OF LICE AND MEN

TRENCH FEVER AND TRENCH LIFE IN THE AIF.

By Dr M. G. Miller ©

Trench fever is an unusual disease because it was first discovered in 1915 and reached epidemic proportions on the Western Front, but then suddenly disappeared in 1918 when the war ended. However, during the course of its epidemic, it infected some 800,000 Allied soldiers.^1. It was yet again reported during the 2nd World War, when it affected thousands of German soldiers on the Russian Front, but it is now exceedingly rare. Colonel Butler's Official History of the Australian Army Medical Services describes it as "a disease of squalor" of which more later.

The first description of trench fever was made by Major J. Graham in September 1915. He wrote a short article called "A Note on a Relapsing Febrile Illness of Unknown Origin." ² but the first publication, actually calling the disease "Trench Fever" was by Captain G. H. Hunt and Major A. C. Rankin in October 1915³.

The louse was not recognised as the transmitter (or vector) until after the war, however a paper by McNee, Renshaw and Brent was published in 1916 entitled "Trench Fever: a Relapsing Fever Occurring with the British Forces in France".⁴ This described human experimentation on enlisted volunteers and showed that the disease was transmitted by whole blood and was most likely carried "by one of the common flies or parasites found in the trenches."

Before continuing with a description of Trench fever, a brief description of life in the trenches is necessary in order to comprehend the enormous potential for disease that existed on the Western Front in WW1. The front line trenches were made up in three parallel zigzag lines; the fire trench, the support trench and the reserve, the three lines being joined by communication trenches. The depth of the trenches varied, but they were usually about four or five feet deep, with a built up wall to allow men to stand upright, the fire trenches also had a fire step built into the front wall. Ideally there were duck-boards lying on the bottom to prevent men from sinking into the mud, but these were often lacking, or were disturbed by explosions. Living pits were reinforced by wooden frames and called dugouts, these gave shelter from the elements and shrapnel, but in the British army dugouts were usually reserved for the officers and the senior NCO's. The other ranks dug sleeping holes, or "pozzies", in the rear of the trench, but these were to be later forbidden following a number of cave-ins in the wet weather. The men were then expected to sleep wherever they could. In wet weather they lived under groundsheets or in tents on the bottom of the trench on the duckboards. The living conditions were particularly unpleasant in Flanders during the Battle of Passchendaele (3rd Ypres) because the fighting took place in an area with a high water table that had been originally reclaimed from the sea

The German trenches were very different as they were designed as semi-permanent features that were part of their policy of defence in depth. The Germans constructed deep, shellproof dugouts, sometimes with several levels, and their drainage was better than the Allies because the Germans usually held the higher ground.

Soldiers served varying periods in the front line. On one occasion the Queenslanders served for fifty three days at Villers Bretteneux, but such long periods were exceptional. The usual time spent in the front line was about four days in the front line, four in support, eight in reserve and the rest of the month in rest^5. However the soldiers, during their 'rest' period were still required to form working parties to supply the trenches with rations, water and ammunition.

Whether in the fire trench, the support or the reserve trench, the men had to live, fight, eat, sleep, wash and relieve themselves in a narrow trench which was open to the elements and often flooded for weeks at a time. The forward wall of the fire trench was constantly under enemy observation and any part of a human body that appeared over the top was promptly shot at by snipers. The whole front line system was regularly bombarded by mortars or high explosive shells, and often bombed or machine gunned by enemy aircraft.

This life was bad enough in summer but it is almost impossible to imagine what it was like to live in a waterlogged, or snow and ice filled trench in midwinter for days at a time. Even the lighting of fires was forbidden because the smoke would attract enemy attention and the men could only huddle together for warmth, thus increasing the risk of louse infestation.

Latrines were ideally dug behind the front line trenches, but obviously these could not be used during enemy attacks, and a small pit was usually dug in the front line trench to accommodate the men. As the war progressed, if the trench was demolished by shellfire, dead bodies were incorporated in the repaired trench wall and the stench of putrefaction was added to that of urine and faeces. It needs no imagination to understand what the trench conditions were like after such a trench had been recently shelled! These crowded, squalid conditions, in which the men had to live and fight, were a fertile breeding ground for rats who lived on scraps of food or the corpses. These rats were described as being as big as cats. There were flies in the warm weather, transmitting dysentery, and, of course there were lice.

LOUSE INFESTATION

This was almost universal in the front lines, infestation of the officers and men ran at about 97%. Lice carried the organism that caused trench fever and the very high infestation rate explains why this disease was so common. It is one of the mysteries of the war that the more serious disease of typhus, also carried by lice, was so rare, typhus was prevalent in the Middle East but occurred, in France, only in the few Australians who had been infected before leaving Egypt.

There are three varieties of lice; head lice, or 'nits', (pediculus capitis), pubic lice, or 'crabs', (Phthirius pubis), and body lice, or 'chats' (pediculus corporis). The first two varieties were no more prevalent on the Western Front than they were in civilian life and did not cause significant disease. Body lice, however, were the carriers of trench fever after being infected by feeding on an infected soldier (the host). Spread of lice was from man to man as the lice migrated to nearby hosts. These lice then infected their hosts by feeding on them, or by a lousy soldier scratching dirty skin that had been contaminated by infected louse excreta; the insect's excreta could remain infective for weeks or months.

The louse's migration from man to man was guided solely by a sense of warmth; the spread was measured in terms of space by a few feet, and in terms of time by a few days. Men huddling together for warmth in a cold, wet trench, therefore made an ideal situation for the louse to spread. Body lice have such an association with man that they are unable to live more than a few days without a host, the longest period known being 9 days. Peacock wrote: "They are a parasite which is utterly dependant on man's blood for sustenance and man's body and clothing for prolonged prosperous longevity and reproduction ... They are expert at digging in among the seams of clothing to which lice strongly adhere by hooked claws. Favoured sites are creases at the back of shirts and seams at the fork of breeches" ⁶.

Lice have an enormous capacity for infestation, a heavy infestation could involve literally thousands of insects and thousands of eggs. One pregnant female produces 8-12 eggs a day and the egg to egg cycle can be only 16 days. The egg is firmly attached to the clothing, and to a lesser degree to the body hair. It hatches within three to thirty, or more, days and was resistant to the chemicals available at that time, although the adult was more vulnerable to oily applications that blocked the breathing pores. During the Great War, treatment of lice was by Naphthalene, usually in the form of "NCI" (Naphthalene, Creosote & Iodoform) powder or paste, and lice in the clothes were killed by the use of heat, either by dry heat, or steam.

Unfortunately these heating facilities were not available at the front. Accordingly the soldiers had to attempt to remove the lice as best they could. This removal, a procedure known as "chatting up" was usually by hand, picking out the lice from the clothes, or with the flame from lighted candles run up and down the seams of the clothes. (This was the origin of the verb "to chat" as the soldiers made the removal of their lice into a social event). These attempts at removal, unfortunately, only removed the lice temporarily and did nothing to halt the spread of trench fever because the infectious louse excreta was not sterilised; actual sterilisation of the clothes could only performed by washing in very hot water.

Although Divisional baths were available in the rear lines, with facilities for bathing and cleaning of clothes, the goal was only for a bath every 10 days and even these infrequent baths were not always possible. It must be remembered that the significance of lice, as the vector of trench fever, was unknown during the war, and cleanliness was not a priority in the trenches. This was a major factor contributing to the epidemic.

TRENCH FEVER

Trench fever had a latent period of 8-30 days before a sudden onset. This was with fever, severe headache, pains in the muscles of trunk and leg and characteristic shin pains. Shivering attacks were common and there was a variable short lived pink rash, sometimes lasting only a few hours so that the diagnosis was often confused with influenza.

Graham's description of trench fever refers to a sudden onset of the illness with headache and giddiness, this giddiness was sometimes so severe that the patient would fall down. There was muscular and shin pain, Graham wrote: "...before the pains concentrate in the shins, which they do eventually and give great distress towards evening and into the night, there is usually a sense of stiffness and soreness about the whole of the lower extremities. The lumbar pain sets in early, is severe, and in some cases quite as unbearable as it is in the invasion period of smallpox. ... The exhaustion following the acute stages of this disease is very marked."

A good description of Trench fever is to be found in the 1948 Lord Horder's Encyclopedia of Medical Practice¹. There is an incubation period of 8-30 days before the sudden onset with severe headache, pains in the muscles of trunk and leg and the characteristic shin pains. Shivering attacks were common and there was sometimes a short lived pink rash, sometimes lasting only hours.

The fever was exceedingly variable, but commonly lasted for about five days, (sometimes the illness was called "Five Day Fever"). The fever was followed by a remission and then a recurrence after 5-6 days. These recurrences were single or multiple and up to 12 recurrences every 5 or 6 days were not uncommon. This resulted in a prolonged disability. Unlike typhus, trench fever was fairly benign, the only late complication being a profound, debilitating depression that occurred in the more prolonged attacks.

Treatment was only symptomatic and very little could be done for the sufferers except admission to hospital for nursing care. Although few men, if any, died from the disease, 80% of infected men remained unfit for duty for up to 3 months Trench Fever was usually benign, the main complication was depression and this occurred in the more prolonged attacks, however during 1916 to 1918, 80% of infected men were found to be unfit for duty for 3 months.

After the war, the infective agent was discovered to be a rickettsial infection due to Rickettsia Quintana (so called because trench fever typically had a five day period of fever).

As some 800,000 cases of trench fever were reported during the war, the disease greatly reduced the numbers of soldiers available to fight. Colonel Butler commented that trench fever had "extraordinary epidemic potentialities as a cause of wastage" through non battle casualties, and "During 1917 ... an army of 1,000,000 would lose in a year at least 45,000 casualties from trench fever. Of these casualties, at least 80% would lose on an average, at least three months off duty."⁷ This great 'wastage of men' was very unfortunate from the point of view of the higher command. However, from the men's point of view, it seems that trench fever, with its low mortality, could also be regarded as a very advantageous disease. This was because hospitalisation for trench fever actually saved many thousands of men from the death or maiming that were such a horrific feature of the futile attrition battles of the Somme and Passchendaele.

REFERENCES:

1. Megaw, Sir J. W. D.; 1948; in Encyclopedia of Medical Practice, Second Edition, Ed. Lord Horder:: Vol XII: P. 294.

2. J. Graham: 1915: "A note on a relapsing febrile illness of unknown origin." The Lancet, September 25th.

3. G. H. Hunt and A. C. Rankin; 1915: The Lancet, November 20th.

4. Mc.Nee, Renshaw and Brent, 1916, "Trench Fever: a relapsing fever occurring with the British Forces in France": B.M.J; February 12th: P. 235

5. Winter D., 1978, "Death's Men", Penguin Edition: P. 81.

6. Peacock A. D.; 1940: Quoted in Butler A. C., Official History of the Australian Army Medical Services, Vol. II; P. 572

7. Butler A. C. , 1943; Official History of the Australian Army Medical Services, Vol III:

P. 249.