[Published by the author in more technical form in the Medical Press and Circular, August 28, 1901]
Of the prevailing diseases with which I had to deal during my recent period of active service in South Africa, by far the most prominent in its severity and medical importance was typhoid or enteric fever. Statements to which I have had access as regards the aetiology of this fever and its prevalence, especially in respect to the colonies of Natal and the Transvaal, before the commencement of hostilities do not in all cases hold true when contrasted with the conditions under which those countries have been placed while in a state of war.
Before the war enteric was said to be very prevalent, especially in the highlands. It was epidemic during the Zulu War at Utrecht, and after the last Boer War at Newcastle, Pietermaritzburg, and Ladysmith, while garrison stations have continuously suffered year after year. February, March, and April are said to be the months of greatest prevalence, those of November, December, and January ranking next. The civil populations and natives were said to suffer severely, so that towns and kraals were to be regarded as suspicious foci.
During this war, previous to embarkation, each officer of the Royal Army Medical Corps was furnished with a memorandum prepared with elaborate care by the Medical Department of the War Office, and having reference to the probable diseases to be encountered in South Africa, and suggestions as to the prophylactic and other measures most suitable to be observed. In this memorandum it was pointed out that the streams and rivers were constantly polluted by adjoining habitations and also by the carcasses of dead animals, and that an equally potent cause of infection was the neglect of conservancy arrangements and the constant pollution of soil, one of the chief sources of infection in camping-grounds being foul matter, of whatever kind, communicated to the soil by men who are suffering, or have suffered, from enteric fever. It was laid down that the best prophylactic measure for medical officers to follow was to see that in all capaps, especially standing camps, an intelligent and daily use of disinfectants be enforced, and that sanitary supervision of the strictest possible nature should be adopted on the following lines: That in addition to the usual precautions required in connection with water-supplies, such as boiling and filtration, the daily use of disinfectants in all latrines, tubs, pits, etc., becomes essential. For this purpose quicklime was recommended as the best material. It was to be added in the form of freshly-prepared milk of lime (1 part hydrate of lime to 8 parts of water); the quantity to be added to receptacles, etc., should be, roughly, in the proportion of i part milk of lime to 20 parts of the contents.
The milk of lime was to be sprinkled freely on the surface of the soil in the neighbourhood, wherever surface pollution was likely to take place. Another important point was the protection of food from the contamination of flies or faecal dust. Kitchen refuse was never to be allowed to accumulate, but was to be immediately burnt, and wherever flies appeared to congregate, it was to be held as an indication that refuse or other organic matter was present, and that steps were to be taken to use strong disinfectants to destroy, if possible, the flies breeding there.
Several other valuable suggestions, which time and space will not allow me to enumerate, were laid down in this memorandum; for instance, in this particular campaign an endeavour was made to move a step in advance of previous campaigns in the methods of obtaining, above all things, a pure water-supply for the troops; the second precaution advised by the Medical Department to the War Office was the provision of a filter suitable for troops on the move. Many of the so-called sterilizing filters used in previous campaigns are next to useless: they get out of order, the candles break, they get coated with mud, they are heavy and difficult to carry about, and generally, as experience has shown (for example, in the Ashantee Campaign), they were left at the base as useless. The Medical Department, on careful consideration, recommended the adoption of the Berkefeld filter. This filter was tested for the first time at the Salisbury Plain manoeuvres of 1899, and, though open to some objections for field service, was by far the best filter in the market. This Berkefeld filter was designed to filter 34 pints in ten minutes, and was sufficiently light to carry with troops. One was to be supplied to every unit of 100 men, and was said to be ready to come into operation whenever a pool or other source of water-supply during the march was found. It was supposed to filter at a sufficiently rapid rate to give each man of a unit of 100 men a fair quantity of drinking water within thirty minutes or an hour of the halt.
But having the defects common to sterilizing filters for troops on the march, it cannot be worked perpetually; the candle gets clogged, and the more clogged it gets the more difficult it is to work; and it was to rest with the men themselves to organize a method of passing this filter from man to man and keep it cleaned.
The third prophylactic measure advised by the Medical Department is one as yet in its infancy—that of vaccination of the troops by an antityphoid vaccine prepared in the laboratory of Professor Wright at the Army Medical School at Netley.
The principles upon which this antityphoid inoculation is based by him are as follows: First, laboratory experiments have clearly proved that animals inoculated with dead cultures of typhoid bacilli have a greater power of resisting infection from living typhoid bacilli than animals not inoculated. It may be inferred that this rule will hold good with man from the feet that the antityphoid inoculations induce in man precisely the same blood changes which they induce in animals. Secondly, the blood changes which occur in man by antityphoid inoculation are precisely the same as result from an actual attack of typhoid fever. The importance of this last fact becomes apparent when it is considered that the insusceptibility against further seizure, which supervenes upon an actual attack of typhoid fever, is almost certainly dependent upon the occurrence of the particular blood changes which are here in question. While at Netley I had the opportunity of seeing the preparation of this serum and personal demonstrations on the means of inoculation.
The vaccines are prepared from sterilized typhoid cultures grown either on agar-agar or nutrient broths of various compositions; the strength of each vaccine is ascertained in the laboratory by inoculation on animals, and a small quantity of antiseptic is added to it to provide against all possibility of contamination. It is then put up for use either in sealed glass capsules for one or two vaccinations or in glass bottles, covered with paraffined india-rubber caps, containing enough serum for occasions when a number of inoculations are to be made simultaneously. The vaccine is sterilized in these bottles before it is sent out. Vaccination against enteric not being compulsory in the army, it was suggested to the various medical officers to call for volunteers among the officers and men of the units going out to the war; some were inoculated before going out, others on board the transports, and some in South Africa. Lectures were given in which the medical officers explained, in as concise and familiar terms as possible, the objects and expectations of inoculation. A call was then made for volunteers, their names were taken, and inoculation was made in batches, a careful record being entered of each man, with his age, number, and name of regiment. While on passage out in H.M.T. Dilwara I made a number of inoculations, chiefly among the officers and men of the Royal Lancaster Regiment and Eleventh Brigade Bearer Company, in conjunction with Captain Tyacke, R.A.M.C., following the usual methods as laid down by Professor Wright.
The men were taken in batches of five, the flank being the site chosen for injection, on account of the looseness of the subcutaneous tissue there, and also because, owing to a certain amount of pain and effusion which follows inoculation, it is always better to choose a site which lies on a part more or less protected from friction or joint movement. The skin having been first made surgically clean, the serum is injected from a hypodermic syringe which had been sterilized in oil at a temperature of 140° C. to 160° C. A thick fold of skin is then pinched up between the finger and thumb, and the needle passed down well into the subcutaneous tissues in the centre of this fold; after the necessary amount has been injected, the needle being gently withdrawn, the track left in the skin should be gently squeezed from without inwards. This last proceeding I think most important, as from the fact of the needle being a large one I have at times noticed a reflux of the serum down the track of the needle, either at its withdrawal or even some time after. The occurrence of such a reflux as this might easily be overlooked and the case registered as inoculated, and such a subject contracting enteric fever at a future time, and perhaps dying, would bias the opinion of some people as regards the advantages of inoculation.
The clinical signs and symptoms which result from antityphoid vaccination are subject to considerable individual variations, and may be divided into constitutional and local. Of the former, most cases manifest some degree of malaise, and some even faintness or vomiting; some few show definite rigor. This symptom generally comes on from four to six hours after inoculation. Temperature is seldom below ioi° F., and may rise to 103° F., but generally subsides within twenty-four hours. The local symptoms are much the same in all cases—effusions at the site of inoculation, heat, redness, swelling, pain—but these pass away within forty-eight hours. Most of my cases I treated at ten in the morning; all turned up for their mid-day meal, some feeling a little stiff in the side; about 25 per cent, were absent from their evening meal at 6 o’clock, and those who were then present were decidedly sore and stiff. The absentees, when inspected, were found lying up in their bunks, their chief complaint being that they were too stiff to rise. Of several hundred cases vaccinated, in no case did any suffering occur after forty-eight hours from the time of inoculation. Professor Wright has pointed out in his memorandum on the subject of vaccination the importance of the additional protection derived from a repetition of the inoculation at a later date, not earlier than eight or ten days from the first injection. This I was unable to carry out, owing to more men coming forward for inoculation than was expected. Finally I inoculated myself, and, though somewhat sick and sore for nearly forty-eight hours, I was able to continue my routine duties and eat my meals.
Having now briefly discussed the main precautions laid down before the war by the Medical Department, 1 shall endeavour to add my own personal observations on the results during the campaign. My observations are limited to the period commencing December, 1899, and terminating February, 1901, and the ground covered may be taken as fairly typical, as I have done duty in all four colonies.
I will first deal with the subject of inoculation. That inoculation has been a success I have no doubt, but this is a subject that will require lengthy statistical reports which cannot be completed until the termination of hostilities, as many of the cases entered in the army returns as enteric, and many other cases entered as other kinds of fever, will have to be revised; for it must be remembered that many obscure fever cases have been diagnosed as enteric in persons who had been previously inoculated. And it must be kept in view that Widal's reaction, when obtained in a person who has been previously inoculated, does not in any way confirm the diagnosis of typhoid which may have been arrived at by ordinary clinical methods; and much less does it conclusively prove the correctness of such diagnosis. In view of the difficulty which has often arisen in diagnosing enteric in inoculated people, it is the reduction of actual typhoid mortality that must be taken, and not the reduction of the presumed cases of typhoid itself among inoculated persons. With this view, I have always made it a point carefully to examine all enteric cases in hospital which had been previously inoculated. From the evidence I have collected I am led to believe that the following results will be found true in the majority of such cases:
First, that inoculated cases, as a rule, run a mild course, and such complications as high fever, haemorrhage, and perforation rarely occur; that there is a very great increase of bactericidal power in properly-inoculated men.
Secondly, that severe cases of enteric occurring among inoculated men will always have a history of no distress at the time of inoculation, pointing to the likelihood of the vaccine not taking. None of the cases I either inoculated myself or saw inoculated have died from enteric to my knowledge, and none of these cases so far as I know have been inoculated a second time.
Passing from the subject of inoculation to that of water-supply, we come to what is really the crux of the whole question of our heavy mortality lists in South Africa. The water available for drinking in that country, south of the Pretoria-Delagoa line, is distinctly bad, having one ever-present ingredient—namely, mud. In the Lydenburg district, north of this line, the water we met with was pure and of a crystalline brightness, and wholesome where not poisoned, as I have found it on several occasions, by the ferrocyanide of potassium used in the mines. The water used by the Natal Field Force in its twelve months' journeying had perforce to be drawn from sources previously occupied and contaminated by the Boers. It had to be taken either from small rivers or pans, the latter being marshy pools, and invariably of a dirty brown colour. The amount of mud in this water was always enormous, even when drawn from a river the size of the Tugela. Mud being never at any time a favourable adjunct to the food of man, he not being a suctorial animal, and acting as an irritant to the intestinal tract, produces an acute gastro-intestinal inflammation, which inevitably results in diarrhoea. Acute gastrointestinal inflammation easily tends to become chronic; this is especially manifest and aggravated in troops fed on preserved field rations and biscuit. When the chronic stage is reached, the condition is most grave. From faulty digestive power the patient emaciates and becomes much debilitated, and the state of the mucous membrane of the intestines is such that a suitable nidus is presented to the germs of enteric or dysentery should they be present in any further water drunk. Should such a patient become infected, and should he not report sick, as is often the case, especially during fighting (for during such times 'Tommy ’ won’t report sick unless he is really 'very sick’), let us see what happens. The patient resorts to the nearest donga; in a hot climate the matter rapidly dries, and is either blown about by the wind or washed by the first heavy rain into the nearest water-supply, ready to infect the next comer who draws water from it. Thus are diseases spread.
Dining the dark days of the three months preceding the relief of Ladysmith, the water question added itself to the numerous difficulties that General Buller and the Natal Field Force had to contend with. Until the Tugela was crossed no available water was fit for drinking at either Chieveley or Frere; it had to be brought by train in specially-constructed trucks, and carried thence in tanks on ox waggons to the troops and dealt out sparingly.
At Spion Kop it was the lack of any kind of water, together with the nature of our position, that led to the evacuation of the hill. Even when the Tugela was reached, the water of that river was already contaminated by corpses and dead animals, and was of a deep brown colour from the amount of mud it contained. Berkefeld filters, or in fact any artificial filters, were soon found to be useless. They became clogged after a few pints had passed through, and could not be further used. Fuel was so scanty that it took the troops all their time to find enough for cooking purposes. Fires could not always be lighted owing to the close proximity of the enemy, as any smoke rising above a hill crest was sure to draw shell-fire. During the fourteen days preceding the battle of Pieter's Hill the entire army were huddled together in a valley through which the Tugela ran. Putrefied corpses of horses, cattle, and men contaminated every donga leading to the river, as well as the river itself. The Boers had also been camping in this ground for the previous three months. Torrents of rain fell daily, washing all kinds of contamination into the river, which at that time was our only water-supply.
The sewage and offal of fever-stricken Ladysmith and Intombi Hospital also passed by means of the Klip River into the Tugela.
Such a condition of affairs gave the medical officers of the Natal Field Force under Colonel Sir Thomas Gallwey their utmost to cope with, in addition to the already heavy work of attending the wounded. It had to be done, and it was done, and no epidemic of enteric of any proportion occurred.
When Ladysmith was relieved on February 28, 1900, it was found that the garrison of that unfortunate town had suffered severely from the water difficulty, and had it not been for the prompt sanitary action taken by the medical officers at the commencement of the siege a still greater amount of sickness would have occurred. As it was, 1,700 soldiers contracted enteric out of a force of 12,000, and about 1,800 contracted dysentery. The only source of water-supply in Ladysmith was the Klip River, giving a fluid of pea-soup consistency, due to the suspension of quantities of red mud. Major Westcott, R.A.M.C., who acted as special sanitary officer during this period, in his report on the analysis of the water available there, reports what was taken from the Klip River, though notoriously suspicious in quality, only contained 1 grain per gallon of chlorine, indicating an almost entire absence of organic matter, thus contrasting very favourably with that from a crystal stream on which he was called to report near the gorge of Ladysmith, which contained 14 grains per gallon, and that from a well in Intombi Spruit, which contained 12 grains per gallon, both of which, of course, were unfit for drinking purposes. As, however, the small extent of animal contamination was no indication of the absence of the typhoid poison, the water of the Klip River was sterilized before being drunk by filtration through Berkefeld filters. The mud was precipitated by alum, as long as it lasted, but by December 19 all the available alum had been used, and another plan of clearing the water previous to filtration was adopted, which proved to be a great improvement on the previous process. Five open hogsheads were sunk in the river-bed at different levels, with the result that there was a constant supply at all water levels of perfectly clear water; this was pumped by the fire-engine into tanks on the bank of the river, of a total capacity of 5,000 gallons. Two water-carts made constant journeys to the filters, and these by working day and night gave a daily supply of 1,500 gallons, which was ample for drinking purposes, each unit drawing from the tanks 1 gallon per head of clear water. In connection with the influence of water-supply on the causation of enteric, Major Westcott noted that when the men in Ladysmith were supplied with filtered water there was a distinct drop in the admissions for dysentery, while those for enteric fever continued to increase.
On the arrival of General Buller’s army in Ladysmith it was manifestly impossible from a sanitary point of view to quarter his troops in the town, and he broke his force up into brigades and stationed them within a convenient radius; some were placed on the line of the Tugela, others at Sunday's River, Smith’s Crossing, Acton Homes, and Elandslaagte. It was to the last-named place that the Fifth Division, to which I was attached, was posted.
The water at Elandslaagte being anything but good, and the health of the troops not being as satisfactory as might be wished after their exposure and precarious living for the last few months, I was asked by the General commanding the Eleventh Brigade to undertake special duties with regard to water-supplies and general sanitary work in the camp, and to furnish him with a detailed list of suggestions dealing with these matters. After enumerating many of the points I have mentioned in this paper, I suggested the following remedies:
1. Diarrhasa.—That soldiers suffering from diarrhoea should in every case report sick as early as possible and come up for immediate medical treatment, as such cases, with proper therapeutic and dietetic treatment, are easily cured in the early stages, whereas the difficulty of curative treatment is greatly increased should the ailment be allowed to go on untreated, even for a few days. The dietetic treatment consisted in substituting a milk, cornflour, and soup diet, instead of the meat, bread, and vegetable diet usual in a standing camp.
2, Water,—All water-supplies to be daily inspected and marked by distinguishing flags. That three separate and distinct water-supplies were to be recognised—water for human drinking and food purposes, water for animals, and water for washing; that sentries were to be posted over each of these to see that no interchange should take place between the uses to which each pool was allotted. That all water used for human drinking purposes was first to be cleared of mud, either by precipitation with alum, 10 grains to the gallon, or passed through mechanical strainers; for this purpose I advised that clean empty barrels, of which we had a sufficient number, be utilized, one barrel to be sawn in half in such a way as to form two tubs, each tub to have a foot square cut out of the bottom, and the aperture covered by a number of layers of fine linen or khaki. This tub strainer was then to be placed over another complete barrel, which received the strained water, and this, when finally drawn off by a tap below, came out clear. The water was now to be passed into a Berkefeld filter, through which it easily ran, and it was finally to be boiled, if possible. Cleansing of water-carts and the men’s water-bottles with permanganate of potash at intervals was also recommended.
3. Disposal of Refuse,—Strict orders were to be enforced as to men using only the recognised latrines, etc., and the proper disinfection of the same with chloride of lime. All kitchen refuse, including preserved-meat tin cans, were to be deposited in pits dug for the purpose, and burnt. All animal refuse was to be removed some distance out of camp before 8 a.m. daily, and burnt when dry. All dead animals were to be taken some miles out of camp, and buried under at least 3 feet of soil. As numbers of dry foetid carcasses of horses lay about the battlefield of Elands-laagte owing to General White’s engagement in the previous year, the most effectual method of destroying them was found to be burning.
4. Inoculation.—Recommendation of inoculation to all, especially young soldiers, with antityphoid serum is advisable.
Major-General Wynne did much to assist the medical officers in their sanitary duties. He embodied the above suggestions in camp orders, and paid daily visits of inspection to the various camps. On May 121 was appointed to Lord Dundonald’s Cavalry Brigade, and with this I remained for the following six months. It consisted chiefly of colonial troops, and comprised 'A' Battery
Royal Horse Artillery, Strathcona’s Horse, South African Light Horse, Thorneycroft's Mounted Infantry, Bethune’s Mounted Infantry, Stewart's Mounted Infantry. As it will be of interest to contrast the health of these Irregular Cavalry with the infantry with whom I had been during the previous six months, I will first give an outline of the composition of each regiment. 'A’ Battery Royal Horse Artillery consisted of men who had been for some time in India at Umballa. Most of them had had malaria at some time or other. The South African Light Horse, as well as Thorneycroft’s and Bethune's Mounted Infantry, were all enlisted in South Africa, and comprised men of remarkable wiry physique, but of very variable ages. Although a large proportion of them were Afrikanders either by birth or adoption, many of the men came from other colonies. This was particularly marked in the South African Light Horse, a number of whom were Australians. Stewart's Mounted Infantry consisted of troops drawn from a number of our regular infantry regiments. Strathcona's Horse was a regiment of Canadians of particularly good build and physique. They were all big men, and came from the north-western districts of Canada.
During General Buller’s continuous advance through Northern Natal into the Orange River Colony, and finally through the Eastern Transvaal, Lord Dundonald’s Brigade acted as the advance-guard of the army, and did all the scouting. We were also responsible for the selection of water-supply and camps and the sanitary conditions necessary for the preservation of the health of the main body when it came up. Colonel W. B. Allin, R.A.M.C., Principal Medical Officer of the Natal Field Army, is to be congratulated on the results of his labours in this direction, for no camp for the succeeding forces was selected without his first making a thorough investigation of the water-supply and other hygienic surroundings. This was in addition to the amount of attention paid to the food and blankets of the men, and although hampering General Buller with extra transport (he carried 1,503 medical diets with the Natal Field Force after the line was left in the great advance north), such a course greatly helped to reduce sickness in the Natal Field Force, the statistics of which will very favourably contrast with any other field force, or with any other campaign our troops have passed through. I was with the cavalry for more than six months, and was agreeably surprised at the very small amount of sickness in Lord Dundonald's Brigade.
At the same time, it must be remembered that in a campaign any comparison between cavalry and infantry in the matter of health and admission to hospital is hardly fair. The mounted man, naturally, does not suffer so much from fatigue and thirst as does the foot soldier, who madly rushes to drink any water, no matter how muddy, that he meets with on the march, stirring up the mud, and thus still further polluting the fluid in his endeavours to fill his water-bottle. The hardened infantry reservist bears a favourable comparison with the infantry recruit in this respect on the march. While the former by experience has learned that he can march most easily, and perspire least, if he keeps from water during a march, and may be seen at a halt cooling and refreshing himself by merely rinsing his mouth with liquid, but not swallowing it, the recruit hugs his water-bottle as his most cherished possession, fills it at every puddle he can get to, and empties it with the same avidity as an infant does its feeding-bottle. The result of such continuous water-drinking is much discomfort, heavy sweating, and exhaustion, and these are the men who fall out on a march and fill up the ambulance-waggons. From what I have seen, I would be almost tempted to take the water-bottle away from the recruit on foreign service. Another, and perhaps the best, explanation as to why this colonial brigade contrasted so favourably with the home infantry was that so many of the men, being South Africans, had become inured to the cKmate and muddy water through long residence in the country, or had been used to country life in some other colonies. Another explanation might be the fact of mounted men constantly moving from one camp to another.
There is little further of interest to relate on the water question until we come to General Buller’s progress north of Lydenburg. Here, while acting as advance Sanitary Officer of the Force, I had reason to condemn the water-supplies in several places, as they had been poisoned by cyanide of potassium. Lord Roberts had previously to this drawn the attention of the medical officers of his force to this danger occurring in the advance through the enemy’s country. But I am not sure that any water was found poisoned on his side. The tests I employed were the ordinary ones, a ferric salt giving a blue precipitate with ferrocyanide of potassium; the precipitate insoluble in dilute hydrochloric acid, and decomposed by a solution of caustic soda. Cyanide of potassium also renders water alkaline. The large amount of iron naturally existing in the water of the Lydenburg district made the poisoning of running water extremely difficult. In conclusion, I should like to remark, notwithstanding the fact that a sanitary officer has been condemned by Lord Wolseley as a useless encumbrance in time of war, that I think the campaign in Natal has clearly proved that the co-operation of the General Staff and the Principal Medical Officer in the first place in selection of camps, feeding, and clothing, and, secondly, what is even more important, the co-operation of regimental Commanding Officers with their regimental medical officers, show the present system to be the best. This could, no doubt, be perfected by the allotment of one or two special medical officers to the staff of the Principal Medical Officer of a field force, which officers would be made responsible for daily sanitary inspection of all standing camps, camping-grounds, and hospitals, and conduct water analyses, report on food and clothing, and perform medical and surgical research duties. They could report direct to the Principal Medical Officer on the spot, and not only assist him in sanitary matters, but be available for other purposes in times of urgency.