Caribbean Diseases Doctor George Low's Expedition in 1901
02 1st Edition
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Preface
The overriding raison d’etre of this book is to document (in George
Carmichael Low’s words) a 1901–02 expedition to the Caribbean (centred
on the Windward Islands) which recorded accurately, probably for the
first time, the disease spectrum (including parasites and their vectors)
in that geographical location. Low was therefore a major pioneer (albeit
a grossly underrated one) of a rapidly expanding specialty and his
correspondence with Dr (later Sir) Patrick Manson (1844–1922) – then
Medical Advisor to the Colonial Office – (transcribed here for the first
time) does much to confirm his influence on the evolution of the spe-
cialty. The letters illustrate Manson’s direction of Low’s researches, and
thus many of the thought processes of ‘the father of tropical medicine’
himself.1 The correspondence also emphasises the importance of a know
ledge of e pidemiology and ecology to the early clinical parasitologists.
There were, of course, older records of disease in the West Indies, but
most lack precision. Thus, Hans Sloane (1660–1753) had documented
some of the diseases of Jamaica in his book: Of the diseases I observed in
Jamaica, and the Methods by which I used to Cure them; he described yaws,
elephantiasis and sleeping sickness in African slaves. Others of the early
pioneers of ‘medicine in the tropics’ had also given accounts of diseases
encountered in circumscribed localities. Thus, William Hillary (17??–63)
and James Grainger (1721–66) had described the disease spectrum in
Barbados and St Kitts, respectively.2
Low sent 31 letters to Manson (12 January 1901–02 April 1902), which
were extant in 1993. They contain accounts of observations made during
this period; many were epidemiological, but he also devoted a great
deal of time sectioning mosquitoes in an attempt to delineate com-
plete life-cycles; Filaria demarquayi (now designated Mansonella ozzardi)
and Filaria ozzardi3 were of particular interest. Manson (founder of the
London School of Tropical Medicine [LSTM] and originator of the spe-
cialty), considered that both F demarquayi and F perstans were important
helminths in a human context. [Looked at in retrospect it was, of course,
unfortunate that Low spent so much time working on two filaria species
which, it has transpired, have little clinical importance for Homo sapiens;
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vi Preface
however, he was also able to accumulate a vast amount of other scien-
tific data.] He also confirmed the causative association between Filaria
bancrofti and elephantiasis, which was known to Manson at Amoy, China
in 1877.4 A later project was to assist in the elimination of malaria and
yellow fever by draining swamps and other areas containing stagnant
water. He mentioned in the correspondence to Manson that he had com-
municated with (Sir) Ronald Ross (1857–1932), (whose major research on
malaria transmission had been undertaken a mere 4–5 years before) on
the best methods and practicability of eradicating malaria from various
Caribbean islands.
Low also recorded the presence or absence of various diseases on vari-
ous West Indian islands; for example, he documented cases of typhoid,
yaws, smallpox, yellow fever and many other infective entities which
before the antimicrobial era were untreatable.
All of these letters from Low to Manson from British possessions in
the Caribbean were until recently in the Manuscript Collection of the
London School of Hygiene and Tropical Medicine, although they are
presently ‘missing’. Chapters 4–9 are transcripts of the original letters
with the exception that I have italicised the names of helminths and
insects, and have highlighted the major diseases in bold font. My editing
throughout has however been minimal. These documents also provide
a great deal to knowledge of disease causation and prevention in the
early days of the LSTM – which had been founded in 1899 – and also the
formal discipline tropical medicine.
Low’s primary ambition was thus to elucidate the complete life-cycles
of previously poorly documented filarial infection(s).5 However, his
expedition became increasingly oriented towards prevention (in the wake
of Manson’s, Ross’ and Walter Reed’s recent pioneering discoveries).6
Thus the correspondence contains much on prevention of both malaria
and yellow fever, and also attempts to convince the lay public resident
in the Caribbean, that mosquitoes must be eliminated from the environ-
ment. Another objective was to collect both helminths and entomologi-
cal specimens for the LSTM. Low therefore helped enormously to place
the new discipline on a scientific basis.
Mary Gibson kindly drew my attention to the Low–Manson cor-
respondence (previously unpublished) which was in the Manuscript
Collection of the Library of the London School of Hygiene and Tropical
Medicine. I am grateful also to Mr Robert N Smark (Keeper of Muniments
at the University of St Andrews) and Dr G O Cowan OBE for making
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Preface vii
available extant information on Low’s undergraduate career. Jo Currie,
Assistant Librarian of the Special Collections at Edinburgh University
Library, provided material on Low’s years at that University. Amberley
Moore, Honorary Secretary of the British Ornithologists’ Club, kindly
supplied information regarding Low’s involvement with ornithology.
G C Cook
April 2009
References and Notes
1 P Manson-Bahr. History of the School of Tropical Medicine in London (1899–1949).
London: H K Lewis 1956: 328; G C Cook. From the Greenwich Hulks to Old St
Pancras: a history of tropical disease in London. London: Athlone Press 1992: 338.
[See also: P Manson-Bahr. The Manson Saga. Trans R Soc trop Med Hyg 1945;
38: 401–17. G C Cook. Disease in the Merchant Navy: a history of the Seamen’s
Hospital Society. Oxford: Radcliffe Publishing 2007: 630; J W W Stephens, M
P Sutphen. Manson, Sir Patrick (1844–1922). In: H C G Matthew, B Harrison
(eds). Oxford Dictionary of National Biography. Oxford: Oxford University
Press: 2004; 36: 553–5.]
2 Op cit. See Note 1 above (Cook, 1992). [See also: G C Cook. Tropical Medicine:
an illustrated history of the pioneers. London: Academic Press 2007: 14–16.]
3 Albert Tronson Ozzard (??–1929) qualified (MRCS, LSA) from the London
Hospital Medical College in 1887. He subsequently served at Suddie, British
Guiana (now Guyana) from 1887 until 1927. His research publications
were on malaria, filariasis, and ankylostomiasis. [See also: Medical Directory.
London: J & A Churchill 1908; 1582.]
4 Op cit. See Note 2 above (Cook, 2007) 53–5.
5 J J C Buckley. On the development, in Culicoides furens Poey, of Filaria (=
Mansonella) ozzardi Manson 1897. J Helminthol 1934; 12: 99–118; D I Grove.
A History of Human Helminthology. Wallingford, UK: CAB International 1990:
734–6.
6 Op cit. See Note 2 above (Cook 2007; 53–5, 88–92, 105–8). [See also: G Williams.
The Plague Killers. New York: Charles Scribner’s Sons 1969: 345.]
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Prologue
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‘Tropical medicine’ as a distinct discipline came into being during a
20–year period (1894–1914) and is sometimes equated with ‘colonial
medicine’. Low himself has outlined the origin(s) of the discipline, which
arguably began with Manson’s demonstration of the man-mosquito
component in the life-cycle of Filaria nocturna (Wuchereria bancrofti) in
1877.1
Thus the formal discipline was in 1901, when Low set out on this
expedition, in its infancy. Ross’ discoveries in India, which demonstrated
scientifically that mosquitoes were involved in malaria (Plasmodium and
Proteosoma) transmission had been carried out as recently as 1897 and
1898. These exciting events were therefore fresh in the minds – not only
of the pioneers of the discipline – but in those of the lay public gener-
ally.2 Implication of another species of mosquito – Aëdes aegypti – in the
transmission of yellow fever by the American Yellow Fever Commission
was not accomplished until late 1900, and the results were not widely
known until February 1901 – i.e. during Low’s expedition.3
However, the aetiology of most tropical diseases was in 1901–02 still
undetermined. It was not until 1903, for example, that the causative
agent of the ‘negro lethargy’ was identified. At about the same time, the
cause of Kala-azar (visceral leishmaniasis) was also determined.4
This was thus an extremely exciting time; clinical parasitology was
fast developing, and Low (working at Manson’s school – the London
School of Tropical Medicine) was at the forefront of activity.5
References and Notes
1 G C Cook. Tropical Medicine: an illustrated history of the pioneers. London:
Academic Press 2007: 53–5.
2 Ibid. 81–102. [See also: G C Cook. Mosquito involvement in the malaria life
cycle. J Med Biog 1998; 6: 182–3.]
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4 Caribbean Diseases: Doctor George Low’s Expedition in 1901–02
3 Ibid. 103–13. [See also: H H Scott. A History of Tropical Medicine. London:
Edward Arnold 1939: 279–453; G Williams. The Plague Killers. New York:
Charles Scribner’s Sons 1969: 345.]
4 Ibid. 153–4, 177–82.
5 F E G Cox (ed). The Wellcome Trust Illustrated History of Tropical Diseases.
London: The Wellcome Trust 1996: 452. [See also: G C Cook. From the Greenwich
Hulks to Old St Pancras: a history of tropical disease in London. London: Athlone
Press 1992: 338; G C Cook. Disease in the Merchant Navy: a history of the Seamen’s
Hospital Society. Oxford: Radcliffe Publishing 2007: 630.]
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Chapter 1
George Carmichael Low (1872–1952)
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Who was George Low? George Carmichael Low (Figure 1.1), the third
son of Samuel Miller Low (master manufacturer of flax machinery),
was born at Monifieth, South Forfarshire, on 14 October, 1872. Little
is known of his early life. Having graduated in arts (MA on 14 April
1892) at Madras College, St Andrews (extant records are incomplete),
he went on to a highly successful undergraduate and early postgraduate
medical career at Edinburgh University. Figure 1.2 shows two pages
from his entry in the medical student schedule, and Figure 1.3 shows
the Edinburgh Medical School in 1896. He subsequently held house
appointments at the Edinburgh Royal Infirmary;1 Figure 1.4 shows
the residents (including Low) in 1898. His MD thesis (229 pages) was
entitled ‘Human filariasis’; he was awarded the University’s Gold Medal
in Tropical Medicine in 1912.
In November 1899, Low joined Dr (later Sir) Patrick Manson immedi
ately after the London School of Tropical Medicine (LSTM) had been
founded at the Albert Dock Hospital (ADH) London.2 Shortly afterwards,
he travelled to Heidelberg and Vienna to learn a technique for sectioning
mosquitoes in celloidin using a sliding microtome. Immediately after
return to London, he used this technique to examine alcohol-preserved
Culex fatigans which had fed on individuals infected with Filaria (now
Wuchereria) bancrofti in Brisbane, Queensland, which had been sent to
Manson by Thomas Bancroft (1860–1933). Demonstration (on 24 March
1900) of filariae in the entire length of the proboscis sheath led to an
obvious conclusion that man is infected by larval filariae via a mosquito
bite.3 (At that time human infection was widely believed to occur via
mosquito-contaminated water, and Manson himself subscribed to this
view.)
In the autumn of 1900, Low, together with L W Sambon, an artist,
and a servant, spent three months on the Roman Campagna in a region
highly endemic for Plasmodium vivax infection. One hour before sunset
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8 Caribbean Diseases: Doctor George Low’s Expedition in 1901–02
Figure 1.1: Dr George Carmichael Low, FRCP (1872–1952). Courtesy of the Wellcome
Library, London (reproduced with permission).
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George Carmichael Low (1872–1952) 9
each day they ‘imprisoned’ themselves in a mosquito-proof hut, where
they remained until dawn, thereby escaping mosquito bites and, as a
result, clinical malaria. During that expedition, P vivax-infected mos
quitoes were dispatched to London, where they were allowed to infect P
T Manson (son of Patrick), a medical student at Guy’s Hospital, and also
Warren, a laboratory technician. Both developed clinical malaria, which
was eventually cured with quinine.4 These two pieces of clinical investi-
gation established beyond doubt that human malaria is contracted by the
bite of mosquitoes (the controversy concerning priority in this discovery
will not be spelled out here, but has recently been reviewed).5
This book documents Low’s contributions during the period January
1901 to April 1902. In 1901, he travelled to the West Indies (the Windward
Islands and British Guiana), where he both confirmed Manson’s work
linking Filaria bancrofti with elephantiasis, and made numerous obser-
vations on other human filarial infections. He also became increasingly
interested in prevention of both malaria and yellow fever.
Shortly after his return to London in May 1902, Low headed the
Royal Society’s first sleeping-sickness expedition (accompanied by
A Castellani and C Christie) to Entebbe, Uganda – on the northern shore
of Lake Victoria Nyanza – in order to investigate the cause of a large
and severe epidemic of the ‘negro lethargy’. This expedition could have
been a triumphant success, because Castellani actually demonstrated
Trypanosoma sp in patients with the disease (sleeping sickness); however
he became obsessed with an idea developed by Portuguese workers, that
Streptococcus sp was responsible. It fell to D Bruce (and D N Nabarro) to
clinch the Trypanosoma sp theory shortly afterwards.6
Returning again to London in 1903, Low had already become a tower-
ing figure in tropical medicine; when the post of superintendent of the
ADH became vacant, he was the obvious choice.7 He was apparently
an excellent teacher and organiser, and remained at the School and
Hospital for virtually the whole of his subsequent professional life. In
1918 he was appointed physician, and in 1919 senor physician, to the
ADH.8 During the Great War (1914–18) he became a major in the Indian
Medical Service, treating officers with tropical diseases at the ADH. In
1920, the LSTM moved to Endsleigh Gardens, London WC1, and Low
became senior physician of the Hospital for Tropical Diseases (HTD)
which until 1929 was housed in the same building as the School. When
the London School of Hygiene and Tropical Medicine (LSHTM) was
founded in 1924, Low became Director of the Division of Clinical Tropical
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10 Caribbean Diseases: Doctor George Low’s Expedition in 1901–02
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George Carmichael Low (1872–1952) 11
Figure 1.2 a, b: Pages 1 and 3 of Low’s entry in the Edinburgh University medical
student schedule – referring to some subjects in the Final Professional Examination.
Page 3 contains a declaration signed by Low on 14 April 1897.
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