This paper was first presented at a clinical meeting of the Second Anzac Medical Society held in France in October 1993.
Trench Fever is an unusual disease in that it was first discovered in 1915 and disappeared in 1918 when the war ended. It was again reported during the 2nd World War when it affected the Germans on the Russian Front but it is now a very rare disease, warranting only a single short paragraph in Harrison's 1994 Textbook of Medicine. However, according to the 1948 Edition of Lord Horder's Encyclopedia of Medical Practice, it infected some 800,000 Allied soldiers in the Great War! Butler's Official History of the Australian Army Medical Services describes it as "a disease of squalor" of which more later.
The first clinical description of Trench Fever was made by Major J. Graham in the Lancet of September 25th. 1915. He wrote a short article called "A note on a relapsing febrile illness of unknown origin." but the first publication actually calling the disease "Trench Fever" was by Captain G.H.Hunt and Major A.C.Rankin in the Lancet of November 20th. 1915.
The louse was not recognised as the vector until after the war, a paper by McNee, Renshaw and Brent was published in the B.M.J. of February 12th. 1916 entitled "Trench Fever: a relapsing fever occurring with the British Forces in France" The paper described human experimentation on enlisted volunteers and showed that the disease was transmitted by whole blood, but not by serum, and was most likely carried "by one of the common flies or parasites found in the trenches."
Before continuing with a clinical 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 WWI.
The British Generals on the Western Front had a policy of attack; indeed, it was seriously thought that the soldiers aggressive spirit would be eroded if the trenches were too comfortable! As a result the soldiers had to live, fight, eat, sleep, wash, urinate and defaecate in a narrow trench which was open to the elements, and often flooded for weeks at a time. The men's attempts to dig sleeping holes in the rear of the trench was soon to be forbidden following a number of cave-ins in the wet weather when the occupants of the holes were buried. The men were subsequently expected to sleep wherever they could; in wet weather they lived under groundsheets or tents in the bottom of the trench on duckboards. The forward wall of the trench was often under enemy observation and any part of the body which was poked over the top could promptly be shot at by snipers. The front line was always at risk of being bombarded by mortars or high explosive shells, and could be bombed or machine gunned by enemy aircraft.
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 shell fire, 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 the trench had been recently shelled!
This 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 weeks at a time; even fires were forbidden because the smoke would attract enemy attention and the men could only huddle together for warmth, thus increasing the risk of louse infestation.
These crowded, squalid conditions in which the men had to live and fight were a fertile breeding ground for rats who lived on the bodies, they were described as being as big as cats. There were flies in the warm weather and of course lice.
Louse infestation ran at about 97% and explains why Trench Fever was so common; it is amazing that Typhus was so rare, usually found only in the few Australians who had been infected before leaving Egypt.
The German trenches were quite different as they were designed as semi-permanent features which were part of a policy of defence in depth. The Germans constructed deep, shellproof dugouts, sometimes with two levels, which were usually better drained as they were on the higher ground; however louse infestation and Trench fever affected the Germans just as badly as it affected the British.
Graham's clinical description of Trench Fever refers to a sudden onset with headache and giddiness, sometimes so severe that the patient fell down. There was muscular and shin pain and he 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....I have thought the pain in the left flank might arise from the spleen but I cannot be sure.... the exhaustion following the acute stages of this disease is very marked."
A good clinical description of Trench fever is in the 1948 edition of Horder's Encyclopedia of Medical Practice, published by Butterworth. There is an incubation period of 8-30 days, a sudden onset with severe headache, myalgia, trunk, leg and, characteristic shin pains. Rigors were common. There was sometimes a short lived maculo-papular pink rash, sometimes lasting only hours.
The spleen was usually enlarged. The fever was exceedingly variable, but was usually of a few days, followed by a remission and then relapsed after 5-6 days. Relapses were single or multiple, up to 12 relapses every 5 or 6 days were not uncommon!
Trench Fever was usually benign, the main complication was depression which occurred in the more prolonged attacks but during 1916 to 1918, 80% of infected men were unfit for duty for 3 months
Treatment was only symptomatic but the Encyclopedia of Medical Practice in 1948 stated that antibiotics, tetracyclines or chloramphenicol, would be expected to be effective and this is still likely to be the treatment today. However if any medical man ever comes across a case, Harrison says that because it is so extremely rare, a textbook of Rickettsiology should be consulted for advice on treatment!
The vector for Trench Fever was, of course the body louse, pediculus corporis which became infected by feeding on the blood of infected soldiers; spread was by migration of the louse and infection of the new host by the insect bite or by scratching the skin which was contaminated by the louse excreta. The excreta remained infective for long periods, weeks or months.
It was not until after the war that the infective agent was discovered to be Rickettsia Quintana (so called because Trench Fever typically had a five day period of remission, sometimes it was called 5 day fever.)
Body lice have such an association with man that they are unable to live more than a few days without him, the longest known is 9 days; "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" (A. D. Peacock, referred to in Butler's Official History of the Australian Army Medical Services, 1914 - 1918. Vol ll, p. 572.)
Spread is from man to man by contact and the louse is guided solely by a sense of warmth; the spread is 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 in winter make an ideal situation for the louse to spread. Peacock found that, in 1916, the infestation rate of British soldiers after six months at the front, was 95%.
The louse has an enormous capacity for infestation, one pregnant female on a man produces 8-12 eggs a day and the egg to egg cycle is only 16 days: the egg hatches within 3-30+ days and is resistant to chemicals, although the adult is more vulnerable to oleaginous applications which block the breathing pores. During the great War, treatment was by Naphthalene, usually in the form of NCI (Naphthalene, Creosote & Iodoform) powder or paste, and the clothes were sterilised by the use of heat, either by dry heat, or steam.
Unfortunately these facilities were not available at the front and the soldiers had to attempt to remove the lice as best they could, usually by hand or with lighted candles along the seams of their clothing, a process called "Chatting."
These attempts failed to sterilise the infected louse excreta which could only be removed by washing and heat, but of course the significance of lice as the vector for Trench Fever was not known during the war. Although Division baths were brought up to the rear, the ideal was only for a bath every 10 days and even this was not usually possible, thus contributing to the epidemic. Cleanliness was not a priority in the Somme in winter. Malcolm Brown, in his recent book The Imperial War Museum Book of the Somme, describes how filthy muddy soldiers, offered a bath in their few days rest from the front line, refused the bath because there were no clean clothes to change into!
It has been estimated that 800,000 cases of trench fever were reported during the war. This greatly reduced the numbers of soldiers available to fight. The Official history of the Australian Army Medical Services commented that Trench Fever had "extraordinary epidemic potentialities as a cause of wastage through non battle casualties."
Although Colonel Butler in his Official Medical History, when referring to diseases of dirt and squalor, wrote ... "if some visionary could have foreseen the havoc the louse and acarus would play, and had devised methods for their destruction ... what a different story would have unfolded in the medical history of the war." However it seems that with such a low mortality, Trench Fever could perhaps be regarded as a beneficial disease in that it actually protected tens of thousands of men from the death and maiming resulting from the great breakthrough battles of 1915, 1916 and 1917.