A brief history of British military experiences withinfectious and tropical diseasesMark S Bailey12

1Department of Infection ampTropical Medicine BirminghamHeartlands HospitalBirmingham UK2Department of MilitaryMedicine Royal Centre forDefence MedicineBirmingham UK

Correspondence toLt Col Mark S BaileyDepartment of Infection ampTropical Medicine BirminghamHeartlands Hospital BordesleyGreen East BirminghamB9 5ST England UKmarkbaileynhsnet

The lecture on which thisarticle was based was awardedthe George Blair MemorialPrize for 2012 by the Friendsof Millbank

Received 17 April 2013Accepted 18 April 2013Published Online First5 July 2013

To cite Bailey MS J RArmy Med Corps2013159150ndash157

ABSTRACTInfectious and tropical diseases have been a problem forBritish expeditionary forces ever since the CrusadesOutbreaks were especially common on Navy ships fromthe 16th to 18th centuries due to poor living conditionsand travel to the tropics However since these occurredin small isolated and controlled environments it meantthat naval medical practitioners were able to keepdetailed records and develop empirical approaches fortheir prevention The first Royal Naval Hospitals wereestablished in response to these diseases and Royal Navydoctors made valuable early contributions towardsunderstanding them Even larger outbreaks of infectiousand tropical diseases occurred in the Army during theNapoleonic Crimean and Boer Wars and throughout thecolonial era which strongly influenced the formation ofthe Army Medical Services including provision for teach-ing and research The establishment of germ theory ledto a golden era of discovery regarding these diseasesand British Army doctors made numerous important con-tributions Subsequent improvements in prevention diag-nosis and treatment reduced the mortality frominfectious and tropical diseases during the World Warsbut they remained a significant problem in the non-European campaigns and also the numerous lsquosmall warsrsquothat followed Even in the 21st century some of thesediseases still cause outbreaks with significant morbidityand impact on deployments but the military clinical andacademic resources to deal with them are now muchreduced Preventive measures such as hygiene sanita-tion infection control vaccination and chemoprophylaxisare invaluable but history shows that these can becomeneglected over time and disrupted or overwhelmedduring the early or most intense stages of military opera-tions This is why military specialists in infectious dis-eases tropical medicine sexual health medicalmicrobiology and communicable diseases control are stillrequired

INTRODUCTIONThere is a long-standing and well-established con-nection between military activities and infectiousdiseases1 Hence it is impossible to summarise thewhole history of British military experiences withinfectious and tropical diseases in a single paperTherefore this review focuses on representativeand important events that had the greatest influencehistorically and which remain of most relevancetoday It is sobering to note how the same diseaseshave re-emerged throughout history and how thesame lessons have had to be relearntInfectious diseases are now easy to define but

the scope of tropical medicine remains debatable Itcertainly includes infections that are most common

in the tropics and diseases such as envenomationheat illness and dietary deficiencies and it alsoemphasises preventative measures as well as clinicalmanagement Tropical medicine overlaps withtravel health (a predominantly primary healthcareactivity that focuses on pretravel preparation andinitial assessment of post-travel disease) but usuallyinvolves working in resource-poor environments inthe tropics or else in specialist secondary healthcareunits Some people never forgive tropical medicinefor having emerged from colonial medicine whichpartly explains attempts to rebrand it as lsquogeograph-ical medicinersquo or merge it into lsquoglobal healthrsquo

BRITISH MILITARY EXPERIENCES IN THEMIDDLE AGESInfectious and tropical diseases have been aproblem for British expeditionary forces ever sincethe time of the Crusades where undifferentiatedfebrile illnesses dysentery envenomation heatillness and scurvy were common (Figure 1)2 In1190ndash1191 Richard the Lionheart took his armydirectly to Palestine by ship (with a brief stopoverto conquer Cyprus) and so avoided many of theoutbreaks that plagued earlier Crusaders who trav-elled by land However on arrival his troops weresoon afflicted by the usual Crusade diseases andeven Richard developed a debilitating fever Thehistorical descriptions of these undifferentiatedfebrile illnesses suggest that malaria or typhus werethe most likely causes but there are numerousother possibilities3 and great care must be takenwhen using historical texts to make retrospectivediagnoses4 A wide range of intestinal parasite eggshave now been identified from ancient Crusaderlatrines5 and it is likely that other infectious causesof gastroenteritis were also prevalentDuring the remainder of the medieval period

the association between infectious diseases andwarfare was repeatedly observed with various the-ories given for their occurrence At this time it wasunderstood that lsquoinfectionrsquo came from outsidesources (rather than by spontaneous generation)but this was usually thought to be due to lsquomiasmasrsquo(poisonous vapours) in unhygienic environmentsrather than lsquocontagionrsquo (spread by direct contact)and there was certainly no concept of germs beingcarried in bodily fluids or by arthropod vectorsOverall little seems to have been learnt until navalforces started to apply hygiene sanitation and quar-antine measures in the 15th century Althoughdirected against miasmas these included washingfacilities for people and clothing fumigation ofliving quarters and safe disposal of human wastewhich helped to prevent the most common ship

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diseases (excluding scurvy) but also reinforced the theory thatmiasmas were to blame

ROYAL NAVY EXPERIENCES IN THE 16THndash18TH CENTURIESOutbreaks of dysentery typhus (also known as gaol or shipfever) smallpox tuberculosis and trachoma were common onships during this period due to the confined and densely-populated living quarters and travel to the tropics brought add-itional threats such as malaria and yellow fever6 However sincethese outbreaks occurred in small isolated and controlled envir-onments it meant that naval medical practitioners were able tokeep detailed records and develop empirical approaches fortheir prevention Although these measures were partially suc-cessful they were often neglected or overwhelmed during majorconflicts

At the Battle of the Gravelines in 1588 the SpanishArmada was weakened by outbreaks of dysentery and thentyphus which probably contributed to their defeat Althoughonly about 100 sailors and marines of the English Navy diedin the conflict it is estimated that approximately 7000 diedshortly afterwards from the same diseases which promptedan outcry from their commanders and the public6 In 1654the first Physician to the Fleet was appointed by Oliver

Cromwell followed by similar appointments in the mainhome ports but hospital care remained an ad hoc civilianaffair until the 18th century when the first Royal NavyHospitals (RNHs) were established This was done in directresponse to repeated outbreaks of malaria and yellow feverin Jamaica and dysentery and typhus in Minorca andGibraltar (and also because naval patients in civilian hospitalswere often unruly and prone to desertion) When the RNHsat Haslar (Gosport) and Stonehouse (Plymouth) were com-pleted in 1761 and 1762 they had the best available ventila-tion and isolation facilities for dealing with infectious(lsquozymoticrsquo) cases (Figure 2)

This was also the era when James Lind (1716ndash1794) workedfor 10 years as a shiprsquos surgeon (mostly off the coast of WestAfrica) and then as the chief physician at RNH Haslar He isoften considered to be the father of nautical medicine and ismost famous for proving that citrus fruits prevented scurvy7

although this was actually first described by an Army surgeon acentury earlier8 However he also made valuable observationsabout the prevention of typhus (by regular washing and changesof clothes and bedding) and malaria (by remaining off-shore intropical areas) and wrote one of the first textbooks of tropicalmedicine9 His work overlapped with that of John Pringle

Figure 1 An epidemic of disease ravages the Crusaders Gustave Doreacute (1887)

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(1707ndash1782) who made similar observations regarding infec-tious diseases in British Army camps and is often considered tobe the father of military medicine10

Despite the good work of Lind and the naval physicians thatsucceeded him the Royal Navy continued to suffer more deathsfrom disease than trauma until the Battle of Trafalgar (1805) In1807 the slave trade in the British Empire was abolished and in1808 the Royal Navy formed the West Africa Squadron to enforcethis From 1819 this force was based in Freetown Sierra Leoneand from 1821 Ascension Island was used as a supply base with aquarantine area (and cemetery) for yellow fever patients atComfort Cove which was soon renamed Comfortless Cove From1808 to 1860 the West Africa Squadron seized more than 1600slave ships and freed over 150 000 slaves but more than 1500Navy personnel died and this was mostly due to infectious andtropical diseases11 On several occasions the outbreaks were sointense that there were barely enough men left to sail the ships In1847 Alexander Bryson wrote a report for the Admiralty on theseproblems in Sierra Leone which makes many astute observationsabout disease prevention and the use of quinine to treat malaria12

He observed that the risk of contracting malaria was increased asships got closer to shore even greater if sailors and marines wentashore and greatest of all if they slept ashore overnight The RoyalNavy physician William Baikie is credited with the first successfuluse of long-term malaria prophylaxis when he used quinine for a118-day exploration of the River Niger in 185413 In due course

early missionary doctors in Africa such as David Livingstone wereto benefit from the Royal Navy Medical Servicersquos expertise onthese matters14

BRITISH ARMY EXPERIENCES IN THE 19TH CENTURYMeanwhile the Army was having similar problems closer tohome during the Napoleonic Wars and it is estimated that from1795 to 1815 there were approximately 240 000 deaths ofwhom only about 30 000 were due to trauma15 The mostnotable military medical disaster of this period was the nowlargely forgotten Walcheren Campaign in 180916 which actu-ally involved more troops than the Peninsular Campaign con-ducted by the Duke of Wellington The strategically importantisland of Walcheren lies off the coast of the Netherlands at themouth of the River Scheldt and was known to be swamp-covered and afflicted by unidentified febrile illnesses High ratesof disease in this area were previously reported in 1747 by JohnPringle17 and were known to be a major problem in the occupy-ing French troops at Walcheren in 1809

From 30 July to 23 December 1809 more than 40 000British troops landed on the island which was flooded by sabo-tage of the dykes and heavy rains leading to an abundance ofmosquitoes On 22 August 1809 the first cases of lsquoWalcherenFeverrsquo were reported (Figure 3) and there were over 8000 casesin the first month and ultimately more than 4000 deaths (com-pared with about 100 deaths from trauma) Misguided

Figure 2 The lsquonewrsquo Haslar Zymotic Hospital built from 1899 to 1902 It is now due for demolition

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preventative measures were attempted and medical reinforce-ments were called for but none were available due to thedemands of the Peninsular Campaign that was in progress at thesame time James McGrigor who had just returned from beingInspector General of the medical services in the IberianPeninsula was dispatched in a similar role and after being ship-wrecked en route made numerous organisational improvementsHe also purchased a large quantity of cinchona bark (the sourceof quinine) from a passing American ship since this was knownto be effective against certain febrile illnesses at the time

In addition to the deaths from Walcheren Fever more than11 000 survivors were still on the sick roll by 1 February 1810and the Duke of Wellington later refused to have Walcheren vet-erans serve with him since their sickness rates from relapseswere so high The cause of the disease remains debatable but acombination of malaria typhus and enteric fever seems mostlikely16 A public and media outcry led to a parliamentaryinquiry in 181018 and although the cause of the diseases wasnot understood the inquiry report did enable McGrigor tomake major organisational improvements to the work of theArmy Medical Department when he became Director Generalof the Army Medical Services (DGAMS) from 1815 to 1851

Unfortunately these improvements were soon neglected andoverwhelmed due to severe military cutbacks over-reliance onthe civilian sector the low status of Army medical personneland the extra challenges faced by larger and more distantdeployments such as the Crimean War (1853ndash1856) Thisconflict involved about 250 000 British troops of whom

21 097 (8) died and 16 323 (77) of these were due to dis-eases such as cholera dysentery enteric fever typhus andother febrile illnesses19 On this occasion it was the livingconditions and the hospital facilities that were responsible forthe spread of infection This was highlighted by civiliannurses such as Florence Nightingale and Mary Seacole and inso doing they laid the foundations of military nursing andinfection control that continue to the present day Howeverat the time the cause of these infections was still not under-stood and so the preventative measures used were empiricaland much debated The established hospital at Scutari whereNightingale worked continued to have much higher deathrates than a new prefabricated one designed by IsambardKingdom Brunel at Renkioi where Edmund Parkes worked20

Another government inquiry (the Royal Sanitary Commission)followed in 1858 and its findings were heavily influenced bythe work of Nightingale and Parkes (who later became thefirst Professor of Military Hygiene) The final report includedthe recommendation that an Army Medical School be createdto improve the training of medical officers on matters relatingto infectious diseases21

Germ theory eventually became established in the latter partof the 19th century and there was then rapid progress in identi-fying the causes of many infections Specific military teachingon hygiene and sanitation and also infectious and tropical dis-eases was provided for Army medical officers from 1860 whenthe first Army Medical School opened at Fort Pitt in ChathamIn 1863 this was transferred to the new Royal Victoria Hospital

Figure 3 English troops with lsquoWalcheren Feverrsquo being evacuated during the Napoleonic War in 1809

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at Netley and Royal Navy medical officers joined the coursefrom 1871 until 1881 when separate teaching began at RNHHaslar6 In 1903 this teaching moved to the magnificent newRoyal Army Medical College at Millbank in London

The cause of enteric fever (typhoid or paratyphoid) was iden-tified in 1884 and an effective typhoid vaccine was developedby Almroth Wright and William Leishman at the Army MedicalSchool at Netley in 1897 However resistance to its use meantthat most of the 556 653 British troops in the Boer War (1899ndash1902) were not vaccinated and so 57 684 (10) developedenteric fever of whom 8225 (14) died compared with 7582killed in action22 The subsequent Royal Commission conductedby Lord Elgin found that the newly-formed Royal ArmyMedical Corps (RAMC) had been overwhelmed at times due toa lack of resources but individuals such as Alfred Keogh werecommended for their handling of enteric fever cases at the mili-tary hospitals under their command (Figure 4)23

As resources improved this soon became the golden era ofinfectious diseases research in the British Army which includeddiscoveries such as the cause of brucellosis by David Bruce in1887 the transmission of malaria by Ronald Ross in 1897 thecause of leishmaniasis by William Leishman in 1903 the causeand transmission of trypanosomiasis by David Bruce in 1903the cause of donovanosis by Charles Donovan in 1905 and thecause of melioidosis by Alfred Whitmore in 191224 25 Otherdistinguished military doctors such as John Sinton (VC FRS)also made major contributions and played a key role in thedevelopment of the Royal Society of Tropical Medicine andHygiene which was founded in 1907

BRITISH ARMY EXPERIENCES IN THE 20TH CENTURYBy the time of the Great War (1914ndash1918) the British Armyhad a comprehensive approach to hygiene and sanitation due tothe work of Alfred Keogh as DGAMS and the Army School ofHygiene that was formed in 190623 In addition to well-organised field hospitals there was also a system of mobilemicrobiology laboratories developed by Leishman and subse-quently the RAMC was able to write lsquostate-of-the-artrsquo summarieson the most relevant infections that occurred during that con-flict26 27 On the Western Front diseases such as dysenteryenteric fever and typhus were reasonably well controlled butnew threats such as trench fever trench nephritis (now thoughtbe a form of hantavirus infection) and gas gangrene of woundspresented new challenges Although there were still more hos-pital admissions for disease than trauma overall deaths fromdisease in France and Belgium were less than those fromtrauma28 for the first time ever in a major British Armycampaign29

However this was not the case in more distant theatres ofwar and there were problems such as typhus and relapsing feverin Serbia30 dysentery and enteric fever (mostly paratyphoid) atGallipoli31 and malaria in Salonika (Figure 5) East Africa andthe Middle East32 In Mesopotamia (Iraq) there were cases ofmalaria leishmaniasis typhus relapsing fever sandfly feverrabies cholera dysentery enteric fever hepatitis liver abscesssmallpox severe skin infections heat illness renal colic andscurvy33ndash35 Even in this remote location there was a deployedlaboratory that proved useful in confirming infections and iden-tifying the causes of undifferentiated febrile illness Similar dis-eases seem to have occurred in the subsequent North PersiaForce which led to the establishment of the North PersianForces Memorial Medal that is still awarded annually for thebest paper on tropical medicine or hygiene by a medicalofficer36

It should be remembered that all of this activity took place inthe pre-antibiotic era and hence prevention was very muchbetter than the purely supportive treatments that could beoffered During this period medical officers received military-specific training in infectious and tropical disease at the RoyalArmy Medical College at Millbank and the Liverpool School ofTropical Medicine37 A useful pocket book called lsquoMemorandaon Medical Diseases in Tropical and Sub-Tropical Areasrsquo wasalso published and updated regularly from 1916 until 1946Although the RAMC suffered severe cuts during the inter-warperiod it managed to retain its facilities and expertise withregard to infectious and tropical diseases which meant that itcould respond rapidly to the clinical teaching and researchdemands of the Second World War

During this conflict (1939ndash1945) the British military experi-ence with infectious and tropical diseases was similar to that inthe First World War and one must look beyond the Europeancampaign to see the full impact on campaigns such as the FarEast and Mediterranean In Europe there were relatively fewproblems although the first recorded military outbreak of Qfever (lsquoBalkan grippersquo) caused over 1000 cases in CorsicaGreece and Italy from November 1944 to June 194538 Not sur-prisingly infection and malnutrition were major problems inNazi concentration camps where typhus gastroenteritis andrespiratory infections were rife Tropical infections were aproblem in the Far East especially among troops such as theChindits with diseases such as malaria gastroenteritis tropicalulcers and various forms of typhus which also caused majoroutbreaks during training exercises in places such as Ceylon (SriLanka)39 However commanders such as Bill Slim understoodthe importance of preventative measures (such as malariaprophylaxis) and so matters did gradually improve29 Not sur-prisingly infectious and tropical diseases were also a majorproblem in Japanese prisoner of war camps where cholera dys-entery strongyloidiasis malaria tropical ulcers and nutritionaldeficiencies were common Captive RAMC medical officersstudied these as best they could40 and this important work hascontinued ever since41 Closer to home in the Mediterraneancampaigns about 25 000 British troops were admitted to hos-pital with sandfly fever42 which had a significant impact onoperations even though the disease is self-limiting with no mor-tality or long-term morbidity Otherwise there was goodcontrol of infectious and tropical diseases in this area leading toclaims that better prevention and treatment of dysentery andvenereal diseases helped Montgomeryrsquos British 8th Army over-come Rommelrsquos Afrika Korps29

After the Second World War infectious and tropical diseasescontinued to be a significant problem for British troops in con-flicts such as the Malayan Emergency (1948ndash1960) the KoreanWar (1950ndash1953) the Borneo Confrontation (1962ndash1966) andthe Aden Emergency (1963ndash1970) The most common pro-blems seem to have been gastroenteritis undifferentiated febrileillnesses respiratory infections and skin diseases The undiffer-entiated febrile illnesses included malaria enteric fever brucel-losis Q fever leptospirosis rickettsial infections (includingtyphus) various arboviruses (including dengue sandfly feverJapanese encephalitis) and hantavirus infection43 These diseaseswere a particular concern because they are often clinically indis-tinguishable and diagnosis requires specialist microbiology inves-tigations that are usually not available on deployments

Throughout this period British Army medical officers contin-ued to receive specific training in infectious and tropical diseasesand make significant research contributions in this field Earlytreatment of leptospirosis with penicillin was proven to be

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effective by RAMC medical officers in Malaya in 195544 Thefirst discovery of entero-toxigenic Escherichia coli (ETEC)which is the main cause of travellers diarrhoea was made inBritish troops in Aden in 196545 Also most of the research oncutaneous leishmaniasis in Belize was conducted by RAMCmedical officers in the 1990s46

BRITISH MILITARY EXPERIENCES IN THE 21ST CENTURYAt the end of the 20th century it was tempting to think thatinfectious diseases in military personnel had been conquered byhygiene sanitation (including infection control) vaccinationchemoprophylaxis microbiological diagnosis and antibiotic

treatment This may have been true for established militaryoperations with good facilities in areas where exotic emergingor re-emerging infections did not occur However during opera-tions in Sierra Leone (1999ndash2002) there were outbreaks ofmalaria47 and intestinal helminths48 in Iraq (2003ndash2009) therewere outbreaks of viral gastroenteritis (Figure 6)49 50 and bacter-ial gastroenteritis (L Lines personal communication) and inAfghanistan (2001 onwards) there were outbreaks of viralgastroenteritis51 bacterial gastroenteritis (E Hutley personalcommunication) cutaneous leishmaniasis52 and lsquoHelmandFeverrsquo caused by sandfly fever acute Q fever or rickettsial infec-tions (including typhus)43 53 In Iraq and Afghanistan complextrauma-related wound infections with multi-drug resistance havealso occurred and these create new challenges for surgeonsmedical microbiologists infectious disease physicians and infec-tion control practitioners54 55 Even during well-establisheddeployments military personnel remain at increased risk oftropical infections compared with civilian travellers and from1998 to 2009 there were 343 confirmed cases of cutaneousleishmaniasis seen at the major tropical medicine centres in theUK of which 156 (45) were in military personnel and 103(66) of these were from regular training exercises in Belize56

Although infectious and tropical diseases now rarely causedeaths in British military personnel they can still have a seriousimpact on operational effectiveness and military medicalresources49 51 Infections such as Q fever and bacterial gastro-enteritis can also have serious long-term sequelae that are notrecognised by current data collection methods Overall a widerange of infectious and tropical diseases continue to be seen inBritish troops overseas and on their return to the UK57

However this century has also seen a marked reduction in thefacilities and other resources available for military teaching andresearch on these diseases58 The Royal Army Medical College atMillbank (now an art college) was downsized to become the Royal

Figure 4 Interior of a field hospital with patients during the Boer War in 1900 Wellcome Library London (GC181C8-9)

Figure 5 Malaria chemoprophylaxis parade at Salonika during theGreat War in 1916 copy IWM (Q 32160)

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Defence Medical College at Gosport and then again to becomethe Royal Centre for Defence Medicine at Birmingham The previ-ous teaching for Army medical officers evolved to become aMilitary Infectious Diseases and Tropical Medicine Course for atri-service and multi-disciplinary audience but has been suspendedsince 2010 for administrative and financial reasons The majorityof Defence funding for microbiology and infectious diseasesresearch is now given to civilian institutions who are unlikely tohave the same priorities as military medical officers who specialisein these areas and see military patients on a regular basis Recentchanges to the funding of secondary healthcare for military per-sonnel may further weaken the connections between militarypatients and military hospital specialists

DISCUSSIONA keen sense of history is important for military infection and trop-ical medicine specialists because the diseases involved and the pro-blems of delivering clinical management and preventative measureshave a tendency to recur Constant change within the UK DefenceMedical Services (DMS) has also compromised their institutionalmemory in these areas Outbreaks such as those in the NapoleonicCrimean and Boer Wars have shaped the DMS and progress wasusually driven by those who had firsthand experience of troopsrsquo suf-fering (such as Lind McGrigor Nightingale Parkes and Keogh) Itis easy to think that infectious and tropical diseases in military per-sonnel stopped being a significant problem after the Second WorldWar or at least by the end of the 20th century Although it is truethat mortality rates are now minimal this does not take account ofthe effects on operational effectiveness and deployed medicalresources the contribution of complex wound infections to deathsfrom trauma and the persisting effects of diseases such as Q feverand bacterial gastroenteritis Primary preventive measures such ashygiene sanitation vaccination and chemoprophylaxis remain vitalbut history shows that these can become neglected over time anddisrupted or overwhelmed during the early or most intense stagesof military operations This is why military specialists in infectious

diseases tropical medicine sexual health medical microbiology andcommunicable disease control are still required

The DMS were once world leaders in all aspects of infectiousand tropical diseases However this expertise has graduallydeclined since the Second World War as the mortality and per-ceived threat from these diseases have diminished It is a great pitythat the DMS has simply scaled down its activity in this arearather than take on a national role as shown by the AustralianArmy Malaria Institute the French Army Tropical MedicineInstitute and the USArsquos Naval Medical Research Center and WalterReed Army Institute of Research Even in an era of declining mili-tary budgets civilian experts have spoken in favour of uniformedmedical services maintaining their capabilities in infectious andtropical diseases59 The DMS is now increasingly dependent oncivilian agencies for its clinical teaching and research activitieswhich can never be as understanding or responsive towards mili-tary problems Perhaps the greatest resource limitation at present isthe amount of time that military infection specialists have availableto spend on such matters because their numbers are so low andthey must also fulfil National Health Service contractual obliga-tions on behalf of the DMS Hence their work is likely to remainreactive and descriptive only unless more military consultants areappointed in these specialties and more resources are made avail-able for teaching and research An adequate number of welltrained and available military specialists properly resourcedlsquoreach-backrsquo services and lsquofield investigational teamsrsquo and military-specific programmes of teaching and research remain essential inour defence against infectious and tropical diseases (including thedeliberate release of biological agents)

Acknowledgements I am grateful to the Wellcome Library and the Imperial WarMuseum for permission to use the images in Figures 4 and 5

Funding None

Disclaimer The opinions expressed here are those of the author and do notnecessarily represent the views of the UK Defence Medical Services

Competing interests None

Figure 6 Isolation assessment area (lsquoThe Vomitoriumrsquo) for a viral gastroenteritis outbreak during the Iraq War in 2003

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Provenance and peer review Not commissioned internally peer reviewed

Data sharing statement This paper is based on an invited lecture that I gave(with military approval) for the George Blair Memorial Prize to the Friends ofMillbank

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North Am 200418341ndash682 Mitchell PD Medicine in the Crusades Warfare Wounds and the Medieval

Surgeon Cambridge Cambridge University Press 20043 Burns DS Bailey MS Undifferentiated febrile illnesses in military personnel J R

Army Med Corps 2013159200ndash54 Mitchell PD Retrospective diagnosis and the use of historical texts for investigating

disease in the past Int J Paleopath 2011181ndash85 Mitchell PD Anastasioua E Syon D Human intestinal parasites in crusader Acre

evidence for migration with disease in the medieval period Int J Paleopath20111132ndash7

6 Brown K Poxed amp Scurvied The Story of Sickness and Health at Sea BarnsleySeaforth Publishing 2011

7 Lind J A Treatise on Scurvy Edinburgh Kincaid amp Donaldson 17538 Woodall J The Surgeonrsquos Mate London Edwards Griffin 16179 Lind J An Essay on Diseases Incidental to Europeans in Hot Climates London

Becket amp De Hondt 176810 Blair JSG Sir John Pringle J R Army Med Corps 2006152273ndash511 National Museum of the Royal Navy Chasing Freedom Information Sheet http

wwwroyalnavalmuseumorgvisit_see_victory_cfexhibition_infosheethtm (accessed1 Aug 2012)

12 Bryson A Report on the Climate and Principal Diseases of the African StationLondon Clowes amp Sons 1847

13 Knobloch J Long-term malaria prophylaxis for travelers J Travel Med 200411374ndash814 Livingstone D Missionary Travels and Researches in South Africa New York Harper

amp Brothers 185815 Howard MR Walcheren 1809 a medical catastrophe BMJ 19993191642ndash516 Lynch J The Lessons of Walcheren Fever 1809 Mil Med 2009174315ndash1917 Pringle J Observations on Diseases of the Army in Camp and Garrison London

Wilson amp Durham 175218 Anonymous A collection of papers relating to the expedition to the Scheldt

presented to Parliament in 1810 London Strahan 181119 Sweetman J The Crimean War 1854ndash6 Oxford Osprey Publishing 200120 Silver CP Renkioi Brunelrsquos Forgotten Crimean War Hospital Sevenoaks Valonia

Press 200721 Atenstaedt RL The development of bacteriology sanitation science and allied

research in the British Army 1850ndash1918 equipping the RAMC for war J R ArmyMed Corps 2010156154ndash8

22 Osler W Typhoid Fever In The Principles and Practice of Medicine 8th ednNew York amp London Appleton 1919 Ch 1 httpwwwarchiveorgdetailscu31924003512161 (accessed 1 Apr 2010)

23 Thompson SV Sir Alfred Keoghmdashthe years of reform 1899ndash1910 J R Army MedCorps 2008154269ndash72

24 Cox FEG Illustrated History of Tropical Diseases London The Wellcome Trust1997

25 Cook GC Tropical Medicine An Illustrated History of the Pioneers LondonAcademic Press 2007

26 MacPherson WG Leishman WB Cummins SL History of the Great War MedicalServices Pathology London His Majestyrsquos Stationary Office 1923

27 MacPherson WG Herringham WP Elliott TR et al History of the Great War MedicalServices Diseases of the War London His Majestyrsquos Stationary Office 1923

28 Mitchell TJ Smith GM Official History of the Great War Medical ServicesCasualties and Medical Statistics London His Majestyrsquos Stationary Office 1931

29 Harrison M Medicine amp Victory British Military Medicine in the Second World WarOxford Oxford University Press 2008

30 Hunter W The Serbian epidemics of typhus and relapsing fever in 1915 theirorigin course and preventive measures employed for their arrest an aetiologicaland preventive study based on records of British military sanitary mission to Serbia1915 Proc R Soc Med 19201329ndash158

31 Butler AG Official History of the Australian Army Medical Services 1914ndash1918Volume ImdashGallipoli Palestine and New Guinea 2nd edn Melbourne AustralianWar Memorial 1938 httpwwwawmgovauhistories (accessed 1 Aug 2012)

32 Harrison M The Medical War Oxford Oxford University Press 201033 Turner GG Medical and surgical notes from MesopotamiamdashPart I Br Med J

1917233ndash734 Turner GG Medical and surgical notes from MesopotamiamdashPart II Br Med J

1917275ndash935 MacKenzie MD The practical prevention of typhus and relapsing fever in

mesopotamia during the war J R Army Med Corps 19213750ndash6136 Anonymous The late North Persian forces Trans R Soc Trop Med Hyg

19231751737 Power HJ Tropical Medicine in the Twentieth Century A History of the Liverpool

School of Tropical Medicine 1898ndash1990 London Kegan Paul International 199938 Blewitt B ldquoQrdquo fever a new disease in armies J R Army Med Corps

195197377ndash8839 Sayers MH Hill IG The occurrence and identification of the typhus group of fevers

in South East Asia Command J R Army Med Corps 1948906ndash2240 Blair G MD Thesis Malnutrition among Prisoners of War in the Far East London

Wellcome Collection 194641 Robson D Welch E Beeching NJ et al Consequences of captivity health effects of

far east imprisonment in World War II QJM 200910287ndash9642 Stout T Sandfly (Phelbotomus) Fever In The Official History of New Zealand in the

Second World War 1939ndash45 War Surgery and Medicine Wellington HistoricalPublications Branch 1954 Ch 7 httpwwwnzetcorgtmscholarlytei-WH2Surghtml (accessed 1 Aug 2012)

43 Bailey MS Trinick TR Dunbar JA et al Undifferentiated febrile illnesses in Britishtroops from Helmand Afghanistan J R Army Med Corps 2011157150ndash5

44 Mackay-Dick J Robinson JF Penicillin in the treatment of 84 cases of leptospirosisin Malaya J R Army Med Corps 1957103186ndash97

45 Rowe B Taylor J The bacteriology of travellerrsquos diarrhoea J Clin Pathol196922744ndash5

46 Hepburn NC Tidman MJ Hunter JA Cutaneous leishmaniasis in British troops fromBelize Br J Dermatol 199312863ndash8

47 Tuck JJ Green AD Roberts K A malaria outbreak following a British militarydeployment to Sierra Leone J Infect 200347225ndash30

48 Bailey MS Thomas R Green AD et al Helminth infections in British troopsfollowing an operation in Sierra Leone Trans R Soc Trop Med Hyg2006100842ndash6

49 Bailey MS Boos CJ Vautier G et al Gastroenteritis outbreak in British troops IraqEmerg Infect Dis 2005111625ndash8

50 Bailey MS Gallimore CI Lines LD et al Viral gastroenteritis outbreaks in deployedBritish troops during 2002ndash7 J R Army Med Corps 2008154156ndash9

51 Morgan D Horstick O Nicoll A et al Illness in military personnel in BagramAfghanistan Euro Surveill 200262140 httpwwweurosurveillanceorgViewArticleaspxArticleId=2140 (accessed 1 Aug 2012)

52 Bailey MS Caddy AJ McKinnon KA et al An outbreak of zoonotic cutaneousleishmaniasis with local dissemination in Balkh Afghanistan J R Army Med Corps2012158225ndash8

53 Newman EN Johnstone P Hatch R et al Undifferentiated febrile illnesses amongstBritish troops in Helmand Afghanistan J R Army Med Corps 2012158143ndash4author reply 144ndash5

54 Hutley EJ Green AD Infection in wounds of conflictmdashold lessons and newchallenges J R Army Med Corps 2009155315ndash19

55 OrsquoShea MK Acinetobacter in modern warfare Int J Antimicrob Agents201239363ndash75

56 Bailey MS Cutaneous leishmaniasis in British troops following jungle training inBelize Travel Med Infect Dis 20119253ndash4

57 Glennie JS Bailey MS UK role 4 military infectious diseases at BirminghamHeartlands Hospital in 2005ndash9 J R Army Med Corps 2010156162ndash4

58 Blair JSG Centenary History of the Royal Army Medical Corps 1898ndash1998 2ndedn Burntisland Iynx Publishing 2001

59 Hotez P Kazura J A military cutback we canrsquot afford fighting tropical diseases TheAtlantic Magazine 2012 Jan 19 httpwwwtheatlanticcomhealtharchive201201a-military-cutback-we-cant-afford-fighting-tropical-diseases251527 (accessed 1 Aug2012)

Bailey MS J R Army Med Corps 2013159150ndash157 doi101136jramc-2013-000087 157

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