Typhus

Peace, of sorts, settled across Serbia alongside the hard chill of the first winter of the war. The twenty-seven future Serbian Herioters all celebrated Christmas on 7 January 1915, according to the Orthodox Julian calendar. It was the first Christmas of the war, which must have cast a shadow over the mood and thoughts of all of them. Many if not all would now have been directly affected by the war. Their able-bodied fathers, elder brothers and uncles had all been called up at the start of the conflict and would not have been there to join in any festivities. Still, some may have felt able to celebrate the festivities in the knowledge that their homes were still intact and all members of the family had survived the hardships to date.

But it would have been a sombre holiday for the families of Milorad Maletić and Mihailo Radovanović from Šabac, whose homes had been destroyed in the brutal reprisals taken by the Austro-Hungarian army during their first invasion of Serbia. So too for the four others who had been driven from their homes by the second invasion: Stanko Ilić from Smederovo, Nikola Vasić from Ljibovija and Miodrag Pavlović and Miodrag Tutunović from Belgrade. Perhaps even the families of these boys would have been able to breathe a sigh of relief at the uneasy peace, safe in the knowledge that there was no immediate prospect of external invasion. They would have been uniformly unaware of a new threat that was beginning to emerge from within.

Diseases of all sorts - now mere footnotes of historic interest in Western nations, like cholera, smallpox, dysentery, enteric, typhoid, tuberculosis and typhus - were endemic in Serbia: they emerged regularly and periodically in the poorer districts of the country where concepts of hygiene and sanitary infrastructure were non-existent. The only place in Serbia that could boast a sewer system was Belgrade. All other towns, villages, institutions and hospitals "accumulated their wastes in large putrescent pools". Neither do anecdotal reports of peasant life demonstrate much concern about sanitation. Peasant families lived alongside their animals, body lice were accepted as inescapable while, later on in the war, Allied women tasked with caring for tuberculosis patients were horrified at the common sight of their patients spitting on the ground.

The Serbian military medical authorities shared the peasants' lack of interest in matters of sanitation and disregarded disease as a significant threat to the hardy soldiers of the Serbian army. Lice were accepted as a fact of army life and little value was placed on personal hygiene, leading one British woman soldier to comment wryly of her comrades, "War with the Serbians having lasted now 500 years. Off and on [since then], I don't suppose many of the present generation have had [a bath]."

Serbian authors, writing after the war, argued that in hindsight the emergence of cholera, typhus, typhoid and malaria in epidemic proportions during the Balkan Wars of 1912 and 1913 should have provided a warning to the Serbian authorities of the importance of preventative sanitary measures. They commented, no doubt correctly, that little that notice was taken of these ominous signs. But even had due notice been taken of such signs, such was the calamity facing Serbia that it is hard to imagine that sanitary measures could have been imposed that were draconian enough to forestall conditions that, by early 1915, were in place to produce the "perfect" epidemic.

The brief Balkan wars, although they had seen the dramatic expansion of Serbian borders to encompass much of the territory that is now Macedonia, had also depleted Serbian stores, not just of military goods, but of medicine and hospital equipment. By the opening battles of the First World War, they had yet to be replaced. And although the Serbs had successfully repelled two waves of invasion, the fighting had served to destroy the little sanitary and medical infrastructure in place in the country at the outset of the war. The population was weakened: three hundred thousand poorly clothed and fed internal refugees fled to the towns safely away from the fighting. Niš, the second largest city in Serbia and the home of Djordje Osmanbegović and Milivoje Stefanović, saw its population swell five-fold from twenty thousand to one hundred thousand almost overnight. And then there were the seventy-five thousand Austro-Hungarian POWs who were crawling with lice and dressed only in their tattered blue uniforms, almost all of whom had to be had to be housed in abandoned barracks, stables or cattle sheds. When the first cases of typhus, a louse-borne disease, began to emerge in these overcrowded towns and barracks, they spread like wildfire.

Initially, the Serbian government did nothing to control the movement of infected populations and inadvertently permitted railways to become "rivers of infection" which spread the disease across the length and breadth of Serbia. POWs were transported across the country where they in turn infected other groups of already weakened prisoners. Soldiers continued to be sent on home leave. When they stepped off the dirty trains, they left behind infected lice in the upholstery and crevices of the carriages, where they later crawled into the clothing of civilian passengers who in turn infected their families after they arrived home.

From the time of the first bite, it took on average twelve days for the symptoms of the disease to appear. Initially they were virtually identical to influenza. Its victims first suffered from a headache, coughs and chills. Within about twenty-fours, they would be barely able to move, racked with a soaring fever, often suffering from excruciating pains in their backs and legs. Soon they would start coughing from the sticky white mucus which accumulated in their mouths and throats, coating their tongues thickly. Their eyes would often start burning and the white of the eye would turn red. Four or five days after the onset symptoms, a pink rash spread from their chests across their bodies and rapidly developed into purplish-red, slightly elevated spots. Some victims became unconscious. Others became delirious or writhed in agony from the wracking pains in their limbs; many became incontinent. After about a week the high fever dropped away suddenly while its victims sweated profusely, only to rise and fall two or three times over subsequent days. Those who survived were often reduced to near skeletons. In 1915 there was no vaccine or medicine able to combat it. The best chance of survival was intensive nursing, but during the epidemic Serbia had no native nurses, only hospital orderlies.

Epidemics rarely affect populations equally. So too with typhus. Feared due to its high mortality rate, it was known as "gaol fever" and considered a "dirty" disease. Historically, it was a disease of the prisoner, the poor or those seen as somehow "unclean". Because it is spread by infected lice, it is also a seasonal disease, infecting those forced to huddle together for warmth, in crowded, unhygienic quarters. Because the twenty-seven future Serbian Herioters were from the small but emerging Serbian middle class, they were far less likely to be exposed to typhus than their poorer compatriots. They lived in relative comfort, away from refugee slums or POW barracks. And at this point in time - although not later - they would have had sufficient access to sanitary facilities to ensure that they remained free from lice. Their living quarters would not have been overcrowded and those who had been forced from their homes would almost certainly have been able to seek refuge with family elsewhere. However, we know from an article in the Scotsman that at least one of the future Herioters managed to survive it, although it is unclear whether he caught it during the epidemic or during the military catastrophe that would soon envelope Serbia. "The influence of the war was also exhibited by the existence of typhus and enteric fevers and cholera," wrote the reporter, who took particular interest in the Serbian students. "One boy had all these in rapid succession, doubtless in consequence of famine and war conditions".

The first the boys would have known of the epidemic were whispered rumours about refugees, soldiers and POWs falling ill in great number. Then, in late January, they would have seen black flags start to appear, nailed to the outside walls, windows or doors of houses, flapping forlornly in the wind, one for every family member lost to the disease. "Typhus had swept the town, where people were living six and ten in a room" wrote an American journalist following his visit to Niš, the home of Djordje Osmanbegović and Milivoje Stefanović, both then aged fourteen, "until everywhere the black flags flapped in long, sinister vistas, and the windows of the cafés were plastered with black paper death-notices." "The stench of the city was appalling," continued the journalist. "In the side streets open sewers trickled down among the cobbles. Some sanitary measures had been taken...but still it was an even chance of typhus if you stayed in a hotel or public building." Almost certainly, had they been allowed to venture out, their families would have kept them well away from such public places, all of which were overflowing with ill-housed and lice-ridden POWs, refugees and soldiers. They too might have been bustled away as ox-wagons full of bodies clattered down the cobbled streets.

They would also have been kept well away from the hospitals, which were seen by the civilian population, far from inaccurately, merely as places to go to die. One was visited by an RAMC surgeon.

"Down at Nish (sic) I saw a ward containing 200 patients," he recalled. "Three were lying on two mattresses, and five on three with lice - the supposed carriers of typhus - crawling over these mattresses. In another part were three typhoid cases lying on the bare floor, one chap dying, obviously from a perforation of the bowel, and their discharges lying on the floor - at least such as had escaped from their clothing - all infecting one another, poor wretches! This particular ward was supervised by one doctor, a fine-looking chap, a Swiss, who had no nurses to assist him, only a couple of ignorant Austrian orderlies. If only you could have heard that chap's piteous appeals to us when we went to see this hospital - ‘Do come and help me please. Do say you will; do, please.' But of course we couldn't, and the day we left Nish he took to bed with typhus too - and no wonder, poor beggar; he was worked to death."

Civilians who caught typhus were almost always kept at home. "The shortage of doctors and hospitals meant that the people had to take care of themselves as best they could," recorded Stevan Idjidović Stevens, a Serbian refugee boy who was educated in Oxford during the war. "Many home remedies were practiced - like drinking fiery šlivovic and eating garlic. If this treatment did not help and the patient died, the failure was not attributed to the treatment but to something else." As a fifteen year old, he had enlisted in the army after his home had been burned to the ground by the Austro-Hungarians at the start of the war. When the epidemic swept across the country, he was based with his unit in Ralja, a village a few miles south-east of Belgrade. It had no more than two hundred inhabitants:

"The grave diggers were busy up on the hill day and might. With the ever increasing numbers of deaths, it was impossible to continue burying the victims in individual graves. Large common graves were dug to hold as many as twenty. Stacked neatly together, the bodies were limed over before they were covered to prevent the spread of the disease. The mounds grew in number and were marked by small wooden crosses bearing no names...Almost every house in the village suffered one or more deaths."

But the Serbs were not alone in fighting this catastrophe. At the outset of the war, there was already a Dutch medical team at work in Valjevo. Next, near the end of August, the first team comprised largely of British personnel, the Anglo-American unit, arrived in large town of Kragujevac, sixty miles south of Belgrade. Other units too soon began to arrive. By the early spring of 1915, most major towns across could boast a medical unit from at least one Allied or neutral country, including America, Switzerland, Greece, Russia and France.

Although the military support given by the British to Serbia for much of the war was half-hearted at best, Britain was at the forefront of providing medical assistance throughout the war. This assistance was not extended primarily from government to government, but by civilian-run medical and relief organisations, many of which were staffed and run by British women. The two most significant were the Scottish Women's Hospitals and the Serbian Relief Fund. Initially, many of their female recruits were women doctors whose offers to help the British war effort were rejected flatly and brusquely by British military authorities. The most famous case was that of the Edinburgh-based suffragist organiser, Dr Elsie Inglis. Upon offering her services to the War Office, she was dismissed by an official with the words "My good lady, go home and sit still."

This refusal at the hands of hoary old officials provided the impetus for many adventurous and determined women to circumvent such restrictions by traveling to places where the British did not control access. In particular, they travelled to Serbia in their hundreds. Dr Inglis, for one, took matters into her own hands when, from offices on St Andrew Square, she came up with the idea of what became the Scottish Women's Hospitals - hospitals entirely staffed by women, from surgeons, doctors, nurses, x-ray technicians to stretcher-bearers, orderlies and drivers. In the autumn of 1914, she offered these hospitals to Serbia and France, both of which accepted with alacrity. Faced with crisis conditions, the Serbs did not have the luxury of discriminating on the grounds of sex, age or background. Only too grateful for any help they could get, they welcomed the British women volunteers with open arms. Above all, the Serbs gave these women what they most wanted: the freedom to work as they wished, even if it meant risking their lives.

Such organisations, particularly the Serbian Relief Fund, would later be instrumental in bringing several hundred Serbian refugee children to British shores in 1916, amongst them the twenty-seven future Herioters. The first the Herioters would have seen of these British units was in early 1915, when the largely female personnel began to appear in the streets. The two boys who were studying in Belgrade, Miodrag Pavlović and Miodrag Tutunović would likely have seen the staff of the two British units that were based there, the British Eastern Auxiliary Hospital, which was attached to a small British naval mission, and the First British Farmers Hospital, which left British shores under the auspices of the Serbian Relief Fund to take over a five-hundred bed military hospital in a former university building near the Danube. Djordje Osmanbegović and Milivoje Stefanović from Niš would have encountered a handful of British nurses, who were attached as temporary staff to a large Russian medical unit. Niš, on the main railway line, also served as a hub for British staff as they travelled through the country to their units. Of all the towns across Serbia, the streets of Kragujevac, the home of Danilo Djokić and Bojidar Molerović, bustled most with British staff. The first Serbian unit of the Scottish Women's Hospitals arrived in early 1915. They were joined that spring by the Stobart unit, which was funded largely by the Serbian Relief Fund, and a small unit of the Wounded Allies, along with a handful of "freelancers" who paid for their own work.

The staff of these units were frequently deeply shocked for the conditions they faced. "One party of nurses had dinner on their arrival in a mortuary that was stacked full of coffins, some of them so hastily made that hands and legs protruded through the gaps," recorded Dr Percy Dearmer, the chaplain to the Stobart unit. The first units to arrive were also dangerously ill-equipped. They had equipped themselves in Britain as surgical outfits but found themselves instead rushed into service as fever hospitals. With little in the way of the protective gear they needed to deal with the highly infectious patients, they began to fall sick in large numbers. By the time the epidemic began to wane in the late spring, several deaths had occurred among the British personnel. In Kragujevac alone, six British women died of disease in 1915, including Margaret Neill Fraser, a golf champion from Edinburgh who played for Scotland every year between 1905 and 1914.

But for many British women, these were exactly the sort of conditions they wanted to experience. Denied the ability to work as they wished by British military authorities, the danger they faced in Serbia allowed them to feel as much a part of the war as their fathers, uncles and brothers. "I feel one is up against something nearly as risky as the front trench in France or Belgium, which is good as it is real active service and what one has longed for all along," wrote one of the women volunteers. Another enthused, on hearing that female staff were needed to battle the typhus epidemic in Serbia, "It was if an archangel had opened the gates of heaven to me."

By the late spring, a combination of measures had helped to get the epidemic under control: the work of the medical units, the imposition of strict sanitary measures and, above all, warmer weather which meant that POWs and refugees no longer had to huddle together in over-crowded accommodation. The epidemic had ravaged the already beleaguered country. Although it was impossible to keep accurate records of the number of dead, it is estimated that almost certainly one hundred and fifty thousand and possibly as many as two hundred thousand died out of a population of five million. The seventy-five thousand POWs had suffered most. Only half survived the epidemic. It is believed that around thirty-five foreign doctors died of typhus. The impact on the brave Serbian doctors who fought the disease was even more devastating. Of the three hundred and fifty doctors at work in Serbia at the start of the war, one hundred and twenty-six died during the epidemic.

Across Serbia, life gradually began to return to normal. The tattered black flags above the doors and windows of houses were gradually taken down. No more did the clatter of ox-carts collecting the bodies of typhus victims rattle over the rough, cobbled streets. The hospitals started to empty. And the grass started to grow over the burial mounds of the dead, in the silent cemeteries on the outskirts of the towns and villages. The twenty-seven future Herioters too would again have the freedom to race freely about their homes under the warm, blue skies of a Balkan summer. With the epidemic over and no signs of invasion on their frontiers, their thoughts also likely returned to the start of the new school term and trying to make up for missed lessons.

With few fever or surgical cases, the staff of the foreign units also gradually began to think of the future. Many were grew bored at the prospect of treating patients recovering from wounds that were six months' old and left for home in the hope of joining a new unit on a more active front. But the Serbian authorities begged the units to stay, convinced that their enemies were merely bidding their time. When the Serbs were proved right, those who had agreed to remain behind would be caught up, along with the future Herioters, in a new catastrophe that would soon engulf Serbia.

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