Tuesday, September 4, 2007

Medical Department #7 - Quinine Substitutes in the Confederacy

In early July, I posted a blog entry about a recent and interesting article in the journal, Military Medicine, by my good friend Guy Hasegawa, Pharm. D. The artcile - and my subsequent interview with Guy - formed the basis for my most recent "Medical Department" column in The Civil War News (September 2007).

The column has since appeared in print, so it's my pleasure to now post the full text of the column on my blog. As I stated when I first started the blog a few months ago, one of the advantages of posting the column is that I can now provide hyperlinks to relevant information and illustrations in the column; in this case, readers will be able to access the text of Francis Porcher's Resources of the Southern Fields and Forests and a wartime article in the Richmond Daily Dispatch which Guy discusses in his paper and in the interview.

"A Bark by Any Other Name"
by Jim Schmidt
from the September 2007 issue of
The Civil War News

Sick Boy: “I know one thing - I wish I was in Dixie.”
Nurse: “And why do you wish you was in Dixie, you wicked boy?”
Sick Boy: “Because I read that quinine is worth $150 an ounce there; and if it was that here you wouldn't pitch it into me so!”

- “Advantage of Famine Prices” (Harper’s Weekly, November 14, 1863)

During the Civil War, the Confederacy – faced with an unreliable and expensive supply of quinine – was forced to use alternative treatments. Substitutes for quinine (derived from the bark of the South American cinchona tree and used to combat malaria) were mentioned in the medical literature of the era, but few of these alternatives were advocated by Confederate officials, and fewer still are described in surviving records.

In his article, “Quinine substitutes in the Confederate Army,” in a recent issue of Military Medicine (June 2007, Vol. 172, No. 6, pp. 650-5), Guy Hasegawa, Pharm. D., discusses the agents that were suggested and used (with unequal success) as the Confederacy faced a shortage of quinine.

Regular readers of this column will remember that Guy is an expert on Civil War medicine and has published previously on medical cadets, Confederate medical laboratories, and other interesting topics. His writing - besides being interesting and new - is always marked by relentless research, especially on primary material in archives, and his new article about quinine substitutes is no different. Guy has become a faithful correspondent – and a very good friend – ever since his research on pharmacy in the Civil War was covered in my column more than six years ago.

As described in his paper, most of the alternative treatments were made from native plants - dogwood, willow, and tulip tree, for example. High hopes were held for Georgia bark, which was thought to be closely related to cinchona. Documentation of the effectiveness of the various quinine substitutes is scarce, although a relatively plentiful record for the external application of turpentine exists. The Confederate Surgeon General's Office was active in seeking out and supplying troops with quinine substitutes, but – in the end – the substitutes were generally considered useful but not as effective as quinine.

Guy was kind enough to answer some of my questions to dig deeper into his study and conclusions. “My research on quinine substitutes was triggered by finding a letter at the National Archives,” he told me. “I was researching a completely different topic - the Brown's Island (Richmond) explosion of 1863 to see how the victims of that mass casualty event were treated – and investigating the surgeons who served at the army hospital that took in many of the patients.”

Guy “struck out” on that line of inquiry, but – in an episode of serendipity – he found a letter in the file for one of the surgeons (William Duncan) referring to "fodder tea" and extract of American hemp being tried for malaria. “This led to a search for the identity of those agents and for the order that prompted the Duncan letter. In the process, I learned a lot about the various remedies that had been used - both by civilians and the military - to treat malaria,” he said. Guy already knew about the more common quinine substitutes, but the Duncan letter – and his subsequent research – gave him some new material to publish.

So what is that new material? “I think my paper differs from other work in that it describes remedies - like fodder tea - not mentioned before and separates military from civilian use of the drugs,” Guy told me. There were already reports in the literature on quinine substitutes used by civilians, but Guy was looking for documentation of Army use because of his general interest in military medicine and because he thought learning how the Confederate authorities selected remedies might be enlightening in its own right.

The foundation of much research and writing on the use of natural remedies in the Civil War era is Confederate Surgeon Francis P. Porcher’s 600-page book, Resources of the Southern Fields and Forests (first published in 1863), which described numerous plants thought to have anti-malarial activity. A lot of the previous reports seem to “celebrate” Porcher's compilation but don't look closer at whether any of his recommendations were actually used.

“I did not set out to prove anything about Porcher, but the timing of events shows that his book was published after the major decisions about quinine substitutes were made by the Surgeon General's Office,” Guy told me. “Moreover, someone reading Porcher’s book would not be able to easily identify the most promising substitutes or learn how to use them,” he added. Guy doesn’t discount Porcher’s contribution; “He wrote a remarkable book in a short time, and it may have helped the military and civilians in many ways,” Guy said, “but I don't think it had much influence on the Army's treatment of malaria.”

Guy provides some basic statistics on malaria in Confederate troops ; while the mortality rate was rather low (less than 2%), there could be more than 250 cases per 1000 men per year, depending on the year and theater of war. “Keep in mind that to be counted in the statistics, a soldier had to receive medical attention,” Guy told me, “so the true number of malaria cases was undoubtedly higher than what the figures show.”

The prevalence of malaria in the Confederate ranks was a burden, to be sure. “Beside its obvious effect on a unit's ability to march or fight, illness also consumed resources - transportation, manpower, and medical supplies - because the sick had to be cared for,” Guy said. “It's like the old wisdom that it's more damaging to debilitate enemy soldiers by wounding them than to kill them outright, because dead soldiers quickly stop consuming resources.” Even sick soldiers who stayed with their units instead of going to a hospital were a burden on comrades who had to look out for them.

Even when quinine was available in the Confederacy, its quality was often uneven or unknown. Guy mentions that ruses used in smuggling led to some labeling mix-ups - sometimes between quinine and morphine – which led to confusion in camps and hospitals. It’s possible that not all of the quality problems were accidental. “I recently found an article in the Richmond Daily Dispatch that claimed that smugglers had bought adulterated quinine from Yankees and sold it to Confederate medical purveyors,” Guy told me. “The stuff was supposedly cut with strychnine and morphine. The correspondent decried the villainy of the Yankees but not the motives of the smugglers or the gullibility of the purveyors,” he added. He admits that the Dispatch story may not be true; adulteration of drugs was common at that time with the motive generally no more sinister than to increase profits.

Guy also discusses the external use of oil of turpentine as a remedy for malaria. Although it was rarely mentioned as a remedy in the medical literature before the war, it had some strong proponents among Confederate medical officers. Surgeon Stiles Kennedy attributed the efficacy of turpentine to producing enough pain to demand "the whole attention of the mind,” acting on nerve centers, and producing a stimulating effect.

Surgeons – pointing to positive numbers in ersatz “clinical trials” in Confederate hospitals – were confident of turpentine as a remedy, but the influential Confederate States Medical and Surgical Journal (CSMSJ) was more conservative. “I was surprised that the CSMSJ seemed so insightful in its evaluation of the turpentine evidence,” Guy told me. “The journal's listing of confounding factors seemed almost modern, and the editors stopped just short of saying that a control group was needed,” he added. Given the anecdotal or subjective nature of most of the literature of the time, Guy is hard-pressed to explain the seemingly higher standard for medical evidence that the journal applied in this case.

The effects and treatment of malaria are important lines of scientific research even today, especially in the Third World, as witnessed by the extensive coverage given it in the most recent issue of National Geographic. As during the Civil War, the limited availability - and affordability - of drugs, means that the majority of the world's population still depends on traditional medical remedies. Recently, herbs such as Artemisia annua have been found to have antimalarial activity, and research continues this day to exploit natural products for the next generation of medicines.


Rose said...

Dear Mr. Schmidt, I am a high school student from the state of Washington and I am in need of some information about Civil War medicine for a research paper. I would really appreciate it if you could give me your take on a few questions for me.
~Why do you think that medicine took on so many changes during the American Civil War as opposed to other times in American history?
~What would you say are the most prevalent areas of medical advancement during this time? Why?
~What are some things discovered during the Civil War period that contribute still to medicine today pertaining to surgery, hygiene, infection control, etc...?
~Were these medical advances more numerous in the North or the South? Why?
~Did these discoveries travel quickly to the other side? Why or why not?
~Were there other challenges the medical side of the war faced, such as political issues or having inadequate supplies, facilities, or staff with medical supplies?

Jim Schmidt said...

Rose - I want to let you know I got your comment - you ask some very interesting questions - if you can give me a day, I'll provide some answers - many thanks

Jim Schmidt said...

Rose - Thank you again for your questions - I've provided some brief answers below - if you'll contact me separately at schmidtjamesm at gmail dot com, I can send you some supporting information by e-mail...good luck with your paper!

As with so many other things, war sometimes accelerates change that may have happened eventually. One important question is what "medicine" actually includes - nursing, surgery, pharmacy, emergency services, long-term care, medical education...and much more...I think each of these various aspects needs to be considered on their own - some of these aspects saw more change than others, but all saw some change.

In terms of medical advancement and things discovered during the Civil War that still contribute to medicine today, one of the most important is not a particular medicine or a particular surgical procedure - it's actually a process for treating and evacuating casualties from the battlefield known as the "Letterman Plan" or "Letterman System," developed by Dr Jonathan Letterman, who should really be considered one of the great heroes of the war. The system included an efficient ambulance system, removal to a first aid station, "triage" to separate the most severely wounded from the lightly wounded, and then surgery at field hospitals. His system has been used in every war since and also in every emergency room in the country each day, especially in situations of mass casualties.

Another important advancement was the use of anesthesia in surgery - most people have an incorrect understanding of how and why amputations were done in the war. First, the vast majority of amputations done by Union doctors were done under anesthesia, using chloroform or ether or combinations of the two; second, it may well be that too few amputations were done rather than too many - for the types of wounds caused by the weapons used during the war, amputation was a safe and quick operation that reduced dangerous infections and saved many lives.

As a rule, I would say they were more numerous in the North - the North had a better established medical education system before the war (many Southern doctors were actually trained in northern schools); they also had a better established pharmaceutical industry than in the South, which helped with drug supply; the army and navy both had small - but already established - medical departments, whereas the Confederates had to build theirs from scratch. But both sides contributed to a lot of ingenuity and advances in medicine during the war.

It's not likely that particular medical discoveries traveled quickly to the other side as there was not much medical communication between the enemy forces. However, both sides set up medical societies so that they could share information and experiences and there was a lot of cooperation after the war.

As mentioned above, the Confederacy had to build from scratch and also had less of an established industry, so they often faced shortages. They got some of their supplies through capture of Union supplies or through ships that ran the blockade of Southern ports. Even though the Union had better industry, they also had a bureaucracy that sometimes slowed the delivery of needed supplies to the front.