David W. Tschanz, MSPH, PhD


            In the decades following the American Civil War, the understanding of the nature and causes of disease, as well as its prevention underwent a revolutionary advance.  In 1876 Robert Koch proved that anthrax was caused by a bacterium, and in the process disporved the age old theory that illness resulted from miasma or an imbalance in humors.  Koch's fundamental discovery  was liking turning on a searchlight in a darkened room.  One disease after another was found to be caused by bacteria as medical researchers trained microscopes on their patients.  Typhoid fever, dysentery, syphilis, plague, and cholera were shown to be caused by  microscopic life forms.

            Then the role of insects in transmitting disease to man was demonstrated when Ronald Ross, a British military doctor, showed that mosquitoes transmit malaria.  US Army medical officer Walter Reed, using Army soldiers who volunteered for his experiments, then proved that  yellow fever is also mosquito-borne.  Another army major, William C. Gorgas, led a campaign against mosquitoes during the construction of the Panama Canal, an effort that allowed American engineers to succeed where Ferdinand de Lesseps, the builder of the Suez Canal, had failed. 

            In short order other microbe hunters showed that bubonic plague was transmitted by fleas and that lice transmitted typhus fever to man. Simultaneously, French scientist Louis Pasteur showed that defenses could be built against disease and developed immunizations against rabies, chicken cholera and anthrax.  A few years later vaccines against typhoid and cholera were introduced.

            Now that it was understood why diseases happened, it was also clear why some measures, such as sanitation had worked. By denying the organisms a chance to breed or find hospitable environments, disease control had been empirically discovered. A whole range of organisms could be attacked at their source.  For the first time after centuries of one sided warfare, with man forever in the open and the diseases ever in ambush, the victim was in a position to organize and rationally plan a strategically sound defense against his historic enemies.

            Military doctors could finally devise the means to prevent disease.  In 1905 the Russo-Japanese War, important for other reasons, became a historic anomalyit was the war in which the number of combat related deaths exceeded those from disease. 

            When World War I broke out in 1914, the progress in medical science had been so significant that there was a reasonable hope that major epidemics would be avoided in the coming conflict.  If the 1918-19 pandemic of influenza is excluded, the Western Front achieved that goal.  Neither side in that theater experienced anything remotely resembling the great war related epidemics of the pasttyphoid fever, dysentery, cholera, plague or typhus fever.  But on the Eastern Front one disease returned in all its medieval ferocity and wreaked havoc on the military plans of the Central Powers.



             After the assassination of the Archduke Ferdinand, in July 1914, Austria declared war on Serbia and immediately attacked. Militarily, the Serbs were in desperate straits.  The small Balkan country had just finished a war with Turkey, the third war that Serbs had fought in two years.  Munitions and war materiel were scarce.  Belgrade, the capital, was dangerously exposed on the frontier with Hungary.  And the entire country was war weary.

            Belgrade was bombarded, and the Austrians tried to push their way across the Sava.   These efforts were repulsed, but later, attacking from the Bosnian border, the Austrians succeeded in taking Valjevo and Belgrade.  There were reverses however and some 20,000 Austrian prisoners were taken by the Serb defenders.

            The loss of Belgrade was of little importance as the city was in no way the heart of the country.  The Serbian government merely relocated to Nish.  At the same time the widespread destruction of towns and villages in northern Serbia, caused the terrified civilian population to flee southwards from the battlefield.  There was no shelter for them.  Instead hospitals, doctors, nurses and drugs were in short supply. Not only were there many sick and wounded soldiers, but there was the burden of 20,000 Austrian prisoners to care for.  Serbia had only 400 physicians in the entire country and a large portion of these were with the army.

            Then in late November, typhus fever began to appear among the Serbian refugees.  A few days later cases were reported from the army and among the prisoners of war.  Typhus fever had been endemic in Serbia for centuries and these first cases caused little alarm.  There was, after all, a war on.  In 1812 typhus fever had shattered Napoleon's invasion of Russia destroying his army long before it reached Moscow.  "General Typhus" was about to reprise its role as a prime determiner of military strategy.



            Typhus fever is not typhoid fever, nor is it related to it, despite their similarity in names.  Typhoid fever is a disease of the gastrointestinal tract caused by a bacterium, Salmonella typhi.  Man acquires the disease by eating or drinking food or water contaminated with feces from an infected person.  Typhoid fever is a disease of poor sanitation and impure food and water supplies.

            Typhus fever, by contrast, is a disease of filth.  It is transmitted from one person to another by the common body louse Pediculus humanus (but not by the head louse) -- the bane of armies throughout history and known variously as "cooties" and "personal livestock."  The etiologic agent of typhus fever is an organism that is not quite a bacteria, but too developed to be a

classified as a virus and called Rickettsia prowazeki.  The Rickettsia cause a variety of illnesses including trench fever and Rocky Mountain Spotted Fever. 

            Typhus fever is common only where lice are common.  Typhus fever was once called "gaol fever" or "ship fever;" because it was common in preisons and on ships that had been at sea a long time.  This epidemiologic fact is because the lice that carry typhus fever are common in large aggregations of persons who do not bathe or change clothes with any regularity and are forced by circumstances to live in close quarters.  These are also the situations that infantry, refugees and prisoners are likely to find themselves.

            The lice cling to the seams of clothing, in cuffs, hems and any other space that provides them a modicum of hiding.   They move from one person to another more or less at random.  Simple acts, such the accidental brushing against, temporary loan of clothing or simple proximity, especially at night, can lead to a migration from one person to another.  Lice will make a mass exodus from a person is when death overtakes their host and the rapidly cooling body forces them to find a more hospitable environment. 

            The lice feed by sucking blood from their hosts. They are incredibly prolific, laying eggs, called nits, that stick to the clothing and body hair of their hosts.  Lice were all once ubiquitous.  A plethora of phrases that refer to them, their progeny and getting rid of them -- "You louse!" "Nit- picking" "Going over it with a fine tooth comb," -- serve as testimony to our long, and uncomfortably intimate, relationship with them.  The association that probably started from the time our distant evolutionary ancestors first stood erect -- the grooming behavior of the great apes is nothing more than the removal of lice.

            Man has known how to get rid of body lice for millennia, long before pesticides.  The method is mentioned by the Greek playwright Aristophanes in one of his comedies.  Head lice are eliminated by shaving one's head (hence the popularity of horsehair wigs among our unwashed ancestors).  Getting rid of body lice requires washing the body and boiling the clothes. Simple actions in some circumstances -- but soldiers, refugees and prisoners can rarely engage in such activities, even when they have another change of clothing.

            The louse becomes infected with typhus fever by biting an infected person (or a rat) who has the disease.  About six days after eating his meal, the louse becomes infectious.  If the louse stays where he is, not much happens, if he moves to another person, the process begins.  Because lice are extremely temperature sensitive they will move from the body of a person suffering from typhus fever as quickly as from a dead person. Rickettsia prowazeki multiplies in the louse's gut and is excreted in large amounts when the louse defecates.  When dry these feces retain their infective power for a considerable time.  Man is infected when the dry feces are rubbed into the skin, fall on the eye, or (and this is still debated) is inhaled in the lungs.  Man is also  infected when he crushes the louse in scratching and rubs the content of the gut into his skin and into

the puncture made by the insect.  For the louse the ingestion of the microbe is also a death sentenceten days after being infected it dies

            Once in the victim's blood stream Rickettsia prowazeki begins to multiply.  About twelve days after infection, the clinical symptoms of the disease begin.  The onset is sudden, with a high fever, headache, chills, numbness, generalized body pains and marked prostration often leading to delirium, coma and cardiac failure.  The most characteristic symptom consists of reddish spots (pettechiae), looking like flea bites which rapidly darken in color and in severe cases may become confluent, involving the whole body.  Before antibiotics the fatality rate varied from 10-80%.  Children, surprisingly, had a lower mortality rate than adults.



            The appearance of typhus fever, the large number of refugees and the general devastation of the country did not, at first, stop the Serbian military.  On December 3rd they launched a counterattack.  After three days of battle the entire Austrian army was shattered and in headlong rout.  The Serbs took more than 40,000 prisoners, but the northern part of the country was devastated.   In the meantime typhus fever spread throughout the civilian and military population, its long incubation period meant that it was probably circulating in the blood of the Serbs who drove out the Austrians.  In the confusion of war it found ample opportunity to spread.

            It is impossible to state, with any accuracy where the epidemic started.  The first accumulation of cases occurred among Austrian prisoners at Valjevo.  Outbreaks throughout the rest of the country followed within a week.  The infection had traveled with the wandering population, with prison trains, and with moving troops and been rapidly disseminated to all parts of the country.   What followed next was a scene of horror that Europe had not seen since the Black Death.

            At the start of World War I Serbia numbered some 3 million people.  Within six month 500,000one in sixdeveloped typhus fever.  Over 200,000, 70,000 of them Serbian troops, died from the disease.  One half of the 60,000 Austrian prisoners also died from typhus.

            The Serbs were unable to cope.  The few existing hospitals were soon full to overflowing and others had to be improvised within building which often lacked sanitary provisions of all but the most primitive order.  There were practically no nurses.  There were no beds, no linens, and no medicines for almost all of the victims who had to make provide themselves what medical care they could.  There were less than 400 doctors in the country, many of them under the colors.  Almost all of them contracted the disease, 126 fatally.  Eventually there were hardly enough grave diggers left as they too fell victim.

            Through February and March the epidemic flared up with a speed and violence never equaled in any typhus outbreak for which there is a reliable record.  In Aprilwhen it reached its peakthe new cases per day ran at 10,000 per day, 2500 of whom were admitted to the military hospitals alone.  The mortality rate ranged from 20% at the beginning and end of the epidemic to 60-70% at its height in March and April.

            For six months Serbia was politically and militarily helpless. A ripe plum ready to be picked, but Austria did not attack again.  Austrian strategists knew better than to enter Serbia while the epidemic raged.  General Typhus, while scourging the Serbian population, held the border.

            The Central Powers lost six months during the most critical time of the war.  It is anybody's guess as to the effect that this delay may have had on the early Russian and even the Western campaigns.  It is at least reasonable to believe that a quick thrust through Serbia at the time -- with its effect on Turkey, Bulgaria, and Greece;  the closing of Salonia and the establishment of a southwestern front against the Russian might -- have tipped the balance in favor the then very vigorous Central Powers.  Typhus Fever may not have won the warbut it certainly helped by denying the Central Powers the Balkans at a critical juncture.

            Typhus quickly established itself along the entire Eastern Front, but was kept from reaching epidemic proportions in either the Austrian or German lines by the energetic delousing of the troops.  Though it penetrated into he prison camps of Central Europe, the disease was successfully prevented form spreading to the civilian population.

            Among the most remarkable phenomena of World War I was the total absence of typhus from the Western Front, while it raged unabated on the Eastern Front tearing at Russian army and made its presence felt in the eastern forces of the Central Powers.

            No easy answer for this has ever been established.  Soldiers in the trenches of the Western Front were as universally lousy as their colleagues in East.  And a louse borne disease, trench fever (see box) closely allied to typhus, was common.  The only reasonable explanation was that armies on the both sides were more afraid of typhus then they were of shot and shell.  The Central Powers, realizing that a typhus fever epidemic introduced with troops transferred from the East could easily lose them the war, took the utmost precautions to avoid this. Troops were deloused whenever they fell back from the front lines.  Army sanitary organizations on both sides were ever conscious of the possible peril, alert for suspicious cases and unusually quick to resort to wholesale delousing.  The mortality of lice in this war must have been the greatest in the history of the world.

            The major powers avoided a typhus fever epidemic from crippling their armies.  But Serbia's was merely a prelude to the greatest typhus fever outbreak in the Twentieth Century. Hapless, calamity prone Russia was the next target.

            World War I had been hard on Russia.  The vaunted Russian army proved itself not to be a bear, but a cub.  Famine swept the country, refugees swarmed throughout the land.  Then the Tsar was overthrown, adding the problems of a violent revolution to the Russian's list of woes.  Cholera, typhoid fever and dysentery swept the countryside as essential services collapsed.  Then in

the winter of 1918, typhus fever appeared in epidemic form.

            Typhus fever was not a new visitor to Russia.  During the 20 years before the revolution there had been an average of 82,000 cases per year.  When the startedwar the disease spread slowly but steadily; in the first years there were 100,000  casesafter the retreat of 1916 the reported number rose to 154,000, though only a handful were in the army.   Now these numbers were about to pale to insignificance.

            The great epidemic that broke out at the end of 1918 invaded the country along three frontsPetrograd, the Rumanian front and the Volga region.

            For four years the epidemic raged amidst the famine and dislocation of the revolution20 million cases occurred. Ten million of them died.  For a while it looked as if the fate of the revolution was at the mercy of typhus fever. Lenin, surveying the situation in 1919, put it succinctly, "Either socialism will defeat the louse, or the louse will defeat socialism."



            Typhus fever was kept from re-establishing its role as a Great Captain and ravaging the armies of all combatants only because medical science finally understood it and how to defeat it. Generals came to appreciate that their greatest enemies were not always their armed opponents, but the microbes that laid in wait for them.  Sanitation, medical care and hygiene became as important to military planners as munitions, tactical innovations and grand strategic concepts.  The experiences on the Eastern Front showed, in graphic and gruesome detail, what would happen if they let down their guard for even a moment. The Serbian campaign will be the last time that typhus fever plays a significant role in the outcome of a military campaign.  That is until someone makes the mistake of forgetting what it can do.




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