by Arthur Allen
Rickettsia are very tiny, primitive bacteria. Recent genetic analyses have shown that they share a common ancestor with mammalian mitochondria, the energy-producing organelles of the cell. Typhus bacteria live in the cells of the host, which they rely upon to metabolize the sugars they need to exist. Typhus germs colonize the cells that line blood vessels in tissues throughout the body, including the brain. The immune system’s attack on the infected cells floods the lungs and other organs with fluid, and like a lighted match in a box of firecrackers, sets off a cascade of immune responses that contribute to the memorable and horrific symptoms of the disease.
Sickness typically begins around a week after the louse bite, with fatigue and a bad headache or backache. Soon the patient begins to appear pale and absent, and his or her reflexes fail. Around the fifth day, red circles pop out on the shoulders, torso, and arms resembling tiny jewels embedded in the skin. This is called petechial rash. Long before doctors knew what caused typhus, they diagnosed it on the basis of the spots and the delirium that typically emerges soon after their appearance. For a week or more, a severely ill patient will lie muttering and inert, with sporadic flashes of anger or frustration accompanied by spastic movements, incontinence, and loss of bowel control. Temperature can rise to 108 degrees Fahrenheit; the heart beats at 120 beats per minute. Complications include bronchitis, deafness, numb extremities, swollen testicles, or gangrene of the toes, penis, labia, or fingers. Deafness and memory loss occur and can be permanent.
At the peak of illness, many patients become profoundly distressed. “A ward full of typhus patients in the second week of the disease bears more resemblance to an acute mental ward in an asylum than to a hospital ward,” one doctor wrote. “Some patients lie in a drowsy, comatose condition, others shout incoherently at the top of their voices, while still others, nearing the critical period, lie with very shaky hands outside the bedclothes and exhibit marked carphology and subsultus tendinum [twitching, plucking, and grasping].” The better typhus hospitals had table straps to keep patients from attacking the staff, throwing themselves out windows, or fleeing down flights of stairs to plunge into traffic or bodies of water. Suicide, if it can be called that, was a common sequela of typhus, because the patients were driven mad by pain and terrible visions that sent them hurtling through windows.
Typhus ward of Grace Hospital in Warsaw, 1921. (Library of Congress.)
An entire literature could be created from the visions of typhus sufferers. An American volunteer who had been put in charge of 6,000 sick Austrian, Turkish, and Russian prisoners of war on a six-week train meander through Siberia in 1920 fell ill himself and lay down on a patch of straw. He was engulfed by an unforgettable vision. “It seemed there were two couches next to me and upon them reposed dark bodies, monsters of indefinite form and at the same time parts of my own body,” he said later. “At other times, I was able to see myself from outside in a relatively logical way.” Another American, a volunteer serving in the Italian army during World War I, suddenly was struck by the not-so-crazy inspiration that war was wrong, and thereafter refused to return to the front and preached pacifism among his fellow patients. Doctors responded to this feverish inspiration by placing him in a mental asylum for the remainder of the war.
Some patients temporarily gained marvelous mental powers, or lost the most basic skills. “Although my memory is not the sort that can normally capture verse, I recited three poems that I had read shortly before my illness,” a Russian patient recalled. “Two days after this exaltation, my mind was a complete blank.”
Some hallucinatory motifs were characteristic of different cultures: during World War II, German soldiers at the eastern front often imagined that the Führer had personally pinned medals on them and promoted them for brave deeds in battle. American famine relief workers, delirious in their camp hospital in Ufa in 1922, entertained fantastic escape dreams in which they boarded comfortable, pillow-cushioned airplanes and flew around the world. The journalist John Reed, who spent his last days in the Moscow typhus hospital after watching his beloved revolution fall to tatters, retreated into an idyll of beautiful visions and dreams of his long-lost boyhood in Portland, Oregon. “He would tell me that the water he drank was full of little songs,” wrote Reed’s widow, Louise Bryant, who sat with him in his dying days. “He told me, ‘You know how it is when you go to Venice. You ask people—Is this Venice?—just for the pleasure of hearing the reply.’”
Those who recovered described a ravenous convalescent hunger and a vivid sense of rebirth. In Chekhov’s 1887 short story “Typhus,” the character Klimov awakens in a stream of light: “His whole body from head to foot was overcome by a sensation of infinite happiness and joy in life, such as the first man must have felt when he was created and first saw the world. Klimov felt a passionate desire for movement, people, talk. . . . He rejoiced in his breathing, in his laughter, rejoiced in the existence of the water-bottle, the ceiling, the sunshine, the tape on the curtains.” When his aunt tells Klimov that his sister, Katya, has died of typhus and that he had infected her, “this terrible, unexpected news . . . startling as it was, could not overcome the animal joy that filled the convalescent. He cried and laughed, and soon began scolding because they would not let him eat.”
Lice-borne typhus has been known under many names: jail fever, malignant fever, spotted fever, but surely the most apt name, at least for latter centuries, is “war fever.” Typhus followed soldiers and refugees into bombed-out houses and mud hovels, burrowed into their trenches and encampments, shrouded their train yards and horse-drawn wagons. The disease played a decisive role in many military campaigns, among them Napoleon’s catastrophic invasion of Russia. The Grand Army marched to Moscow with 500,000 men and returned with 3,000. It is likely that 20 percent of the casualties were typhus deaths.
Napoleon’s benighted soldiers had no idea what hit them, but scientists ascertained the primacy of the louse in typhus just in time for World War I. The French scientist Charles Nicolle, a methodical protégé of Pasteur’s aide, Émile Roux, was the first to prove louse transmission of typhus. After taking over the Pasteur Institute’s branch in Tunis in 1903, Nicolle noticed that at the city hospital, admission workers often fell ill with typhus, but nurses on the typhus ward did not. After learning that patients entering the hospital were stripped and washed, Nicolle reasoned that the agent spreading the disease was in their clothes. He carried out a few decisive experiments, using lice to transmit the human disease to a chimpanzee, from the chimp to a macaque, and from the macaque to another chimp. His study, published in 1909, was enormously influential and won Nicolle the Nobel Prize in Medicine in 1928.
As World War I began, doctors now knew that the louse spread typhus, and armies, accordingly, started to take action against the louse. Each country had a corpus of medical men whose sights were trained on typhus, and many tried, and failed, to create vaccines. France had a group at the Pasteur Institute, Britain physicians such as Arthur Bacot of the Lister Institute, the Americans Hans Zinsser and Richard Strong, both from Harvard. The hygienic corps of the Prussian army was the best organized of the lot, with a strong tradition dating to the previous century. Prussia in 1870 had been the first power to thoroughly vaccinate its army against smallpox. In 1914, German medical institutes sent top scientists into the field to study and combat infectious diseases. In Turkey, where the enfeebled Ottoman army had put German officers in charge of its military staff, scientists such as Ernst Rodenwaldt, Claus Schilling, and Heinz Zeiss of the Institute for Maritime and Tropical Diseases—each would be associated with Nazi medicine during World War II—found opportunities to study typhus in prisoner-of-war camps. German doctors carried out typhus experiments on Armenians, and when 50,000 Armenian refugees at Aleppo were suspected of carrying typhus and other diseases, German doctors urged they be removed from contact with soldiers. The Turks herded the refugees into concentration camps and murdered most of them.
German military doctors first becam
e keenly aware of the threat of typhus to their troops after the 1914 Battle of Tannenberg, in which an outmanned German force destroyed two czarist armies and captured 92,000 Russians by capitalizing on the obtuseness of the czarist commanders, who transmitted their orders in plain code. (“Russia,” a Russian officer told the relief worker and writer S. Ansky, “is fighting three enemies: The Germans, lice and our own generals—the last is the most dangerous.”) Typhus was always lurking in parts of Russia. It traveled wherever the czar’s conscript armies went, in the lice that clung to their unwashed clothes. One German doctor found 6,000 lice on a single Russian prisoner. Typhus broke out quickly in the POW camps.
The Germans, with characteristic punctiliousness, took extreme measures against the vermin. The army set up delousing columns where soldiers stripped and waited for hours in drafty tents or concrete buildings while their clothes were exposed to high-pressure steam or creosote baths designed to kill the lice. Prisoners faced the same treatment. Even Aleksandra Piłsudska, wife of Józef Piłsudski, the leader of the Polish independence movement, was forcibly deloused after being taken into custody in 1915. She and her compatriots had to disrobe outside in winter and bathe in a tub full of powerful disinfectant that “stung our skins until we were the color of lobsters.” Her hair was washed with a strong carbolic lotion “which left it as hard and brittle as straw and so sticky and unmanageable that it took weeks to recover.” The Germans deloused 3.5 million prisoners during the war, and while the system was certainly brutal, it brought results. Of the 33,000 German military deaths of infectious disease during the war, fewer than 1,500 were caused by typhus.
German disease control probably prevented typhus from spreading to the western front. This was quite an achievement, for the western trenches was every bit as lousy as those on the eastern side. In Erich Maria Remarque’s All Quiet on the Western Front, the narrator describes German soldiers tossing their lice into a boot polish tin placed over a candle to kill them. British soldiers called the bugs “cooties”; a characteristic shrug of the shoulders and a careworn appearance told officers that their men were lousy and hadn’t slept well. Lice are nocturnal creatures that like warm, dark, quiet spots, and one had to go to sleep sometime. “The only way to obtain relief was to get out of the dugout, put a rifle barrel between the belt and rub up and down like a donkey at a gatepost,” one soldier wrote. “This stopped it for a bit, but as soon as one got back into the dugout, and was getting reasonably warm, so would the little brutes get going again.” The poet Robert Graves, an officer in the Royal Welsh Fusiliers, said that lice were a source of bitter humor among his men. “Young Bumford handed me one: ‘We was just having an argument as to whether it’s best to kill the old ones or the young ones, sir. Morgan here says that if you kill the old ones, the young ones die of grief; but Parry here, sir, he says that the young ones are easier to kill and you can catch the old ones when they go to the funeral.’ He appealed to me as an arbiter: ‘You’ve been to college, sir, haven’t you?’”
Though no typhus was reported in the West, the troops did get trench fever, a louse-carried illness that the Germans called Wolhynian fever, the Poles “Quintana” (the causative agent was eventually named Rickettsia quintana). It rarely killed but was very unpleasant and extremely common, accounting for more than a third of British casualties. Fever spiked every five days and sometimes recurred years later. Hundreds of thousands of cases occurred among Allied and German armies at the western front.
German soldiers delousing at the eastern front, 1917. (Corbis.)
Typhus broke out in Serbia following the Austrian invasion of August 1914 that began World War I. One bloody maneuver after another over a Balkan landscape already battered by Serbia’s wars with Turkey and Bulgaria ended when the Serbs seized 60,000 Austrian prisoners in December. Many of them died of typhus before the year was out. The epidemic was sudden and extraordinarily deadly, and before long neither side had the stomach to launch an offensive, leading to a six-month cease-fire. Of the estimated 500,000 cases during the epidemic, 120,000 were fatal. More than half of Serbia’s 450 medical doctors died or were incapacitated. Volunteer doctors from around the world rushed in to help, including a Polish immunologist named Ludwik Hirszfeld, who would later earn fame as a creator of the ABO blood-typing system. On any given day at the small rural hospital where Hirszfeld worked in February 1915, there were 100 new patients, he wrote, “half of them so sick you couldn’t get their names out of them.” Fifty died every day. Caravans of horses carried off the dead but couldn’t keep up, leaving piles of corpses all around the hospital.
During the Great War, nearly every medic or scientist who had anything to do with the disease could recount a gruesome experience. Each laboratory had its martyrs, and typhus publications of the era were inevitably dedicated to fallen colleagues. Doctors and biologists walked a razor’s edge treating and studying the disease in an era without prophylaxis or cure. This is evident in the final missives of the Czech aristocrat Stanislaus von Prowazek—a scientist based at the Hamburg Institute for Naval and Tropical Diseases—from his work station at a Russian POW camp in Cottbus, Germany, in January 1915. Lice had burrowed so thickly into the prisoners’ barracks that the creatures rained down from the straw mattresses whenever someone slammed a door. Prowazek and his scientific partner, the Brazilian aristocrat Henrique da Rocha Lima, were fighting their colleagues’ refusal to accept the evidence that lice were the vector of typhus. They were prevailing, in wretched circumstances. “Of 39 Russian doctors who did not believe in the louse theory, and who instead thought they could protect themselves with facemasks and Mummenschanz, 21 have fallen ill and five died,” Prowazek wrote to the Austrian medical command. “Only three of the German doctors have sickened.” Prowazek protected himself from lice with a tight coat, rubber gloves, and shoes smeared with creosote, but this was not enough. Three weeks after submitting this report, he died of typhus. Rocha Lima, who fell ill but recovered, honored his colleague by naming the causative organism Rickettsia prowazekii, thereby also paying homage to the American scientist Howard Ricketts, who had died in 1910 while studying typhus in Mexico.
One of the few typhus specialists who stayed well (though he did infect himself with a different form of typhus in 1929) was Hans Zinsser, the Harvard microbiologist. To avoid contamination with lice in a typhus region required great care. This is how Zinsser described his precautions at a grubby bordello where he was forced to overnight in Ipek, Serbia, in 1915. Prostitutes were battering on the door for the good professor’s attention, but he ignored them:
The first thing to do was to strip to the skin. Outer clothes were hung on a hook or laid over a chair, away from the washing area. The discarded underwear was loosely packed into my boots, a tablespoonful of chloroform poured into each one, and a string tightly tied around the tips. This executed any vermin that happened to be in the underwear, and made the clothing safer for use the following day. Then came a thorough wash—especially of the hairy parts of the body—with soap and water. After this, I could put on the clean underwear. Before wrapping myself in [my] blanket for sleep on the floor, I would sprinkle it with kerosene.
Though evidence of louse transmission was firm in 1914, the nature of the germ that caused the disease was not. In May of that year, The New York Times announced with a splash that young Harry Plotz, barely 24 years old and a recent graduate of Columbia Medical School, had discovered the cause of typhus. Plotz and his vaccine traveled the next year to Serbia accompanied by another brace of headlines, on a mercy mission sponsored by Mt. Sinai Hospital. But the bug Plotz had isolated was not the same as the one killing the Serbs, who refused his offer to immunize their soldiers. It was never exactly clear what Plotz had found—he was unable to maintain his cultures or share them with other scientists—but it wasn’t Rickettsia prowazekii.
Eisenberg, seated left, Weigl, seated right, with colleagues in the Austro-Hungarian medical corps, 1914. (Courtesy of National Museum, Przemyl. Photo
graph of original by S. Kosiedowski.)
In 1916, Edmund Weil and Arthur Felix, two Czech physicians serving in the Austrian army, developed a diagnostic test for typhus that involved mixing serum from a suspected patient with an organism called Proteus OX-19. If the suspension clumped, it indicated the patient had typhus—the clumps representing bonds between typhus antibodies and pieces, or antigens, of OX-19. The test was far from perfect, with frequent false positives, and it seemed to work only when the patient had been sick for several days. It also led to the mistaken theory that typhus was caused by Proteus OX-19. (Later, scientists would discover that OX-19 and R. prowazekii each contained proteins that reacted with antibodies in the blood of typhus patients.) Other physicians, including Nicolle, believed that a virus was the causative agent. Both theories were wrong, but understandable.
Consider that before 1930 or so, most scientists believed that bacteria could not live inside cells. To prove that a particular organism caused a disease, the eminent German bacteriologist Robert Koch had stated in 1890, it was necessary to extract it from a sick person, grow it in an artificial medium, and reproduce the disease by injecting it into an experimental animal. Furthermore, by extracting the organism in question from animal blood, one could make a protective vaccine with it through chemical deactivation. Alternatively, broths containing the organism could be injected into a horse, which would produce antibodies that could be harvested and used as a passive immune serum—that is, a serum containing antibodies specific to the disease.
Cultures of the bacteria causing anthrax, typhoid fever, diphtheria, or tetanus met the postulates neatly, or at least seemed to. But no one could figure out how to grow typhus germs in an artificial medium like the bull’s blood used for diphtheria and tetanus. Nor could the disease easily be transferred from animal to animal. An ape could get louse-borne typhus, with great experimental difficulties, but the germ at most gave guinea pigs a bit of fever. Typhus-infected blood from the adorable little rodents could not be cultured in a broth.
