1. General Observations regarding Typhus Fever
Typhus fever, as a specific disease, was well known to the military physicians during the age of Napoleon, since, as set forth in the previous chapter, it regularly appeared during the numerous Napoleonic wars in the form of widespread epidemics. In France the simple word ‘typhus’ was often used to denote the disease, and the custom still prevails there. In Germany the disease was called infectious nerve fever, war plague, lazaret fever, &c.
At the beginning of the nineteenth century it was generally believed that great hardships, colds, lack of the necessaries of life, and the consequent consumption of spoiled foodstuffs give rise to fevers, and that these fevers, in accordance with the epidemic character of the year and of the season, and also in accordance with the severity of the hardships undergone, might develop into dysentery and typhus fever. At all events, even the eminent physicians of the day, men like Hildenbrand of Vienna[[106]] and Hufeland of Berlin, who in the course of two decades had abundant opportunity to study the disease, assumed that it is possible for typhus fever to break out spontaneously. It was believed that this fever, originating spontaneously, gradually developed the power of infection. Hufeland’s position was self-contradictory, for he assumes that the disease can break out spontaneously and yet that it can be warded off by means of isolation.[[107]] He says: ‘A proof of the fact that this disease can spread only through infection is offered by the stronghold of Küstrin, which, being closed up tightly during the entire year of 1813, was free from disease, whereas all the surrounding country, even the army of the besiegers, suffered terribly.’ Whereupon Hufeland immediately adds: ‘The war carried on among us and by us with such unheard-of exertion and hardship caused the disease to break out several times anew throughout our country, and hence it could but become general.’ That it is possible for typhus fever to break out spontaneously and subsequently spread by infection was everywhere believed, even by French physicians. It is hardly necessary to say, however, that the theory of the spontaneous origination of the disease does not accord with modern views. The severe hardships undergone, the hunger and cold, the effluvium of gangrenous wounds, the moral depression, and the many other bad effects which characterized this war more than any other, necessarily decreased the soldiers’ power of resistance and increased their susceptibility to infection. Incidentally, all sorts of telluric and meteorological phenomena, volcanic eruptions, earthquakes, the great heat and dryness of the year 1811, the meteors of that year—all these things were at the time brought into causal connexion with the war pestilences of the years 1813–14.
‘Many people stated positively’, says Hufeland,[[108]] ‘that they contracted the disease almost immediately after they had occupied small, narrow rooms in company with infected French soldiers, or after they had washed their clothes or waited upon them. This frequently happened in small houses that undertook, for a small profit, to shelter invalid soldiers quartered upon the wealthier citizens. Many asserted that they contracted the disease by passing the night in small inns in the towns and villages around Berlin, and on the roads from Königsberg, Danzig, and Frankfurt, and by sleeping on beds or straw which had shortly before been used by infected Frenchmen or Russians. A certain number of men contracted typhus fever by serving as attendants, in order to earn a little money, in the local French military hospital. In this way many of the servants and attendants employed there, as well as numerous surgeons and apothecaries, contracted the disease and subsequently infected the members of their families who brought them home and took care of them, and who, in turn, infected the other inhabitants of the house and of the neighbouring houses.’ Further on, Hufeland adds that only those inmates of the hospital contracted the disease who, as servants and attendants, had been in close and constant contact with the patients.
In the years 1813–14 a large number of physicians were carried away by typhus fever; it was estimated at that time that some 500 of them throughout Germany (excluding the surgeons) fell victims to the disease—in Silesia alone 63 physicians died, in Leipzig 17, in Württemberg 17, and in Baden 35.[[109]]
Emphasis was always laid upon the fact that the clothes and other effects of people who had succumbed to typhus fever were highly infectious. The wide prevalence of the disease among the Jewish inhabitants of Vilna was attributed to ignorance or disregard of this fact; for when orders were issued to destroy such clothing, the Jews, out of sheer avarice, disobeyed them. The persons who acquired such effects in this cheap and illicit manner usually paid the penalty themselves; in addition, they did a great deal toward spreading the disease.
The military hospitals were also largely responsible for the dissemination of typhus fever; Parenteau-Desgranges[[110]] called them outright ‘centres de contagion’. The cities in which military hospitals were erected were always severely attacked by the disease. It was generally complained, even by the French physicians, that the French hospitals were poorly arranged and badly managed—even simple cleanliness and competent attendants were lacking. Patients suffering from infectious disease were placed together with others suffering from some mild form of sickness or from a wound, thus giving the infection the best conceivable chance to spread. Let us read how a French physician describes the conditions in Verdun during the severe epidemic of typhus fever that raged there in the years 1792–5:[[111]]
‘The disease spread with no less severity from other sources of infection, such as the temporary hospitals established in the Convent of Canons of Saint Nicholas, in the Monastery of Saint Vannes, and in the barracks. The unfortunate patients, thrown in heaps on the damp stone and earth floors, scarcely having under them a few mats, or perhaps some dirty straw, filthy with their excrement, three of them often sharing a single blanket of coarse wool, presented the most dismal picture one could possibly imagine. At least three-quarters of the patients died. They were buried in huge ditches dug in the vicinity of the ramparts, and in the gardens surrounding the abbeys of Saint Vannes and of Saint Nicholas.’
The German Central Hospital Management, which was founded in the latter part of November 1813, and from which Bavaria and Württemberg held aloof, sought to introduce certain improvements into the military lazaret system, but it was unable to accomplish a great deal, owing to the lack of hospitals, physicians, and all the means necessary for the treatment of sick and injured people.
Very dangerous for the dissemination of the disease was the belief that the placing of typhus fever patients together with other invalids did no harm, but rather that the congregating of numerous typhus fever patients by themselves caused the contagion to develop with especial severity. The Saxon staff surgeon Neumann, for example, writes in regard to this question:[[112]] ‘Anybody who lies in a bed to which the poison is still clinging will without fail contract the disease; on the other hand, I have often seen people suffering from other forms of sickness lie alongside of typhus-fever patients and escape infection, provided they had nothing in common, did not touch one another, or make use of one another’s linen. Hence I draw the conclusion that the poison of typhus fever, like the poison of bubonic plague and small-pox, cannot enter the system from a distance, not even from a very short distance, and can be communicated only by close and direct contact. This seems to contradict our experience that the intensity of the poison is greatly increased when several patients lie side by side. Accordingly, I warn all military physicians not to congregate all their typhus fever patients in a single room by themselves; for few would come forth from such a room alive, while the poisoned atmosphere of the room would pervade the entire lazaret, infect the physicians and attendants, and finally spread throughout the immediate neighbourhood. People think that they can prevent the disease from spreading by congregating and isolating the patients, but as a matter of fact this has the opposite effect. This is clear when we consider that the mere being together of unhealthy people causes the poison to develop, and that not only the people themselves, but also the very exhalations from their bodies, are sufficient to spread the infection. For example, if a considerable quantity of dirty clothes or linen is allowed to accumulate in a pile, and after a short time is picked up, the usual result is that the people who do the work experience a severe attack of typhus fever.’
Very often conditions made segregation impossible, even when it was desired, or else the French generals refused to permit it. Consequently, infection was so frequent in the hospitals that the disease at a very early date acquired the name ‘hôpital fever’ (fièvre d’hôpital).
The fact that the weather conditions exerted some influence was not to be overlooked; in the year 1813, when the warm weather began, the disease abated a little, whereas in the year 1814 it ceased altogether at the beginning of the warm weather. The reason for this was that the cold weather forced people to huddle together in houses, and that bathing and washing, particularly among the soldiers and poor people, was less frequently and profusely indulged in; another reason was that the heavier clothing worn in winter facilitated the breeding of vermin.
Failure to take measures of precaution, if the disease once broke out in a neighbouring place, also contributed greatly toward the dissemination of it. ‘If typhus fever was present in any military halting-place, frequently nothing was done to prevent it from infecting the next place, where it had not yet made its appearance; or, if anything was done, it was often merely to issue an order which was not complied with.’[[113]] At the same time, to be sure, one must take into account the fact that sheer ignorance rendered useful measures impossible. If this ignorance prevailed in the highest places, nothing better was to be expected of the small cities and towns.
That the ‘contagious typhus’ prevalent during the Napoleonic wars was the same disease which we call typhus fever is very certain. The physicians of the middle of the nineteenth century, when views of typhus and typhoid fever had cleared up somewhat, have confirmed this fact.[[114]] The descriptions of the disease are almost invariably reproductions of the same picture, the sole difference being that it was much more severe and fatal among the half-starved soldiers on their return from Russia, and among soldiers packed together in strongholds, than it was among people who were less afflicted by the war and who lived at a distance from the military routes.
As a rule, the disease broke out eight or nine days after infection. It began with a general indisposition, which lasted several days, or, if this indisposition failed to appear, with a chill, great languor, loss of appetite, and weakness in the limbs; frequently brain disorders also manifested themselves, at first in the form of a mild stupefaction, singing in the ears, violent headache, somnolence, or wild delirium. The exanthema usually appeared between the fourth and the seventh day. Hufeland describes it as ‘an outbreak of red spots, covering most of the body; they were mostly of a violet tinge, but were not sharply defined, and often gradually merged into the colour of the rest of the skin’. It was frequently asserted that the petechiae now and then failed to appear at all, even in severe cases. Jörg says expressly:[[115]] ‘Sometimes they broke out sparsely, one here and one there, and in such cases it was easy to overlook them.’ After the disease had progressed for two or three weeks the patient’s temperature went down, and there were few fatalities after the twenty-first day. Convalescence was of short duration, provided the outbreak had not been preceded by exhaustion due to hardships. In regard to abdominal and intestinal symptoms, great dissimilarity was observed; Hufeland states that when there were no complications, an autopsy revealed not the slightest change in the intestinal organs, and Horn says that ‘the colour of the intestines was often almost natural.’ The severity of the disease varied greatly; it was particularly fatal among the soldiers homeward-bound from Russia, more than half of whom died. It is frequently asserted that the majority of those who were thus directly infected succumbed to the disease, and that it carried away some ten per cent of the civil inhabitants who contracted it.
Of course it would be a mistake to say that all the epidemics of that time were epidemics of typhus fever; undoubtedly typhoid fever carried away large numbers of people, since it is to be assumed that the disease was endemic in many cities. But owing to the inaccuracy of the descriptions and the lack of autopsies, it is usually impossible to distinguish the diseases with certainty. Even when the results of autopsies were made known, the condition of the intestines was often described so inaccurately that we cannot even make out whether or not there were intestinal ulcers, which are the most important pathological-anatomical symptoms of typhoid fever. But the initial chill, the short duration of the disease (three weeks), the presence of petechiae, the rapid fall of temperature, and the shorter convalescence, all of which are ever-recurring symptoms, enable us to distinguish the epidemic of the years 1812–14 with certainty from typhoid fever.
Through the influence of the works of Hildenbrand and Hufeland the larger part of the medical world of that time came to look upon contagious typhus as a specific disease; other views, however, were vigorously supported, for example, by Markus of Bamberg, who held it to be an inflammation of the brain. The difference of opinion regarding the character of the disease was important, not only theoretically, but also practically, in view of the therapeutic practice of the time; for those who regarded the disease as an inflammation of the brain had naturally, in accordance with the methods then in vogue, to resort to bleeding. But all unprejudiced observers came to the conclusion that bleeding was harmful, and that it killed all the patients upon whom it was frequently practised. Very soon the beneficial influence of fresh air and cold came to be recognized, and the latter was often provided by means of cold-water baths and douches. ‘It was a universally confirmed principle, derived from experience, that the warmer the patients were kept, the more severe was the disease, and the colder they were kept, the milder the disease.’ How beneficial fresh air was for the patients was shown by the fact that those who were kept out in the open air withstood the disease much more easily than those who were kept shut up in houses and hospitals, and that it was much less dangerous to transport patients from place to place in the open air, than to keep them shut up in overcrowded hospitals. ‘Thousands of patients’, says H. Häser,[[116]] ‘survived even the most severe forms of the disease without human help of any kind. Many, especially physicians, attributed their recovery to the fact that for weeks at a time they were constantly being transported in the cold winter from one halting-place to another, and were not compelled to lie in overcrowded hospitals, where typhus fever and dysentery raged most terribly.’
In dealing with the epidemic of typhus fever of the years 1812–14 we have a double epidemic to consider. The one was disseminated directly by the returning remnants of the ‘Grand Army’, and after causing terrible devastation in East Prussia it spread, in a relatively milder form, to other parts of Germany. The other epidemic broke out during the great battles in Saxony, which lasted several months, and from there spread virulently over a large part of Germany. In order to avoid repetition, the following account will treat of the dissemination of the two epidemics jointly.
2. The Russian Campaign and Typhus Fever in Russia[[117]]
Napoleon began to make preparations for his Russian campaign as early as the year 1811; troops were assembled in Westphalia, Hamburg, Saxony, Holland, on the Rhine, and near Verona, and several hospitals were founded, as in Danzig. An army of 550,000 men was organized to take part in the expedition into Russia; it consisted of Frenchmen, Germans, Italians, Spaniards, and Poles. How this army was destroyed on its march to and from Moscow, and in what a pitiable condition the remnants of it arrived in Germany, is well known. Since it is our purpose to point out here how that severe epidemic of typhus fever spread abroad from those remnants, we can deal but briefly with the prevalence of the disease in the army itself.
In consequence of the great heat, of the lack of drinking-water and good food, and of the continual bivouacking (the peasants burned and deserted all the villages along the way), the army suffered greatly even on the march to Moscow. After crossing the Polish border the soldiers were severely attacked by dysentery and diarrhoea; Kerckhoffs estimates that no less than 80,000 men were suffering from dysentery at the beginning of August 1812. Typhus fever broke out, very sparsely, to be sure, as early as the latter part of July, when the army arrived at Vilna; there were also cases in the hospitals at Minsk, Vilkomir, Globokie, and Mittau, but the disease was not yet so infectious as it proved to be later. After the battle of Smolensk (August 14–18) large numbers of wounded soldiers (between 6,000 and 10,000 according to various reports) were brought to that city, and from that time on, typhus fever and other diseases (hospital fever, diarrhoea, dysentery, gastric fever, &c.) continued to spread throughout the army. On September 14, Moscow was entered, and on September 15 the city was in flames. The army then had peace until October 19, when the return march began. During their sojourn in Moscow the soldiers were very improperly nourished, eating almost nothing but salted meat and fish, and drinking large quantities of wine and spirits. According to Lemazurier, the number of sick and wounded soldiers in Moscow was 15,000. The most common disease even in Moscow was typhus fever; according to Scheerer, when Napoleon’s army withdrew from the city it left behind several thousand typhus-fever patients, almost all of whom died—only the stronger patients were taken along on wagons.
The horrors of the return march are well known. Thousands froze to death in the extreme cold of November, horse-meat and melted snow were the sole means of nourishment, and any soldier who lay down was irretrievably lost. Between Moscow and Smolensk, which was reached on November 9, one-half of the soldiers who had started out from Moscow died; the number of sick soldiers was enormous, and typhus fever raged more and more extensively. On December 8 Vilna was reached, but there the army was not given a moment’s rest; two days later the Russians advanced and captured 30,000 of Napoleon’s soldiers who could go no further.
In pursuing the French army the Russians also suffered severely from diseases; according to Ebstein,[[118]] between October 20 and December 14, 1812, they lost 61,964 men, most of whom died of ‘nerve fever’ (typhus fever).
In Vilna, which was greatly overcrowded, typhus fever raged furiously. The large number of sick and exhausted soldiers that were left behind, owing to the extreme cold (the thermometer went down as low as –28° Réaumur) sought shelter, partly in private houses, and partly in hospitals. The latter, for the first few days after the arrival of the Russians, were in a terrible condition; sick men and dead men were packed together in the cold, unheated rooms, the former lying on rotten straw, completely deserted, and without care or nourishment. The corridors and courts were filled with dead bodies and with refuse of all kinds, while in the rooms themselves there was no less filth, since nobody removed the excrements. ‘The courts and corridors of the hospitals’, says Gasc, an eye-witness,[[119]] ‘were so covered with dead bodies that it was necessary to walk over heaps of them in order to enter the rooms.’
Not until after the Emperor of Russia arrived in Vilna was some semblance of order restored. But it was then too late; almost all the patients in the hospitals were infected with typhus fever, and according to Gasc and Lemazurier the great majority of the 30,000 French prisoners died. For owing to the long series of extreme hardships which the soldiers had undergone, the disease broke out in its most severe form, causing wild delirium, very large petechiae, abscesses, and gangrene. Many patients succumbed within twenty-four hours, and recovery was very slow for those who survived the attack.
In a short time the disease spread throughout the city, not so much because the soldiers were quartered in private houses, as because the Jews got possession of the clothes of the dead. Of some 30,000 Jewish inhabitants no less than 8,000 died. In February and March all classes of society, even the wealthiest people, were attacked. The disease also spread to the surrounding country; Lemazurier says that between the middle of 1812 and the beginning of 1813 some 55,000 bodies were buried in Vilna and vicinity, and that the estimates made in Wittepsk, Smolensk, and Moscow were in proportion. The pestilence spread southward and eastward, and according to Faure, in February 1813 thousands of French prisoners died in the overcrowded hospitals in Orel. The same writer says that all of the French soldiers who fell into the hands of the Russians succumbed to typhus fever.[[120]] We may safely assume that the civil inhabitants of all places in that part of the country were also attacked, even though we have no figures or statistics to confirm the assumption.
The pestilence also raged extensively in the region of the Baltic Sea; St. Petersburg was severely attacked by it. According to Parrot,[[121]] in the last months of the year 1812 there were a great many cases of ‘nerve fever’ in Dorpat; in Riga the military hospitals were overcrowded, and out of a population of 36,000 and a garrison of 20,000 there were 5,000 sick. The mortality in the hospitals was very high, since, on account of the extreme cold, two-thirds of the small windows were covered with boards and hay.
Regarding conditions in Warsaw we have more detailed information. According to Wolf,[[122]] two distinct epidemics raged there after the end of December 1812; the one was an epidemic of typhus fever (probably typhoid) and appeared only among the soldiers; the other was an epidemic of typhus fever, which did not attain to epidemic dimensions until January 1813, although a few isolated cases had been observed in Warsaw in the last months of the year 1812. ‘This disease was almost invariably accompanied by a spotted exanthema, which, if the disease was at first rather difficult to diagnose, often gave the first clue. In the case of many people the eruption was so severe and so general, appearing even on the face, that it resembled measles.’ The comparison with measles was also drawn by other observers. Typhus fever was conveyed to Warsaw by the Austrian auxiliary corps, and it quickly spread to the French hospitals, which were in a wretched condition. Later the Russian army also brought typhus fever to the city. A great many civilians in Warsaw contracted the disease; according to Wolf, the epidemic reached its climax in February, and lasted until the end of the year 1813. The lower classes suffered more than the upper classes from the disease, which, moreover, seems to have raged much more furiously in the vicinity of Warsaw than in the city itself.