Wednesday, July 21, 2021



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:












Typho-malarial fever



Acute diarrhoea



Chronic dysentery













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. 




  1. Fascinating article, Keith. The number of deaths from disease--opposed to deaths in battle--surprised me. But, after considering the conditions these men fought and lived in, it makes sense. I was also intrigued by what you wrote about the protective qualities of moustaches and beards. Thanks for posting this!

    1. Thanks, Tom. Yes, the idea that malaria could be prevented by the filtering effect of the moustache is in keeping with the age old idea that it was caused by 'mal' 'aria', bad air.
      Thanks for stopping by.

  2. Keith, as always, your post is so informative and interesting! My dad had malaria when he was about 10 or 11. Since he had two younger siblings, an older woman had him come stay with her and she took care of him until he was well enough to go home. He told me once he didn't remember much about all that except he did take quinine for it. he was born in 1922, so this would have been early '30's. I wish I had learned more about that.

    And thank God for Dr. Ross! I really enjoy these posts of yours!

    1. Thank, Cheryl. It is hard to imagine, but there was a time when malaria was endemic in every state n the USA except Alaska, but it was. 1951 marks the year it was deemed eradicated. However, there have been multiple outbreaks since then, caused by mosquitoes becoming infected from biting people who had picked up the illness other endemic areas. And then they transmitted it!

  3. Always so interesting Keith! It's amazing that disease carried off more soldiers than did battle itself ... but knowing the conditions rampant on the battlefield, we probably shouldn't be surprised at those figures. Thanks for another fascinating article.

  4. Thanks Jes. Dr JJ Chisolm also said in The Manual of Military Surgery that:

    "It is a common impression the surgeons alone are wanted in the army, under the erroneous belief that the only risks to which troops are exposed are the bullets of the enemy. As we have elsewhere shown that for every one killed by the enemy at least eight die of diseases contracted in camp, this will be sufficient proof that the physician must be even more important than the surgeon."

  5. What an amazing and coordinating effort that went into finding the cause of Malaria and working on a cure. I don’t think I ever knew how difficult it was to get quinine during the Civil War. That people helped by gathering the necessary plants to be used in the making of quinine showed the devotion by many to find a cure. I so enjoyed reading this article, Keith. It was full of information and I liked the efforts made by so many to help Ross in his dedicated effort to find a cure for a most dreaded disease.
    All the best to you.

    1. Thanks, Sarah. I find there are so many interesting stories behind the great medical discoveries. Yet malaria is still a great problem in the world.

      I saw a lot of cases in India and when you have a palpable spleen the clinical diagnosis was easy. If it was not palpable then it could be far from easy and you had to wait for the blood test. A dangerous condition.

  6. Replies
    1. Thank you, Kassandra. I am glad you enjoyed it.

  7. Thank you for sharing this information, Keith. What a reminder that we are blessed to be living today with the benefits of modern medicine!

    1. Thank you, Mark. Ross’s discovery about malaria was the first description of a vector disease. The microscope became a great tool and other diseases followed, allowing us to understand about life cycles and one of the ways that many diseases spread.

  8. Wow. I knew of quinine for Malaria, but hadn't heard of the treatment developed by Dr. Chisolm.

    The thing that drew me in was the mustache. That and cutting the hair close to the head. I'm going to have to remember that. Thank you again for an educational post. I appreciate your sharing you knowledge with us. Doris

    1. Thank you, Doris. It was a question of invention through necessity, caused by the Naval Blockade.