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

Return to Contents 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 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.

Queen Victoria's First Visit to her Wounded Soldiers by Jerry Barrett Oil on canvas, 1856 NPG 6203 © National Portrait Gallery, London 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, Netley Boer Wars 1899-1902 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."

Surgeon-Major William Campbell Maclean (1811-1898) 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.

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

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

Royal Army Medical College, Millbank 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”.

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

Return to Contents 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 map Robin 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 Pasteur Institut 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 room Wellcome 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, London The 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

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

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. 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)

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.

Timothy Richards Lewis (1841-1886) The Royal Society 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 1884 Robert Koch (1843-1910) is third from right Paul 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, 2020 Photo credit: Anadolu Agency Malaria

Return to Contents 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 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.

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 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. Ross Wellcome Images Leishmaniasis

Return to Contents 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 face M. 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)

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.

Charles Donovan (1863-1951) Wellcome Images 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 cell Centers 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

Return to Contents 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 Microbiologist Journal 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 Commission Themistocles Zammit: top row, far left David Bruce: front row, centre Wellcome 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 background Malta 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 Dingli Culture 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

Return to Contents 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 Goodall Wellcome 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)

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.

Sir Leonard Rogers (1868-1962) J. Russell & Sons, Wellcome Images 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 stage J. Craig Venter Institute Typhoid Enteric Fever

Return to Contents 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 Africa Wellcome 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.

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.

World War One British soldier receives his typhoid inoculation from a military doctor at Salonika, Greece Getty Images Trench Fever

Return to Contents 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)

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.

Sir Arthur Frederick Hurst (1879-1944) British Medical Journal 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 Disinfector Beamish Transport Online Research: Tim Ford – Heritage Volunteer Editing: Ursula Pearce, MA – Heritage & Education Officer Royal Victoria Chapel 2021