The typhus epidemic in eastern Macedonia, 1919
Η επιδημία τύφου στην περιοχή μας στο βιβλίο The typhus epidemic in eastern Macedonia
Αναφορές (με google μετάφραση, σύντομα σε κανονική μετάφραση) :
στους οποίους χορηγήθηκε καθαρό πιστοποιητικό υγείας από το
υγειονομικές αρχές, και έστειλε στη Δράμα, Σέρρες και Σμύρνη
Demir Hissar με εντολή να αναφέρει στην υγειονομική υπηρεσία
αρχές αυτών των πόλεων. Όλα αυτά ακούγονται τέλεια
καλή διαρρύθμιση και θα ήταν έτσι εάν το Ka-
οι αρχές της Βαλαίας έκαναν το έργο τους αποτελεσματικά, αλλά δυστυχώς
Πάντως απέτυχαν σε δύο πιο σημαντικά στοιχεία. Ήταν
την ίδια παλιά ιστορία: τόσο την καραντίνα όσο και την ιατρική
Έλεγχος των προσφύγων στους καθαρούς στρατώνες ήταν
αναποτελεσματικό, με αποτέλεσμα να είναι πολλοί αυτοί οι πρόσφυγες
από τον πυρετό τυφου στην Καβάλα, με την ελεαν-
τα πιστοποιητικά υγείας, στη Δράμα, στις Σέρρες και στο Ντεμίρ
Χισάρ. Στις Σέρρες δεν υπήρξε ασυνήθιστο φαινόμενο για το
πρόσφυγες, ήδη θύματα τυφού πυρετού, να τους παρουσιάσουν -
με τις υγειονομικές αρχές συγχρόνως,
τα πιστοποιητικά καθαριότητας της Kavalla στα χέρια τους -
μια κατάσταση ahnost διασκεδαστικό εάν δεν ήταν τόσο λυπημένος και τραγικό.
Αυτή η αδιάκριτη αποστολή εκατοντάδων
από την Καβάλα χωρίς προηγούμενη ορθή ιατρική επιθεώρηση.
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Λόγω της βελτίωσης της κατάστασης με τον τύφο στις Σέρρες
φάνηκε να μην χρειάζεται πλέον
τη συνεργασία μας. Συνεπώς, στις 27 Μαΐου,
οι γιατροί σταμάτησαν να εργάζονται στην πόλη των Σερρών.
Την 2η Μαρτίου ο Ιατρικός σας Διευθυντής συνοδεύεται από
Ο υπολοχαγός Κυριαζίδης έκανε επίσκεψη στο Δεμιρ Ισαρ,
μια γραφική μικρή πόλη με (30 (X) κατοίκους, που βρίσκεται πάνω
τον ποταμό Στρυμόνα και περίπου 'Μ' χιλιόμετρα από τις Σέρρες.
Βρήκαμε την ίδια παλιά ιστορία - επαρκή. εξοπλισμό, αλλά
κακή, - πολύ κακή, - οργάνωση, στην πραγματικότητα εύκολα χειρότερη
αντι-τυφώδη οργάνωση που είχαμε δει μέχρι τώρα στη Μακεδονία.
Κατά συνέπεια, αυτή η όμορφη μικρή πόλη υπέφερε επίσης
αδικαιολόγητα από τον πυρετό του τυφού. Μέχρι τη στιγμή της επίσκεψής μας
Το Δεμίρ Ισάρ είχε μόλις 1 (H) περιπτώσεις πυρετού με
10 θάνατοους*.
Με την εργασία που πραγματοποιήθηκε στις Σέρρες, το μερίδιο του Αμερικάνικου
Ερυθρού Σταυρού στην αντι-τυφου εκστρατεία στη Μακεδοδία τελείωσε. Δεν υπάρχει πλέον πυρετός τυφού στη Καβάλα, δεν υπάρχει πλέον πυρετός τυφου στη Δράμα, μόνο μερικές περιπτώσεις στη Σέρρεςκαι, όπως ακούμε, δεν υπάρχουν καθόλου στο Δεμίρ Ισάρ.
* Βλ. Διάγραμμα 4, σελ. 29, για την πορεία του τυφού πυρετού στο Δεμίρ Χισάρ. Σημειώστε την ανησυχητική αύξηση των περιπτώσεων κατά τη διάρκεια, τον Μάρτιο,
κατά τη διάρκεια του οποίου αποφασίστηκε να βελτιωθεί η κατάσταση τυφώδους στη χώρα
τόσο η Ka Βάλλα όσο και η Δράμα. Οι αρχές του Δεμίρ Ισάρ
ισχυρίστηκαν ότι σχεδόν όλα τα νέα κρούσματα τυφοειδούς πυρετού συμβαίνουν
Δεμίρ Ισάρ κατά τη διάρκεια του πρώτου μέρους του Μαρτίου βρέθηκαν μεταξύ των
οι πρόσφυγες που έστειλαν εκεί με τα πιστοποιητικά υγείας των υγειονομικών πιστοποιητικών Καβάλας
-------
Όλο το βιβλίο στα αγγλικά
GIFT OF
Prof .Deutsch
THE AMERICAN RED CROSS
COMMISSION TO GREECE
THE TYPHUS EPIDEMIC ΙΝ EASTERN MACEDONIA
BY MAJOR SAMUEL J. WALKER, M. D.,
DEPUTY COMMISSIONER
HEAD OF THE DEPARTMENT OF MEDICINE AND SANITATION
Athens
June /, 1919
ATHENS
PRINTED BY P. D. SAKELLARIOS
1919
THE AMERICAN RED CROSS
COMMISSION TO GREECE
TH E TYPH US EPIDEMIC IN EASTERN MACEDONIA
BY MAJOR SAMUEL J. WALKER, M. D.,
DEPUTY COMMISSIONER
HEAD OF THE DEPARTMENT OF MEDICINE AND SANITATION
ATHENS
PRINTED BY P. D. SAKELLARIOS 1919
Athens, June 1, 1919,
From : Major Samuel J. Walker, Deputy Commissioner,
Head of the Department of Medicine and Sani-
tation.
To: Lietttenant- Colonel Rdtvard. Capps , Commis-
sioner.
Subject: Typhus Fever in Oriental Macedonia and
The American Red Cross.
INTRODUCTION
Burdened with all the misery that human flesh is heir
to, the Greek refugees from Bulgaria began to pour into
Oriental Macedonia shortly after the declaration of the
armistice, and the stream continued through the fall and
winter of UU8 and through January 11M9, since which time
they have continued to come, but in gradually diminishing
numbers.
They came by thousands, cold, hungry, thirsty, filthy
and vermin -infested from a country lousy with typhus
fe.ver; they suffered such frightful privations that many
died by the wayside.
Human wretchedness in all its protean varieties affec-
ting large groups of peo|>le blazes the way for the spread
of disease. No wonder, therefore, that typhus fever ap-
peared in sporadic form in Ka valla, Drama, Serres, Demir
Hissar and a few other smaller centers through January,
1918, and 'continued to smoulder in these centers through
January, U>19; the wonder is that the disease did not
assume epidemic form iiiuch earlier than it did . All the
conditions necessary for the rapid spread of the disease
were j)resent; potentially there was an epidemic of typhus
fever in Oriental Macedonia long before it appeared.
It is interesting to note here that on January 17, 1919,
your Medical Director held a long conversation with a
prominent Greek Army official directly concerned with
Macedonian affairs. This conversation was solicited by your
Director solely to discuss the typhus situation in Macedo-
nia, which in his opinion showed distinct mutterings of
impending trouble. He was reassured, however, by this
official, who stated that all necessary measures were being-
taken by the Greek sanitary officers, and that in their
opinion there was no danger of an epidemic. Later inves-
tigations revealed, however, that the «nev'iessary measures »
had not really been taken, and at the time referred to the
sanitary authorities had been by no means alive to the
situation.
The time to control an epidemic is in the pre-epidemic
stage. This is especially true of typhus fever, because,
given proper organization and equipment, typhus fever,
even in epidemic form, can easily and surely be controlled,
and naturally in the pre-epidemic stage more easily and
more quickly stamped out.
On January 25 and 26, 1919, kindling was added to
the smouldering typhus situation in Oriental Macedonia by
the arrival at Kavalla of three Greek ships from Varna
bearing 2150 Greek refugees, and among them twenty -one
cases of typhus fever. The local authorities seem unfortu-
nately not to have appreciated the conditions thus con-
fronting them and missed the opportunity thrust upon
them of stamping out the disease.
Not until February 25th did the Greek authorities
awake to the seriousness of the situation, when they reor-
ganized and greatly strengthened the force of inspectors,
with the result that on that date and the four following
days 252 cases of typhus fever were officially uncovered
among the refugees who had landed at Ka valla on Jan-
uary 25 and 26.
This alarming news was wired to the headquarters in
Athens of the American Red Cross Comission to Greece
by Major Horace S. Oakley, at that time our representa-
tive in Macedonia. The Commission immediately went into
conference. The situation which confronted us was this:
If the disease could immediately be brought under con-
trol, so that the lives of our workers, who to the number
of about thirty-five were administering relief to the war-
sufferers of that region, would not be increasingly and
unnecessarily exposed, our workers would be allowed to
remain at their posts; otherwise we should be obliged to
withdraw our forces from Eastern Macedonia. We natu-
rally proposed the former alternative, which, however,
presupposed that the Greek authorities would welcome
our participation in the anti-typhus fight and would ac-
cord our Medical Department such a degree of support
and authority as would reasonably insure the safety of
our workers and the success of the enterprise as a whole.
Several conversations were then held with Mr. Athanasaki,
Under-Secretary of State for War, in charge of Hygiene
and Sanitation, in which we offered the Greek Govern-
ment our fullest cooperation in medical personnel and
supplies to help combat the typhus fever epidemic- in Ka-
valla and Oriental Macedonia.
Mr Athanasaki accepted the offer in the spirit in which
it was made and did everything in his power to prepare
and smooth the way for the participation of the American
Red Cross in the anti- typhus campaign. To meet the emer-
gency an American Red Cross medical unit was organized
consisting of Major Samuel J. Walker and four other phy-
sicians, namely, Captain Paul D. White and Lieutenants
D. S. Clark, C. A. L. Binger, and J. S. Hodgson. With
6
them was associated Mr. B. H. Hill. Director of the Amer-
ican School in Athens, who volunteered to accompany
the unit and to act as its interpreter and diplomat. The
first contingent of this unit, consisting of Major Walker
and Mr. Hill, was rushed to Ka valla by special boat, the
Submarine Chaser No. 248 U. S. N., leaving Piraeus March
2nd and arriving at Kavalla March 4th.
Fig. 1. — May 67' Typhiis Hospital, Kavalla.
KAVALLA
Preliminary Observations and Investigations.
Kavalla has a population of 1H000 (correct figures from
a recent census) and is easily the most important city of
Oriental Macedonia. The principal industry is the sorting,
curing and shipping of the finest grades of cigarette to-
bacco; the city is full of huge tobacco warehouses largely
operated by American interests.
^ We arrived in Kavalla March 4th, beset by many ru-
mors as to the actual number of typhus cases in the city.
Mr. Athanasaki, on February 27th, had official telegraphic
inforipation that the total number of cases was eighty;
another well-informed source stated the number to be six
hundred; still another rumor placed the total number of
cases as something over one thousand. As a matter of
fact there were, on March 6th, two hundred and seventy-
six cases of typhus fever in the Kavalla hospirtals; of this
number ten were soldiers, eight nurses, three doctors and
twenty civilians, thus showing that the disease had assumed
epidemic form outside the refugee ranks.
After several satisfactory conversations with General
Negroponte, ranking army officer of the Kavalla district,
and his chief medical officer Colonel Kourtakis, we began
our preliminary observations and investigations.
Under the guidance of Colonel Kourtakis the following
facts were uncovered: —
1. The refugees arriving at Kavalla January 25 and 26,
2150 in number (every one of whom had been directly or
indirectly exposed to typhus fever), had been huddled
together in eight large tobacco warehouses (hereinafter
to be called «barracks») under lax quarantine regulations
and lax medical inspections, as was plainly evidenced by
the explosive outburst of 252 cases of typhus in five days,
when the figures for the entire week previous to these
momentous five days showed only eight cases. It is simply
impossible for such discrepancies in figures to occur in
any epidemic under efficient daily medical inspections. In
other words, most of those 252 bases were present many
days in the refugee barracks before they were properly
diagnosed and isolated.
Under the circumstances it is difficult to understand
how these poor refugees, after such thorough exposure to
typhus fever, escaped as well as they did. The most rea-
sonable explanation seems to be that probablj' many^iof
them had ah^eady had typhus fever and were therefore
typhus - immune.
2. Some days after the arrival of these 2150 refugees
at Kavalla the authorities began systematically to delouse
them at the rate of about 200 per day ; after being de-
loused^ they were placed in so-called clean » barracks,
where they were held in quarantine for '2\ days; they
Fig. 2. — Refugees leaving Kavalla, affe?' haviin/ hct'ii
deloiised aiid qitaraufined .
were then given clean -bill -of -health certificates by the
civil sanitary authorities, and sent to Drama, Serres and
Demir Hissar with orders to report to the sanitary au-
thorities of these cities. All of this sounds like a perfectly
good arrangement and would have been so had the Ka-
valla authorities done their work efficiently, but unfortu-
nately they failed in two most vital particulars. It was
the same old story: both the quarantine and the medical
inspection of the refugees in the clean barracks were
inefficient, the result being that many ol" these refugees
from Ka valla cai-ried typhus fever, alon.^r with their elean-
bill-of-health certificates, into Drama, Serres and Demir
Hissar. In Serres it was no uncommon occurrence for the
refugees, already victims of typhus fever, to present them-
selves to the sanitary authorities at the same time clutch-
ing Kavalla clean-bill-of-health certificates in their hands —
a situation ahnost amusing if it were not so sad and tragic.
This indiscriminate sending forth of hundreds of refu-
gees from Kavalla without previous proper medical inspec-
Fig. S. — Typhus Ward in Mayer H()sj)ifa/, Kavalla.
tion was decidedly, in the opinion of your Medical Direc-
tor, the most criticisable single act of the Greek sanitary
authorities in their management of the typhus situation
in Oriental Macedonia. It undoubtedly had much to do
with the putting of typhus fever on an epidemic basis in
the centers outside of Kavalla.
o. The city of Kavalla had l)een divided into seven san-
itary sections, the medieval responsibility for these sections
being about equally divided botw'oen the militai*y author-
ities Q\} the one hand and the civil authorities on the
10
other hand. A sanitary committee, consisting of one phy-
sician, one civilian and one police inspector, was appointed
for each section and held responsible for the daily medi-
cal inspection of the inhabitants' of that section, in order
that no case of typhus fever or typhus suspect might
remain undiagnosed or hidden.
The usual regulations for reporting and after-handling
of all cases were used, proved typhus cases, typhus sus-
pects, and those exposed to typhus being quarantined or
isolated as their status demanded.
4. The typhus equipment in Kavalla was good and
sufficient, consisting of —
a. The Mayer Hospital (until February 25, 1919, the main
military hospital for the Kavalla district) for refugee
and civilian typhus cases ; accomodations for 400 patients.
b. The Military Hospital (until February 25, 1919, the
Officers' Hospital for the Kavalla District) for officer and
soldier typhus cases; accomodations for 40 patients.
c. The Kolakitha Hospital (just opened) for well-to do
civilian typhus cases; accomodations for 25 patients. All
the above hospitals were equipped with separate delousing
plants for the patients and their clothes.
d. One large house for quarantining families of typhus
patients; practically impossible to operate efficiently; closed
early in March.
e. One military delousing plant, an old Turkish bath,
well arranged and capable of delousing about ;J0() persons
and their clothing daily.
f. One civil delousing plant, an old Turkish bath, also
well arranged and capable of delousing about 400 persons
and their clothing each day. The Serbian barrel system
was used in all the delousing plants in Kavalla for the
disinfecting of clothing.
g. One so-called « clean » barracks for quartering the
11
deloused refugees, sufficient for the very indifferent hous-
ing of about 1200 refugees.
5. Colonel Kourtakis informed us that the medical
control and inspection of the refugees in the barracks was
vested in the civil authorities until February 25, on which
Fig. 4. — MUitary Typhns Hospital, Kavalla.
date the military sanitary authorities took over the medi-
cal control of the refugees; and that the military medical
inspectors uncovered the 252 cases of typhus fever found
in the barracks on February 2b and the four following days.
These preliminary observations and investigations
brought to light two most important and outstanding facts;
12
first, that there had been in the Greek anti - typhus
organization a division of authority and responsibility —
a situation intolerable in the management of any epidemic
and always invil;ing failure; second, that as a consequence
of this fundamental weakness in their organization the
sanitary authorities were almost flagrantly inefficient down
to the time of the explosive outbreak in February, this
inefficiency continuhig, but to a very much lesser degree
for some time thereafter.
Plans for the participation of the Anieriean Red Cross
in the anti -typhus fight.
The American Red Cross medical unit plainly had
important functions to perform; therefore on Sunday,
March 9, armed with the facts as above outlined, we had
a conference with General Negroponle and his chief med-
ical officer, Colonel Kourtakis. At this conference it was
arranged that henceforth all the authority and i*esponsi-
bility for the management of the epidemic should rest hi
one person, Colonel Kourtakis, which arrangement formed
at least the nucleus, and the nucleus fundamentally neces-
sary, of an efficient oi'ganization. Next, a plan for the
participation of the American Red Cross in the Ka valla
anti-typhus, campaign was formulated. The plan adopted,
briefly outlined, provided for the following program:
1. A daily conference between the Chief of the Greek
anti- typhus organization and the American Red Cross
medical officers.
2. Daily inspections and investigations of the typhus
field in Kavalla by the American Red Cross medical of-
ficers, these inspections and investigations to have the
fullest cooperation of the Greek sanitary officers.
H. The results^ of these inspections and investigations in
13
the form of suggestions and recommendations to be pre-
sented each day at the conference.
4. All suggestions and recommendations made by the
American Red Cross medical unit to receive the utmost
consideration from the Greek sanitary authorities, and to
be carried out as soon as possible.
5. The program, as outlined, to go into effect immediately.
A conference was held on the same day and was- at-
tended by the entire American Red Cross medical unit,
3» -^.
'ni
i I /i
wM * ; 'fl^^ir ^^E^B i^E
Fig. 5.— Rich Mans Typhus Hospital, Ka valla.
the second contingent having arrived in Kavalla by this
time; present at this conference were Major Walker, Mr.
Hill, Captain White, Lieutenants Dinger, Clark and Hodgson,
also Major Roger Perkins of the Balkan Commission. At
this conference the plan above outlined was presented
and agreed upon as a good working basis for the partic-
ipation of the American Red Cross in the anti- typhus
campaign in Kavalla.
The above embodies the data obtained and the work
accompHshed by the first contingent of the American Red
14
Cross medical unit, and prepared the way for our active
cooperation.
Active work.
Exactly according to program, we began our work the
next day, March K); it took the form of independent in-
spections of the delousing plants, and the methods used
therein, by Lieutenants Binger and Hodgson, and obser-
vations of the medical inspections in the different city
sections by Captain White and Lieutenant Clark.
After two days of such inspections and obervations
sufficient data were collected to justify the following con-
clusions :
The delousing plants: That the apparatus was ade-
quate, and that the plants on the whole were working
fairly well; that, however, numerous errors of technique
prevailed — errors which materially vitiated the final results
of the disinfecting process. Therefore we presented to
Colonel Kourtakis definite recommendations, the adoption
of which we believed would distinctly improve the disin-
fecting technique. Our recommendations were well received
and we were immediately given the authority necessary
to carry out our recommendations.
The medical inspections: That the Greek medical in-
spection of the city sections was well organized and was
of much value so far as it went; it was not adequate
because some of the sections were so large that two or
even three days were required for the doctors to cover
them. Now these daily inspections of all the houses in
each section were extremely important, in our opinion,
and necessary to bring about the best results in the anti-
typhus campaign. We therefore recommended to Colonel
Kourtakis that the number of sections, and necessarily
also the number of medical inspectors, be increased from
seven to twelve, and that Kavalla be redistricted accord-
15
ingiy, the American Red Cross agreeing to take over
four of the new sections. This recommendation was en-
thusiastically received and immediately orders were given
to carry out the recommendations.
Colonel Kanavatsoglou, Surgeon-General of the Greek
Army and the medical head of all typhus work in Mace-
donia, arrived in Kavalla March 11, bringing with him
Lieutenant Moutoussis, chief epidemiologist of the Greek
Army. Colonel Kanavatsoglou, an unusually able and ef-
Fig. 6. — Waitijig to be Delov^ed, Kavalla.
ficient leader, made careful inspections of the whole typhus
situation in the city and subsequently very materially
strengthened the Kavalla typhus organization.
With the changes which had been made in the delous-
ing plants working smoothly, with the increased number
of city sections in operation, and with the stimulus given
to the whole organization by the presence of Colonel
Kanavatsoglou, the anti-typhus campaign in Kavalla was
on in earnest.
The organization at this time was made up of twenty-
16
three physicians, including our own unit, all devoting their
entire time to typhus work.
On March 17 Lieutenant Moutoussis, the epidemiologist,
was placed in command by Colonel Kanavatsoglou of all
typhus work in Kavalla, as Colonel Kourtakis was leavhig
for duty in Russia. Lieutenant Moutoussis proved to be
an able and efficient commander, and still further system-
atized the organization.
Fiy. 7. — Deloiising Plant (Old Tiirkish Bath), Kavalla.
Daily evening conferences were held, attended by all
the medical typhus workers. At each conference written
and oral reports were submitted, which formed the basis
for the Kavalla typhus fever statistics. These statistics
showed for each day:
1. The number of new typhus cases found;
2. The number of typhus suspects found ;
3. The number and location of quarantined houses ;
4. The number of persons deloused ;
o. The total number of typhus cases in hospital, clas-
sified as to whether civilian, refugee, soldier or officer;
17
6. The number of deaths.
In addition the conference served to bring out sug-
gestions and led to an exchange of views, thus stimulat-
ing the work of every one.
Another factor which contributed materially to the sit-
uation was the great good - feeling always existing be-
Fig. 8. — (Woup of Typhus Doctm^s, Kavalla.
tweeii our medical officers and the Greek medical officers.
We admired the Greeks and their work and the Greeks
reciprocated, plainly showing their appreciation of our
work and help.
Results.
Good results just had to follow such radical improve-
ments, and they immediately became evident, as reference
to the graphic chart* plainly indicates.
* Chart No 1, p. 18. Note the explosive outburst of cases from Feb-
ruary 25 to March 1 inclusive ; also that all cases charted from April
16 to 30 inclusive came from Kalamitza Camp; i. e., no new cases of
tyj3hus fever were found in Kavalla during this period.
18
6
o
19
Briefly summarized, the number of new typhus cases
uncovered in Ka valla, from February 19 to April 1 inclus-
ive, was 398; this period of six weeks includes the statis-
tics of the two weeks i^revious to our arrival and the four
weeks of our active work in Kavalla. Divided into weeks
the figures are as follows :
Feb. 19 to Feb. 25 . . . 135
Feb. 26 to March 4 ... 139
March 5 to March 11 . . . 52
March 12 to March is . . . 46
March 19 to March 25 ... 20
March 2H to April 1 . . . 14
The above figures speak for themselves and show con-
clusively the almost brilliant results obtainable given good
organization and adequate equipment. Such results, brought
about in such a short time, were a source of great satis-
faction and pride to all concerned.
This marked decrease in the Kavalla epidemic, and the
excellence of the Greek organization, made it seem no
longer necessary for the American Red Cross to continue
its full cooperation in Kavalla, especially as typhus con-
ditions in Drama and Serres were distinctly worse than
in Kavalla.
Therefore on April 2nd it was decided to send Captain
White and Lieutenant Hodgson to Drama to study the
typhus situation in that city; Lieutenant Binger was to
remain in Kavalla to carry on, at the earnest request of
Lieutenant Moutoussis. Lieutenant Clark left Kavalla at this
time to return to America.
New Danger for Kavalla.
Before passhig on to Drama, however, mention must
be made of what seemed at first blush like a startling-
situation,
20
On April 8 a shipload of refugees arrived unannounced
in Kavalla harbor. Rumors had reached Kavalla that more
refugees were coming, but nothing definite was known as
to their numbers or time of arrival. The ship contained
700 Greek refugees from Constanza and Varna, among them
5 certain cases of typhus fever and 31 suspects, all of
whom were removed to the typhus hospital in Kavalla.
The rest of the exposed refugees were kept on board the
-T-^-
" VHT
1
"SB
m
M':ft
U^
"^^1
1 1|y
Jk
*
i
m
1 ft
^li^l
I
1^
1
s
m
M
1
1
1
Fig, 9.— Serbian Disinfecting Barrels, in full operation, Kavalla.
ship, in quarantine and not removed until complete pro-
vision had been made for their isolation and care.
The situation was the exact counterpart of the tragic
landing of the 2150 refugees at Kavalla on January 25,
fraught with such disastrous results already so feelingly
referred to.
The way these 700 fresh refugees were handled, how-
ever, brilliantly illustrates what a really good typhus organ-
ization can do in an emergency. The news that more
refugees were coming, although absolutely indefinite as to
nun^ber and time of arrival, was nevertheless c[uite suf-
21
ficient to bring about active preparation for their recep-
tion, and consequently, when they did arrive^ unannoun-
ced, the typhus organization was ready for them.
An excellent site for a quarantine camp had been found
and equipped on a point of land called Kalamitza, just
west of Kavalla. The equipment of this camp was splen-
didly good and complete, consisting of sufficient small tents
to accomodate all the refugees in groups of not more than
5 or H in each tent; several large hospital tents sufficient
Fig. 10. ~ Kalamitza Refugee Quarantine Camp, Kavalla.
to care for 60 patients with diseases other than typhus ;
an excellent emergency delousing plant (sufficient to de-
louse 300 persons and their clothes daily), consisting of
well arranged shower-baths and a series of eight Serbian
barrels, all new equipment put into an old house already
on the grounds; also numerous tents for attendants and
a fine kitchen kept scrupulously clean. The camp was
strictly policed, and all danger of spreading typhus fever
in Kavalla from this camp practically eliminated.
The first lot of refugees were taken from their quar-
o-^
antined ship to this quarantine camp on April 12, since
which time, to May 1, »-)8 cases of typhus have appeared
in the camp; but during this same period, April 12 to May
1, not a single new case of typhus fever has heen found
in Kavalla. Moreover, all the refugees in this camp have
been vaccinated against typhoid and paratyphoid, the
American Red Cross donating the vaccine for the purpose,
also against small pox, the Greek Government furnishing
the vaccine. It was an ideal camp, ideally located and
Fig. 11. — Another view, K(il(iinitz(( ('amj>.
extremely well managed, and furnishing a beautiful exam-
ple of what a good, brainy organization can do.
In the opinion of your Medical Director, had the 2150
refugees of Jaiuiary 2;') and 2(5 been handled in anything
like the above manner, this report would never have
been written.
As already stated, the typhus situation in Kavalla had
improved so markedly by April 2nd that on that day it
was decided partially to ^^baudon Kavalla and proceed
to Drama,
n
D R A M A
Drama is the capital of Oriental Macedonia and has
a population of not more than 24000, about one third of
whom are Turks.
On March 29 your Medical Director had a conference
with Mr. Gotsis, the Governor -General of Oriental Mace-
Fig, 12.— Typhus Sentinel Post, Kavalla- Drama Road.
donia and Lieutenant Kyriazides, an able and experienced
epidemiologist and the chief of the typhus campaign in
Drama. At this conference the whole typhus situation in
Oriental Macedonia was discussed and arrangements made
for the co-operation of the American Red Cross in the
typhus campaign in Drama along lines similar to those of
the work in Kavalla. On April :> Captain White and Lieu-
tenant Hodgson arrived in Drama to begin their inves-
tigations in that city.
The American Red Cross work in Drama opened under
24
the most favorable auspices. Several conferences were
held with Colonel Kanavatsoglou, who fortunately hap-^
pened to be in Drama at that time, Lieutenant Kyriazides
and Lieutenant Moutoussis; under the guidance of the
above-named Greek medical officers an inspection of the
Drama typhus equipment was made. Later a special study
of the delousing stations was made and recommendations
offered for necessary improvements in technique; also thor-
ough inspections of several of the Drama typhus districts
were made to study the routine and methods used in the
daily district inspections. Our officers also attended the
daily evening conferences of the Drama anti-typhus organ-
ization.
The result of these investigations and obserA^ations
made obvious these facts :
1. That the typhus epidemic in Drama was not severe,
there being few cases among the natives at any time, the
vast majority of cases being among the refugees with a
moderate number among the soldiers.
2. That the typhus organization at Drama was good,
though not so good as the Kavalla organization, but that
it could quickly and. easily be made so.
These investigations also unearthed the very inter-
esting fact that there had been a severe typhus fever epi-
demic in Drama during the Bulgarian occupation in the
winter of 1917-18. The epidemic began early in December,
1917, and lasted until June, 1918; there were about 500(>
cases in all with 20(K> deaths. For a community of less
than U)0(X> people this was an excessive morbidity and
also an excessive mortality rate, thus stamping the epi
demic as severe in extent and type. The disease spread
into Kavalla the latter part of December, 1917, and soon
prevailed in epidemic form in that city; the total number
of cases in Kavalla during the winter of 1917-1918 was
about KXKl with I2f) deaths,
25
It is very important to note tliat the mildness of the
present typhus epidemic in Oriental Macedonia is proba-
bly due to this severe epidemic of 1917-18, as the number
of typhus immunes in both Drama and Kavalla must nec-
essarily have been large at the outbreak of the present
epidemic *.
Fie/. lS.~-Ty2)hiis Hospital, Dranid.
On account of the above findings, and with the advice
of Colonel Kanavatsoglou, it was decided to be best for the
American Red Cross medical officers to leave Drama and
move on to Serres, where conditions had been and were
at that time unsatisfactory.
■ See Chart No 2, p. 18, for the history of the typhus epidemic at
Drama in 1919.
^M
S E R R E S
Before the Balkan Wars Serres was a prosperous to-
bacco and sheep center and had a population of 25000.
It was sadly devastated by the Bulgarians during the
Second Balkan War in 191^; and now has hardly liooii
inhabitants.
Fiy. 14.-~Refugee Quarantine Camp, Diama.
The typhus campaign in Serres was not being well
handled.
Your Medical Director had had abundant opportunity
during the last two weeks in March to study the typhus
situation in Serres. His investigations and observations
brought out the following facts.
I. That the physical typhus equipment in Serres was
adequate, in fact better in many resi)ects tlian that of
either Kavalla or Drama, consisting of:
a. An excellent typh\is hospital with tents sufficient
'21
to care for 14() patients. To this hospital all typhus patients
were sent, refugees, civilians rich and poor, soldiers and
officers — a system much more desirable than having three
separate hospitals for different classes of people as in
Kavalla. One liospital for all classes economizes medical
and nursing care as well as all other hospital work and
in addition minimizes the danger of spreading infection,
which of course is a big item always to be considered.
-.^^^
•
li^PIt'- ■:;;»rji
f^^
i^-^mm^^^
'^u^*-
Fig. 15. — Delousiny Plant on Kavalla Ro(t(l, Drama.
b. A convalescent hospital, well equipped to care for
40 patients.
c. Three detention camps situated at the three en-
trances to the city, one on the Salonica road, one at the
railroad station, and the third on the road leading to the
villages east and north of the city. Each detention camp
has its own delousing plant. Before being allowed into
the city all refugees as well as other suspicious persons
were deloused at one or the other of these detention camps
and afterwards held there in quarantine for fifteen days.
d. A central delousing plant, a fine old Turkish bath,
i}8
well arranged and capable of disinfecting 400 persons with
their clothing daily.
:>. That the anti-typhus organization in Serres was
sadly inefficient, this inefficiency being partly due to the
fact that the authority foi* the management of the campaign
did not rest securely in one person; inefficient too be-
cause the ostensible head of the organization was not an
experienced epidemiologist. It is veritably impossible to
manage any epidemic successfully with the above con-
ditions prevailing in the organization.
Consequently the population of Serres suffered unduly
from typhus fever an(|[ij "fj^^^^^^^ would continue to
suffer unduly just so long as theii* typhus organization
remained so fundamentally faulty*.
Our Medical Officers in Serres.
Such were the conditions confronting our medical of-
ficers, Captain White and Lieutenant Hodgson, when they
arrived in Serres on April 11. Plainly there was much
work mapped out for them in their new station. They
followed pretty much the same program as already carried
out so successfully in Kavalla and Drama - careful in-
spections of delousing plants and medical inspections of
the different city sections, followed by suggestions and
recommendations.
Later two city sections were turned over to them, each
with a full corps of assistants, and they took over the
responsibility for the daily medical inspections of these
sections.
* See Chart No 3, p. 29, showing the course of the typhus fever at
Serres. Note the marked increase in cases during March and the first
week of April; during this same period of time typhus conditions in
both Kavalla and Drama had distinctly improved.
29
o
X
QC
30
Of course this was useful work, but no radical im
provemeiit in the Serres typhus work could be expected
until the \vhole typhus organization was overhauled and
renovated.
That the people of Serres did not have complete faith
in their organization, not even in their American doctor,
is shown by the following interesting quotation from
Captain White's report. « Yesterday an interesting religious
procession chanted its way through my section to scare
Fig. 16. -Typhus Hospital, Serres.
away the pestilence of typhus. Boys bearing holy banners
and relics, priests in their I'ohes and ci'owds of people
bearing lighted candles trudged along in broad daylight .
After exas[)erating delay, the much desired reorgani-
zation finally took place. An entirely new typhus organi
zation was formed at a meeting held on April 2Hrd,
attended by the Nomarch, Colonel Kanavatsogiou, doctors,
priests and school teachers. At this meeting I.ieutenant
Kyriazides, an expert epidemiologist, was definitely placed
in charge of the Serres campaign by (^olonej Kanavatso-
31
glou, thus replacing- the old regime under which things
had gone so laxly and badly. Our representations to Col-
onel Kanavatsoglou had had much to do with bringing
about this all-important move.
From now on the situation began to improve; there
was however a considerable increase of cases during the
first week in May, due, in the opinion of our medical
officer, to the careless work done by the officials during
^^^•i^l^
'i'^<
1?!^
Fig. 17. — Captain White's Inspection Group for
Section J, Serves.
the four Easter holidays, April is to 21 inclusive, some
of them ueglecting their inspections almost entirely.
A good idea of the undiscipline prevailing hi the Serres
organization may be had by noting that one physician
was penalized to two weeks' confinement for failure to
report a dying typhus case, and other penalties are pend-
ing for two other physicians for failure to report cases.
The latest report from Serres shows the typhus situa-
tion in that city to be at last quite satisfactory, and our
medical officers confidently feel that by the end of May
32
at thp latest the epidemic of typhus fever in Serres will
have been entirely wiped out.
On account of this decided improvement in the typhus
situation in Serres there seemed to be no longer need for
our cooperation; therefore on May 27th our medical offi-
cers ceased work in the citj'^ of Serres.
On March 2o your Medical Director accompanied by
Lieutenant Kyriazides made a flying visit to Demir Hissar,
a picturesque little city of (30(X) inhabitants, situated on
the Struma River and about 'M) kilometers from Serres.
We found the same old story — sufficient. equipment, but
poor, — very poor, — organization, in fact easily the worst
anti-typhus organization we had so far seen in Macedonia.
In consequence this beautiful little city was also suffering
unduly from typhus fever. Up to the time of our visit
Demir Hissar had had just 1(H) cases of the fever with
10 deaths*.
With the work in Serres over, the share of the Amer-
ican Red Cross in the anti-ty[>hus campaign in Oriental
Macedodia ended. There is no more typhus fever in Ka-
valla, no more typhus fever in Drama, only very occas-
ional cases hi Serres, and, as we hear, none at all in
Demir Hissar.
•^
* See Chart No 4, p. 29, for the course of typhus fever at Demir
Hissar. Note the alarming increase of cases during, the month of March,
during whicli month decided improvement in the typhus situation in
both Ka valla and Drama had taken place. The Demir Hissar authorities
claimed that practically all the new cases of typhus fever occurrnig in
Demir Hissar during the first part of March were found among the
refugees sent there with clean- bill -of-health certificates fronj Kavaila-
GENERAL COMMENTS
I. The total luimber of typhus (mses occuiTing in Orien-
tal Macedonia in the four most important centers of in-
fection foi- the period from January 1, 1919, to May 1,
1919, which period practically covers the whole life of the
epidemic, was K-^IS with 168 deaths, making- the average
mortality rate for the epidemic 12.74 ^fl-
it may be interesting to note the following division of
the statistics :
Place
Total Cases
Total Deaths
Mortality Rate
Kavalla
(>47
86
18.29%
Drama
222
28
12.60%
Serres
310
42
18.55 7o
Demir Hissar
139
12
XM Vo
181 s
168
12.74 %,
Therefore it will be seen that the epidemic of typhus
fever in Oriental Macedonia in the winter and spring of
1919 was not severe either in extent or type.
2. The sanitary authorities were notoriously lax and
negligent in the measures taken to control the epidemic
in its early stages; in some instances their methods really
encouraged rather than checked the epidemic. Not until
February 25th and after did the authorities adopt anything
like proper methods to control the epidemic, and then
only in Kavalla; in othei' places much later; in Serres
for instance not until April 28rd was an efficient anti-
typhus organization formed.
8. The Greek anti- typhus organizations as finally for-
med were model and efficient bodies. The Greek medical
officers are exceedingly well-trained men and entirely
u
competent to handle properly important public healtli
problems.
4. The co-operation of the American Red Cross with
the Greek authorities in the anti- typhus campaign in
Oriental Macedonia was satisfactory from every point of
view. The plan of co-operation worked smoothly and well,
and can be urgently recommended for similar situations.
The part played by the American Red Cross in helping
Fig. 18.— Typhus Cotnmanders for Oriental Macedonia: left to right,
Lieiitenant Kyriazides, Colonel Kanavatsoglou, Colonel
Schultze, and Liente7iant Montoussis.
to control the epidemic was well worth while: we brought
to the Greeks both morale and intrinsic service.
5. We gave the Greeks much advice, a commodity not
usually highly appreciated, especially when given often
and free; in addition, however, the American Red Cross
(contributed the following supplies, all directly concerned
with the typhus situation: for the Mayer hospital, Kavalla,
830 hospital bed -shirts, 1000 pairs socks, 450 mens' flannel
shirts, 4(K) mens' drawers and 500 mens' undershirts; also
^'i
3fe
ion typhus blouses for the doctors, nurses and attendants
in the Ka valla hospitals and delousing stations. We also
furnished all the bread used at the Kalamitza camp, the
tent quarantine camp, for the 700 refugees arriving April 8;
this distribution began on April 12 and continued until
May ;)0. Two large tents were contributed by us to this
camp. In Drama typhus blouses were provided for the
doctors, nurses and attendants in the Drama hospitals and
delousing stations. All this, taken altogetlier, was not a
large contribution, but it helped.
SPECIAL AND FfNAL COiMMENT
The entire personnel of the American Red Gross in
Oriental Macedonia conducted themselves splendidly during
the whole period of the epidemic. Facing an epidemic of
a strange disease in a strange land is no laughing matter,
yet our personnel to each man, to each woman, showing
not the slightest fear, the slightest panic, remained on
duty, faithfully performing their unselfish work of carry-
ing relief to the sick and needy, just as if no such thing
as typhus fever existed.
Such faithfulness, such fortitude, came high, and unfor-
tunately the price was exacted; one after another five
American Red Gross workers in Oriental Macedonia were
stricken with typhus fever contracted in the line of duty.
Lieutenant Edward Walker of New York Gity and
Blacksburg, Va., contracted typhus fever in Kavalla and
was taken sick in Drama on February 19. He arrived in
Athens February 2ord, an extremely sick man, in spite of
every care and attention. His condition continued despe-
rate until his death on March 3, 1919.
:J6
Lieutenant Kenneth A. Thomas of Bridgeport, Conn.,
contracted typlius fever in Kavalla and was taken sick in
Kavalla February :?2nd, had a mild type of the disease,
convalesced well and rapidly, and was able to return to
light duty the first part of April.
Miss Clarissa A. Blakeslee of Philadelphia, Pa., con-
tracted typhus fever in Kavalla and was taken sick in
Drama February 21st, had a severe typf* of the disease,
and convalesced satisfactorily.
Miss Florence A. Stone of Plainfield, N. ,]., contracted
typhus fever in Kavalla, and was taken sick in Serres
March 11; she had a severe type of the disease, and is
now in Athens completing her convalescence.
Lieutenant J. H. Hodgson of Boston, Mass., contracted
typhus fever in Serres and was taken sick in Serres
April 26th; he is now in Athens completing his convales-
cence. Lieutenant Hodgson was a member of the American
Red Cross anti-typhus medical unit and undoubtedly con-
tracted the disease as a direct consequence of his daily
association with many typhus cases.
P E K 8 O N A L
I wish to take this opportunity to thank the follow-
ing Greek officials and officers for their unvarying cour-
tesy and kindness to me personally and to the organiza-
tion which 1 represented, the American Red ('ross.
Mr. (xotsis, Governor General of Oriental Macedonia;
General Negroponte, ranking army officer of the Kavalla
District at the time of my arrival in Kavalla; Colonel
Kanavatsoglou, Surgeon -General of the Greek Army
and General Commander of the typhus work in all Mace-
donia; Colonel Kourtakis, Chief M(»dical Offieei* of the
r^'
57
iBth Division, Greek Army; Major Syrichas, Commander
of the typhus organization in Serres ; Lieutenant Mou-
toussis, epidemiologist and Commander of the Greek ty-
phus organization in Kavalia; and Lieutenant Kyriazides,
epidemiologist and Commander of the typhus organization
in Drama and Serres.
Our relations with Colonel Kanavatsoglou, Lieutenant
Moutoussis, Lieutenant Kyriazides and Major Syrichas were
unusually intimate and personal, and I feel that any suc-
cess that attended the efforts of the American lied Cross
medical unit in Oriental Macedonia was largely due to
the splendid personal feeling that existed between these
four men and ourselves. We appreciated them and they
appreciated us; they deserved it from us, and we deser-
ved it from them. This sort of mutual- admiration society
helped tremendously; it made our work easier, pleasanter,
more worth while and undoubtedly more efficient.
For the members of our own medical unit, Captain
White and Lieutenants Binger, Hodgson and Clark, I have
only praise; they did their work in Macedonia faithfully
and well. Such a gi'oup of men would make any organi-
zation a going concern and I wish to thank them for
their loyalty and cooperation throughout the campaign.
Also 1 wish to thank Mr. Hill, Director of the Amer-
ican School at Athens, for his invaluable services as secre-
tary, interpreter, diplomat and adviser to the medical unit.
Finally I wish to thank the trained nurses Miss Hartz,
Miss Martin and Miss Addison for their splendid, self-
sacrificing and skillful nunsing of our personnel sick with
typhus. I saw a great deal of their work and T know
they deserve all the praise being heaped upon them.
38
FINALE
The typhus epidemic in Orieiiial Macedonia is over,
and it will always be a pleasure to be able to look back
and say that the American Red Cross helped to «put it
over> and helped to check the Typhus Fev^er Epidemic
in Oriental Macedonia in the winter and spring of 1919.
(C?^"
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