|Kala azar disease|
In 1934 the third edition of Cecil’s A Textbook of Medicine contained a chapter by an academically obscure missionary in China.1 Russell Cecil, still editing the book by himself with only the help of a neurology colleague, chose Ernest Black Struthers to write about kala azar (visceral leishmaniasis). Most North American physicians have never seen kala azar, but the name mysteriously rolls off the tongue as a cause of splenomegaly in the Socratic atmosphere of medical training. Struthers was working in the city of Tsinan in Shantung Province, an endemic area for the disease in China. To write for North America’s leading textbook with little in terms of formal postgraduate training was a product of circumstance and war.
Struthers was born in 1886 in the small town of Galt in Ontario, Canada. His father ran a prosperous hardware store and his family frequently hosted missionaries passing through the tiny hamlet. Finishing high school in his hometown, he proceeded to medical school and graduated from the University of Toronto in 1912. He studied for several months in England and Scotland before undertaking a locum tenens position in Hong Kong in February 1913.
In Hong Kong he worked alongside a taciturn Scotsman who taught him to perform hysterectomies and appendectomies, remove bladder stones and repair hare lips. He encountered cholera and bubonic plague, diseases never seen in North American medical practice. Now convinced that he wished to be a missionary to China, he was preparing to return to Canada for more studies when he was talked into beginning work immediately in Henan province in northern China.2
When the First World War broke out in 1914, the British began to recruit medical personnel to escort a Chinese Labor Corps to France. He volunteered for what would be the first of five major military conflicts to impact his life. In France he helped establish and run a hospital for the Chinese workers. This experience at the age of 28 served him well later. At the close of the war he treated people in the influenza epidemic and finally came down with a severe case himself.
Returning to North America to recover, he completed five weeks of postgraduate study in New York and then returned to Tsinan to teach at the Shantung Christian University Medical College in 1920. Here he experienced his first exposure to kala azar, which was endemic in the area. Several patients had the signs and symptoms of kala azar but no attempts were being made to confirm the diagnosis or give treatment. Some were thought to have malaria. He began doing splenic punctures to confirm the diagnosis. After the hospital pathologist attended a conference in Calcutta, he returned with a book by Ernest Muir on the signs and symptoms of the disease and its treatment with tartar emetic.
Tartar emetic was potassium antimony tartrate. It was tried on the first kala azar patients on a whim as it had enjoyed some success in treating South American cutaneous leishmaniasis. Italian workers tried it on children with the visceral form and published their success in 1915. This was followed by further positive results on adults by Leonard Rogers, an English physician with the Indian Medical Service.3 Struthers and his colleagues began using tartar emetic with good results in an otherwise fatal disease, although the course of treatment was long and could be very toxic.
On his second furlough in 1924–5 he took a six month course in tropical medicine at the London School of Tropical Medicine and Hygiene. Rather brashly, he recorded in his memoirs that he rather enjoyed the final examination, feeling that he knew more than his examiners. He also spent six weeks with Francis Peabody in Boston. After his return to Tsinan he found himself caught up in war again as the civil war in China between the Nationalists and Communists was raging. As the Nationalist forces advanced towards the city, he was forced to evacuate to a nearby coastal city (Tsengtao) in the spring of 1926 Further north, during a vacation, he collected sandfly and mosquito specimens for the British Museum. While his memoirs do not mention it, this was not likely an idle hobby but an attempt to help piece together the puzzle of the kala azar vector, shown later to be the sandfly. He returned to Canada on his third furlough, passing through Calcutta to further his knowledge of kala azar. A month attending a tuberculosis course at Saranac Lake in New York became an early intellectual seed that later blossomed.
After his return to the medical school in Tsinan in 1931 he visited the world’s largest kala azar clinic in nearby Tsing Kiang Pu, where he viewed their successful use of neurostibosan. He enjoyed a visit from Lady Leishman, the wife of the co-discoverer of the Leishman-Donovan body, and entertained Professor E. Hindle and Major W. S. Patton of the Royal Society who were working on the sandfly theory of kala azar transmission.
During this period he prepared his chapter for Cecil’s text. Not only did he have broad exposure to the disease, but he had also been active in trials of the antimonial compounds that were developed by the Bayer Company in Germany and Wellcome in England.4,5 Francis Peabody had suggested this scientific pursuit to him after he had lamented the paucity of research at the medical school in Tsinan.
Following another year’s furlough where he studied public health and tuberculosis, he returned to the Tsinan medical school in 1938 to find that military strife had driven the students to West China to escape the Japanese invasion. He was sent to a nearby mission hospital, where despite coaching a Japanese military physician on diagnosing kala azar by splenic puncture, Japanese Army harassment caused him to leave and go to West China. There the West China Union Medical School had given asylum to two other medical schools. Circumstances led him to be appointed the Dean of the Shantung Medical School, now called Cheeloo. On furlough in 1944, his desire to contribute to the war effort led to a year in Washington as consultant on China to the Surgeon General.
He returned to China in 1945. With the defeat of the Japanese, the Nationalists had taken over the university hospital in Tsinan. They asked him to resume his duties and re-establish the hospital. However by March 1948 the advancing Communist Army caused the staff to evacuate. They left for the city of Foo Chow where there was a mission hospital that could be used for teaching. He carried on medical school teaching for a year, but when Shanghai fell to the communists in 1949 he knew he would soon have to leave. The new government instructed the school to return to Tsinan with their equipment, but on arrival they found their living facilities occupied by Communist students unwilling to move. In May 1950 he left on furlough ending his China work.
At sixty-four he took a job in Toronto, Canada in tuberculosis surveillance, aspects of which he found stifling. When Severance Medical College in Seoul, Korea was recruiting staff, his name was suggested and he agreed to teach tropical medicine and tuberculosis for two years. He departed in July 1953 as the Korean War was ending. Two years became ten, with a brief interlude to marry and honeymoon. In Korea he organized a series of ambulatory clinics to treat tuberculosis. Outpatient treatment was unprecedented but was badly needed in a country rife with the disease. He also sought to establish a fifty-bed sanatorium in Seoul. The US Eighth Army, seeking to memorialize their Korean War fallen soldiers, agreed to build it but suggested 100 beds. After a protracted gestation it opened as a general thoracic hospital with a tuberculosis ward.6 The opening of this new hospital was a thin silver lining for Koreans behind the dark cloud of the military conflict. He returned to Canada in 1963 and died at the age of ninety-one. In between, with the help of his wife, he wrote his memoirs. His life spanned five major military conflicts. As a result of the wars he was at various times welcomed, harassed, displaced, and eventually dismissed from China. As a missionary, his medical career was enriched by exposure to a disease he had never seen in his training. He became an expert and at the same time participated in the trials of drug treatment in the infancy of antimicrobial therapy. Korea drew on all the administrative and negotiating skills he had learned as a dean and hospital administrator. It was a life well lived.
- Cecil, Russell. A Textbook of Medicine. 3rd ed. Philadelphia: WB Saunders; 1934
- Struthers EB. A Doctor Remembers: Days in China and Korea. 1st ed. Mississauga: Published by the author with the assistance of the United Church of Canada; 1976
- Greenwood D. Antimicrobial Drugs: Chronicle of a Twentieth Century Medical Triumph.1st ed. Oxford, New York: Oxford University Press; 2008.
- Struthers E. The Treatment of Kala Azar by Stibosan (Heyden 471) and Antimosan (Heyden 661). China Med J. 1927; XLI (9):755-761.
- Struthers E. The Advantage of the Organic Preparations of Antimony in the Treatment of Kala Azar: A Preliminary Note. China Med J. 1926; XL: 849-850
- http://www.yuhs.or.kr/en/Edu_Research/Coll_Medicine/. Accessed January 28, 2017
PETER KOPPLIN, MD, is a practicing internist in Toronto and a member of the Toronto Medical Historical Club.