Innovating for the future:

The Army Medical School at Netley and developments in infectious diseases

Introduction

British Science Week 2021 has the theme of 'Innovating

for the Future'. With this in mind, we have chosen to

celebrate the medical developments that came out of the

Army Medical School at Netley in the mid to late 19th

century, particularly in the field of infectious diseases. Not

only did these tackle some of the most serious problems

facing British forces stationed overseas at the time, but

they also paved the way for many future developments.

The Netley staff and students you will encounter over the

following pages really were 'innovating for the future' -

our present.

We would like to acknowledge the considerable contribution made by volunteer Tim Ford, whose extensive research forms the basis for this presentation.

We would also like to thank the University of Southampton for their generous sponsorship of our British Science Week activities.

Contents

Historical & Military Context 5

Scientific & Medical Context 15

Cholera 24

Malaria 36

Leishmaniasis 42

Brucellosis 50

Dysentery 59

Typhoid (Enteric) Fever 64

Trench Fever 72

Historical and Military Context

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Any consideration of the advances in medical science

pioneered at the Royal Victoria Hospital, or by those

associated with its Army Medical School, must start with

the military background.

It must take account of the following: Great Britain’s

global standing and international relationships in the mid-

nineteenth century; the reasons for the foundation of the

hospital; and the purpose of a military medical school.

Painting: The Founding of Australia 1787 by A. Talmage 1937.Creative Commons

The nineteenth century saw Britain's interest and activity expand

throughout Asia as it attempted to increase its commercial

activities with China. Singapore, Hong Kong and Malaya were all

taken to facilitate trade and economic opportunities in the region,

especially between India and China. The nineteenth century also

saw Britain's interest in Africa bloom as it attempted to control the

maritime routes via the Cape and later the Suez Canal. As rival

European powers expanded their own imperial interest in the

continent, there occurred something of a 'scramble'. This saw the

majority of Africa come under direct European control in a

remarkably short period of time. Britain's interest in the Gulf and

Middle East also intensified as it sought to control access routes to

and from the 'Jewel in the Crown'. British foreign policy both

European and globally was generally to ensure that no other single

power came to dominate either the continent or other parts of the

world. Britain frequently joined alliances against the French in the

eighteenth and early nineteenth centuries, the Russians in the mid-

nineteenth century and the Germans in the early twentieth century.

Those alliances brought Britain into conflict with opposing powers

with the same intentions – the wars known respectively as the

Napoleonic Wars, the Crimean War and World War One. Besides

these, there were other local and equally draining campaigns in

India and South Africa - indeed, wherever British interests came

under threat. Inevitably these came at a cost in lives.

The World in 1897. "The British Possessions are coloured Red“Cambridge University Library

Queen Victoria's First Visit to her Wounded Soldiers by Jerry BarrettOil on canvas, 1856 NPG 6203© National Portrait Gallery, London

However, the lives lost in military engagements were often more than

equalled by deaths from the tropical diseases to which the troops and

supporting personnel and Empire officials were subjected. This had

been the case even since the Crusades. During the Crimean War

(1854–1856) 34,000 British, French and Russian combatants were

killed in action and 26,000 died from wounds. However, more than

twice as many - 130,000 - died from diseases, particularly cholera,

dysentery and typhus fever. Indeed, within a few weeks of the arrival

of the British Army in the Crimea, more than 8,000 soldiers had

contracted either malaria or cholera. Poor hygiene and insanitary

conditions in the hospitals that were supposed to care for the

casualties contributed to their swift spread.

Events in the Crimea were quite explicitly reported in contemporary

newspapers and letters sent home. A direct outcome of these was

the establishment in 1857 of the Royal Commission on the Health of

the Army. It was chaired by Sidney Herbert, the former secretary of

state for war. Among the Commission's reforming recommendations

was the establishment of an army medical school, with a particular

focus on the teaching of hygiene and disease prevention. Running

parallel to this was Queen Victoria's demand for a new military

hospital, with more superior facilities than those she had seen in

1855 at Fort Pitt, Chatham.

These two facets coalesced at Netley. The Army Medical School was

established at Chatham in 1860, then moved in 1863 to the newly-

opened Royal Victoria Hospital. The logic of having both the new

hospital and a teaching and learning centre of excellence on the one

site was unarguable.

The four schools of study at Netley were military surgery, military

medicine, military hygiene and pathology. These reflected Florence

Nightingale's insistence, and the Commission's recommendations,

that army doctors gain an understanding of the principles and

practices of preventative medicine.

In the initial lecture that he gave new students in the 1880s, the

Professor of Military Medicine, William Campbell Maclean provided an

insight into the extent and global remit of the subject:

"This great hospital… is intended for the reception of invalids from

every part of the world where the British soldier serves, whether

suffering from diseases or wounds. Opportunities are thus offered to

you to study the effects of various climates and diseases..."

Ward in the Royal Victoria Hospital, NetleyBoer Wars 1899-1902

Surgeon-Major William Campbell Maclean (1811-1898)

Maclean was equally explicit as to the need of such special

instruction for military medical personnel:

"above all because 60,000 British soldiers are always serving in

India, requiring a large staff of carefully instructed medical officers

for their care. Nor is this all. Side by side with those who devote

their lives to the service of the British army sit a body of gentlemen,

for whose benefit no less than theirs, this school was established.

For them the study of tropical medicine is of vital importance. All

their professional lives will be spent in India; on them the medical

charge of a large native army will devolve, without the aid of which

it would be impossible to hold India as a British possession... To

them will in the future be committed the care of the valuable lives of

those charged with the civil administration of India... From the ablest

of them, the selection of teachers will be made to fill the chairs of

the medical and allied sciences in the colleges established by an

enlightened Government, and to be advisers on all questions

affecting the health of the 200,000,000 people of the various races

of the Queen’s empire of Hindustan."

A group of hospital patients at Netley during World War One.

The importance of India and the medical care of both the British

armed forces and the civilian population is clear. This is reinforced by

the fact that for 15 years from 1865, students for the Indian Medical

Service were required to undertake the same training as their British

counterparts at Netley. However other parts of the Empire, and a

world in which British geo-political interests were paramount,

brought their own local medical challenges. The pages that follow

highlight the most significant diseases encountered by the military.

Although most prevalent in tropical areas, in a world where

sanitation was often still rudimentary, they could develop and blight

forces and the supporting civilians almost anywhere.

The campaigns fought in South Africa in the late nineteenth century

brought significant loss of life from typhoid. The strategic outpost of

Malta in the Mediterranean was frequently and significantly impacted

by brucellosis. British interests in India were severely affected by

outbreaks of malaria, leishmaniasis and cholera. Finally, even

fighting close to home on the Western Front in the early twentieth

century saw the emergence of a new debilitating condition, trench

fever, to be diagnosed, treated and overcome by those associated

with the Army Medical School.

The London School of Hygiene & Tropical Medicine and its frieze.

Whatever one's views on the British Empire from a twenty-first century

perspective, the good intentions of many of its servants, leaders and

specifically those connected with Netley at the time cannot be denied.

However much they may have been intended initially for military ends,

their achievements significantly benefitted humanity across the Empire

and other parts of the world.

Public recognition of several of those who worked or were trained at

the Army Medical School came in the 1920s, when the London School

of Hygiene & Tropical Medicine moved to its new premises in London.

Among the twenty-three scientists named on the original frieze above

the building were five from Netley: Edmund Alexander Parkes, the first

Professor of Military Hygiene; Sir David Bruce, who trained in the 1880s

and later served as Assistant Professor of Pathology; Sir Ronald Ross

who also trained in the 1880s; Sir William Leishman who also served as

Assistant Professor of Pathology; and Timothy Richards Lewis who, on

graduating from the school in the 1860s, worked in India on several

aspects of tropical medicine.

The pages that follow outline the contributions made by these scientists

and physicians in the field of tropical medicine. They also make

mention of others acknowledged within the LSHTM frieze, such as Sir

Patrick Manson and the German scientists Koch and Pettenkofer, who

made their own pioneering progress in this area or worked with

those with Netley connections.

Royal Army Medical College, Millbank

There is a rather sad postscript to this account of the successes and

developments attributable to the Army Medical School at Netley. The

school in general, and army doctors in particular, were blamed for the

significant loss of life amongst medical personnel during the Boer War

(1899-1902) and the very considerable proportion of lives lost to

disease. Among many issues arising from the conduct of the war, a

debate was held in Parliament relating to medical provision. This

generated the appointment of a royal commission, a further

committee and finally an advisory board. The ultimate outcome was

the recommendation that a new military hospital and army medical

staff college should be founded in London.

In 1904, after 41 years and the graduation of over 3,000 officers, the

Army Medical School at Netley closed, moving first to private rooms in

London and then the new Royal Army Medical College at Millbank,

London. Professor of Pathology Sir Almroth Wright is known to have

made enemies before and after the Boer War and it is clear that this

decision was at least in part a result of personal conflicts involving

him.

Laboratory at the Army Medical School, Netley in the late 19th Century.

The decision was fiercely opposed by at least one writer to the

journal Nature. They predicted “a disastrous effect on the future

prospects of the development of scientific research in connection

with the Service”. The writer lamented that “clinical study in

tropical medicine has been eliminated from the programme of

instruction for officers entering the Army Medical Service” and how

“the transfer of the research laboratories must be detrimental to

the progress of research in tropical medicine”.

This letter was penned nearly 120 years ago. It is therefore

interesting, if disheartening, to recall the many enquiries in recent

years into the Science, Technology, Engineering and Maths (STEM)

skills gap in the UK. A 2018 report from STEM Learning noted that

the shortage of high level STEM skills is costing British businesses

£1.5 billion a year. Yvonne Baker, Chief Executive of STEM Learning

said: “We are heading towards a perfect storm for STEM

businesses in the UK - a very real skills crisis at a time of

uncertainty for the economy..."

What a pity it is that the words penned by the writer to the journal

Nature fell on deaf ears. With staggering foresight they concluded:

“the rulers of the Empire will some day understand what immense

loss the neglect of science entails, and until this is fully appreciated

it is the duty of all who know to explain on every occasion”.

Scientific and Medical Context

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The second half of the nineteenth century was an era of

very significant developments in medical science. The

achievements of those who trained or worked at the Royal

Victoria Hospital cannot be seen in isolation from (and

were in large part a product of) such progress made in

the Victorian age both in Great Britain and across Europe.

The list featured here of these milestones and other

significant events is set in the context of the

commissioning of a new military hospital in 1855 and its

opening at Netley in 1863. It is striking in the twenty-first

century to realise just how recent some of the innovations

are. However, it is also valuable to understand the level of

progress that had been made in medical science and how

standardised were treatments at the time the hospital

opened - the base from which its operations started.

Before the Hospital was commissioned

The first half of the nineteenth century may be termed the pre-sanitary

age. Medical treatments relied heavily on the following: a ‘change of

air’ (to the coast or mountains perhaps); the taking of emetic or

laxative substances; bleeding by cup or leeches to clear impurities; the

ingestion of mercury in small doses; and the power of prayer.

1796: Edward Jenner developed and pioneered the use of a vaccine

against smallpox, one of the great killer diseases. He believed that

vaccines should be free at the point of delivery, available to everyone,

no matter who they were or where they were from.

1847: James Simpson – pioneered the use of chloroform as the first

effective anaesthetic used during surgery. This notably helped women

in childbirth. In 1853 Queen Victoria’s eighth child was born with the

use of chloroform. This effectively silenced all opposition to Simpson

and his stance on pain-free childbirth. Simpson went on to work on

hospital infection and surgical sepsis. He advocated preventative

methods such as cleansing hands and instruments to avoid infection.

This reinforced the findings of the Hungarian Ignaz Semmelweis,

who insisted that doctors should disinfect their hands before

involvement in childbirth procedures.

Illustration of Edward Jenner vaccinating a child against smallpox.The New York Academy of Medicine Library

1848: the publication of Buchan’s Domestic Medicine. Listed

among the general causes of common illnesses were: night air,

sedentary habits, anger, wet feet and abrupt changes in temperature.

Cholera was said to be caused by rancid or putrid food, by ‘cold food’

such as cucumbers and melons and by passionate fear or rage.

Miasma or ‘bad air’ theory was borne out in contemporary views about

the spread of malaria and cholera. It was commonly believed, and

had been since ancient times, that diseases were the product of

environmental factors such as contaminated water, foul air, and poor

hygienic conditions. By this theory, diseases were not passed from

person to person, but would affect individuals within the locale that

gave rise to these foul smells.

1853: Scottish physician Alexander Wood added a plunger and

glass syringe to the hollow needle invented in 1844 by Francis Rynd,

creating the modern hypodermic needle. This allowed doctors to

estimate dosage based on the amount of liquid observed through the

glass. This gave a new and effective way of administering drugs into

the human body.

An 1831 colour lithograph by Robert Seymour depicts cholera as a robed, skeletal creature emanating a deadly black cloud.US National Library of Medicine photographic archive.

1849 and 1854: London cholera outbreaks. John Snow mapped

deaths from cholera in the Soho area in 1854 and traced the source of

the outbreak to a contaminated public water pump. He was an early

proponent of the germ theory of transmission and attributed the high

number of cholera cases to water sources contaminated with human

waste.

What is remarkable is that John Snow’s largely accurate theories about

the spread of the disease were essentially refuted by Edmund Parkes.

Engaged to review Snow’s findings, Parkes – then the Professor of

Clinical Medicine at University College, London – was willing to accept

contaminated water as a cause but found it no more convincing than

air-borne transmission. Within a few years, and after service in the

Crimea, Parkes would be appointed to the position of Professor of

Military Hygiene at the new Army Medical School. This clearly

evidences both the state of contemporary thinking and how it quite

rapidly altered.

Digitised version of John Snow’s 1854 cholera mapRobin Wilson

During the construction of the hospital

1858: the ‘Great Stink’. Hot weather in central London in July and

August 1858 exacerbated the smell of untreated human waste and

industrial effluent that was present on the banks of the River Thames.

The problem had been mounting for some years and was due to an

ageing and inadequate sewer system that emptied directly into the

Thames. The miasma from the effluent was thought to transmit

contagious diseases. The smell and fears of its possible effects

prompted action from the local and national administrators. They

accepted a proposal from the civil engineer Joseph Bazalgette to

move the effluent eastwards along a series of interconnecting sewers

that sloped towards outfalls beyond the metropolitan area.

1861: Louis Pasteur and ‘germ theory’. Pasteur published his theory

suggesting bacteria cause human diseases. He based his ideas on

experiments which proved that germs make milk go bad and cause

diseases in animals. Pasteur insisted that ‘germs’ could be spread by

human contact and even transmitted by medical instruments. Further

experiments convinced many doctors he was correct, however the

miasma ‘bad air’ theory persisted for some decades. Commentators

maintain that of all nineteenth century medical/scientific discoveries,

this was the one that was the most significant as it had the greatest

effect on future developments.

Studio portrait of Louis PasteurInstitut Pasteur

After the hospital opened

1867: Joseph Lister pioneered the use of antiseptics effective against

infection. On reading about Pasteur’s germ theory, Lister experimented

with carbolic acid spray to produce the first antiseptic. Its application

greatly reduced the chances of patients dying from infection and made

longer, more complex operations possible. Lister is now recognised as

‘the father of modern surgery’. In 1871 Queen Victoria underwent a

minor operation on her arm conducted by Lister using his new

technique.

1875: UK Public Health Act – this legislation heralded a major change

in the attitudes of governments to improving people’s health. It was

the first British law to make it compulsory for local councils to improve

sewers and drainage, provide fresh, clean water supplies and appoint

medical offices and sanitary inspectors. Previous legislation had been

no more than advisory.

1882 and 1883: Using Pasteur’s work, Robert Koch identified the

bacteria causing tuberculosis and cholera. His methods were copied by

other scientists who discovered the bacteria causing other diseases.

Once the bacteria were identified then, applying the same principles as

Jenner did with smallpox, vaccines could be developed.

The antiseptic system in practice in an operating roomWellcome Collection

This then was the background and context within which the Royal

Victoria Hospital and Army Medical School opened and operated, from

the spring of 1863.

In addition, medical publications such as The Lancet and Provincial

Medical and Surgical Journal (later the British Medical Journal), and

upon which professionals are so reliant, had been in existence since

the first half of the nineteenth century. However, for all that,

information technology and dissemination of new learning in late

nineteenth century Britain and Europe bore little resemblance to what

we experience and benefit from today. Whilst telegraph services

connected Britain to most of the empire for the whole of the period

under review, a telephone system was not operational until c.1900. In

short, the easy exchange of knowledge was problematic in Victorian

Britain. News of progress made by medical scientists in Europe or

especially in India (as with cholera) would have been slow to reach

Netley.

The great telegraphing room at the new offices of the Electric and International Telegraph Company, Bell Alley, Moorgate Street, LondonThe Illustrated London News, 31 December 1859.

Yet it is clear that such developments elsewhere did reach the Army

Medical School and were embraced: David Douglas Cunningham and

Timothy Richards Lewis were sent to Germany in 1868 to develop their

skills before going to India and the Ukrainian microbiologist WM

Haffkine was invited to Netley in the 1890s. The Royal Victoria Hospital

was among the first establishments to acquire an X-ray machine after

the process was discovered in 1896 and, however cumbersome the

equipment, advocated its transport to and use in theatres of conflict

almost immediately.

The pages that follow demonstrate the very significant role played by

those from Netley in the acquisition of knowledge about and the

prevention and treatment of many of the diseases that blighted the

empire and mankind at large at the start of the Victorian age. Thanks

in no small way to their contributions, great progress had been made

by its end.

X-Ray Apparatus at the Royal Victoria Hospital, Netley

Cholera

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There were many infectious diseases prevalent in the 19th century. Of

these, cholera epitomises the impacts they all had in Great Britain and

parts of the Empire. It also shows the piecemeal and sometimes

confused efforts to analyse the cause and combat the effects of such

diseases.

In 1854, the year before the Royal Victoria Hospital was

commissioned, London suffered its fourth major cholera outbreak in

just over thirty years. The general view at the time was that the

disease was caused by poisonous vapours. These were thought to

come from the foul smelling air in areas with poor sanitation. This was

known as miasma theory. It suggested that diseases were not passed

from person to tperson, but would affect individuals in the area where

these foul smells were to be found. This was thought to explain why

diseases like cholera were epidemic in the 'undrained, filthy and

stinking areas' inhabited by the poor.

An 1831 colour lithograph by Robert Seymour depicts cholera as a robed, skeletal creature emanating a deadly black cloud.US National Library of Medicine photographic archive.

This notion even prevailed at Netley. The Chair of Military Hygiene,

Professor Edmund Parkes had established himself as an authority

on cholera in the late 1840s. The General Board of Health

commissioned him to investigate the first few cases of cholera as

they appeared in London in 1849.

His brief was to test the theory that cholera was contagious.

Parkes had already concluded from his previous experience in

India that it could not be spread from person to person. Nothing in

the disparate cases he examined in London changed his thinking.

He described himself as a modified contagionist. He believed that

cholera had a specific material cause, but that certain local and

environmental conditions had to be present for it to become an

epidemic.

Parkes' views about local causes were in line with those held by

the General Board of Health. They stressed that cholera was

primarily caused by the moisture, effluvia and impure air in

unsanitary districts of the city.

Edmund Alexander Parkes (1819-1876)Wellcome Images

Edmund Alexander Parkes (1819-1876)

Parkes studied for his medical degree at University College London,

also becoming a member of the Royal College of Surgeons. He

became Assistant Surgeon to the 84th (York & Lancaster) Regiment in

1842 and spent 3 years serving in Burma and India. He left the army

to take up a position as Assistant Physician at University College

Hospital, London. His first-hand experience of cholera, hepatitis and

dysentery in the army had a profound and lasting impact on his

career. On leaving, he published several pieces of research into the

cause, effect and treatment of these diseases. In 1849, Parkes was

promoted to the post of physician and Chair of Clinical Medicine at

University College London, where one of his students was William

Jenner.

He resumed his military service during the Crimean War (1854-1856),

when he was called on to superintend the formation and running of

the hutted military hospital at Renkioi in Turkey. After the Crimean,

Parkes advised the War Office on the reform of military medicine and

advocated the creation of an army medical school. He became the

Chair of Military Hygiene at the school, first in Chatham, then at

Netley. It was the first such post anywhere in the world.

Edmund Alexander Parkes (1819-1876)Wellcome Images

The London physician John Snow was one person who questioned

the validity of the miasma theory. He mapped deaths from cholera

in the Soho area of London in 1854. From this he was able to

identify the source of the outbreak as a contaminated public water

pump on Broad Street. His studies of the pattern of the disease

persuaded the local council to disable the well pump by removing

its handle. This contributed significantly to the containment of the

disease in the area.

Snow was an early proponent of the germ theory of transmission.

He attributed the high number of cholera cases to water sources

contaminated with human waste. He also correctly suggested that

the disease replicated in the lower intestine and that the structure

of cholera was that of a cell. However after the cholera epidemic

subsided, government officials replaced the pump handle and

rejected his ideas, still holding to the miasma theory.

Main: John Snow Cholera Map (1854)Left: John Snow (1813-1858)

After the 'Great Stink' in London in 1857, the government passed a

new Public Health Act looking at health and sanitary regulations. The

engineer Joseph Bazalgette was also commissioned to design and

build a comprehensive system of sewers for London. These diverted

human waste away from the water supply and contributed to the non-

return of cholera to the capital.

Main: Map of proposed Metropolitan Drainage System (1858)Above: Joseph Bazalgette (1819-1891)The Engineer Magazine

Somewhat surprisingly, the links between cholera and sewage-

contaminated water do not seem to have been shared, or fully

grasped, across the wider British Empire.

The British Army in India had suffered considerably from a cholera

outbreak in 1817. More widely in India, epidemics in the 1830s, 1840s

and 1860s are thought to have killed anywhere between 10-15

million. These epidemics caused popular unrest in the country,

accentuating social conflict. Cholera was generally a disease of the

rural poor, but there were greater incidences at times of Hindu

pilgrimages and significant troop movements. The 1867 epidemic, for

example, was centred on the religious fair in Hardwar and killed more

than 100,000 people.

Even before the Hardwar outbreak, pressure was mounting on the

British to act to prevent cholera spreading from India to Europe. The

International Sanitary Conference met at Constantinople in 1866.

They demanded that the government in India take further measures

to control the disease on the sub-continent. Part of the British

response to this situation was to initiate a scientific study of the

causes of cholera. This was to be carried out under the direction of

James McNabb Cuningham, Sanitary Commissioner for the Bengal

Medical Service. Cuningham was a capable administrator and

pushed for improved sanitation across India. However he

doubted the value of bacteriological research.

James McNabb Cuningham (1829-1905) Wellcome Images

It was clear to the professors at Netley that no-one working in India

had the specialist skills needed to perform a study using microscopic

and botanical research. They therefore proposed that the two most

able doctors from the Netley 1868 cohorts be trained to undertake the

enquiry.

The top candidate from the Indian Medical Service exams was

Scotsman David Douglas Cunningham. Timothy Richards Lewis, a

Welsh doctor, obtained the highest mark in the Army Medical

Department exams. At the instigation of Professor Parkes,

Cunningham and Lewis travelled first to Germany. There they

received instruction from noted botanists looking at fungi as a

possible cause of the spread of disease.

David Douglas Cunningham (1843-1914)

David Douglas Cunningham obtained his medical degree

from Edinburgh in 1867. He passed the entry exam for the

Indian Medical Services in April 1868 and was sent to Netley

for the summer session. He completed the four month

course in military medicine, graduating top of his class. On

leaving Netley, Cunningham, along with fellow graduate

Timothy Richards Lewis, was posted to India to carry out

an enquiry into the causes of cholera.

David Douglas Cunningham (1843-1914)The Royal Society

Timothy Richards Lewis (1841-1886)The Royal Society

Timothy Richards Lewis (1841-1886)

Lewis was born in Wales and became a chemist and dispenser before

qualifying in medicine from the university of Aberdeen in 1867. The

following year he went to the Army Medical School at Netley,

qualifying top of his class.

He worked in India on several aspects of tropical medicine, including

cholera, leprosy, trypanosoma, and fungal infections. In 1883 Lewis

returned to Netley as Assistant Professor of Pathology, where he

introduced practical bacteriology to the curriculum.

Douglas David Cunningham and Timothy Richards Lewis arrived in

India in January 1869 to be supervised in their work by James

Cuningham. This is perhaps at the root of the difficulties they faced.

Although recruited by Parkes at Netley, they were under the direction

of the Sanitary Commission. Between them, Cunningham and Lewis

carried out considerable microscopic work, and investigated a vast

range of environmental and physical factors. However they did not

draw any conclusive, scientific answers for the causes of the

outbreaks of cholera. In fact, their research really served only to

validate British sanitary policy in India.

Working in India in 1883, the German biologist Robert Koch

identified Vibrio cholerae as the bacteria causing the disease. He

found the bacilli in the bowels of people who had died of cholera, as

well as on their clothing and bed linen. He traced these cases of

cholera to a nearby water tank, which had been used by the locals

for drinking, washing, and waste disposal.

Among other scientists globally, Cunningham and Lewis initially

rebutted Koch’s contagionist theory. They felt he had not proved

that the bacteria caused the disease and only that they were

present as a result of contracting cholera. However there were

concerns on a political and economic level too. A contagionist

model would suggest that the spread of the disease could only be

stopped by the introduction of strict quarantine measures. It was

felt this would cause 'incalculable damage to commercial interests.'

This outcome was something the government was anxious to avoid.

Cholera expedition to India in 1884Robert Koch (1843-1910) is third from rightPaul de Kruif: “Mikrobenjäger”, Zurich, 1927, public domain

Sanitary improvements were made in India, including the building of

water purification works. However it would be many years before

the Anglo-Indian medical scientists would finally embrace Koch’s

findings and the implications of what John Snow had suggested

back in the 1850s. The Indian authorities were equally less than

enthusiastic when the Russian Waldemar Haffkine trialled the first

cholera vaccine in Calcutta on 40,000 people in the period 1893-96.

They questioned its effectiveness and feared how mass inoculations

might be received by the local people.

The military establishment did not fully embrace research into the

cause and prevention of cholera until well into the 20th century.

In the 19th century it was considered that a cold abdomen would

lead to cholera, diarrhoea and other stomach complaints. In 1848

the instructions to army medical officers in India included the

suggestion that every soldier should be provided with two 'cholera

belts'. These were wide strips of (usually red) flannel or knitted

wool, twisted round the waist before wearing a shirt. The belts are

thought to have a connection to the cummerbunds worn with dinner

jackets and tuxedos to this day! In the early 1900s, well after the

cause of cholera was known, their use was still recommended for

preventing dysentery. The idea of abdominal chilling as a factor in

illness remained as late as 1947, although it was countered by

those who pointed out that the idea was not based on

experimental evidence.

It is now known that cholera is an acute diarrhoeal infection caused

by the ingestion of food or water contaminated with the Vibrio

cholerae bacteria. Most people with the infection do not develop any

symptoms, although the bacteria are present in their faeces for 1-10

days after infection. Among people who develop symptoms, the

majority have mild or moderate symptoms. However a minority

develop acute watery diarrhoea with severe dehydration. This can

lead to death if left untreated.

Cholera remains a global threat to public health and is an indicator

of inequity and lack of social development. It is still prevalent in

areas where there is limited access to safe water and sanitation.

Researchers have estimated that every year, there are up to 4

million cases, and 143,000 deaths worldwide due to cholera.

Woman and child in Yemen, 2020Photo credit: Anadolu Agency

Malaria

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The term malaria dates to the mid-18th century, where it comes

from the Italian mala aria, meaning ‘bad air’. It was originally used

to describe the unwholesome atmosphere in marshlands, to which

the disease was attributed.

The idea that 'bad air' or 'marsh miasma' caused malarial infections

lingered as a misconception amongst scientists until the end of the

19th century. It persisted even as more scientific explanations

were established for the causes of other infectious diseases.

An insight into the impact of malaria on the British Army and other

forces can be gained from Professor William Maclean’s lecture

notes. These were published in 1886 in his book, Diseases of

Tropical Climates.

Maclean notes that in 1809, a British expeditionary force had been

sent to the Netherlands to destroy an invading French force. Within

50 days of landing nearly 10,000 men were in hospital with

malaria, with between 25-80 men dying daily. He also quotes a

source from the Italian War Office which stated that the annual

costs of malaria on the Italian army were £400,000 (or close to

£50m, 2021).

Surgeon-Major William Campbell Maclean (1811-1898)

William Campbell Maclean (1811-1898)

William Maclean was born in Ayr in 1811. He went to Edinburgh

Medical School, then at the height of its fame as the most

important in the world. He joined the Madras Army in 1838 and

worked exclusively in India as a medical officer. He held the post of

Residency Surgeon at the Court of Hyderabad from 1844-1845.

Here he organised a medical school where Indian people could be

instructed in Western medical science in their own languages.

In 1860, Maclean accepted the post of Professor of Military

Medicine at the new Army Medical School at Fort Pitt. He moved

with the school to Netley when the Royal Victoria Hospital opened

in 1863 and remained there until his retirement in 1886.

He was the army authority on malaria, enteric (typhoid) fever,

dengue fever, yellow fever, dysentery and cholera. He also

researched heart disease amongst soldiers and made

recommendations to redistribute the equipment they carried to

improve respiration and circulation.

Surgeon-Major William Campbell Maclean (1811-1898)

Maclean notes that in 1809, a British expeditionary force had been

sent to the Netherlands to destroy an invading French force. Within

50 days of landing nearly 10,000 men were in hospital with

malaria, with between 25-80 men dying daily. He also quotes a

source from the Italian War Office which stated that the annual

costs of malaria on the Italian army were £400,000 (or close to

£50m, 2021).

From the same lecture notes from 1886, it is clear that scientists

had progressed from a simple belief that the disease arose from

'bad air'. Maclean outlined in detail the environmental conditions in

which malaria was most common. The link to rank vegetation and

standing water was clearly understood. He also described the

French physician Charles Laveran's discovery of parasites in the

blood of malaria patients. The lecture also noted that these

parasites affected the red blood cells, leading to anaemia and

enlarging of the spleen and liver, and that the effects of the disease

were frequently recurring. However, scientists did not know the

host of the parasite, nor the means of transmission.

The breakthrough into the transmission of malaria came after

Maclean’s retirement from Netley in the 1886. Central to the work

was a former product of the Army Medical School, Ronald Ross.

Laveran’s 1880 illustration of various stages of malaria parasites as seen on fresh blood Center for Disease Control and Prevention

During his time in India, Ross took an increasing interest Malaria. It

was the cause of many of the fevers which he deemed to be his

biggest problem. About one third of the 300,000 men in the army

in India were admitted to hospital with malaria each year.

Ross knew of the French physician Charles Laveran’s 1880

discovery of malarial parasites in the blood. He carried out his own

microscopic research, but failed to find the parasites, which caused

him to question the whole theory.

On leave back in England in 1894, Ross was directed to physician

Patrick Manson, who demonstrated the parasites in specimens of

blood derived from a hospital patient. Manson had already

identified mosquitoes as important stages in the lifecycle of

another parasitic tropical disease. He raised with Ross the

possibility that mosquitoes might carry malaria.

Ronald Ross (1857-1932)Liverpool School of Tropical Medicine

Ronald Ross (1857-1932)

Ronald Ross completed his medical degree at St Bartholomew’s

Hospital Medical School. He graduated from Netley in 1880 and

entered the Madras Medical Service in 1881. He is best known for

his work on malaria, but also researched kālā āzār (now known as

Leishmaniasis) and dysentery.

On returning to India, Ross tried to prove Manson’s theory. He bred

different species of mosquito and fed them on blood from malarial

victims. His work was an attempt to culture the malarial parasite in

the mosquito. It took two years before his work was successful. In

August 1897 Ross observed the parasite in the stomach tissue of

Anopheles mosquitoes fed on the blood of a malarial patient. His

dissections of the mosquitoes over a number of days proved the

lifecycle of the parasite. This demonstrated that mosquitoes serve

as intermediate hosts for malaria.

He continued his research with a study of malaria in birds. After

feeding mosquitoes on infected birds, he found that the malaria

parasites could develop in the mosquitoes and migrate to the

insects’ salivary glands. This allowed the mosquitoes to infect other

previously-healthy birds during subsequent blood meals. This

closed the circle on the problem of malaria. With an understanding

of the method of transmission, it was possible to approach the

control of the disease on a defined scientific basis. In recognition

of his work, Ronald Ross was awarded a Nobel Prize in 1902.

In the 20th century others with Army connections also advanced

treatments of malaria, most notably Surgeon-Captain John Sinton

(1884-1956). He was appointed the first Director of the Malaria

Survey of India, an institution that become one of the chief centres

of malaria research in the world. His work contributed

significantly to the eradication of the disease in much of India. A dissection of malariated mosquito by R. RossWellcome Images

Leishmaniasis

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Leishmaniasis was named after William Boog Leishman, Netley

graduate and later Professor of Pathology at the Army Medical

School. It has a long history, with descriptions of similar-sounding

conditions dating back to Ancient Egypt. However the

understanding of the disease that came in the late 19th and early

20th centuries is heavily linked to the Army Medical School at

Netley through several of its graduating officers.

From the 16th century onwards, there are records of people

suffering skin lesions and sores in various places in the Middle

East. These were often named according to the place in which they

were acquired: Nile pimple, Baghdad boil, Oriental sore or Jericho

buttons. The ulcers resembled leprosy lesions and caused long-

term scarring. On the Indian subcontinent, the disease was known

as kālā āzār, or black fever, for the discolouration of the skin.

The search for the cause of the different forms of Leishmaniasis

did not begin until the end of the 19th century. The disease was

widespread in India after the Indian Rebellion of 1857 and had

reached epidemic proportions by 1870.

Leishmaniasis lesions on the faceM. Saeedi, World Health Organisation

The search for the cause of the different forms of Leishmaniasis did

not begin until the end of the 19th century. The disease was

widespread in India after the Indian Rebellion of 1857 and had

reached epidemic proportions by 1870.

In 1885, David Douglas Cunningham, Netley graduate and now

Surgeon Major of the British Indian Army, published a paper noting

the presence of “peculiar parasitic organisms in the tissue of a

specimen of Delhi boil.” However he did not realise what they were

or make the connection with kālā āzār.

In 1898 Peter Borovsky, a Russian military surgeon in Tashkent,

conducted research into the cause of ‘Oriental sore’. He published the

first accurate description of the causative agent – the bite of a

phlebotomine sandfly. However because his results were published in

Russian in a journal with low circulation, they were not then

internationally acknowledged. Instead the story is picked up later in

1898 by another Netley graduate, Ronald Ross.

David Douglas Cunningham (1843-1914)The Royal Society

In September 1898 Ross was invited by a local medical officer to

work in southern Assam (north east India) to study an epidemic of

kālā āzār. He had recently identified mosquitoes as the means of

transmission of malaria. This may account for him incorrectly

reaching the conclusion that kālā āzār was a quinine-resistant form

of the disease. He believed that the kālā āzār parasite was

transmitted by a mosquito, which he referred to as

Anopheles Rossi.

In 1900 there came a breakthrough when William Boog Leishman

discovered ovoid bodies in smears taken post-mortem from the

spleen of a soldier who had died from emaciation and splenomegaly.

The following year he developed a method of staining blood smears

to identify and differentiate between white blood cells, malaria

parasites and other protozoan parasites, called trypanosomes. He

used this to suggest that the ovoid bodies were degenerate

trypanosomes. He theorised that the soldier’s illness (which he called

‘Dum Dum fever’ from the town near Calcutta where the soldier had

been stationed) was a form of trypanosomiasis. He published his

findings in May 1903.

Sir William Boog Leishman (1865-1926)Wellcome Images

William Boog Leishman (1865-1926)

William Boog Leishman was just 20 when he qualified in medicine

in Glasgow. He completed the course at Netley in 1867 and was

posted to India. Here he began the research into the causes of

kālā āzār, for which he is best known.

On leaving India, Leishman returned to Netley, where he worked

with Almroth Wright on typhoid vaccine. In 1900 Leishman was

appointed Assistant Professor of Pathology at the Army Medical

School. He developed a method of staining blood samples, which

is known as Leishman’s stains and is still used today.

Leishman became Chair of Pathology when the Army Medical

School moved to London in 1904. He continued Almroth Wright’s

work on an anti-typhoid vaccine, which resulted in the successful

protection of British troops during the First World War.

Sir William Boog Leishman (1865-1926)Wellcome Images

A matter of weeks later, Lieutenant-Colonel Charles Donovan, yet

another graduate of Netley and now professor of physiology at the

Madras Medical College, published a paper with very similar

findings. He reported that he had found parasitic bodies in samples

taken from native Indian subjects with remittent fever and

enlarged spleens. He identified these parasites as the causative

agent of kālā āzār.

Charles Donovan (1863-1951)Wellcome Images

Charles Donovan (1863-1951)

Charles Donovan was born in India in 1863, son of an Irish judge

working in the Indian Civil Service. He studied medicine at Trinity

College Dublin and received his MD degree in 1889 from the Royal

University of Ireland. He graduated from the Army Medical School

at Netley in 1891 and was commissioned as Captain in the Indian

Medical Service. In 1898 he was posted to the Madras Medical

College and Government General Hospital, where he became

Chair of the Physiology Department.

There was some controversy as to whom should be credited with the

discovery, and confusion over the correct identity of the parasite.

It was Ronald Ross who resolved the conflict and linked the two

discoveries. He identified that the ovoid bodies were in fact a new

parasite species, which he named Leishman-Donovan bodies. They

were later formally named Leishmania donovani, equally crediting the

two scientists.

Donovan’s continued work on the biology of Leishmania donovani

established him as the leading authority on kālā āzār. He and Ronald

Ross coined the term leishmaniasis to cover all conditions associated

with this and closely allied parasites.

Leishmania donovani in bone marrow cellCenters for Disease Control and Prevention's Public Health Image Library

Despite work to discover its cause over a century ago, this infection

has never been eradicated. There are three main forms of

leishmaniasis – visceral, cutaneous and mucocutaneous. Of these,

visceral leishmaniasis (still also known as kālā āzār) is the most

serious. Leishmaniasis is caused by parasites which are transmitted

by the bite of infected female phlebotomine sandflies. The disease

affects some of the poorest people on earth. It is associated with

malnutrition, population displacement, poor housing and a weak

immune system.

According to the World Health Organisation, visceral leishmaniasis

infects 300,000 people annually, causing 20,000 deaths. It is the

second largest cause of parasitic death after malaria. To this day, the

WHO strives to prevent and mitigate its impacts in its most prevalent

areas.

Chepsera Limaru watches over her son Pturu Limaruk who suffers from kala-azar at the Amudat hospital in Uganda.Lameck Ododo/DNDi

Brucellosis

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Brucellosis was named after David Bruce, Assistant Professor of

Pathology at the Army Medical School, Netley. It was the second

disease, after leishmaniasis, to be named after a doctor with

associations to the Royal Victoria Hospital. This account, however, starts

before the discovery attributed to Bruce. It is, like others a complex one

of controversies, misunderstandings and slowly acquired knowledge.

There was considerable confusion in the Victorian era over the cause

and diagnosis of various fever-based diseases. These were prevalent in

the Mediterranean, but hard to distinguish due to the similarities of

their symptoms. One such disease came to be known by a variety of

regional names, including Malta, Gibraltar and Cyprus fever. It was also

common in the Crimean War theatre of the mid 1850s, where it was

locally labelled Crimea fever. Key symptoms, along with the fever, were

joint and muscle pain, night sweats and gastric irritation. However in

some cases it could also cause neurological disorders, including

agitation and confusion.

One of the most noted sufferers of Crimea fever was Florence

Nightingale, who was diagnosed with the condition in May 1855. She

spent several weeks in hospital, at times delirious, critically ill and

unable even to feed herself. Florence took months to recover from

the initial illness and suffered from poor health for the rest of her life.

Sir David Bruce (1855–1931)London School of Hygiene & Tropical Medicine

Sir David Bruce (1855–1931)

Bruce graduated in medicine from the University of Edinburgh and

joined the Army Medical Service in 1883. After graduating from Netley,

he was posted to Malta, where he researched the causes of Malta

Fever. It later came to be known as Brucellosis in his honour.

From 1889 to 1894, David Bruce served as Assistant Professor of

Pathology at the Army Medical School at Netley, where he introduced a

course in bacteriology.

Bruce was later posted to South Africa, where he researched African

trypanosomiasis (sleeping sickness in humans and nagana in animals),

identifying the tsetse fly as the means of transmission. His discovery of

the organism causing nagana led to it being named Trypanosoma

brucei. He was rewarded with a knighthood in 1908.

During the First World War Bruce was Commandant of the Royal Army

Medical College. He chaired the War Office Trench Fever Investigation

Commission to help identify the cause and means of transmission of

trench fever.

Sir David Bruce (1855–1931)London School of Hygiene & Tropical Medicine

The first clinical description of the disease was made in 1861 by the

army surgeon Dr Jeffery Allen Marston, stationed in Malta. He defined

the disease as Mediterranean gastric remittent fever, noting that

symptoms would worsen over time (relapse), followed by a period of

improvement (remission). Although Marston did not know the cause

of the disease, he made a clear distinction between it and other

Mediterranean fevers. He reported his findings to the army medical

department in 1861, but the report was only published in 1863.

There were no further developments for more than twenty years. In

1884 David Bruce, a young graduate of the Army Medical School at

Netley, was posted to Malta. This island, being in a strategic position

in the Mediterranean, was an important naval base with 25,000

permanent British soldiers and sailors. It was also used as a

temporary station for British troops to acclimatise to the change in

climate on the way from England to India. Malta fever had a big

impact on the health of the British troops stationed there and the

government was concerned about the large number of reported

cases. Doctors were sent from Great Britain to Malta to find out the

cause of this disease.

Bruce carried out the post-mortem examination of a soldier who died

fifteen days after developing an acute case of Malta fever.

Examination of tissue from the spleen revealed the bacteria that

caused the infection. Bruce called it ‘micrococcus melitensis’.

Dr Giuseppe Caruana Scicluna was a Maltese analytical chemist, who

collaborated with Bruce. He prepared the agar plates used for the

spleen smears in his laboratory in the Public Health Department.

Later he succeeded in culturing the bacteria from spleen samples of

four British soldiers dying of Malta Fever. However Bruce never

properly acknowledged Caruana Scicluna’s contributions to this

important research.

From 1889 to 1894, David Bruce served as Assistant Professor of

Pathology at the Army Medical School at Netley. Having previously

studied bacteriology under the German microbiologist Robert Koch in

Berlin, Bruce instituted the first systematic course on the subject to be

given in any British medical school. In his early years at Netley, Bruce

seems to have inspired an interest in Malta fever in his students.

Surgeon Matthew Louis Hughes passed out of Netley at the head of

the list in 1890 and was awarded the Parkes Memorial Prize. In

December 1890, he was posted to Malta. He wrote a book about the

disease, ‘Mediterranean, Malta, or Undulant Fever’, which was

published in 1897. This gave a clear and detailed description of the

signs and symptoms of the disease, as well as epidemiological

information about its distribution.

Dr G Caruana Scicluna, the First Maltese MicrobiologistJournal of Medical Biography, 2000

Another significant advance in 1897 was made by Professors Almroth

Wright and David Semple at the Army Medical School at Netley. They

developed a blood test which could distinguish typhoid fever from

Malta fever through the presence of specific antibodies. This made it

possible to make a clinical diagnosis of Malta fever for the first time.

However, despite these achievements, the source of the bacteria

remained unknown. Impure water in the Grand Harbour of Valletta

was thought by many to be the breeding place of the fever, though

bad air and drains were also considered likely. A Maltese scientist with

no connection to the military, Dr Themistocles Zammit, was also

working on the problem. In 1902, he carried out a survey of cases of

Malta fever, compared them with typhoid fever and concluded that the

disease might be spread by insects.

The British Government formed the Mediterranean Fever Commission

(MFC) in 1904 to identify the source and mode of transmission of the

disease. The Royal Society named David Bruce chairman of the

commission. Other members included Dr Themistocles Zammit and a

close associate of Bruce’s from Netley, Major William Horrocks.

Horrocks had graduated from the Army Medical School in 1887 and by

1904 had returned as Assistant Professor of Military Hygiene.

Some of the members of the Mediterranean Fever CommissionThemistocles Zammit: top row, far leftDavid Bruce: front row, centreWellcome Images

Members of the MFC conducted surveys to establish the prevalence of

Malta fever and identify the extent of the problem. They also carried

out microbiological investigations, including the experimental

transmission of the disease to laboratory animals. For this they used

goats, which were readily available locally. In carrying out blood tests

on the goats prior to experimentation, Zammit discovered that many

of them carried the micrococcus melitensis bacteria in their blood.

Thousands of goats were then examined in Malta and it was found

that nearly half of them were infected, even apparently healthy

animals. Further tests showed that around 10% of them had the

bacteria in their urine and milk. This gave a method of transmission

of the disease to humans through ingesting the infected milk.

This finding explained the hitherto baffling fact as to why patients and

medical staff in the military and naval hospitals were more likely to

contract Malta fever while there. At the time, the Maltese distributed

milk directly from goats at the door, where they were freshly milked.

In 1906, the use of goats’ milk by the British Armed Services was

prohibited and case numbers dropped dramatically. Between 1900 and

1906 there had been a total of 3,631 cases, but by 1907 there were

only 21. Condensed, evaporated and sterilised milks were used

instead.

Goats at St George’s Bay Malta with St George’s Barracks in the backgroundMalta RMC/QA Archives photo album 1914-1918

David Bruce had discouraged the experiments on goats being carried

out by Zammit and cast doubt on his ability as a microbiologist.

Between them, Bruce and Horrocks played down Zammit’s role and

Bruce took steps to take credit to himself. As editor of the Journal of

the Royal Army Medical Corps, he published frequent articles in the

journal about Malta fever. These articles emphasised the role of the

RAMC members of the Commission, but omitted or played down the

work by Zammit and the naval officer, Shaw.

To a certain extent, Bruce succeeded in claiming credit for the

discovery of both the bacteria and its source. The disease was later

named brucellosis in his honour. However, people outside the RAMC

also recognised Zammit’s contribution. He achieved an international

reputation both as a chemist and later as an archaeologist.

Themistocles Zammit was knighted in 1930 in recognition of his role in

helping eliminate undulant fever from Malta.

Portrait of Dr. Themistocles Zammit (1864-1935)painted by Edward Caruana DingliCulture Malta

It is now known that brucellosis is a highly contagious zoonosis - a

disease that can be transmitted from animals to humans. It is caused

by the ingestion of unpasteurised milk or undercooked meat from

infected animals, or close contact with their secretions. The most

common symptoms of brucellosis are fever, sweats, back and joint

pain, loss of appetite and extreme tiredness. However in severe cases,

the central nervous system and lining of the heart may be affected.

Brucellosis can also trigger an autoimmune response in some people,

causing inflammatory conditions such as arthritis, spondylitis and

meningitis. One form of the disease manifests itself in various

neurological conditions, including confusion, agitation, depression and

behavioural changes.

Florence Nightingale struggled with a chronic form of brucellosis,

which caused her many and varied health problems into old age. She

suffered heart palpitations, fainting fits, weakness, nausea and severe

spinal and joint pain. She also experienced persistent neurological

effects of the disease. These included depression, insomnia and

nervousness. Some historians say that these account for her ‘gloomy,

agitated and obsessive personality’ during her later life.

Florence Nightingale (1820-1910)Wellcome Images

Dysentery

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A close medical companion of cholera, dysentery is a type of

gastroenteritis that results in diarrhoea with blood. Other symptoms

may include fever, abdominal pain, and mucus or blood in the

faeces. Dysentery can be caused by bacterial infection, viral infection

or parasitic worms. It is one of the symptoms of cholera and, just as

in the nineteenth century, treatments today are similar. The English

word dysentery comes from two Greek words meaning 'ill' or 'bad'

and ‘intestine’. Prior to the Victorian age, it was known as ‘the

Bloodie Flux’.

One commentator of that age wrote: “Of the diseases incident to

Europeans in tropical climates, there is perhaps none of more

importance, whether we consider the amount of mortality arising

from it, or the permanently impaired health produced by alteration

of structure in those who have laboured under it. In the army this is

even more marked than in civil life, for the soldier … suffers

repeated relapses until the disease terminates either in death or in

organic alterations of such a character as to render him permanently

unfit for military service.”

A Dysentery ward of the General Hospital at Port Said© IWM Art.IWM ART 2941

This is borne out by some statistics: typhus and dysentery decimated

Napoleon's Grande Armée in Russia, while more than 80,000 Union

soldiers died of dysentery during the American Civil War. Critically

from a British perspective, during the Crimean War many more

soldiers died from cholera and dysentery than battle wounds.

In a lecture to students at the Army Medical School, the Professor of

Military Medicine, William Campbell Maclean told them that in the

1830s, roughly one third of British soldiers serving in India could be

expected to suffer from the disease - a rate eleven times higher than

local soldiers! Maclean left his students in no doubt as to the ravage

and suffering this disease brought.

Fortunately, treatment methods by the 1880s had advanced from the

bloodletting, blistering and ingesting of lead salts and emetics

common during the age of the Napoleonic wars. Instead, doses of

varying amounts of ipecacuanha, sometimes in association with

quinine, were favoured and are reported to have been successful. In

what Maclean referred to as the sanitary age, focus then appears to

have concentrated on improved hygienic practices to prevent its

occurrence and effective methods of successful treatment to

remediate the patient.

Hospital in Sebastopol – Dr Durgan attending the wounded from a sketch by EA GoodallWellcome Images

Unlike many of the other common infectious diseases of the age,

medical scientists from Netley can claim no part in the discovery of

the underlying cause of dysentery. That prize goes to the Japanese

bacteriologist, Shiga Kiyoshi, (1871-1957) who, in 1897, identified the

dysentery bacillus Shigella, which is named after him. However a

Netley graduate, Leonard Rogers, can be credited with finding an

effective treatment.

Sir Leonard Rogers (1868-1962)J. Russell & Sons, Wellcome Images

Sir Leonard Rogers (1868-1962)

Leonard Rogers was born in Cornwall in 1868 and qualified in

medicine at St Mary’s medical school in London in 1891. After

attending the medical officers’ course at Netley, he received a

commission in the Indian Medical Service in 1893. His research

interests were varied, and he developed treatments for

dysentery, cholera and leprosy. He was also greatly interested in

medical education. He founded a School of Tropical Medicine in

Calcutta and was a founder member of the Royal Society for

Tropical Medicine in 1907.

Posted to Calcutta in 1900, Rogers ultimately became Professor of

Pathology in the medical college. In fact, he spent much of his time in

the hospital wards. He differentiated between the symptoms of

bacillary dysentery (caused by the Shigella bacteria) and amoebic

dysentery (caused by a parasite called Entamoeba histolytica). In

1912, he developed a new treatment for the amoebic form, injecting

patients with emetine, a pure extract from the ipecacuanha root. Its

immediate success led to it becoming the accepted treatment.

Ronald Ross (Netley graduate whose work on Malaria is discussed

elsewhere in this collection) gave a lecture to the Royal Society of

Medicine in 1915. He made no mention of Shiga Kiyoshi's research

into the bacterial form of dysentery but did acknowledge Rogers'

work. Ross remarked: “as an immediately applicable routine

treatment, the hypodermic injection of emetine has certainly become

a great boon to humanity, for which we owe a debt to Sir Leonard

Rogers which can never be repaid.”

Rogers was recognised by the Royal Society for Tropical Medicine in

1938: “by his insistence on the value of emetine in amoebic dysentery

and by his introduction of the soluble salts of emetine, he very greatly

stimulated the use of this valuable drug in the treatment of amoebic

dysentery in all parts of the tropics.”

Entamoeba histolytica in the trophozoite stageJ. Craig Venter Institute

Typhoid Enteric Fever

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In a lecture to his students at Netley, the Professor of Military

Medicine William Maclean quoted his colleague Professor Aitken:

“enteric fever is the most treacherous of all diseases”.

Had he been alive just twenty years later and informed about ’Typhoid

Mary’, Maclean would probably have been unsurprised to learn how

such a ‘super-spreader’ could have existed, undetected, in the

community for so long. Mary Mallon’s story is synonymous with

typhoid but not one that can be told in the context of the Royal

Victoria Hospital and the Army Medical School.

Maclean was essentially referring to what we now know as typhoid,

but which was only specifically identified and labelled in the 1880s.

Before then there had been outbreaks of typhoid in England and it

had ravaged British troops serving overseas. This was particularly

notable during the Crimea War where it was prevalent with cholera

and dysentery.

Surgeon-Major William Campbell Maclean (1811-1898)

In 1853, Physician William Budd recorded an outbreak of the as yet

unnamed fever in the Welsh town of Cowbridge. He learned that all

eight individuals who became ill had consumed lemonade made with

water from a well near a local septic tank. Budd was familiar with John

Snow’s essay on cholera in London. He became suspicious about

water as a possible source of the Cowbridge infection. In 1866 Budd

and a colleague investigated another outbreak involving a group of

farm cottages with drains linked to the same stream. They observed

that the later infections had all occurred downstream from the cottage

where the first case had arisen. This led Budd to conclude that water

had been the source of transmission and that its mode was faecal-

oral. He suggested that poor hygiene and unsanitary living conditions

contributed to its spread. He recommended improved sanitary

measures to slow and prevent transmission. Application of these

measures in Bristol helped to significantly reduce the spread of cholera

there by the late 1860s.

However the medical and scientific communities did not fully recognise

the role of micro-organisms in infectious disease until the work of

Robert Koch and Louis Pasteur in the 1880s. Specific to typhoid, in

1880 Karl Joseph Eberth described a bacillus that he suspected was its

cause. In 1884, pathologist Georg Theodor August Gaffky confirmed

Eberth's findings. The organism was given names such as Eberth's

bacillus, Eberthella Typhi, and Gaffky-Eberth bacillus, but is known

today as Salmonella enterica, serovar Typhi.

William Budd (1811-1880)Historia Sanitaria

Graduates of the Army Medical School at Netley do not appear to have

contributed to discoveries into the specific causes of typhoid. Their

contribution, and where they have been widely recognised, is found in

the methods of preventing its contraction.

In 1892 the Ukrainian microbiologist WM Haffkine was invited to Netley

to demonstrate his cholera vaccine. This worked by the injection of live

cultures of the causative vibrio. Almroth Wright, Professor of Pathology

later demonstrated this method of preparing the vaccine to his class.

Haffkine’s visit suggested to Wright the practical possibilities of anti-

typhoid immunisation. Working with Surgeon-Major David Semple, he

started intensive work on the dosage, strength and testing of such

vaccines. Significantly, he discovered the all-important fact that dead

typhoid bacteria made effective immunising agents.

Clinical trials were not undertaken then in quite the same way as in the

21st century. As well as a horse (!) in the autumn of 1896, two officers

from the Army Medical School had the ‘privilege’ of being inoculated to

ascertain the correct dose. Both officers consented and were duly

inoculated. They had what is described by one of the subjects, as a

‘bad reaction’, being laid up for twenty-four hours and two days

respectively. However they loyally assured Wright that they were

‘doing well’. On the strength of these ‘trials’, Wright persuaded

Surgeon-General Cleghorn to undertake a wider trial of his vaccine

on 3,000 British Army volunteers in India.

Sir Almroth Edward Wright (1861-1947)

Sir Almroth Edward Wright (1861-1947)

Almroth Wright graduated with a degree in medicine from Trinity

College Dublin in 1883. He went on to hold positions at the Royal

College of Physicians and Surgeons, the University of Cambridge (as

Demonstrator of Pathology) and the University of Sydney (Professor

of Physiology).

He was appointed Professor of Pathology at Army Medical School

Netley in 1892. His lectures were (according to one student) “by far

the most interesting and popular of the course.”

Wright revolutionised the collection of blood and fluid samples for

testing, attaching a rubberised teat to the end of the pipette, which

led to cleaner and more aseptic collection of samples. He also

developed a disposable capsule for the collection, testing and storage

of blood specimens.

Wright published studies on typhoid, anthrax, TB, pneumonia,

plague, cholera, haemorrhage and microscopy but it his work as an

immunologist for which he is best remembered.

Sir Almroth Edward Wright (1861-1947)

Wright was further able to persuade the British authorities to permit

the vaccination of troops for the South African (Boer) War in 1899.

Sources differ on the numbers of soldiers who may have been

inoculated. Although Wright advocated the treatment for all, the

Government limited it to volunteers. Only a small percentage of

troops received the vaccination. Of the 22,000 British soldiers who

died during the war, 14,000 succumbed to illness, 9000 of these the

result of typhoid. Typhoid had once again claimed more lives than

enemy action.

Despite this, there was significant opposition to the programme, not

least amongst the scientific community. Infamously it is reported that

some consignments of the vaccine were dumped overboard in

Southampton Water and were later returned to Wright by the local

coastguards!

Anecdotal evidence suggested that only half of those inoculated went

on to develop the disease. However record keeping during the war

was poor. It is further suggested that Wright had a deep aversion to

statistics, making it hard to prove the efficacy of the vaccine. This

was raised as a matter of concern by the leading biological

mathematician of the time, Karl Pearson, who said the data showed

nothing.

Interior of Portland Hospital, Boer War, South AfricaWellcome Images

At the end of the war, a Medical Advisory Board was established by

the British government to investigate the typhoid vaccine. The panel

included David Bruce, who had been Wright’s rival for the post of

Professor of Pathology at Netley back in 1892. They concluded that

the vaccine was ineffective, and the programme was suspended. The

immediate outcome of the committee’s investigation was the

resignation of Almroth Wright from the post at Netley. Longer term, it

also led to the Army Medical School's relocation to Millbank in

London.

With regard to typhoid, the committee recommended that inoculation

be resumed voluntarily in the British Army and that further

investigative work be undertaken. This was led by William Leishman,

who had succeeded Wright’s successor, David Semple, at Netley in

1900.

In 1910 Leishman concluded that the disappointing results during the

Boer War were almost entirely due to irregularities in the preparation

and standardisation of the vaccines. As a result of the lengthy trials

(including guinea pigs and rabbits as their subjects!) very specific

changes were made.

Sir William Boog Leishman (1865-1926)Wellcome Images

The timing of Leishman’s findings was apposite. In the early weeks of

World War One, more than 170,000 doses of anti-typhoid inoculation

were issued to the troops. Successive doses were administered to

other soldiers during the course of the war. In all, 10 million vaccine

doses were produced for troops sent to the Western Front, saving an

estimated half a million lives. The British Army was the only one at

the outbreak of the war to have its troops fully immunised against the

bacterium. For the first time, casualties due to combat exceeded

those from disease.

World War One British soldier receives his typhoid inoculation from a military doctor at Salonika, GreeceGetty Images

Typhoid fever still occurs worldwide, primarily in developing nations

whose sanitary conditions are poor. Eighty percent of cases come

from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or

Vietnam. Within those countries, typhoid fever is most common in

underdeveloped areas. Typhoid fever infects roughly 21.6 million

people and kills an estimated 200,000 people every year.

Trench Fever

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The last of the infectious diseases within this study brings together

several graduates of the Army Medical School at Netley. They have

been encountered previously in this work, but we see them now in a

different setting and a new conflict: trench warfare on the Western

Front during World War One.

In mid-1915 physicians in the British Expeditionary Force on the

Western Front in France noticed an unusual acute febrile illness in

soldiers. The first reported case was in June 1915 when a British

medical officer in Flanders, Major John Graham, reported: “A private

[from] an infantry regiment was admitted to a casualty clearing

station suffering from a febrile illness of three days’ duration...

headache, dizziness, severe lumbago, a feeling of stiffness down the

front of the thighs, and severe pains in the legs referred chiefly to the

shins”.

The private’s fever resolved for several days, and then he had another

bout of fever and the aforementioned symptoms. After the second

round of fever, he recovered, except for fatigue. Within a few months,

hundreds of cases had been identified. As it was confined to the

trenches, the soldiers began calling it trench fever. Their superiors

eventually followed suit in the summer of 1916.

Soldiers in a front-line trench in World War One

The British troops in France were not alone in suffering from this

disease. Their French, German, Austrian and American counterparts

also complained of it and there was even an outbreak in Greece near

Salonika. Estimates of the numbers infected vary from 500,000 to the

1 million that Sir David Bruce quoted in a report to the Trench Fever

Commission published in 1922. As a proportion of the fighting forces,

between one-fifth and one-third of all British troops who reported ill

had trench fever, while about one-fifth of ill German and Austrian

troops had the disease.

The cases described by Graham were brought to the attention of

Colonel Wilmot Herringham, consulting physician to the British First

Army and Colonel William Leishman, now advisor in pathology to the

British Expeditionary Force.

Initially Leishman wrote of the new ailment “I am doubtful whether it

deserves serious attention.” In a meeting with Lieutenant-General

Alfred Keogh, Director-General of the Army Medical Service (himself a

graduate from Netley in 1880) Leishman did not even mention the

illness. Nevertheless, when he returned to France, Leishman carried

out further investigations of the disease, visiting hospital patients and

reviewing case studies.

Sir William Boog Leishman (1865-1926)Wellcome Images

Initially few thought it could be anything other than an infection. The

intermittent nature of the fever meant that comparisons with malaria

and relapsing fever were commonly made. A seeming increase of

cases in summer and a corresponding decrease in winter also lent

credence to the possibility of it being spread by mosquitoes. Some

doctors hypothesized that the illness might be one of the enteric

group of fevers, modified by preventive inoculation, such as that

given for typhoid.

Other pathologists, including Captain GH Hunt and Major AC Rankin,

disagreed vehemently with this view. They, along with a growing

number of medical officers, believed that the cause was a specific

organism that had never previously been recognised.

Hundreds of cases were examined in laboratories before it was widely

accepted that the fever was not enteric. It was only in the summer of

1916 that authorities moved to officially recognise it as a novel clinical

syndrome.

But what caused this new, mysterious ailment? Attempts to culture

the causative organism from blood, faeces, urine and nasal mucous

were unsuccessful. Blood smears were unrevealing. Tests for virus

antigens and antibodies for typhoid, paratyphoid and brucellosis

were negative.

Pathological Laboratory, Royal Victoria Hospital, Netley

Throughout 1916 there was a vigorous debate about the causes of

trench fever. Malaria was known to be spread by the anopheles

mosquito. It was suggested that a similar transmission vector might

be responsible here too. A number of medics theorised that the

condition might be carried by one of the common flies or parasites

found in the trenches, most likely the human body louse. Notable

among them were Captain T Strethill Wright, Major JW McNee and

Major Arthur Hurst. Hurst, for instance, described a situation where a

‘lousy’ sergeant had transmitted the disease to six of his compatriots.

Sir Arthur Frederick Hurst (1879-1944)British Medical Journal

Sir Arthur Frederick Hurst (1879-1944)

Arthur Frederick Hurst graduated from Magdalen College, Oxford,

in 1904 and went on to join the staff of Guy's Hospital. In the

early part of World War One he was a consulting physician

stationed in Salonika (modern Thessaloniki), Greece. He led the

neurology department at Netley from 1916 to 1919 and is best

known for his work there treating patients with shell shock.

However he was also a pioneer in the use of x-rays, test meal

analysis, sigmoidoscopy, and the gastroscope. He was a

co-founder of the British Society of Gastroenterology.

Other agents were also proposed, including field voles and rats, which

were common in the trenches. There were even some commentators

who had not fully embraced “germ theory” and contended that

climatic conditions in the trenches were the cause of the new disease.

The process of identifying the cause and means of transmission of

trench fever was tortuous. Lieutenant-General Alfred Keogh

established the War Office Trench Fever Investigation Commission

(TFIC) to investigate the matter. The commission was chaired by

David Bruce (who had discovered the cause of brucellosis) and held

its first meeting in November 1917.

It took three years from the first cases of trench fever being

described by Graham for the cause of the disease to be confirmed. In

February 1918 the TFIC announced that the human body louse was

responsible for trench fever. Infected louse faeces entering the body

through the eyes or skin wounds were responsible for transmitting the

disease.

Sir David Bruce (1855–1931)London School of Hygiene & Tropical Medicine

In 1916, long before lice were identified as the cause of trench fever,

the entomologist Alexander Peacock and Major Arthur Hurst published

reports on louse infestation in the army. The War Office issued a

pamphlet on the louse problem. Schools of sanitation for medical

officers were established, with weekly lectures on louse infestation.

Treatment of the condition was not wholly effective. The more useful

weapon against trench fever was direct action against the parasitic

cause. Recommendations were made to minimise infestation including

baths, insecticides, and the use of steam-propelled disinfectors.

At the end of the war, the Allies implemented rigorous disinfestation

procedures at French ports to prevent lice from returning with the

troops. Within months of the armistice, trench fever disappeared from

the British Army on the continent. Far fewer cases of trench fever were

reported during World War Two. More effective lousicides, including

DDT, were used early in the war by most of the combatants.

Furthermore, the mobile nature of tactics in the war meant that soldiers

were not generally crowded closely together for long periods as they

had been in World War One.

Trench fever has not gone away, although now it is more commonly

seen in populations of the homeless. However, the body louse still

lies at the root of the problem, as it did in the trenches of World

War One.

Thresh Portable DisinfectorBeamish Transport Online

Research: Tim Ford – Heritage VolunteerEditing: Ursula Pearce, MA – Heritage & Education OfficerRoyal Victoria Chapel 2021