The Miraculous Fever-Tree

by Fiammetta Rocco

  New England troops fighting for the first time in the South in the Revolutionary War were particularly susceptible. As early as 1776, the Continental Congress ordered that three hundred pounds of Peruvian bark be sent to the Southern Department to treat them. By the time the war was well under way, and Dr Craik was treating George Washington’s tertian fever in August and September 1786 with eight doses of red bark at a time, malaria was about to extend its hold even further westwards.

  The first settlers to cross the Appalachian Mountains expressed their amazement at the beauty and apparent healthiness of the Ohio Valley. Within a short time, though, they were commenting upon the appearance of ‘fevers and agues’, and soon travellers were noting the sallow skin and anaemic appearance of the residents. With the restrictions barring the westward expansion of settlement removed at the close of the Revolution, an unparalleled movement of indigenous and immigrant populations began which would last for well over a century. Everywhere the new emigrants went – over the Allegheny Mountains, across the Great Lakes, along the Grand River, in the vicinity of the Rideau canal and into upper Canada – malaria would follow. In 1793 a Mrs Jarvis, who lived in Niagara, wrote to her father in England imploring him to bring ‘plenty of bark, for the children are all ill with fever’.

  Since the rivers were still the principal routes of travel across the United States, a huge proportion of this migration was obliged to pass through intensely malarious regions, from which it would spread the disease further afield. In this way malaria was carried up the river valleys of the Atlantic coast, across the Appalachian divide into western New York State and Pennsylvania, and into the Ohio Valley. In 1810, one writer warned all travellers who proposed to travel down the Ohio and Mississippi rivers to provide themselves with mosquito curtains, otherwise they could not reckon on a single night’s undisturbed repose during the spring, summer and autumn. Later, writing of the river settlements in the Mississippi territory, he says: ‘on the subsistence of the waters the sickly season commences and lasts with little variation from July to October. The driest seasons are the most unhealthy. The prevailing malady is a fever of the intermittent species, sometimes accompanied by ague, and sometimes not. It is rarely fatal in itself, but its consequences are dreadful, as it frequently lasts for five or six months in defiance of medicine, and leaving the patient in so relaxed and debilitated a state that he often never regains the strength he had lost.’

  From the southern Atlantic states, the fever was soon to be found in Kentucky, Tennessee, Alabama, Mississippi, Arkansas and northern Louisiana. The early overland immigrants to the west coast also carried the disease with them, and it took hold on the lower Columbia River and in the Sacramento-San Joaquin river valleys. By 1850, practically the entire United States constituted one vast expanse of malarious country, except for Maine, the northern portions of Wisconsin and Minnesota, the Appalachian highlands, the cool, arid north-west plains, the Rocky Mountain area, the western desert and the Sierra ranges.

  In many regions the disease was mild, and occurred only in the warm summer months. The Plasmodium vivax and malariae that came, probably, from Europe were the most common and, fortunately, the least serious of the malaria parasites, and usually died out in the winter months unless the weather was unusually mild. But in an extensive south-eastern triangle from Baltimore to central Florida and westward to the state of Mississippi, as well as in the areas drained by the Ohio and Mississippi rivers and in eastern Texas, where malaria persisted all year round, the falciparum strain was more common. An English proverb of the time said, ‘They who want to die quickly go to Carolina,’ while in 1737 a German observer told his readers: ‘Carolina is in the spring a paradise, in the summer a hell, and in the autumn a hospital.’

  Many of the Africans who had been shipped to the South as slaves suffered from sickle-cell anaemia, an inherited blood condition common among Africans and some peoples living around the Mediterranean that has the unusual benefit of offering some natural resistance to falciparum malaria, as it stops the malaria parasite from reproducing in them. The result was that slaves seemed less likely to catch malaria; those most prone to it were new immigrants and white northerners visiting the South, a fact that became obvious when the Union forces were on the offensive during the Civil War.

  The conflict between the North and the South was a watershed, not just politically and militarily – the triumph of the Union represented that of the industrial over the agrarian – but medically as well. The American Civil War was the last great conflict to be fought without any knowledge of germs and how they spread disease. Within a few years perspicacious men such as Louis Pasteur, Joseph Lister and Robert Koch would shed fresh light on the nature of microbial infection. But for the hapless participants of that early war, sickness and death from the commonest causes still remained a mystery, striking savagely at both sides. As far as medicine was concerned, the American Civil War was like the Middle Ages before the Renaissance – as one observer described it, ‘the sepulchre of unscientific medical thinking and a monument to the awesome power of disease’.

  In the 1860s epidemic infection still ran riot, unchecked by antiseptics, quarantine or even simple decent cleanliness. Measles, smallpox and typhoid were common. Of all the infectious diseases, only smallpox had been proved to be preventable by vaccination, and even that was still the subject of debate. In some circles, especially in Philadelphia and Missouri, malaria was known to be alleviated by quinine, but no two doctors agreed either on dosage or on timing.

  Indeed, at the time of the Civil War so little was known about preventive medicine of even the most basic kind that little effort was made to keep military camps hygienic. Training camps brought together huge numbers of susceptible men, many of them young and of rural origins, who may not previously have been exposed to childhood illnesses. Measles and mumps took their toll. Soldiers in the field preferred to relieve themselves close by their tents rather than at any distance for fear of being caught ‘with their pants down’. Water was thus almost always contaminated: ‘I could hardly get my horse to drink it,’ complained one Texas surgeon at the start of the war.

  As time wore on, men fed on poorly preserved salt pork, hardtack (stale biscuits) and heavily boiled vegetables – what the troops called ‘desecrated greens’ – suffered badly from malnutrition, which did little to aid their recovery from disease. And the wounds received in battle were virtually welcoming posts for gangrene and fatal bacteria. The .57-calibre minié balls fired by most small arms were of such low velocity that they usually introduced filthy bits of cloth from the soldiers’ tattered uniforms into wounds, but offered no sterilisation. Any bone wound was invariably dealt with by amputation, while nearly two-thirds of those suffering intestinal injuries died. One Civil War general, describing a typical surgical routine, wrote: ‘There stood the surgeons, their sleeves rolled up to their elbows, their bare arms as well as their linen aprons smeared with blood, their knives not seldom held between their teeth, while they were helping a patient on or off the table … The surgeon snatched his knife from between his teeth … wiped it rapidly once or twice across his bloodstained apron, and the cutting began.’ Mortality from battlefield infection was horrendous, with almost 275,000 Union soldiers dying out of a total of 2.2 million, according to figures collated by the Surgeon-General shortly after the war, and 164,000 out of 750,000 soldiers in the Confederate army.

  For every death from battle wounds, there were two from disease. Although this ratio represented some improvement over earlier conflicts—in the Crimean War it had been three to one; in the Mexican-American War seven to one; and for the British forces in the Napoleonic Wars as high as eight to one – death by disease during the American Civil War was still so common that the dead were known, after the blue and grey forces, as the ‘Third Army’. The most common causes were pneumonia, influenza and bronchitis. But epidemics of malaria also took their toll, especially during the early years.

  From 1861 on, Union a
ttempts to establish a bridgehead along the Atlantic coast were stopped largely because of outbreaks of malaria, typhoid and yellow fever. In 1862 General Henry Halleck’s forces in the west, which totalled more than 100,000 men, were unable to overcome the threat of malaria to take control of the Mississippi at Corinth. Soon after, another attempt to take the Mississippi at Vicksburg was also thwarted by the disease. As a result, it would take more than a year before the Union forces succeeded in taking Vicksburg.

  The town lay about four hundred miles above New Orleans and the same distance below Memphis, on a high bluff on the east bank of the river. The surrounding low countryside was cut by bayous that were prone to flooding during high water. Much of the land around was known then as the DeSota Swamp. During most of the campaign, which began in May 1862, the weather was hot and dry, but there was much greenscummed standing water left behind when a recent bout of flooding had subsided, the perfect conditions for mosquitoes to breed. Plantation owners in the area reported that their families and slaves suffered unusually severely from malaria that summer, and it is likely that the local population was responsible for the rapid spread of the disease. Vicksburg then had the second highest mortality rate from malaria among twenty-three Southern cities, worse even than New Orleans. ‘This is certainly the most unhealthy place I have seen,’ wrote Assistant Surgeon Junius N. Bragg of the 11th Arkansas Regiment, who suffered for three years from recurrent malaria, while General Halleck wrote in June 1862, less than a month before he was relieved of his command: ‘If we follow the enemy into the swamps of the Mississippi there can be no doubt that our army will be disabled by disease.’

  How right he was. The eventual seizure of Vicksburg, and with it control of the Mississippi River, marked the end of the possibility of a Confederate victory, but it came at enormous cost. The further south the Union forces advanced, the more common it was for their soldiers to die of malaria. Many of them, especially those from Kentucky and north Connecticut, had never been so exposed to mosquitoes. Within days they began falling sick. The 1st Kentucky Brigade lost a third of its strength within a month; another regiment was reduced from nine hundred men to 197 in an even shorter time. The company that replaced it started with a hundred men in mid-June; by the end of July there were only three left. Virtually every regiment at Vicksburg that summer reported that it was short of rations, and crucially, also of quinine. When supplies were exhausted, requisitions sent to New Orleans were not honoured by the medical director because of ‘irregularity’.

  In the Union army alone, 595,544 ounces of quinine sulphate and 518,957 ounces of fluid cinchona extract were issued by the authorities. The exactness of the figures, down to the last ounce, says much for the efficiency of the Union quartermasters. But down the line, supplies were nowhere nearly so well organised. Regiment after regiment in the early years of the war began campaigns in the summer months, rather than during the frost when the danger of catching malaria would have been far lower. From the Carolina coast, from Corinth, Richmond, Vicksburg, Chickahominy and Baton Rouge, came reports of camp doctors trying to treat malaria with capsicum, nitric acid or boiled bark from willow or dogwood trees; or, failing that, with just straight whiskey, because the quinine had run out and much-need replenishments had failed to arrive.

  By the end of the Civil War, the three-volume Medical and Surgical History of the War of the Rebellion (1861–65) reported, the Union army had diagnosed more than 1.3 million cases of malaria. The disease was largely untreated, and by the end of the war had killed more than ten thousand men.

  The higgledy-piggledy manner in which soldiers on both sides of the war were supplied with medicine can be blamed on many things: medical ignorance, diagnostic disagreements, bad communications and long distances to name but a few. That so many doctors still disagreed about prescription and treatment, especially of remittent fever, is perhaps the most surprising factor, for the healing properties of quinine had been known for more than two centuries. Among American doctors, no one believed in its qualities quite so much as the great-great-great grandfather of Ginger Rogers, the pioneering Dr John Sappington, whose Sappington’s Fever Pills became one of the most successful patent medicines in America in the early nineteenth century.

  Dr Sappington, who was just six weeks old when America gained its independence in 1776, came from a pioneering medical family. He was born in Maryland, on Chesapeake Bay, but by 1785 his father had moved the family from that genteel environment westward to Nashville, Tennessee. Young John began his medical studies as an apprentice to his father at an early age. When the time came for more formal learning, he attended a term’s lectures at the Philadelphia Medical College, but left before he had graduated, disheartened perhaps by the harsh winters and too much theory. In 1817, he followed his father’s example and moved his seven children from Nashville westward to the frontier of mid-Missouri, about two hundred miles up the Missouri River from St Louis.

  Although the region was sparsely populated, within five years he had built up a sizeable practice. As a frontier physician, John Sappington was a well-known pioneering type. With his medicine case in his saddlebags, he rode the narrow trails to any household where someone ill awaited him. It might be in the heat of summer, or in the dead of winter when his horse was forced to kick aside the snow; it might be in the night, when his body called for sleep, or on the day after such a night; it might be to attend the well-to-do, or some poor person who could not be expected to pay. Sappington’s charges were typical of the times. His ledger books show numerous entries such as ‘to visit and riding 10 miles, $3.50’, and occasionally ‘to riding 65 miles and three days and nights attendance, $50’. Even more frequent are the notations of payment in salt, dry beans, work, ‘one hind of beef’, bacon, corn, wheat or ferriage, and on one occasion, two barrels of whiskey.

  Dr Sappington became renowned for treating malaria with powdered cinchona bark, avoiding the dreadful practices of bloodletting, purging and the huge doses of harsh drugs that were more typically employed. Indeed, his reputation was such that families with children sought to settle close by his farm at Arrow Rock so that he would be close at hand for the inevitable malaria attacks in the summer and autumn. In later years one visitor, Captain J.A. Pritchard, described Sappington as ‘a very adroit and singularly eccentric character – jocular and lively and rather quisical, possessing a high degree of hospitality and gentlemanly demeanour – He is a large fine looking man about 6 feet high and looks to be about 70 years of age with heavy suit of hair and it white as snow – his beard as white as his head and hung to his breast.’

  When Sappington was learning medicine, it was still commonly believed that fever was the result of an irritation or excitement. Thus the first step in its treatment, many physicians believed, was to ‘calm’ the patient. This would generally be done by bleeding or by repeated uses of purgatives and emetics such as calomel, or even pepper, tobacco, rhubarb and lobelia powder, or a combination of these methods. Quinine, which had been introduced to America in about 1745, had never been very popular in any form – due, one authority says, to its early abuse by quacks. The prevailing view was that it was a stimulant which should properly be administered in the absence of fever, and then only after a period of preparation by all the bloodletting and purging that the patient could stand.

  What Captain Pritchard took to be eccentricity in Dr Sappington might rather have been evidence of an independent spirit. Sappington differed fundamentally from other doctors. He might bleed if a patient seemed ‘overly full-blooded’, but only moderately and very rarely. He held to the then unusual view that the blood, with its load of oxygen and ‘food substances’, was needed for vitality. He was unusual for his time too in advocating cool water for those suffering from fever, reasoning that it replaced liquids lost through perspiration, as well as being very pleasant to patients. He was also among the first doctors to use quinine not just as a cure, but also as a preventive.

  In later life, Sappington recalled that
he first learned about cinchona bark a short time after finishing his medical apprenticeship when he came across a pamphlet recounting the history of its discovery in Peru, or at least the fictitious version involving the Countess of Chinchón, and of its use in fevers. He began by experimenting on himself with one-ounce doses (equivalent to 10–12 grains) of sulphate of quinine while he was well. Emboldened by the fact that none of the side effects he’d been warned of seemed to appear and that his pulse and temperature remained normal, he began trying the drug out on his feverish patients, though not without some anxiety. ‘Many times have I sat by the bedside of my patients for days together, giving it, anxiously waiting to see the effect it would have upon them,’ he would write later in his book The Theory and Treatment of Fevers, while at the same time making a great show of administering a harmless placebo, a bread pill, for instance, to keep the confidence of both the patient and his relatives.

  By the time Sappington left his childhood home in Tennessee to pursue his studies in Philadelphia in the second decade of the nineteenth century, he had become a firm convert to quinine’s cause. He even persuaded one of the doctors at Philadelphia Medical College to try it. One afternoon over tea, his colleague Dr Barton mentioned that he had a most vexing patient. For three weeks the man had been in hospital suffering from ‘simple ague’. He had been having fits of chills and fever, and although he was able to move about between the episodes, his condition wasn’t really improving. Sappington said that he believed he could cure the man with one-ounce doses of bark in wine, ‘as much as the stomach would bear, then doubling or tripling the dose at a time just before the return of the chill’. Barton followed Sappington’s advice, and the patient was cured.