THE DOCTOR'S BAG
Dr Keith Souter aka Clay More
As I continue my research into medical history the medical textbooks that were used by the military of both sides in the Civil War continue to be a fascinating resource. The these snippets from JJ Chisolm's Manual of Military Surgery for the surgeons in the Confederate States army.
He does not just talk about surgery, but begins the book in the very first chapter by talking about susceptibility to disease. Indeed, the very first sentence:
"As the strength of an army depends more upon the health and physical development of the soldier than its mere numbers, the hygiene of camps, and the susceptibility of soldiers to disease, has long been a worthy study for military leaders."
After extensively going through all of the equipment and clothing needed for a soldier he then says:
'In the above list we have purposely omitted shaving apparatus, as every soldier in the field should allow his beard to grow. It protects his throat, and often prevents lung diseases, catarrhal affections, etc. A heavy moustache is known to protect the wearer, to a certain extent, from malarial influences, acting as a sieve to the lungs. It also purified from dust the atmosphere inhaled during marches, and thereby prevents many troublesome diseases. Cleanliness dictates that the hair be cut close to the head, and, although the beard be allowed to grow, it should be kept within bounds.'
Malaria - bad air?
Hippocrates, the father of Medicine, writing in the sixth century BC described the condition beautifully. He actually differentiated the different types of fever associated with it. He thought that it was caused by bad air, which thought persisted until the 19th century in the name 'mal' 'aria', literally meaning 'bad air.'
You can see why JJ Chisolm thought that the heavy moustache might be so beneficial in filtering out this bad air.
The actual cause
Malaria is still the most common and serious of all the tropical infectious diseases. It is still endemic in large areas of the Pacific, Southern Asia, Central and Southern America and Africa. If it is not treated promptly it is frequently fatal.
Malaria is caused by protozoal parasites of the Plasmodium group. They are spread by a single bite of an infected Anopheles mosquito. There are many different Plasmodium parasites, but only five of these cause the disease in humans.
Three of these, Plasmodium vivax, Plasmodium ovale and Plasmodium malaria cause a relatively benign illness with tertian (alternate day) fevers, or occasionally quartan (every third day) fever. Plasmodium falciparum causes a more serious type of malaria, which used to be called 'malignant malaria' or 'blackwater fever.' In this the kidneys are affected and broken down blood appears in the urine to make it appear extremely dark, like black water. This is called haemoglobinuria.
The different types of fever, which Hippocrates described, relate to the life cycle of the malarial parasites in the blood. The condition causes the variable fevers mentioned above, chills, headaches, abdominal pains, muscles pains, vomiting and diarrhoea and general prostration. The spleen can become extremely enlarged, as outlined in Fevers and Pest Houses.
A difficult diagnosis
In the 19th century before the malarial parasite was discovered it was found difficult to differentiate it from typhoid fever, hence it was often called typho-malarial fever. I can attest to the difficulty of distinguishing them on purely clinical grounds, having worked in an infectious disease hospital in India back in the seventies. Fortunately, we now have blood tests, which will distinguish them, as the parasites will be found in the blood.
According to Medicine of the Civil War by Paul E Steiner, publish by the National Library of Medicine, there were almost 3 million enlistments to the Union Army and between 1.3 - 1.4 million to the Confederacy.
The total deaths in battle amounted to 204,070, compared to 388,586 deaths from disease. Effectively, diseases caused almost twice as many deaths as did actual battle.
Figures for admissions to hospital for the Union:
These sickness figures show that some conditions had an alarmingly high mortality rate. The mortality rate for typhoid was over 35 per cent of cases. Typhus was less common, but had a mortality rate of 34 per cent. Typho-malarial fever, a common diagnosis, which showed the lack of understanding about the conditions of typhoid and of malaria (which are separate conditions) and the non-specificity of diagnosis, had a mortality rate of 8 per cent. Other conditions like acute diarrhoea caused huge numbers of cases, throwing a terrific drain on resources and taking so many men off the field of battle, without having a high mortality rate.
Drug treatment of malaria
Quinine was used to treat malaria since the 17th century. The bark of the cinchona tree (quina quina) was called Jesuit's bark, Cardinal's bark or Sacred bark. It was discovered by a Jesuit priest in South America in 1630, although their are legends about it being used by the local native population before then.
The introduction of quinine to Europe involves the Spanish Countess of Chinon, who contracted malaria in Peru. She was given a draught concocted from the bark of a tree and recovered. When she returned to Spain she introduced quinine to Europe in 1638. It was known as the Countess's powder. In 1742 the botanist Carl Linnaeus called the tree Cinchona in her honour.
The Union Naval Blockade
Supplies of quinine were critical during the Civil War. The Union Naval blockade cut off supplies to the Confederacy, who were forced to find alternatives.
Dr John Chisolm, the inventor of the Chisolm inhaler and the author of The Manual of Military Surgery was tasked with doing this, which he set about quite ingeniously. He established a laboratory in Columbia, where he developed medicines that were also in scarce supply because of the Union Naval blockade. The drugs were made from indigenous plants
Members of the public were asked to help the war effort and grow plants, which were sent to Chisolm. There he had in his laboratory 'a series of copper kettles for evaporating.' He recommended staffing other laboratories with chemists from Europe, skilled in extracting alkaloids from plants. In particular, he gave the example of finding a substitute for quinine, which was in extremely short supply and which was needed to treat malaria. The normal source of quinine was the cinchona trees, which do not grow in the south. A tincture could be made of willow, dogwood and poplar bark as a substitute.
Science gives the answer - or part of it!
Although there was a treatment for malaria in the form of quinine, or perhaps the tinctures that JJ Chisolm came up with, yet the cause was still not known. It would come three decades later.
Sir Ronald Ross (1857-1932) was a British doctor working in India. In 1895 he discovered the Plasmodium parasite in the stomach of the Anopheles mosquito. He conducted research over two years and managed to cultivate mosquitoes from eggs, effectively elucidating the life cycle of the mosquito. He then had a volunteer patient who already had malaria and managed to get them to bite him. When they did they sucked up blood into their stomachs. He examined them over the following days and was able to see how the parasites developed in their stomach. He had found that the mosquito was an important link in the chain.
Notebook belonging to Ronald Ross, describing the parasites from the mosquito stomachs he had seen down the microscope
Ross knew that he was on the verge of a discovery that could save countless lives. By attacking the life cycle of the mosquito which develops in stagnant water, the sort of surroundings that hippocrates had thought produced 'mal' 'aria'.
In 1902 he was awarded the Nobel Prize for medicine.
Malarial campaigns targeted the anopheline mosquito. Unfortunately, it is still a major cause of death and morbidity in many parts of the world.