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)934441
Dec. 3–Dec. 9 (1912)540229
Dec. 10–Dec. 16 (1912)451244
Dec. 17–Dec. 23 (1912)276158
Dec. 24–Dec. 30 (1912)14174
Dec. 31–Feb. 1 (1913)17399
Nov. 5, 1912–Feb. 1, 19132,5151,245

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.

CHAPTER X
EPIDEMICS IN BESIEGED STRONGHOLDS

When fortified cities are subjected to a long siege the death-rate in them increases considerably; if diseases break out during the siege, they spread beyond expectation and carry away large numbers of people. The greatest enemy of the people in a besieged city is hunger. Since the approaching hostile army causes the inhabitants of the surrounding country to take refuge in the cities, the latter suddenly become overcrowded, moreover with people who are generally quite penniless and have to be provided for by the rest. In former years, when warfare was much more cruel than it is to-day, this was especially the case. Furthermore, the size of the garrison must be rapidly increased, or perhaps the whole of a retreating army, as was the case in Metz, must be quartered in the stronghold. Accordingly, the first step taken by the commander of a fortress must be to ascertain the quantity of provisions on hand, and to work out an appropriate plan for the distribution of them. How the quality of the bread becomes more and more unsatisfactory, and finally reaches the point where the product is scarcely worthy of the name bread; how people are obliged to eat the flesh of horses, dogs, and other animals; how the prices of the necessaries of life soar ad infinitum—all this is so well known that it needs no further exposition. Besides the absence of these necessaries of life, the lack of milk, fats, salt, and vegetables is accompanied by various consequences; very frequently improper and badly prepared food gives rise to a large number of severe cases of intestinal catarrh.

Insufficient nourishment is seldom the direct cause of death; on the other hand, it frequently so weakens people that they are much more subject to sickness, or, if they have already contracted some disease, they are much more likely to die, or, if they recover, to convalesce slowly. Thus Vacher[[324]] states that typhoid fever, which usually results fatally in one out of four cases, during the siege of Paris carried away no less than forty per cent of those who contracted it; tuberculosis, he says, often acquired an acute form and caused death within a few weeks. Little children present slight resistance to famine. ‘In regard to new-born and one-year-old infants I have observed in certain cases that become more frequent every day, that the effects of insufficient alimentation show themselves in the form of a progressive emaciation, which includes all the tissues of the body and almost always has fatal consequences; oedema of the teguments, anaemia, uncontrollable diarrhoea, and continual plaintive crying on the part of the little patients are the characteristic symptoms of that hunger-fever which actually decimates our infant generation.’

Another result of insufficient nourishment, one which has frequently been observed in besieged strongholds, is the appearance of scurvy.

During sieges, the hygienic measures of precaution, which are absolutely essential to the maintenance of health in cities, can no longer be carried out. If spring-water is secured outside the city for the inhabitants, the besiegers cut off the source of supply; if the water of rivers is used, then filtration plants have to be erected. But even filtration does not prevent the appearance of those infectious diseases the germs of which are carried in water, since for washing purposes the river-water is used just as it is found. The removal of refuse constitutes an extremely difficult problem; the cleaning out of privies is often possible only to a very insufficient extent, especially when the besiegers have advanced very close to the city, and the failure to dispose of garbage necessarily causes large accumulations of dirt and filth in the streets; this was especially the case in former times.

The burying of so many dead bodies, of both men and animals, especially horses, has met in many sieges with serious obstacles;[[325]] if the ditches intended for a large number of bodies are not dug deep enough, the atmosphere becomes polluted; to burn them is impossible, owing to lack of fuel; and if they are cast into the river, this jeopardizes the health of those living further downstream. During certain sieges in the past, hard conditions have made it necessary to leave corpses and carcases lying in the open, with terrible consequences.

If the siege takes place in the winter, it is very difficult to procure fuel for heating purposes, unless sufficient provision has been made beforehand. In Paris, for example, the inhabitants suffered severely from cold, and to meet the emergency artificial fuel was prepared by mixing stable manure with tar and reducing the mass to solid form under the hydraulic press.

In the following pages we discuss a few sieges which were characterized by severe outbreaks of pestilence.

1. The Siege of Mantua (1796–7)[[326]]

During the siege of Mantua, which the French carried on from May 30, 1796, to February 3, 1797, war-pestilences raged with fearful severity among both besiegers and besieged. The city lay in an extremely unhealthy region—malaria was ever prevalent and the drinking-water was bad. The intentional flooding of the region and the great heat of the summer of 1796 caused malaria to break out with great severity and to acquire virulent forms that rendered the disease more dangerous than usual. In the latter part of May 1796, the garrison consisted of 18,000 Austrian troops, whose power of resistance had been greatly reduced by hard service from November on, and by exposure to rain and cold with inadequate means of shelter. Besides intermittent fever, both intestinal catarrh and typhus fever made their appearance in July; the latter, at least, was probably the ‘nervous fever’ mentioned by Stegmeyer. Thus as early as the latter part of July there were some 2,000 sick men in the garrison. In August the investment was not yet complete, so that the soldiers did not suffer from lack of food. Notwithstanding this fact, however, the diseases increased in prevalence and caused many deaths; the number of sick men was no less than 6,000. On September 12 the Austrian general, Würmser, with about 12,000 men, succeeded in gaining entrance into the city; he brought with him a large number of disabled men who had been wounded in recent fighting, and many of whom succumbed to tetanus and hospital fever. The number of patients now increased to 8,500; as there was no bedding or straw available, the patients were compelled to lie on the bare ground, and the uncleanliness of the hospitals grew worse. When the investment was finally rendered complete in October, it caused a great scarcity of meat, fat, and wine; the number of patients that month was 9,000 and the number of deaths 2,560. These figures, however, are not complete, since they do not include the patients in the houses set aside for troops overcome by exhaustion. Up to this time the weather had been good, but in November rain set in; and while intermittent fever then decreased in prevalence, dysentery raged even more furiously, and typhus fever also broke out in a virulent, quickly fatal form. The supply of food now ran very low, and although there was sufficient bread on hand, horse-flesh was the only meat. To add to the general misery, scurvy made its appearance in November, and all those who contracted it died. The extreme cold compelled the patients to keep their clothes on, and they lay without blankets on the hard floors of the hospital corridors; their number had now increased to 9,500, and 2,400 died in November. In December the misery increased; the cold became more and more intense, the supply of food was almost exhausted, and the wine gave out altogether; scurvy raged in an even more severe and virulent form, being frequently accompanied by copious hemorrhages from various parts of the body. In the hospitals there were 7,354 patients, and 2,021 died in the month of December. In January the acme of misery was reached; the scarcity of food was terrible, and the ravages of scurvy were no less than frightful; 1,968 men in the garrison were carried away in the course of that month. On February 3, 1797, the stronghold was surrendered to the French. The number of patients taken in by the hospitals between September and January exceeded 40,000, and of the garrison, which numbered some 30,000 men, 10,249 (more than one-third of the total) died. Fodéré estimates the total number of deaths in the city of Mantua during the siege at 20,000;[[327]] regarding the prevalence of diseases and the number of deaths among the civil inhabitants Steegmeyer unfortunately gives us no information.