842 DR. MANSON : NECESSITY FOR SPECIAL EDUCATION IN TROPICAL MEDICINE. [

triumph is what brings the void. Not the Jews. of thecaptivity, but those of the days of Solomon’s glory. are

those from whom the pessimistic utterances of the Biblecome." " It is idle men or men of studious and reflectivehabits that taedium vital chiefly visits, nofl those who haveto wrestle with strenuous responsibilities. No doubt menof melancholy temperament, constitutionally insusceptible ofhappiness, enter the medical profession now and then ; nodoubt weakly members of it break down here and thereunder the trials and disappointments that are inci-dental to it, and become a prey to misanthropicalgloom ; but, taken as a whole, I maintain that themedical profession is, of all professions, the most cheerfuland contented. Meetings of medical men are, in my ex-perience, all but invariably characterised by geniality andgood humour, notwithstanding acute differences of opinion.The doctor’s home is for the most part bright with domesticsunshine. The doctor’s heart is never soured, but overflows tothe last with " the milk of human kindness." I could draw acontrast, but I refrain. Let me congratulate you, gentlemen, ion your adhesion to what is an anxious and laborious, but anennobling and satisfying profession. "The claims of thefuture," said Lord Beaconsfield, " are represented by sufferingmillions, and the youth of a nation are the trustees of

posterity." The future is yours. The suffering millions cryaloud for help. In the faithful execution of the trustconfided to you, you will reap " an exceeding great reward."

An Introductory AddressON

THE NECESSITY FOR SPECIAL EDUCATIONIN TROPICAL MEDICINE.

Delivered at St. George’s Hospital at the Opening of theWinter Session, Oct. 1st, 1897,

BY PATRICK MANSON, LLD, M.D. ABERD.,F.R.C.P. LOND,

LECTURER ON TROPICAL DISEASES AT THE HOSPITAL.

GENTLEMEN,-I have been asked by the authorities of thisschool to speak a word of welcome to those of you whoto-day commence your systematic medical studies. I con-

gratulate you on two things-one, your choice of medicinefor your profession ; the other, your choice of St. George’sfor a school. Though the medical profession is by no meansa bed of roses, perhaps more than any other it is one whichto him who follows it in the proper spirit is full of goodthings. It is intensely interesting ; it is a recreation as wellas a study ; its influence on society is rapidly increasing ; it isa fairly satisfactory means of getting a livelihood ; and,above all, it is full of boundless opportunities for doing good.What reasonable man could wish for more ? As regards yourschool, apart from its associations with the past-associa-tions such as few can boast-I can confidently claimthat of all the metropolitan medical schools none have shownof late years more energy, greater determination to

keep with the times, or more far-sighted enterprise.Nor have the students been unworthy of their school,for St. George’s men are known all over the English-speaking world as accomplished physicians and surgeons.More than this, and in a greater measure owing to the hightone of the school and of its social life, which has beencarefully cherished by the teachers, they are known as goodcitizens, brave soldiers, loyal and devoted public servants,and, even better than that, as gentlemen. You come there-fore to an alma maTer of honourable repute ; it must be yourcare to maintain and, if possible, to add to this reputa-tion. In congratulating you on your choice of a schoolI do so on the strength of what, since I had thehonour of being connected in a humble way with St.George’s, I have observed here for myself. I have beenespecially struck with the energy I have already referredto and that foresight in the management. In everydepartment I find these. Naturally the institution ofa lectureship on tropical medicine has appealed to

! me more especially ; but this is, I see, only one evidence ofthe spirit that runs through the entire management. Labo-

I ratories, museum, teaching appliances, and teaching are allt of the best and most advanced description ; and I amI especially pleased to remark that the students, so far as my, opportunities have enabled me to judge, are not slow to avail, themselves of their exceptional opportunities. The mere’I fact of my being asked to address you on this occasion, I

believe, is but another evidence of the desire of the author!.ties to advance, to extend, and to improve the training theyoffer. They seem to be impressed with the desirability ofsomething being done for one of the neglected departmentsof medical education, for tropical medicine, and as theyknow the interest I take in this subject I have an ideathat this is the reason why I have been asked to comehere to-day. I fancy I am expected to ventilate thematter. This being so, the first remark I wouldmake is, that the systematic teaching of tropical medi-cine, ere many years are over, will be universal in our-medical schools. Those who can read the signs of the timesand who are best able to judge regard this as inevitable.Why ? Because our country is the centre of a great andgrowing tropical empire ; and, second, because tropical’disease in many respects is widely different from thediseases of temperate climates, which, practically, are theonly diseases about which at present the student receivesinstruction. There are dozens of diseases more or lessspecial to the tropics-diseases which demand special know-ledge for their diagnosis and successful treatment. Ratherover a fifth part of the medical graduates of Great Britainand Ireland practise in warm climates or, being in the armyor navy, may be called upon at any time to do so. Surely iftropical practice is so different from practice here it is highlydesirable that this vast army of medical men should beproperly equipped for their special work. It may be said,and has been said, that as the principles of pathology andtherapeutics are the same the world over they apply in India:as well as in England,. Quite true. Bat we have not to domerely with the principles of pathology and therapeutics.As a practical profession we are more concerned withtheir application which is quite another matter. Similarobjections might be, and formerly often were, raised aboutgiving special instructions in such branches as eye disease,skin disease, and so forth, but the advance of our art and therequirements of the public have long ago swept aside theseobjections. So it is now with the teachings of tropicalmedicine as a special subject, and so in the near future itwill be. A principal reason why hitherto there has beenso little done in this matter is this. Candidates for medical’degrees know very well that they will not be asked anyquestions about tropical disease by their examiners, and sothey have not demanded instruction on this subject. Andthe reason why questions are rarely put on tropical medicineis that the leaders of the profession, those who man ourhospitals, who fill the teaching chairs, who examine for

degrees, who grant licences to practise, who make the-

regulations for the education of the youth of the profession,are, in almost every instance, men who have never practisedin warm countries, and who themselves have never felt thenecessity for a wider and more practical knowledge of the-diseases peculiar to these climates. Not having themselvesfelt the want, they have been slow to acknowledge that sucha want exists, and slower still to apply the remedy. Butask those who are best qualified to express an opinion on this-subject. Ask the medical men who have themselves felt theresponsibilities of practice in the tropics, and more especialthose of them who have endeavoured to follow rf’!ent"developments in tropical pathology. Ask them if ey donot think that the medical man who goes out to little withtropical disease should have some special insction andtraining for the very special and responsible wor he has before-him, and if they do not think that the ]npileal authoritiesshould take care that the men who do s(,90 out to practise’should be properly qualified so far as 4daching can qualify.I am sure of their answer. Unfortunately, most of the menof tropical experience live and prp6tise away from the greatmedical centres. They are hardir represented on the medicalteaching, graduating, or legislting bodies, and so it comesthat their opinions do not zoake themselves felt, and thata much needed reform is delayed. It is more especiallyof recent years, partly in consequence of the enormous

expansion of our emp5,,e and partly in consequence of the-advances in tropical pathology which have 6ignalised thelast two decades, that the claims of tropical medicine havo

843I DR.MANSON: NECESSITY FOR SPECIAL EDUCATION IN TROPICAL MEDICINE. [(

’become urgent. Formerly the little that was known about- tropical disease could be carried in a waistcoat pocket. But- cf late years so great has been the advance that now-adays the subject is quite as extensive and quite as

special, so to speak, as ophthalmology, dermatology,tgynascology, or as any of those departments of medicine whichdaim and receive special teaching. More so. When the

practitioner in this country is puzzled about a case it is aneasy matter for him to call in someone known to be familiarwith the class of case he is in trouble about. But in the wildsof Africa, in the islands of the Pacific, in lonely stations inIndia or China there is no consultant to fall back upon. The

practitioner there has himself alone to depend upon. Andwoe to his patient and, if he has a conscience, to hisfuture peace of mind if he is not up to date in hisknowledge.The course of instruction in general medicine usually

received in this country is utterly inadequate to qualify for’tropical practice. I say so emphatically, basing my asser-tion on my own experience, my own mistakes, and what Ihave seen and still daily see of the mistakes of others. Letme illustrate this by a few examples. Take that greatscourge of mankind, greater, perhaps, than tubercleitself-namely, malaria. This is eminently a tropical,disease. Every day the tropical practitioner is fightingit. Yet what does the student and future tropicalpractitioner actually know about malaria when he is’stamped as qualified to practise his profession even in the’haunts of this disease ? He may possibly recognise a tertianor a quartan ague, and he may know that quinine will curethem. Ten chances to one his malarial patients know allthat quite as well as he does himself. But could he, anymore than his patients, tell a malarial remittent from an,enteric fever; could he diagnose a pernicious malarialattack from cholera, it may be, from thermic fever, fromapoplegy ? He has heard of the malaria germ, but has heseen it; could he recognise it ; has he been taught to find itfor himself ; to make use of the fact of its presence orabsence in the circulation as an infallible means of diagnosis? ’What would an examiner nowadays do with a student whocould not recognise and demonstrate the tubercle bacillus? He would pluck him. At all events, were I an examiner Iwould pluck him. And if I were an examiner and foundthat a student, intending by-and-by to practise in the tropics,could not recognise and demonstrate the malaria parasite’I would do the same. For I know that the malaria

parasite is just as important to him and his pro-’spective patients as the tubercle bacillus is, and that theability to recognise and demonstrate it is just as necessaryfor the tropical practitioner. In those terrible sudden formsof malaria which now and again will be sprung on himperhaps the only reliable means of diagnosis lies in abilityto recognise the malaria parasite. Life hangs on it. Dr.Andrew Davidson, whose experience in tropical medicine hasbeen very great, and whose judgment and knowledge are on apar with his experience, on my telling him I was to speakabout these things to-day, and sympathising with my views,at my request sent me some memoranda on the subject. Herelates a case which well exemplifies the necessity for know-ing something about malarial disease before attempting totreat it. He writes: "I had not landed many weeks inMadagascar when I was called upon to see a patient who, Iwas told, had been suddenly seized with what was looked

as an apoplectic fit. This was in the afternoon, andwhen I saw him about an hour afterwards he was lyingunconscious, the body in a state of complete resolution.The skin was cool, the pulse and respiration were slow,and there was no stertor. His condition suggestedcerebral haemorrhage or thrombosis. It was, indeed, in acertain sense a case of for, as it turned out, thepatient was suffering from tha apoplectic form of perniciousmalarial seizure, in which, as we now know, certaincapillary areas in the brain are permanently or temporarilyblocked by malarial parasites and pigment. The disease isby no means a rare one m countries. It had longbefore been described by Torti. I had read in Graves’sLectures of the soporose or comatose seizure, in which feveris a prominent symptom. Here there was no fever, and thepossibility that it was a malarial attack never entered mymind. What the precise brain lesion might be I could notdecide. But something had to be done, and I saw nothingbetter than to place a of croton oil on the tongue, applya blister to the nape of neck, and warn the relations to,prepare for the worst. I was gratified to hear next

morning that, after remaining ten hours insensible, thepatient had recovered consciousness ; but what surprisedme most was that there was no paralysis. The patient’schief complaint, in fact, was the blister. In the after-noon of the same day the patient was seized with shivering,fever, and sweating. There could now be no difficulty eitheras to diagnosis or treatment. The patient probably owed hislife to the fact that the apoplectic seizure did not recurand prove fatal, as it often does when treated on the lines Ihad followed. What I conclude from this is that gravemistakes would often be obviated by special instruction intropical medicine." Dr. Davidson remarks : "Experience, nodoubt, is a good teacher, only the fees are very heavy."The microscope would probably have diagnosed this casecorrectly, but then one must be taught how to apply it.

I could relate from my own experience many similar storiesillustrative of the danger to life with which a workingexperience in malaria has been bought. As with malaria, sowith many less important, though nevertheless very important,tropical diseases. What, I would ask, does the student learnof practical value about beri-beri, a disease which, if he is topractise in the tropics, he is almost sure to encounter oftenenough, although he may not recognise it when he does comeacross it ? Beri-beri is a very important malady. Occurringboth endemically and epidemically it annually kills itsthousands and tens of thousands. It makes the settlement ofmany fertile lands almost impossible. It kills off the planters’coolies like flies and makes his plantations unprofitable. Itfills the hospitals and is a downright scourge in some of thefairest lands of the earth. But it is a disease which can to agreat extent be prevented ; and it is a disease which can byproper management be robbed of much of its danger. Itsrecognition, therefore, is of the first importance. Ms ny times,in beri-beri perhaps more than in most diseases, early andcorrect diagnosis means the saving of life. When I firstwent to the east all I knew about beri-beri was its name.This I had sometimes seen in books. I had wondered at itsquaintness ; perhaps, medical student-like, I had waxedfacetious about it and had punned upon it. So little did Iknow about beri-beri that I believed some medical writerswho said that it was a kind of anasmia. Examiners,I was told, were not likely to ask any troublesomequestions about the symptoms, pathology, or treatment,so I skipped the chapter on beri-beri in "Aitken’s Practiceof Medicine " as being for my immediate purpose useless.Students then, as I suppose students now, worked to passtheir examinations as their primary object; to learn their pro-fession was altogether a secondary affair. Little wonder,therefore, I failed to recognise the disease when I first cameacross it. I well recollect my first case, and the horror andthe shame with which it filled me, and still fills me. I wasthen in practice in Formosa. One day I was called to see aChinese clerk employed in a European firm. I had knownhim well as an active, obliging young fellow. I found thepatient sitting propped up in a chair, short of breath,dropsical from head to foot, with a cardiac bruit, irregular,tumbling action of the heart, and complaining of a feelingof distress in his chest. As there was no albumin in theurine, and as there was a loud bruit with manifest dis-turbance of the heart, I felt convinced it was a case ofheart disease, and from other circumstances in the caseone which treatment would benefit. I prescribed and gavedirections, and went away feeling, and probably expressingby my manner, that we Europeans knew a great deal moreabout disease than the old Chinese doctor who hitherto, withthe assistance of the village idol, had been treating thepatient. Next day I went to see the lad expecting to find animprovement. I thought as I passed the that there wasa strange hush about the house. I entered what was mypatient’s room. On the bed, covered with a blanket, therewas something long and rounded and still, which explainedthe hush I had noticed ; and so I left the house sadder,wiser, and, I trust, humbler than I did the day before.Some years later, being then in general practice at Amoyand in charge of a large native hospital, I used to see anumber of Chinese soldiers who came to hospital sufferingfrom what appeared to me, in my ignorance, to be locomotorataxia. Some could hardly walk, others could just staggerinto the out-patient room, and some had to be carried in.The significance of the knee-jerk symptom in spinal diseasewas then a new discovery, and in those days was regardedas a sure sign of locomotor ataxia. In all of these soldiersthe knee-jerk was absent, and all of them exhibited whatI took to be ataxic symptoms. If you would criticise

844 DR. MANSON: NECESSITY FOR SPECIAL EDUCATION IN TROPICAL MEDICINE.

my diagnostic acumen please bear in mind that in those days peripheral neuritis had not been invented. However 4

that may be, I diagnosed these cases as locomotor ataxia, 1

prognosticated that they would never recover, declared that there was no immediate danger to life, put them to bed, and

strychniiae in various forms. But by-and-by, inutter disregard of prognosis and of my reputation, in thecourse of a month or two some of those soldiers whom I badregarded axd pronounced as hopeless cripples were walkingabout ; some had even returned to their military duties. This is pleasant, to say the funny, side of mymistake. There is anether side, however-one not quite so funny. A good many of these patients died-died suddenly,jast as dropsical Formosa patient had done. I wasmortified as well as puzzled. What was the natureof these cases ? My backs did help me. I noticedthat whereas some of these patients were wastedto shadows, others were swollen and Ialso noticed that in most of them the muscles, especially thecalf muscles, were tender. Occurring as this disease did asan epidemic, and confined to a very limited area (for most ofthe cases came from a damp, ill-constructed fort, the case-mates of which served as a barrack), and knowing that theChinese are very fond of pork, I thought that the muscle ten-derness and the cedema might be symptomatic of trichinosis.I thought I might be dealing with an epidemic of trichinosis.Indeed, I went the length of searching the muscle for

If they can help it the Chinese will not allowtheir dead to be dissected. I always entertained a greatrespect for what we in our civilised pride call "native preju-dices"; but in this instance, in view of the importance ofcorrect diagnosis, I thought I would run the risk of offendingthese for once. So with the aid of an old and seasonednative porter I smuggled one of the dead bodies into apiece of waste ground near the hospital, and there behinda wall excised a piece of muscle. Needless to say I foundno trichinas. In this way I groped about for a long time insearch of a diagnosis. It was not till months had elapsedand not a few deaths had occurred that I recognised that Ihad to deal with an epidemic of beri-beri, and it was onlythen that it began to dawn on me that the poor dropsicalfellow who had died in Formosa some years before hadreally died from beri-beri and not from heart disease after all.

For exactly the same reason-lack of proper teaching-the history of my education in the matter of beri-beri is thatof most of the medical men of my generation who, in lonelyplaces in the tropics, essayed to practise their profession.And I am grieved to say that in this matter even at thepresent day it is just as it was thirty years ago. My educa-tion in beri-beri was got by experience ; the young medicalman of the present day has to learn in exactly the samecostly way as I did and in the same stern school of

experience As Dr. Andrew Davidson says in his letterto me, "The fees are heavy." Only the other day I

got to know that there had been no improvement on theteaching of beri-beri in all these thirty years. This is howI came to realise the ugly fact. Beri-beri is very common,you may be astonished to hear, in the port of London,especially among the lascars and seedy boys who in manyinstances form the bulk of the crews of the large steamerstrading to the east. The cases are often brought to theSeamen’s Hospital. They come on written medical recom-mendation and are sent as cases of heart disease, kidneydisease, almost anything but beri-beri. They are veryrarely correctly diagnosed. Now the ship-surgeons whomake out the certificates are usually men fresh from theschools and from their examinations, and therefore,presumably, well up in all that is newest in medicine.Here is a verbatim enumeration of some of their diagnoses :anasarca, rheumatism, pericarditis and fits, dyspnoea, cardiacdisease, debility, asthma and anasarca, Bright’s disease,locomotor ataxia, myelitis, tachycardia, apoplexy, paraplegia,progressive muscular atrophy, and, of course, hysteria. Itranscribe these diagnoses from the admission registers.Not once in a dozen instances is the diagnosis correct. Nowit does not matter so much whether the cases are correctlydiagnosed or not provided they are sent to hospital. Butthere is every reason to believe that many of the cases ofship beri-bt-ri are not sent to hospital, but are treated onboard their ships, and that many die in consequence. Whenwe admit a case of beri-beri from a ship we ask if there areany more cases of the disease on board and if there havebeen any We are generally told that there are ncmore cases cn board, but that there have been deaths from

heart disease, asthma, or some such name, which fromexperience we know under the circumstances stands forberi-beri. Sailors, we may be sure, are not shipped with activeheart disease or with asthma such as would be likely to havea speedily fatal issue. I heard of one instance of a lascarwho had been shipped in India as an effective seaman.

Within a few weeks he died on board ship, and the cause ofhis death was officially logged as locomotor ataxia ; as iflocomotor ataxia ever ran its course in four or five weeks.The man died from undiagnosed beri-beri as many othershave done. All this represents a very serious, not to saydisgraceful, state of matters. Most of these deaths areavoidable. No beri-beric should be allowed to remain in theplace, whether house or ship, in which his disease was con-tracted ; to allow this is like treating a ease of alcoholicneuritis with brandy. To treat alcoholic neuritis properlyyou must first diagnose it, and similarly to be able to treatberi-beri properly you must also first diagnose it correctly,But without special instruction or without an experiencebought 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 over-looked, and about which there are many absurd and evendangerous misconceptions. In most tropical countries inwhich the subject has been investigated it has been foundthat about one man in every ten is affected with blood worms.In some places the proportion is as high as one in three, inothers one in two, and I know of at least two places wherenearly every inhabitant is victimised in this way. Surely,therefore, it is of importance, seeing that these parasitesgive rise in many instances to grave disease, that themedical practitioner should know something about them, beable to diagnose their presence, and recognise their effects.But ten chances to one if one asks a student, or even a medicalpractitioner, to set about examining a patient for filarias hewill prepare a very fine film of blood, such as would besuitable for the demonstration of bacteria, and that hewould set to work to examine it with a twelfth of an inchimmersion lens and an Abbe condenser. Now, althoughthere may be tens of millions of niarise in the patient’s bloodthe chances are they will not be discovered by such means.Most people think that when they have to make a microscopicexamination the more microscope they have the better. Asa rule, the reverse is the truth. should be soughtfor with an inch objective, otherwise they will be-missed. Though the individual niarise are large compared to bacteria they are relatively few in the blood.You require, therefore, to include a large field with yourmicroscope to have a reasonable chance of finding them. Ifa sailor could command with his eye only the narrow horizonvisible from a small boat he is not likely to see many whalesin the sea, so he ascends into the crow’s-nest at the mast-head, and, commanding there a wide view, he can see anywhale that spouts for miles around. So it is in searchingthe blood for filaria-a large field is indispensable. But thisis a self-evident fact hardly ever grasped by the studentunless he has it actually demonstrated to him. He seldomarrives at it spontaneously. Now, exactly the opposite is thecase for the malaria parasite. All this needs teaching, needsdemonstration. The malaria parasite I tried to find for

nearly ten years before, through accident, I finally suc-

ceeded. A Chinaman found my first filaria for me. Imention these things to show how necessary it is, if wewould save time and make the best of our opportunities, to’have someone to teach us even simple technique.

In connexion with filariasis and blunders in diagnosis fromwant of elementary instruction in tropical disease I mayrefer to a case which I came across. The patient was ahandsome young fellow, who some years before had joined aregiment of horse artillery then in India. He got on verywell for a year, liked bis work, and was on the high road topromotion One day he got a smart fever, and with the-fever a pain in his left groin, which he now and for thefirst time noticed to be swollen. In due course the fever

subsided ; not so the swelling, which grew and grew until itbecame the size of a fist. It interfered with his riding, andbso he consulted the regimental surgeon. The swelling was’ soft and to a certain extent reducible. Accordingly ruptureiwas diagnosed and a truss applied. But the truss caused so

pain that it could not be worn. It irritated theswelling, and brought on attacks of inflammation andfever. Getting no better he went to one of the Presi-

towns to consult a surgeon of experience in tropicali disease. This surgeon recognised at once the true nature of. £

845ABSTRACTS OF INTRODUCTORY ADDRESSES, ETC.

swelling, diagnosed the case as one of varicose groinglands, confirmed his diagnosis by an examination of theblood, which he found to be full of and very properlyadvised the patient to throw away his truss and to give upsoldiering. Now a very little instruction in tropical diseasegiven to the regimental surgeon would have put himon the right track, would have spared this 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 inone of the leading medical pointing out thatankylostomiasis is very prevalent in St. Lucia and probablyall over the West Indies, and narrating his experience of thewonderful efficiency of thymol 1 as an anthelmintic. As manyof you are doubtless there is a form of perniciousacssmia common among Dfgroes and the natives of hotcountries generally. The patient, without obvious reason,becomes breathless, weak, anaemic, dropsical, and very likely,.after a long and distressing illness, dies. Many years agoGriesinger showed that the Egyptian form of this diseasewas associated with-in fact, caused by-a blood-suckingintestinal parasite-the ankylostomum duodenale. In 1880,in consequence of the publicity given to this discovery bythe epidemic of ankylostomum anaemia among the workmenin the St. Gothard tunnel, this fact of the relation of theankylostomum to a form of pernicious anasmia was

thoroughly established. In the same year Bozzolo intro-duced thymol as an anthelmintic in this helminthiasis.Experience in Jamaica, Ceylon, Java, Brazil, the StraitsSsttlements, and elsewhere confirmed Griesinger’s dis-

covery of the cause of this ansemia and also Bozzolo’sdiscovery of its curability by thymol. But althoughthese things were well known in Italy and in manyparts of the tropics their importance was missed by theteachers of medicine in England, and as a consequencethe medical men who went out even subsequently to 1880 tothe West Indies went out imperfectly informed in a matter ofthe highest importance to a considerable section of the

committed to their charge. Thus our fellow subjects,the poor negroes, did not have the benefit of an importantadvance in medical science and in practical therapeuticsuntil Mr. Galgey found, fifteen years after it was known inEurope, that ankylostomiasis was the cause of the anaemiaof the negro, and that tbymol could cure it. Who canestimate the number of lives that might have been saved iftropical medicine had been taught to our West Indiancolonial surgeons and if they had gone out thoroughly in-formed on the subject of ankylostomiasis ? Mr. Galgey writesthat in the six years 1890-95 there were 72 deaths in thehospital of Castries, St. Lucia. In the year 1896-thatis to say, since he diagnosed the nature of thesecases and treated them informs us thatthere was not a single fatal case of this disease.From this we are entitled to infer that the seventy-two deaths from pernicious anasmia occurring in the

preceding six years were from ankylostomiasis, and thatthese seventy-two lives might have been saved. That is tosay, an average of twelve lives a year. Or, assuming that thismortality had been going on ever since 1880, the date of thediscovery of the anthelmintic properties of thymol, we mustconclude that in the hospital of Castries alone 180 peopledied whose lives might easily have been saved. But this isnot all. There are four or five hospitals and dispensaries inSt. Lucia, and as there is no reason to suppose that anky lo-stomiasis is confined to the Castries district of the island weare forced to conclude that in these fifteen years about 900have died unnecessarily in St. Lucia. St. Lucia is one of thesmaller West India islands. Although I know that thymolhas been in use for some time in British Guiana, Ido not know that, except in the hospital in Kingston,Jamaica, it has been generally employed in the neigh-bouring archipelago. I also know that the existenceof the ankylostomum has not been recognised, at allevents until very recently in many of the islands. Theavoidable mortality from ankylostomiasis therefore forhe whole of the West Indies during these fifteen yearsmust run into tens of thousands. This is a serious indict-ment against our present system of medical education, andthe worst of it is that what holds good for ankylostomiasis..holds good for a dozen other tropical diseases, some of them

perhaps not so serious as ankylostomiasis, but some of themeven more serious.

I fear that, as so often happens in medical lectures, I havespent so much of my hour in describing the symptoms andpathology of this disease of the body medical that I havelittle time left in which to speak of that very practicalmatter, the treatment. I hope, however, I have convincedyou that we are speaking of a very grave disease in our educa-tional system, and that there can be no question about thediagnosis and the indications for active and prompt treat-ment. I have my own ideas about the latter, but as theresponsibility in the case is serious I have called in a specialistof experience to prescribe. I need hardly say I fully endorsehis prescription. Dr. Andrew Davidson writes: I do notthink that attendance on a course of lectures on tropicalmedicine should be made a part of the ordinary curriculum.It seems to me, however, urgently necessary (1) that a courseof lectures on the hygiene and diseases of warm climatesshould be instituted in each medical school ; (2) that acertificate of qualification in these subjects be granted bythe licensing bodies after examination to those who haveattended this course of lectures ; and (3) that the Govern-ment should encourage the study of tropical pathology bygiving a preference to those possessed of this certificateif equally proficient in other subjects, and that appoint-ments made from home of medical officers for tropicaland sub-tropical colonies should be restricted to men

holding this qualification." If these suggestions are

acted on, not only would vast benefits accrue to thenatives of warm climates and to those Europeans whohave to reside among them, but an enormous impetuswould be given to tropical pathology and therapeutics,and, doubtless, indirectly to medical science in general.By instituting a lectureship on tropical medicine St. George’sHospital has done its share in encouraging this necessaryreform in medical teaching. Other schools are following ourlead ; but be the schools ever so willing to second each otherwithout the cooperation of the General Medical Council theycan do but little. Dr. Davidson suggests-and it is theGeneral Medical Council that can alone give effect to thesuggestion-there should be a special examination and somekind of diploma for tropical medicine, and Governmentshould countenance and encourage it. If this reform becarried out of one thing I am sure, and that is that thoseof you who in the future may go abroad to practise yourprofession will bless the General Medical Council for forcingyou to qualify yourself for your work.

AbstractsOF

INTRODUCTORY ADDRESSES, ETC.,DELIVERED AT THE

LONDON AND PROVINCIAL MEDICALSCHOOLSAT THE

Opening of the Session 1897-98.

UNIVERSITY COLLEGE, SHEFFIELD.INTRODUCTORY ADDRESS BY DR. PYE-SMITH, F.R.S.

AFTER congratulating Sheffield on the union of Firth

College and the Medical School to form the new UniversityCollege, and on its approaching admission as a constituent ofthe Victoria University, Dr. Pye-Smith referred to the historyof university education in England. The mediaeval universitiesof Bologna and Padua, Salamanca, Paris, Oxford, Leipzig, andWittenberg were succeeded at the revival of learning by thefoundation of many new ones on the continent of Europe.The four national universities of Scotland were foundedduring the same period between the end of the fifteenthand the beginning of the seventeenth centuries. In the six-teenth century also were founded many of the colleges atOxford and Cambridge and the University of Dublin.But it was strange that in the six centuries of national

development which extended from the time of Magna