity.
And because soldiers are always associated with the civilian
population, it means that such diseases are readily communicated from
the army to the civilians, and from the civilians to the army. It is
therefore apparent that during a war, disease, unless quickly checked,
may run like wild fire through a country, and be disseminated far and
wide by soldiers returning to and from their own homes, or other
distant places while on leave.
Advances made in our knowledge of how diseases are spread and
controlled, particularly through recent studies in bacteriology and
immunity, have made it possible to keep communicable diseases in
absolute subjection. The marvel of the age is the lack of epidemic
disease in the army to-day. This is particularly striking in view of
our experiences in other recent wars. In the Franco-Prussian war of
1870, for instance, smallpox was fanned into a great flame, and there
resulted the largest smallpox epidemic in 80 years. It is interesting
to note that the medical authorities in Paris, in the first year and a
half of the present war, vaccinated over 25,000 strangers passing
through Paris; they are taking no chances with another outbreak of
smallpox.
In the Boer War the British losses through typhoid fever alone were
8,000 against 7,700 killed by bullets, shells and other agencies.
The British army of nearly five million men in France and England
to-day, has so little typhoid that it is practically a negligible
quantity, and this holds with other communicable diseases. There must
be some basic reason for this freedom from contagious diseases, for we
know that such freedom does not come by accident.
No attempt will be made to deal with those auxiliary forces employed
to keep the men physically and mentally fit. Such things as the
provision of an adequate and wholesome food supply; proper clothing;
amusements, such as games, competitions, horse shows, cinemas, variety
shows; and Y.M.C.A.'s are all an integral part of the machinery
necessary to keep an army in the field well and happy.
Only an attempt will be made to discuss the principles underlying the
prevention of disease in use in the British army in France,--principles
with which the average layman is comparatively unacquainted.
In the first place, it is well to realize that in the temperate
climate of Europe, the vast majority of communicable diseases of
importance from the military standpoint are contracted largely from
three sources:
Group 1. From throat and nose secretions; e.g., diphtheria, measles,
etc.
Group 2. From biting insects; e.g., malaria, typhus fever, plague,
etc.
Group 3. Through intestinal secretions; e.g., typhoid fever, cholera,
dysentery, etc.
The first group, which includes practically all the ordinary diseases
like measles, mumps, whooping cough, influenza, colds, pneumonia,
scarlet fever, diphtheria, etc., is conveyed in most cases by one
infected person transmitting directly to another person,--through
coughing, spitting or sneezing,--germs present in the nose and mouth
secretions.
The second group is conveyed by insects biting people or animals
infected with the disease, and subsequently biting people who are
healthy. In this way the disease-producing organism is introduced into
the body of the healthy person, and beginning to multiply, brings
about the symptoms of the disease. Malaria is transmitted in this way
by the anopheles mosquito; typhus fever by lice, and plague by the rat
flea. These are all diseases greatly to be dreaded in the army.
The third group, including typhoid and paratyphoid fevers, cholera,
and dysentery, all of which are intestinal diseases, is largely
conveyed from the sick to the well indirectly through contaminated
water and food. To develop one of these diseases means that the
excreta of somebody who has the disease or who has had it, has been
taken into the mouth and swallowed, and the germs finding a favorable
medium in the intestines have multiplied and produced the typical
symptoms. One of the chief ways in which this type of infection occurs
is through drinking sewage-contaminated water or milk; another is
through contamination of food by the hands of the person excreting
the germs; and the third is through the contamination of the food or
eating utensils by flies and other insects which carry filth germs
from place to place on their feet and bodies.
With these facts in mind and with some knowledge of sanitation and
medicine it is easy to see how most epidemic diseases can be held in
check. Put briefly, it means that the sanitary organization must be
such that the germs from one infected soldier are prevented from
reaching another, or as is sometimes said, some link in the chain of
circumstances whereby disease germs can pass from one to another, must
be broken.
The methods employed to break these links are simple; the carrying out
of the methods is oftentimes very difficult.
It is obviously essential in the first place to remove from the army,
at the earliest possible moment after it has been diagnosed, every
case of communicable disease. This means the adoption of measures for
picking out soldiers who show symptoms of disease, which really comes
down to the fact that the medical officers must always be on the alert
and carry out the instructions of the director of medical services of
the army with despatch. In the British Army this is one of the most
important features in the control of epidemics. If a man is suspected
of having any communicable disease he is instantly placed under
quarantine until the diagnosis has been confirmed, after which he is
removed from the army area altogether as a possible focus of
infection. The British Army takes no chances, and its wonderful
record of freedom from contagious disease proves that it has been
absolutely sound in its technique.
This is practically the only way of eliminating diseases, such as
measles and scarlet fever which cannot be diagnosed by bacteriological
methods, but of course the procedure is employed in all other kinds of
epidemic disease as well.
Great Britain has been fortunate above all other nations in this
respect that she sent over at first a small army of regular troops,
perfectly equipped from the medical standpoint as well as in every
other way. Efforts had been made for years to remove typhoid carriers
from the regular army, and naturally no soldier was sent into the
field who was known to have typhoid, or to be a carrier of typhoid or
any other contagious disease germs. Furthermore, the soldiers had
practically all been vaccinated against smallpox and inoculated
against typhoid fever.
As division after division was sent out to the army in France, they
too were completely equipped with sanitary squads, casualty clearing
stations, field ambulances, water carts, and other necessary medical
equipment. Consequently as the army grew and expanded into a huge
force it was thoroughly equipped not only with the necessary apparatus
for caring for sick and wounded, but also with the experience acquired
by those already in the field. In this way the British Army differed
from all of our European Allies who had been compelled to mobilize
everything at once and found themselves woefully lacking in medical
equipment and personnel, so much so in fact that they had been in the
beginning unable to handle all epidemics successfully.
With a realization that the medical equipment of the British Army was
complete; that it had been sent into the field free of communicable
diseases; that it had been vaccinated and inoculated against two of
the most dreaded diseases, smallpox and typhoid fever, and that every
reinforcement subsequently sent out had been carefully freed from
suspicious cases of disease, it can be readily understood that the
British Army began under auspicious circumstances, and that thereafter
its freedom from contagious disease depended to a great extent on the
preventive measures adopted.
It is impossible, however, to prevent our soldiers billeted in France
from occasionally contracting communicable diseases from the French
civilian population, and it is obvious that as there were from 3 to 5
per cent. of the soldiers uninoculated against typhoid fever, we would
get some cases of typhoid fever.
Besides this, unless further precautions were taken, the army would be
susceptible to disease such as cholera, dysentery and the like should
there be cases of these in the war zone.
We therefore arrive at the conclusion that, as there might be some
"carriers" and undiagnosed cases of disease among soldiers and
civilians excreting disease germs, additional means must be adopted to
destroy such germs before they could reach other soldiers. This is the
place where sanitation and hygiene steps in, and it is in these
matters that the army of Great Britain is unexcelled by any army in
the field to-day.
Since the group of intestinal diseases can originate only from the
excretions of people who are giving off the specific germs, it would
be logical to endeavour to destroy such excreta or render it incapable
of contaminating water or food. This is done. All excreta behind the
front line and reserve trenches is destroyed in numerous incinerators,
which are kept burning night and day. The British Army is the only
army which has succeeded in doing this. All excreta which cannot be
burned is buried so that it cannot be reached by flies.
As it may happen through accident or carelessness that water supplies
have been contaminated, it is the rule to sterilize all water used for
drinking purposes, either by boiling, by the use of bisulphate of
soda, or by chlorine. The chlorine method is the one in general use in
the British Army, as it is in all of the other allied armies.
The possibility of using chlorine in the field was brought to the
attention of the British Army authorities by the publication of a
method evolved by the writer in 1909. According to this method a stock
solution of hypochlorite of lime was added to the water, the amount
necessary for any given water being determined by a solution of
potassium iodide and starch. This was particularly useful in the
trenches where it was possible to accurately sterilize a pail or a
barrel of water if necessary. Small tablets of hypochlorite of lime,
each one sufficient to sterilize a pail of water, were also ordered
and issued to the first Canadian division, and proved useful.
The great bulk of the water supply, however, is sterilized directly
in the water carts by adding one or two spoonfuls of the dry chloride
of lime to the partly filled water cart, the mixing being done by the
addition of the rest of the water and by agitation during the trip
back to the place where the cart is stationed.
In addition to this, large mobile filter units, after a plan draughted
in September, 1914, and officially suggested by the writer in 1915
after experience in the field, were built and issued to all the
British armies. These mobile filters are capable of filtering and
sterilizing large quantities of water and delivering it to water carts
or into stand pipes, ready to drink. A check is kept on the efficiency
of the filtration and sterilization by mobile field laboratories.
Standing orders forbid the use of unboiled milk in the army as well as
fresh uncooked vegetables, so that there is little danger from these
sources. When ones sees the peasants watering their vegetables with
sewage, the reason for such regulations are apparent.
As it is possible for flies to carry typhoid bacilli and other disease
germs from excreta to food, a constant war is waged against these
filthy insects. Flies breed chiefly in manure, and one fly will
produce many millions of flies in the course of one summer. The
obvious method of keeping down flies is to destroy their breeding
places, and therefore it is the duty of everybody concerned to see
that all manure piles in the army area are gotten rid of. Some of it
is burned, some spread on the fields, some buried, and so forth. On
the other hand food is screened from flies whenever possible, and
privy pits made inaccessible to them by the same means. On the whole
the house fly has not yet, in so far as we know, played any great part
in causing epidemic disease in the British Army in France, because so
many of the precautions outlined have been carried out.
By getting rid of cases of intestinal disease, and "carriers" of
intestinal disease, destruction of excreta and garbage, screening of
food, destruction of breeding places of flies, sterilization of
drinking water, boiling of milk and vegetables, and in the case of
typhoid and paratyphoid fevers, inoculation, the chances of intestinal
disease germs getting through from one person to another are
comparatively small, as the results would indicate.
To show that these results are not due to accident an example will
demonstrate: Early in the war when the British took over from the
French a section of the line in the Ypres salient, the Belgian
population in the little village of Vlamertinge and neighborhood was
being devastated with typhoid fever, and the French troops also had a
great many cases. When the British troops took over the line they not
only escaped getting typhoid fever themselves, but they succeeded in
absolutely stamping it out among the civilian population, and in
getting rid of any "carriers" of the disease.
The cases were discovered by a house-to-house investigation by "The
Friends' Search Party"--a group of Quakers who had conscientious
scruples against bloodshed. This search party notified the medical
authorities, particularly the laboratory in the area, of any doubtful
cases, and the diagnosis was then made by laboratory methods. In the
last six months of my stay in France, near the Belgian border, I do
not think that the Friends' search party unearthed a single case of
typhoid, and as a matter of fact few cases of the ordinary epidemic
diseases such as measles or diphtheria were discovered, although they
continued to make house to house investigations and report to us
regularly.
The insect-borne diseases in the Western Europe war zone are, as far
as we know, carried by flies, lice and mosquitoes. Flies carry disease
germs more or less mechanically, and are controlled by the methods
outlined above.
Mosquitoes are responsible for transmitting malaria and yellow fever,
though the latter never occurs in Europe. Malaria in France is also
comparatively unknown, though we found the Anopheles mosquito which is
responsible for transmitting the disease elsewhere.
There were also numerous cases of malaria recurring in soldiers from
India, Egypt, and other hot countries, so that we had both the
infected individual with the malaria parasites in his blood, and the
mosquito which was capable of carrying the organisms. Yet in 1915 we
had only a dozen cases of malaria develop in men who had never been
out of England, and were therefore, presumably, infected in France.
Possibly the chief reason for this was due to the fact that after the
mosquito has sucked the blood of an individual infected with malaria,
and been infected with the malaria parasite, the weather was not warm
enough for the parasite to undergo its necessary transformation in
the blood of the mosquito. A continuous warm period of several days'
duration is necessary for this purpose, and in France these time
periods never occurred of sufficient duration. Here was a climatic
feature which proved to be of very great importance in preventing the
spread of a disease most inimical to the health of any army.
Here again, any cases of malaria developing were removed as rapidly as
diagnosed, so that mosquitoes did not have much opportunity of
becoming infected.
Typhus fever is one of the most dreaded diseases in the army, for it
is highly fatal, and both in former wars and in the recent Serbian
campaign has proved a terrible scourge. It is quite a different
disease from typhoid fever, and is conveyed from man to man solely
through lice. In other words, the phrase "No lice, no typhus" is
scientifically true.
Every army in the field is a lousy army, and every soldier in a
fighting unit is more or less lousy. The louse commonly present is the
body louse, and it lays its eggs in the seams of the uniforms and on
the underclothes. The eggs hatch out quickly so that when a man once
becomes infected the lice multiply with great rapidity.
For typhus to get a grip on an army means that there must be at least
one case of the disease, and there must be lice on the case. Some of
these lice will fall off, wander away, or be left on the bedding, in
the straw, or in the patient's discarded clothes. If these lice have
bitten the typhus patient and thereby been infected, it seems to be
necessary for a certain length of time to elapse for the organism to
develop in the body of the lice before they are able to introduce the
virus into uninfected individuals by biting them.
As yet there have been no cases of typhus fever in the British Army in
France, though it has occurred to a greater or less extent in Germany,
Austria, Russia and Serbia. The quarantine services at the ports of
the countries bordering on the Mediterranean have prevented it
spreading to any other country.
Typhus fever is known as a dirt disease, and its control is possible
through the plentiful use of soap and water. The most difficult thing
for a soldier to obtain in the field is a bath. Normally he is in the
front line trenches for a week, in the reserve trenches for a week,
and in rest for a week. This means that he cannot get a bath for at
least two weeks, and he doesn't. So that though a soldier goes back
into the trenches clean and free from vermin he is sure to become
reinfected from lice left in the dugouts; or some lice eggs on his
clothes perhaps have escaped destruction, and he may be as lousy as
ever when he comes out of the trenches again. The old straw in the
barns and the billets is sure to be infected with lice, and it is very
difficult to sterilize the men's blankets. Consequently a persistent
continuous fight against this variety of vermin must be kept up, for
lice are not only a potential source of danger in transmitting typhus
fever and relapsing fever, but they are a great source of irritation
to the men and responsible for much loss of sleep.
The greatest luxury at the front is a hot bath, and these are provided
in every divisional area on the British front. Three or four miles
behind the trenches in the rest areas, in places where a plentiful
supply of water can be obtained, the army has established bath houses.
Sometimes a brewery, or part of it, has been taken over for this
purpose, because the breweries all have deep wells from which a
plentiful supply of water can be obtained. If the bath house is in a
brewery they may utilize the large beer barrels cut in two for baths.
These are filled with cold water and live steam turned into the water
to warm it. After the bath the men dump the barrels, which are
immediately refilled by attendants, for the next group.
Most of the bath houses, however, are in improvised shacks built upon
the edge of creeks or ponds. The water is pumped into an elevated
reservoir and heated frequently by means of a threshing machine
boiler, rented or purchased from some neighboring farmer. One section
of the shack is divided off for a bathroom with a number of showers
and the other rooms devoted to the receiving of dirty clothing,
storing the clean clothing, washing, drying and sterilizing.
As you pass along the road you will see perhaps a platoon or a section
of a platoon marching to the bath house, without belt or equipment,
and carrying towels. At the bath house a certain number, say twenty
men, pass into the first room where they undress. Their underclothes
and shirts are thrown to one side to be washed; their caps and boots
are not treated in any way. The uniforms are hung on numbered racks
and placed in the disinfection chamber where they are immediately
treated with live steam, or they are taken into an adjoining room
where the seams are ironed with hot irons to destroy lice and eggs.
The men then pass on into the bathroom where they are given about ten
minutes to luxuriate with plenty of soap and hot water. As they pass
out of the bath through another room they are given clean socks,
underclothes and shirts, and by the time they are dressed their own
uniforms, disinfected, are handed back to them. The whole operation
takes from twenty-five to thirty minutes, and from a thousand to
fifteen hundred men can be put through each bath house in a day.
The discarded clothes are washed by local peasant women paid by the
army; in one of these establishments in our area there were 160
Belgian peasant women engaged in this work. Mending is also done by
them, while socks and clothes too far gone to be mended are packed in
bundles and sent away to be sold.
The waste wash water from the baths and laundries entering the creeks
naturally causes trouble from troops down stream who may have to use
it. Horses will not touch soapy water, and the brewers object to
making beer with it; they say it spoils the beer.
Consequently the sanitary officers have in many cases been compelled
to put in tanks to treat this dirty water and purify it. This is
usually done by adding an excess of chloride of lime, which
precipitates the soap as a curd and carries the dirt down with it. By
sedimentation, and filtration through canvas, cinders and sand, the
water is clarified and turned into the creeks again clean. So
completely can this be accomplished that the experience at one bath
house is worth narrating.
This bath house was built on a little pond which accumulated in winter
and was not fed by springs or any other auxiliary source of supply;
consequently with the advent of warm weather it would have dried up
unless the water had been conserved in some way.
The sanitary officer in charge was equal to the task. With the advice
of engineers and the laboratory he built a plant which subsequently
worked to perfection. The water used to bath at least a thousand men a
day, as well as the wash water from the laundry attached to the bath
house, was collected and treated with acid to remove the soap; the
scum formed carried to the top all of the dirt, which was then
filtered off by means of sacking, cinders, and sand. The excess of
acid was treated with lime which neutralized it, and the excess of
lime was removed by soda. The water was all filtered before it was
returned to the pond into which it flowed just as clear as it had been
before, and with enough hardness present to give it a lather with
soap.
The system was operated during the whole summer and gave complete
satisfaction. It really did what nature would have done in a much
longer time and with a much bigger plant. Had the pond been used to
bathe in direct it would have been unfit for use in the course of a
few days, whereas by the method employed it was always perfectly sweet
and clean.
The common sense and resourcefulness of the British sanitary officer
is well shown by this solution of a difficult and apparently hopeless
problem. It is indeed a difficult problem which a British officer will
acknowledge to be hopeless, and it is this very British quality that
the Hun should always keep in mind in thinking of the end of the war
and the reckoning afterwards.
As far as we know there has been no plague among the warring armies in
Europe. Plague is conveyed from rats having this disease to human
beings by means of rat fleas. These fleas become infected by biting
the infected rats and subsequently infect human beings by biting them.
There are plenty of rats in the trenches and dugouts, particularly in
winter; in the summer they breed along the water courses, and in the
autumn are attracted to the trenches where there is plenty of waste
food to be had.
Numerous devices are used to destroy them, and it is a common thing to
see a soldier sitting patiently in the trenches with his rifle between
his knees and a piece of toasted cheese on the end of his bayonet. As
Mr. Rat, attracted by the savoury odour, approaches and takes the
first sniff, the trigger is pulled and there is one living rat less.
Prizes are sometimes given to the man who can kill the largest number
in a week, and bags of 25 and 30 are not uncommon. Sometimes poison is
used, and even ferrets have been employed with, however, little
success.
In connection with the rat problem, we had an illustration of how
impossible it is even for a rat to escape the British army system.
Army routine, the result of many years of experience, once put into
operation is as sure and certain as death and taxation.
The regulations are that if any considerable number of rats have been
noticed around the trenches sick or dying, some of them shall be sent
to the field laboratories for examination. Bubonic plague is a rat
disease; consequently if rats are dying in any great numbers, we would
conclude that some disease, possibly plague, must be the cause.
In this case the Director of Medical Services of the army had been
notified that a rat had been despatched to a laboratory for
examination. Consequently he was anxious to know the result of the
examination, and when a report was not forthcoming he sent a telegram
to the officer commanding the Canadian laboratory asking that a report
on the rat be forwarded at once. As we had not received the rat we
reported the same to the D.M.S. who put the matter up to the D.D.M.S.
of the corps who had forwarded the rat. The rat had gone to another
laboratory, and "the system" to locate the rat was put into operation.
The following is the correspondence upon the subject:
1. _To D.D.M.S. J. Corps._
In accordance with your 1w/ER, 16 of 1/2/3, a rat is being sent
from trench x.y.z. to No. 1 mobile laboratory at ----.
(Signed) A.D.M.S. K. Div.
2. _To O.C. No. 1 Mobile Laboratory._
Please let me know the result of your examination of this rat.
(Signed) D.M.S. Z Army.
3. _D.M.S. Z Army._
I have not received this rat.
(Signed) O.C. No. 1 Mobile Lab'y.
4. _To D.D.M.S. J. Corps._
With reference to attached, will you please say what has become
of this rat.
(Signed) D.M.S. Z Army.
5. _To D.M.S. Z Army._
It has been sent to Canadian laboratory and report has been
called for.
(Signed) D.D.M.S. J. Corps.
6. _To O.C. (Canadian) Mobile Laboratory._
Will you please let me know the result of your examination of
this rat.
(Signed) D.M.S. Z Army.
7. _To D.M.S. Z Army._
This rat was quite normal and had evidently been killed by a
blow. The report was forwarded to A.D.M.S. K. Div.
(Signed) O.C. No. 5 (Can.) Mobile Lab.
Even a partly decomposed rat was unable to escape the army system.