BOOKS.
DR. HUNTER'S VICTORY.* WE are delighted to see that the Royal Society of Medicine has given to the world Dr. Hunter's exceedingly interesting account of the terrible epidemics of typhus and relapsing fever which well-nigh destroyed Serbia in 1915.
Colonel William Hunter, to give him his military rank, has long been known to the medical profession for his admirable work as a physician, and especially for researches into the origin and treatment of fevers. After the first six months of the Great War he was called upon by the British medical and military authorities, proving thereby that we can sometimes put the right man in the right place, to deal with the appalling outbreak of typhus and allied fevers which took place in Serbia, The book before us is the record of the doings of Colonel Hunter and his colleagues, and a marvellous record it is. Colonel Hunter had to face the greatest typhus epidemic of which we have any record, and he had to face it under conditions which might have made the bravest of men despair. Nay, we may go further and say that if he had declared that the conditions made the successful issue of any attempt to deal with them impossible, and if he had therefore advised that no such attempt should be made, no fair-minded man could have denied that such a decision was justified. Instead, Colonel
• The Serbian. Epalemiesil Typhus and Relapsing Fever in 1915. By William Hunter, C.B.. Colonel A. .8. London : John Bale. Sons. and Danielsson. gid. net.' Hunter, with his devoted band of helpers and colleagues drawn from the R.A.M.C.„ started on what seemed an utterly forlorn. hope. Like knights of old, these young men and their trusted leader went forth to fight the dragon ofdisease, or rather legions of dragons, for death stalked through Serbia, not in one but in many forms. A large part of the band of doctors who attended the rendezvous at Victoria Station on the morning of Monday, February 15th, 1915, did not know where they were going or what would be their work, except that it must be arduous and dangerous in a high degree. Some of them, Colonel Hunter tells us, were "under the happy impression that they were on their way to France." Here, again, like Knights Errant, they had no idea whether it was to be " a loathly worm," a dragon in scaly armour, or a vast serpent green and spotted with whom they would do battle.
Here is Colonel Hunter's perfectly simple and straightforward story of how he was appointed and how he started. Its sim- plicity and directness could not possibly be bettered. Never has a man who had passed most of his life, like Colonel Hunter, as an English consulting physician and had not had an appren- ticeship in perilous lands oversea, received a mandate more sudden and more bewildering. The whole population of Serbia was infected with a loathsome and deadly disease, and he had to overcome it with his scanty band of followers in a land that had few of the developments of modern civilization. The roads were tracks, the railways poorly equipped, and the country generally by no means rich in material resources. Finally, the whole population was in arms attempting to resist the invasion of a great, wealthy, and powerful neighbour.
" On February 9th,. 1915, the Serbian Government appealed to the English Foreign Office (under Sir Edward Grey) for the help of a mission of doctors—if possible about 100 in number. The response was immediate. The request was handed on the same day to the War Office (Lord Kitchener), and immediately submitted by him to the Director-General (Sir Alfred Keogh). On the following, day, Wednesday, February 10th, Sir Alfred telephoned to me as senior physician to the London Fever Hospital, to confer with him as to the measures to be taken in the selection and command of a. corps of twenty-five R.A..M.C. officers, which he had decided to send out to be attached to the Serbian Armies. This was the greatest number which it was possible for him to send, in view of the great calls which he had to meet for the British Armies in the field ; and I was authorized to invite the help of any physicians or doctors willing to accept the duty. I attempted that evening to obtain the services of five physicians known to me, but without success ; their official or other engagements preventing them giving up their duties at so short a notice. On the following day (Thursday, February 11th) I therefore accepted the duty and was appointed Colonel-in-charge of the Mission myself. The nature or extent of the chief epidemic diseases was not known at the time. It was reported to be ' typhus.' Whether this was ' typhus abdo- minalis (typhoid), or ' typhus exanthematicus ' (typhus), or ` typhus recurrens ' (relapsing fever) was not known, and I asked that a telegram be sent asking for information. On the following Friday morning (February 12th) I was informed by telephone that a reply had been received. The prevalent fever was typhus exanthematicus.' I was asked whether I could leave the following day (Saturday). I said I could, and I spent the day in providing the necessary equipment for Field Service. The following day (Saturday), Major (afterwards Lieutenant- Colonel) G. E. F. Stammers, R.A.M.C.—an officer with wide sanitary experience in India and South Africa—was appointed. second officer in charge ; Captain W. W. C. Topley, R.A.M.C., as bacteriologist, and twenty-two Lieutenants of the R.A.M.C., as members of the Mission, were directed to meet me at Victoria Station on Monday morning, February 15th, ` for foreign service.' The place of service was not known to them ; they joined me under the happy impression that they were on their way to France."
So much for the tremendous task with which Colonel Hunter was faced. Here are the actual conditions which he found prevailing when he reached Serbia:-
" The experiences of the week after our arrival were to include many surprises, as will presently be seen, fully confirming, and going far beyond anything above described from the past history of the disease. I little knew then, that within a few days I was to be amidst conditions in which I was to see not 1,000 cases in a year, but 1,000 cases in a day ; to find &maximum not of 2,500 cases in a year, but of over 4,000 cases in the hospitals at the time, rapidly rising to over 8,000 in the course of the next three weeks, plus an unknown number among the civilian population of Serbia, probably three or four times as many, of whom there was no information. New cases arrived in hospitals at esti- mated rates as high as 1,000 to 1,500 a day. There was a mortality not of 19 per cent. (1 in 5) but of 1 in 3—viz., 30 per cent., in January and February, and rising in a week or two to nearly 1 in 2, 40 per cent., in March. That mortality was, as usual, highest amongst the doctors, ten to twelve doctors already dead in one hospital alone ; out of an original total of 450 doctors, sixty-two dead (soon rising to over 100) and 200 -unfit Lae duty ; in the army fifteen doctors to a division instead of sixty ; in one hospital out of five doctors, three down with typhus, and only two at work ; in the first hospital visited in Serbia, containing 956 cases of typhus, relapsing and enteric, there were only two young doctors in charge, one of them, a handsome young Swiss, dead about ten days later ; my first official duty on the day after my arrival two days later in Kragujewatz being to attend the funeral of a brave young Scottish mission worker, Miss Neill Fraser, of Edinburgh. And lastly, to find hospital conditions appallingly overcrowded and insanitary, with 13,000 wounded, over 37,000 sick, and over 18,000 fever cases ; of typhus, over 4,000, soon rising to 8,200 ; relapsing, 7,500, rising soon to 8,500 ; and enteric over 2,000."
We shall spare our readers most of the details in regard to the awful condition of the so-called hospitals in Serbia. We must, however, make two exceptions. The first is to quote the remark made by the representative of the Serbian Foreign Office when he met the British Mission on their arrival at Nish on March - 4th :- " Just like the English ; we ask for 100 doctors to help ; they apologize for being-able to send only twenty-five, but they send them at once—and they arrive unexpectedly, provided with all their kit and asking only for empty barracks in which to sleep."
The other passage is taken from the chapter to which Colonel Hunter has given the very reticent heading of " Conditions of Hospitals on Arrival " :-
" Thus, in the first hospital visited by me in Nish—es described in my first report on March 7th—there were 700 fever cases in all, with only 200 beds amongst them ; only two young doctors in charge—one of them a brave young Swiss doctor, Dr. Ernst, who took typhus a few days after I saw him and died the follow- ing week. Groups of thirty, forty, fifty and sixty cases of typhus, relapsing and typhoid patients all mixed together, lay in ill-ventilated rooms, close together on wooden boards, in some cases three or four in two or three beds, with one blanket covering the whole, many of them on the floor ; and some of them under the beds and in the passages between the beds. There were no nurses : the only attendants being Austrian prisoners ; no bath rooms or arrangements for washing ; no sanitary arrangements. The sewage from typhoid patients and others was discharged through the floor into an open ditch just outside the ward ; no arrangements existed for disin- fection, either on admission or discharge. The only thing of this kind shown me was a small brick kiln capable of disinfecting one or two articles at a time. It was explained to me that this was quite good if a piece of blotting paper were placed on each article, and if the disinfection were stopped when the paper began to turn brown ! The arrangements in various inns and eating-houses used for typhus patients which I afterwards visited the same day were of a similar or even worse character. In one small inn I found a small bedroom unoccupied, and on my asking what it was for, it was explained to me that it was reserved for visitors. An instructive experience which made clear the dangers run by anyone occupying a room even for one night in any house whose previous history or freedom from infection was not guaranteed. No such place, it might be assumed, existed. One other great source of spread of infection was also made clear by these first inspections, and fully con- firmed all my later experience. This was the absence or in- adequacy of all disinfection, of arrangements for washing or bathing, supply of hospital linen, blankets and sheets for the patients either on admission or discharge. Hence they infected each other while in hospital, and spread the disease to others on their discharge."
Enough of horrors. We must now turn to the record of how Colonel Hunter and his men did the impossible. In a country in which there was not even wood enough to build disinfecting stations Colonel Hunter managed to improvize his " barrel disinfectors " and to improvize also disinfecting trains. By bringing the population to the railway to get their clothes, their bedding and other household gear disinfected in the sanitary train he accomplished a task he could have accomplished in no other way. He could never have got his disinfecting plant to the lonely farms and villages. Very early in the day Colonel Hunter realized that the only possibility of dealing adequately with the situation was to disinfect the whole Serbian popula. tion—men, women and children. Most practical men would have scouted the attempt as an utter absurdity. Yet it was successful. His triumph was not merely of medicine but of morale. It was the combination that won. But this must be read in Dr. Hunter's own book. We can only say that it reads like a romance.
We wish we could reprint the chart showing the results obtained and let the readers see with their own eyes how the figures of disease towered up till the moment when the preventive measures began to take effect. Then the fall was instant. It is specially interesting to note that these preventive measures took to get under weigh exactly the amount of time required for the development of the disease, calculating from the moment of infection—an absolute proof, if any were needed, that it was the cutting off of infection by these preventive measures which produced the result, and not a mere pathological accident.
We shall not be surprised if our readers ask, " How is it that so little has been heard of this memorable achievement ? " The answer is, we presume, that the military events in 1915 were so tremendous that no one was able to give time and thought even to such a victory as that obtained by Colonel Hunter over the Serbian typhus. " For the press of knights not every brow can receive the laurel." Still, since disease will be with us even if we succeed in eradicating war, and so must be regarded as the first enemy, the Captain-General of Death, we may wonder how it is that in public estimation Colonel Hunter has not had the recognition that unquestionably he deserves. Be that as it may, Colonel Hunter can point to a military and medical record and to the faithful carrying out of orders to which it would be hard to find a parallel.
" My instructions were to break the epidemic and free the country as soon as possible for the possible use of British troops."
This was done in two months from his leaving England. Well might Sir Alfred Keogh, the late Director-General of Medical Services, say of Colonel Hunter's work : " The greatest piece of preventive work done in this war."
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