War stimulates medical advances. The surgical treatment of
wounds, prevention and treatment of disease, even high altitude and space
problems have all benefitted from military considerations. And war created the
specialty of tropical diseases in the U.S.
In Great Britain
tropical medicine as a specialty had gotten off to an earlier start, owing to
some 300 years of overseas commercial, military, and colonization activities.
Patrick Manson, the "father" of tropical medicine in England,
published his important textbook in 1898, after contributing heavily to a
similar text 5 years earlier edited by Andrew Davidson (Hygiene and Diseases
of Warm Climates, 1893). The London and Liverpool Schools of
Tropical Medicine were founded in 1899, putting tropical medicine on a firm
academic and research footing.
In the U.S., by
contrast, the term "tropical medicine" was seldom heard until the
Spanish-American War, though southern states had wrestled with malaria and
yellow fever for some time. A devastating epidemic of yellow fever in 1878, for
example, originating in New Orleans and sweeping up the Mississippi as far as
Ohio leaving wrecked economies and thousands dead (John H Ellis: Yellow
Fever and Public Health in the New South, 1992), generated interest in a
national public health system and provoked the first of several committees to
study yellow fever.
By the 1880s the germ
theory was well entrenched, and in 1880 Alfonse Laveran discovered the malaria
parasite, proposed as an alternative to the marsh bacilli claimed by Klebs and
Tommasi-Crudeli as being the cause of malaria. William Osler, an
excellent microscopist, appreciated its importance and published on malarial
parasites in 1886, when their significance was still questioned (G C Cook: "William
Osler's Fascination with Diseases of Warm Climates", J Med Biog, 1995;
3:20-29). William Councilman, pathologist at Hopkins, and colleagues, wrote
groundbreaking papers on cerebral malaria and amebic colitis(Am J Med Sci 1885,
89: 416-29; Johns Hopkins Hosp Rep 1891, 2:395-548). George Sternberg, a
military physician and one of the first American experts in microbiology, later
to become Surgeon General, wrote an excellent book about malaria and another
about yellow fever.
These were beginnings,
but it was the Spanish-American War that impelled research and offered careers
in this area. Cuba was the site of the famous experiments of the Yellow Fever
Commission led by Walter Reed that delineated the mosquito transmission of
yellow fever, allowing the construction of the Panama Canal. It was the
Philippines, though, where the war against the Spanish had merged into war
against Philippine guerrillas, keeping troops there for years, allowing
longer-term research - and career opportunities. Very early in the war the Army
established laboratories in the Philippines, mainly for diagnostic purposes,
and a Research Board. The original order, from S.Gen. Sternberg, included the
phrase, "Special attention shall be given to tropical dysentery, to the
malarial fevers prevailing in the Philippines, to beriberi, to intestinal
parasites, and, in general, to all tropical diseases, the etiology of which has
not been worked out." (Army Med Bull. 1929. "A Synopsis of the Army
Medical Research Boards in the Philippines". Much of what follows is found
there, as are references to all the original papers)
The principle hospital
laboratory was at the First Reserve Hospital in Manila. The first director died
of typhoid fever shortly after arrival, and was succeeded by Richard Strong.
Strong was a graduate of the first class at the new Hopkins Medical School, and
deliberately enlisted so as to be able to work with tropical diseases, citing
Osler, Welch and others as creating his interest in this area. He was also
assigned to head the Army Research Bureau. He too was incapacitated by typhoid
the year after he arrived, but managed to resume work. The Research Board was
disbanded in Jan. 1902, and Strong transferred to the newly organized
laboratory of the Philippine Government, which soon became the Biological
Laboratories of the Philippine Bureau of Science.
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| Philippine Bureau of Science |
As a measure of the
disease toll on troops, in the first ten months the First Reserve Hospital had
21,955 admissions, only 1,874 of which were for wounds and injuries. 21% of the
rest were cases of dysentery and diarrhea, dysentery (2/3 were amebic)
accounting for the highest mortality. Malaria, typhoid, brucellosis, dengue
fever, and tropical ulcer were prevalent. In the general population
smallpox was endemic, as were leprosy, beriberi, tuberculosis, yaws and other
skin ailments, and soon cholera and plague made their entrance(Science
1900, V11 ns,p521-28). Many "fevers" were undiagnosed, the only tests
that were helpful being malaria smears, Widal tests, blood counts, and
eventually stool cultures and stool examination for parasites.(Bost Med Surg J
1901, 144:175-8)
Others from Hopkins
arrived. James Flexner, pathologist, later director of the Rockefeller
Institute, and Llewelyn Barker, later to be chief of medicine at Hopkins, and a
pair of medical students plunged into research, one result of which was the
description of a new Shiga bacillus causing much of the dysentery, named shigella
flexneri after its discoverer.
A Second Board of
Research was established in 1906 under Percy Ashburn and Charles Craig, which
lasted considerably longer. This Board made a number of discoveries and
elaborated important information. A few examples: Filariasis was first
described in the Philippines, originally thought to be due to a new
species, but eventually proved to be Filaria bancrofti; dengue fever was
discovered by Charles Craig and Percy Ashburn to be caused by a filterable
agent,to be non-contagious, and to be mosquito-transmitted (though an incorrect
mosquito was named at first). Craig later was head of the Tropical Medicine
Department at Tulane, and Ashburn wrote a text pathology in the tropics and a
history of the Medical Department of the Army. The existence of
pathogenic and nonpathogenic amebae, first noted by Schaudinn, was confirmed
through both microscopic exam and numerous feeding experiments on prison
volunteers (with signed informed consent) done by Andrew Sellards and Ernest
Walker. These experiments also delineated the clinical course of amebiasis and
uncovered the carrier state (Philipp J Sci 1913, 8:253-330). Sellards went to
Harvard, then on to be intimately involved in the development of the French
version of the yellow fever vaccine, and Walker came to UCSF to work in the
Hooper Foundation where he focused mainly on leprosy(see http://texts.cdlib.org/view?docId=hb0w10035d&doc.view=frames&chunk.id=div00061&toc.depth=1&toc.id=).
Much
effort was expended studying the effect of the tropics on arriving soldiers. It
was determined that overall health was seldom affected as long as infectious
diseases were avoided, that there was no difference in tolerance to tropical
life between blonds and brunettes, and that the use of red-orange underwear (to
protect against UV light) made no difference, except that it was less
comfortable.(JAMA 1912, 58:998-1002)
In addition to military
issues, the Philippines were now a U.S. colony and the health of the population
was at stake. The Philippine Bureau of Science was heavily involved in this
effort. Americans worked hard, for example, to find infectious causes for
beriberi, without success. British workers in Malaya had studied dietary
factors, gradually focusing on rice polishing and showing that polished rice
seemed to be the culprit. The Americans confirmed this idea when their own
native scouts developed beriberi and were cured with consumption of unmilled
rice, though the exact explanation for this was still obscure (for summary see
Carpenter, KJ, Beriberi, White Rice, and Vitamin B, 2000).
Victor Heiser arrived
as Quarantine Officer with the Marine Hospital Service, later was Health
Officer for the Philippines, and dealt with plague, cholera, and smallpox
epidemics, the latter suppressed with mass vaccination using material made
from caribou. (Phil J Sci 1910, 6:171-9). He later was a major officer in the
Rockefeller Foundation's International Health Board. Edward Stitt, a naval
surgeon who had studied under Manson and was in the Philippines, wrote the
first American text on Tropical Disease, a book that went through six editions
and then was taken over by Richard Strong.
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| Richard P Strong |
Richard Strong,
mentioned above, is perhaps the best candidate for the title of the American
"father of tropical medicine". In addition to work mentioned, he was
the first to show the curative properties of compound 606, which he obtained
directly from Paul Ehrlich, in treating yaws, a prevalent disease there (Phil J
Sci 1910, 5B:433-54). Strong was called in 1912 to become the first professor
of tropical medicine at Harvard. In this capacity he organized several expeditions
to Guatemala, South America, and Africa to study tropical disease (as well as
local food and cultural practices). In 1915 he headed, through the American Red
Cross and Rockefeller Foundation, an expedition to Serbia to combat a massive
typhus epidemic, and was part of the Typhus Commission, Medical Research
Committee, American Red Cross, that established the louse transmission of
trench fever during WWI (Avail. at Hathi Trust). In WWII he served as director
of tropical medicine at the Army Medical School. The only blemish on his career
was an accidental infection of prisoners with plague during a trial of a
cholera vaccine (Rev Inf Dis 1989, v11: 996-1004). He needs a good
biography.
I could go on, but
this is enough to indicate the role of the American occupation of the
Philippines in the creation of tropical medicine as a specialty in the
U.S. The origin of the American Society of Tropical Medicine is another, and
interesting, story for a future blog.
