CO885-(6-7) — Page 682

119

PUBLIC RECORD

OFFICE

Reference :-

C.O.885

7

PUBLIC RECORD OFFICE, LONDON

ALLY WITHOUT PERMISSION OF THE BE REPRODUCED PHOTOGRAPHIC-

COPYRIGHT PHOTOGRAPH-NOT TO

10

disease was contracted; to allow this is like treating a case of alcoholic neuritis with brandy. To treat alcoholic neuritis properly you must first diagnose it, and similarly to be able to treat beri-beri properly you must also first diagnose it correctly. But without special instruction or without an experience bought with human life there is as little chance of being able to diagnose the one as there is to diagnose the other.

Filariasis is another tropical disease which is often overlooked, and about which there are many absurd and even dangerous misconceptions. In most tropical countries in which the subject has been investigated it has been found that about one man in every ten is affected with blood worms. In some places the proportion is as high as one in three, in others one in two, and I know of at least two places where nearly every inhabitant is victimised in this way. Surely, therefore, it is of importance, seeing that these parasites give rise in many instances to grave disease, that the medical practitioner should know something about then, be able to diagnose their presence, and recognise their effects. But ten chances to one if one asks a student, or even a medical practi- tioner, to set about examining a patient for filaria he will prepare a very fine film of blood, such as would be suitable for the demonstration of bacteria, and that he would set to work to examine it with a twelfth of an inch immersion lens and an Abbe conden- ser. Now, although there may be tens of millions of filaria in the patient's blood, the chances are they will not be discovered by such means. Most people think that when they have to make a microscopic examination the more microscope they have the better. As a rule, the reverse is the truth. Filariæ should be sought for with an inch objective, otherwise they will be missed. Though the individual filaria are large as compared to bacteria they are relatively few in the blood. You require, therefore, to include a large field with your microscope to have a reasonable chance of finding them. If a sailor could command with his eye only the narrow horizon visible from a small boat he is not likely to see many whales in the sea, so he ascends into the crow's-nest at the mast-head, and, commanding there a wide view, he can see any whale that spouts for miles around. So it is in searching the blood for filaria-a large field is indispensable. But this is a self-evident fact hardly ever grasped by the student unless he has it ac tually demonstrated to him. He seldom arrives at it spontaneously. Now, exactly the opposite is the case for the malaria parasite. All this needs teaching, needs de- monstration. The malaria parasite I tried to find for nearly ten years before, through 1 mention accident, I finally succeeded. A Chinaman found my first filaria for me. these things to show how necessary it is, if we would save time and make the best of our opportunities, to have someone to teach us even simple technique.

In

In connexion with filariasis and blunders in diagnosis from want of elementary The patient instruction in tropical disease I may refer to a case which I came across. was a handsome young fellow, who some years before had joined a regiment of horse artillery then in India. He got on very well for a year, liked his work, and was on the high road to promotion. One day he got a smart fever, and with the fever a pain in his left groin, which he now and for the first time noticed to be swollen. due course the fever subsided; not so the swelling, which grew and grew until it became the size of a fist. It interfered with his riding, and so he consulted the regimental sur- geon. The swelling was soft and to a certain extent reducible. Accordingly rupture was diagnosed and a truss applied. But the truss caused so much pain that it could not be worn.

It irritated the swelling, and brought on attacks of inflammation and fever. Getting no better he went to one of the Presidency towns to consult a surgeon of experience in tropical disease. This surgeon recognised at once the true nature of the swelling, diagnosed the case as one of varicose groin glands, confirmed his diagnosis by an examination of the blood, which he found to be full of filaria, and very properly Now a very advised the patient to throw away his truss and to give up soldiering. little instruction in tropical disease given to the regimental surgeon would have put him on the right track, would have spared his patient much suffering, time, and expense, and have reduced to some extent the military burdens of our over-taxed Indian empire.

One more illustration of my contention. In 1895 and again in 1896, Mr. Galgey, colonial assistant surgeon. St. Lucia. West Indies, sent certain valuable reports to the Government, part of which were subsequently published in one of the leading medical journals, pointing out that ankylostomiasis is very prevalent in St. Lucia and probably all over the West Indies, and narrating his experience of the wonderful efficiency of thymol as an anthelmintic. As many of you are doubtless aware, there is a form of per-

• Vide West Indian, No. 78.

11

nicious anæmia common among negroes and the natives of hot countries generally. The patient, without obvious reason, becomes breathless, weak, anæmic, dropsical, and very likely, after a long and distressing illness, dies. Many years ago Griesinger showed that the Egyptian form of this disease was associated with-in fact, caused by--a blood-sucking intestinal parasite--the ankylostomum duodenale. In 1880, in conse- quence of the publicity given to this discovery by the epidemic of ankylostomum anæmia among the workmen in the St. Gothard tunnel, this fact of the relation of the ankylostomum to a form of pernicious anæmia was thoroughly established. In the same year Bozzolo introduced thymol as an anthelmintic in this helminthiasis. Expe- rience in Jamaica, Ceylon, Java, Brazil, the Straits Settlements, and elsewhere con- firmed Griesinger's discovery of the cause of this anæmia and also Bozzolo's discovery of its curability by thymol. But although these things were well known in Italy and in many parts of the tropics their importance was missed by the teachers of medicine in England, and as a consequence the medical men who went out even subsequently to 1880 to the West Indies went out imperfectly informed in a matter of the highest im- portance to a considerable section of the people committed to their charge. Thus ur fellow subjects, the poor negroes, did not have the benefit of an important advance in medical science and in practical therapeutics until Mr. Galgey found, fifteen years after it was known in Europe, that ankylostomiasis was the cause of the anæmia of the negro, and that thymol could cure it. Who can estimate the number of lives that might have been saved if tropical medicine had been taught to our West Indian colonial surgeons and if they had gone out thoroughly informed on the subject of ankylostomiasis? Mr. Galgey writes that in the six years, 1890-95, there were 72 deaths in the hospital of Castries, St. Lucia. In the year 1896-that is to say, since he diagnosed the nature of these cases and treated them efficiently--he informs us that there was not a single fatal case of this disease. From this we are entitled to infer that the seventy-two deaths from pernicious anæmia occurring in the preceding six years were from ankylostomiasis, and that these seventy-two lives might have been saved. That is to say, an average of twelve lives a year. Or, assuming that this mortality had been going on ever since 1880, the date of the discovery of the anthelmintic properties of thymol, we must con- clude that in the hospital of Castries alone 180 people died whose lives might easily have been saved. But this is not all. There are four or five hospitals and dispensaries in St. Lucia, and as there is no reason to suppose that ankylostomiasis is contined to the Castries district of the island, we are forced to conclude that in these fifteen years about 900 have died unnecessarily in St. Lucia. St. Lucia is one of the smaller West Indian islands. Although I know that thymol has been in use for some time in British Guiana, I do not know that, except in the hospital in Kingston, Jamaica, it has been generally employed in the neighbouring archipelago. I also know that the existence of the ankylostomum has not been recognised, at all events until very recently, in many of the islands. The avoidable mortality from ankylostomiasis therefore for the whole of the West Indies during these fifteen years must run into tens of thousands. serious indictment against our present system of medical education, and the worst of it is that what holds good for ankylostomiasis holds good for a dozen other tropical discases, some of them perhaps not so serious as ankylostomiasis, but some of them even more serious.

This is a

I fear that, as so often happens in medical lectures, I have spent so much of my hour in describing the symptoms and pathology of this disease of the body medical that I have little time left in which to speak of that very practical matter, the treatment. I hope, however, I have convinced you that we are speaking of a very grave disease in our educational system, and that there can be no question about the diagnosis and the in- dications for active and prompt treatment. I have my own ideas about the latter, but as the responsibility in the case is serious I have called in a specialist of experience to prescribe. I need hardly say I fully endorse his prescription. Dr. Andrew Davidson writes: "I do not think that attendance on a course of lectures on tropical medicine should be made a part of the ordinary curriculum. It seems to me, however, urgently necessary (1) that a course of lectures on the hygiene and diseases of warm climates should be instituted in each medical school; (2) that a certificate of qualification in these subjects be granted by the licensing bodies after examination to those who have attended this course of lectures; and (3) that the Government should encourage the study of tropical pathology by giving a preference to those possessed of this certificate if equally proficient in other subjects, and that appointments made from home of medical officers for tropical and sub-tropical colonies should be restricted to men holding this qualification." If these suggestions are acted on, not only would vast benefits

1919

B 2