J R Army Med Corps: first published as 10.1136/jramc-2013-000087 on 5 July 2013. Downloaded from Review A brief history of British military experiences with infectious and tropical diseases 1,2 Editor’s choice Mark S Bailey Scan to access more free content 1Department of Infection & ABSTRACT in the tropics and diseases such as envenomation, Tropical Medicine, Birmingham Infectious and tropical diseases have been a problem for heat illness and dietary deficiencies and it also Heartlands Hospital, Birmingham, UK British expeditionary forces ever since the Crusades. emphasises preventative measures as well as clinical 2Department of Military Outbreaks were especially common on Navy ships from management. Tropical medicine overlaps with Medicine, Royal Centre for the 16th to 18th centuries due to poor living conditions travel health (a predominantly primary healthcare Defence Medicine, and travel to the tropics. However, since these occurred activity that focuses on pretravel preparation and Birmingham, UK in small, isolated and controlled environments it meant initial assessment of post-travel disease), but usually Correspondence to that naval medical practitioners were able to keep involves working in resource-poor environments in Lt Col Mark S Bailey, detailed records and develop empirical approaches for the tropics or else in specialist secondary healthcare Department of Infection & their prevention. The first Royal Naval Hospitals were units. Some people never forgive tropical medicine Tropical Medicine, Birmingham established in response to these diseases and Royal Navy for having emerged from colonial medicine, which Heartlands Hospital, Bordesley ‘ Green East, Birmingham, doctors made valuable early contributions towards partly explains attempts to rebrand it as geograph- B9 5ST, England, UK; understanding them. Even larger outbreaks of infectious ical medicine’ or merge it into ‘global health’. [email protected] and tropical diseases occurred in the Army during the Napoleonic, Crimean and Boer Wars and throughout the BRITISH MILITARY EXPERIENCES IN THE The lecture on which this colonial era, which strongly influenced the formation of MIDDLE AGES article was based was awarded the George Blair Memorial the Army Medical Services including provision for teach- Infectious and tropical diseases have been a Prize for 2012 by the Friends ing and research. The establishment of germ theory led problem for British expeditionary forces ever since of Millbank to a golden era of discovery regarding these diseases the time of the Crusades, where undifferentiated and British Army doctors made numerous important con- febrile illnesses, dysentery, envenomation, heat Received 17 April 2013 2 Accepted 18 April 2013 tributions. Subsequent improvements in prevention, diag- illness and scurvy were common (Figure 1). In Published Online First nosis and treatment reduced the mortality from 1190–1191, Richard the Lionheart took his army 5 July 2013 infectious and tropical diseases during the World Wars, directly to Palestine by ship (with a brief stopover but they remained a significant problem in the non- to conquer Cyprus) and so avoided many of the European campaigns and also the numerous ‘small wars’ outbreaks that plagued earlier Crusaders who trav- that followed. Even in the 21st century some of these elled by land. However, on arrival his troops were http://militaryhealth.bmj.com/ diseases still cause outbreaks with significant morbidity soon afflicted by the usual Crusade diseases and and impact on deployments, but the military clinical and even Richard developed a debilitating fever. The academic resources to deal with them are now much historical descriptions of these undifferentiated reduced. Preventive measures such as hygiene, sanita- febrile illnesses suggest that malaria or typhus were tion, infection control, vaccination and chemoprophylaxis the most likely causes, but there are numerous are invaluable, but history shows that these can become other possibilities3 and great care must be taken neglected over time and disrupted or overwhelmed when using historical texts to make retrospective during the early or most intense stages of military opera- diagnoses.4 A wide range of intestinal parasite eggs tions. This is why military specialists in infectious dis- have now been identified from ancient Crusader 5 eases, tropical medicine, sexual health, medical latrines and it is likely that other infectious causes on September 25, 2021 by guest. Protected copyright. microbiology and communicable diseases control are still of gastroenteritis were also prevalent. required. During the remainder of the medieval period, the association between infectious diseases and warfare was repeatedly observed with various the- INTRODUCTION ories given for their occurrence. At this time it was There is a long-standing and well-established con- understood that ‘infection’ came from outside nection between military activities and infectious sources (rather than by spontaneous generation), diseases.1 Hence, it is impossible to summarise the but this was usually thought to be due to ‘miasmas’ whole history of British military experiences with (poisonous vapours) in unhygienic environments infectious and tropical diseases in a single paper. rather than ‘contagion’ (spread by direct contact) Therefore, this review focuses on representative and there was certainly no concept of germs being and important events that had the greatest influence carried in bodily fluids or by arthropod vectors. historically and which remain of most relevance Overall, little seems to have been learnt until naval today. It is sobering to note how the same diseases forces started to apply hygiene, sanitation and quar- have re-emerged throughout history and how the antine measures in the 15th century. Although same lessons have had to be relearnt. directed against miasmas, these included washing To cite: Bailey MS. JR Infectious diseases are now easy to define, but facilities for people and clothing, fumigation of Army Med Corps the scope of tropical medicine remains debatable. It living quarters and safe disposal of human waste, – 2013;159:150 157. certainly includes infections that are most common which helped to prevent the most common ship 150 Bailey MS. J R Army Med Corps 2013;159:150–157. doi:10.1136/jramc-2013-000087 J R Army Med Corps: first published as 10.1136/jramc-2013-000087 on 5 July 2013. Downloaded from Review http://militaryhealth.bmj.com/ Figure 1 An epidemic of disease ravages the Crusaders. Gustave Doré (1887). diseases (excluding scurvy), but also reinforced the theory that Cromwell followed by similar appointments in the main miasmas were to blame. home ports, but hospital care remained an ad hoc civilian affair until the 18th century when the first Royal Navy ROYAL NAVY EXPERIENCES IN THE 16TH–18TH CENTURIES Hospitals (RNHs) were established. This was done in direct on September 25, 2021 by guest. Protected copyright. Outbreaks of dysentery, typhus (also known as gaol or ship response to repeated outbreaks of malaria and yellow fever fever), smallpox, tuberculosis and trachoma were common on in Jamaica and dysentery and typhus in Minorca and ships during this period due to the confined and densely- Gibraltar (and also because naval patients in civilian hospitals populated living quarters and travel to the tropics brought add- were often unruly and prone to desertion). When the RNHs itional threats such as malaria and yellow fever.6 However, since at Haslar (Gosport) and Stonehouse (Plymouth) were com- these outbreaks occurred in small, isolated and controlled envir- pleted in 1761 and 1762, they had the best available ventila- onments it meant that naval medical practitioners were able to tion and isolation facilities for dealing with infectious keep detailed records and develop empirical approaches for (‘zymotic’) cases (Figure 2). their prevention. Although these measures were partially suc- This was also the era when James Lind (1716–1794) worked cessful, they were often neglected or overwhelmed during major for 10 years as a ship’s surgeon (mostly off the coast of West conflicts. Africa) and then as the chief physician at RNH Haslar. He is At the Battle of the Gravelines in 1588, the Spanish often considered to be the father of nautical medicine and is Armada was weakened by outbreaks of dysentery and then most famous for proving that citrus fruits prevented scurvy,7 typhus, which probably contributed to their defeat. Although although this was actually first described by an Army surgeon a only about 100 sailors and marines of the English Navy died century earlier.8 However, he also made valuable observations in the conflict, it is estimated that approximately 7000 died about the prevention of typhus (by regular washing and changes shortly afterwards from the same diseases, which prompted of clothes and bedding) and malaria (by remaining off-shore in an outcry from their commanders and the public.6 In 1654, tropical areas) and wrote one of the first textbooks of tropical the first Physician to the Fleet was appointed by Oliver medicine.9 His work overlapped with that of John Pringle Bailey MS. J R Army Med Corps 2013;159:150–157. doi:10.1136/jramc-2013-000087 151 J R Army Med Corps: first published as 10.1136/jramc-2013-000087 on 5 July 2013. Downloaded from Review http://militaryhealth.bmj.com/ Figure 2 The ‘new’ Haslar Zymotic Hospital built from 1899 to 1902. It is now due for demolition. (1707–1782), who made similar observations regarding infec- early missionary doctors in Africa such as David Livingstone were tious diseases in British Army camps and is often considered to to benefit from the Royal Navy Medical Service’s expertise on be the father of military medicine.10 these matters.14 Despite the good work of Lind and the naval physicians that succeeded him, the Royal Navy continued to suffer more deaths BRITISH ARMY EXPERIENCES IN THE 19TH CENTURY from disease than trauma until the Battle of Trafalgar (1805). In Meanwhile, the Army was having similar problems closer to 1807, the slave trade in the British Empire was abolished and in home during the Napoleonic Wars and it is estimated that from on September 25, 2021 by guest.