THE
Glasgow Medical Journal.
No. VI. December, 1924.
ORIGINAL ARTICLES.
VISTAS AND VISIONS: SOME ASPECTS OF THE COLONIAL MEDICAL SERVICES*
By ANDREW BALFOUR, C.B., C.M.G., M.D., London School of Hygiene and Tropical Medicine.
At this, the commencement of another session at the well-known extra-mural School of Medicine in Glasgow, I cannot help wondering how many of you students have in your own minds outlined your future careers. The French say "L'homme can no doubt that our propose mais Dieu dispose," and there be national poet was right when he told us in his homely doric " that the best laid schemes o' mice and men gang aft agley." Yet that need not prevent us, when young and sanguine, from speculating upon the future, harbouring our secret hopes, and even formulating our plans. Glasgow has ever been, and I suppose always will be, a Mecca for the men of the West Highlands, and it is at least very certain that those amongst * Address delivered at the opening of Session 1924-1925 at The Anderson College of Medicine, 14th October, 1924. No. a. Vol. CIL 354 Dr. Andrew Balfour?Vistas and Visions: you who hail from the lone sheiling or the misty isle, in whose veins courses the blood of the Celt, have dreamed dreams and seen visions. It would be discourteous to pry too closely into these cherished anticipations, but I take it that the majority look forward to the day when they will be let loose upon a confiding public and will practise, at first no doubt at that public's expense, employing the phrase in two senses, the lessons they have learned from a band of able and devoted teachers. The greater number also, I fancy, are content to envisage themselves as prosperous general practitioners, either here in Scotland or perhaps more especially within the confines of that southern kingdom which is so well disposed toward the peripatetic North Briton, and which, in many instances, benefits by his presence. It is a worthy ambition, and will be yet worthier when the general practitioner pays more attention to the preventive side of medicine than is the case at present and becomes, as he is bound to become, the unofficial, but none the less indispensable, ally of the medical officer of health. Still, remember that, as Sir Humphry Rolleston has pointed out, there will, in these islands, soon be one doctor to every 1,000 of the inhabitants. The outlook is alarming for the doctors, possibly also for the populace; and surely amongst a gathering which must contain many Scots there are some " blessed with the wanderlust," some who hear the call of that greater Britain which lies overseas, and especially those portions of it "where the palm, most gracious and marvellous of tropic trees, flourishes and bestows its bounties upon man. Yet I find that, speaking generally, there is a lamentable ignorance amongst medical students as to the prospects which the Colonial Medical Services hold out to those who think " of faring foreign," as the old phrase runs. To-day I thought we might profitably consider this point of " view, and I have termed my address Vistas and Visions," for I propose, as best I can, to give you some glimpse of what awaits those who seek the sun within the torrid zone, and to comment, not only upon the opportunities now afforded the Colonial Medical Officer in the practice of his profession, but to refer very briefly to some points regarding the possible future of Some Aspects of the Colonial Medical Services. ?S55 medicine, and of hygiene in our tropical possessions. I am not going to deal wiith the purely mundane side of the business. It is undoubtedly important, it is, and must always be, a powerful determining factor?pounds, shillings, and pence, paid monthly, to say nothing of pensions, will influence doctors like other men and women till the end of time. But particulars as to pay and financial prospects can easily be obtained, and I would only say that at the present period, in our larger and more important tropical possessions, these are fairly satisfactory, and may even in some cases be regarded as satisfying, if indeed, anyone, or should I say any Scot, is ever satisfied with his monetary remuneration. There is such a thing as divine discontent, and it has its uses. Let us, then, ignore the almighty dollar for the nonce. I would ask you rather to consider the question upon loftier and more romantic grounds. I would strive to attract you by portraying the interest and beauty of the setting in which the Colonial Medical Officer is often privileged to work, and by the opportunities vouchsafed to him for benefiting humanity, advancing the prestige of the Empire which he serves, and more especially for solving some of the problems which still perplex the student of tropical medicine?problems as fascinating as they are elusive. Knowing possibly the almost feverish activity which has characterised the study of tropical diseases, since the days when the problem of malaria transmission was " solved, some of you may be tempted to exclaim, Is there any- thing left to be discovered ?" Has not tropical disease become as hum-drum as, say, chronic bronchitis ? Well, in the first place, I cannot agree that chronic bronchitis is hum-drum. It may be so in the strictly clinical sense, but from the prophy- lactic point of view, it remains a most important disease. The same is true of most of our common respiratory complaints. They are cripplers of mankind, enemies of efficiency, foes to be fought. In the second place, though much has been done in the way of revealing the secrets of tropical pathology, there is still a great deal to be accomplished. Sir Alexander Houston, writing about a subject which might " well be considered stereotyped, namely, The London Water Supply," very truly says there is no limit to knowledge, no 356 Dr. Andrew Balfour?Vistas and Visions: . boundaries to the value of applied science, and no feeling but that of deep humility in the presence of so much that remains obscure and unexplained. If this can be predicated of the London Water Supply, what may not be said regarding the vast field of medical research in the tropics ? Let us discuss some of the lacunae which yet exist in our knowledge of exotic maladies, and consider where we still require light and learning in our efforts to preserve and better the health of tropical communities. Long ago, in Great St. Mary's Church, Cambridge, I heard that famous divine, the late Dean Farrar, deliver a missionary sermon. With the gift of vivid imagery which he possessed, and with those powers of oratory whereby he swayed the multitude, he proved most impressive. He began his sermon by picturing an angel of God sent forth to visit the dark places of the earth, and he described the flight of that angel, and the scenes which passed before the gaze of the heavenly messenger. There is no need to invoke the assistance of an angel in our survey. The aeroplane has appeared since Farrar's day, and it is easy to imagine ourselves speeding southward in a well-found Handley-Page, or perhaps, in view of a recent American exploit, " we should choose a Douglas World Cruiser." We pass speedily from the capricious weather and the gloomy skies of the north into balmier regions with a bright, strong sun above, and a vivid blue sea below, and ere long descry afar off a long coast-line, bordered by a ribbon of snowy surf. The low-lying littoral covered with scrub, bush and trees, amongst which the oil palm attains prominence, slopes inland to the higher forested ground, and to the distant heights which guard what used to be called the dark heart of Africa. That heart has been revealed, thanks, on this side of the great continent, to the labours and sacrifice of many pioneers from the days of Captain Richard Jobson, " the author of The Golden Trade," to those of that intrepid Scottish physician, Mungo Park, of his handsome, but equally ill- fated compatriot, Hugh Clapperton, of the indomitable Denham, and the remarkable Richard Lander. Yet, until comparatively recently, the whole coastal belt from the River Gambia to the Niger, comprising the British Colonies of the Gambia, Sierra Leone, the Gold Coast, and Southern Nigeria bore a most evil Some Aspects of the Colonial Medical Services. 357
" reputation, and was in very truth the White Man's Grave." It is, perhaps, due to a woman, to Mary Kingsley, more than to anyone else, that this opprobrious term no longer holds good, though it was Joseph Chamberlain, inspired by Sir Patrick Manson, who first took the steps necessary to remove the reproach, and it was the work of Manson, and of Ross, which made possible the transformation. The mere mention of the West Coast suggests malaria, and at once we are faced with possibilities. The uninitiated may " say, Surely we know all there is to be known about this common disease?" We have been acquainted with its cause since the time of Laveran, the researches of Ross and others have shown how its infection is conveyed, and how to cope with its vector, the mosquito, the Countess of Chinchon long ago introduced its specific cure, there is a huge literature, both lay and medical, regarding it. What, they may ask, remains to be accomplished ? Well, thirteen years ago Professor Stephens, of the Liverpool School of Tropical Medicine, set down some points upon which our knowledge was still defective. Here they are :? 1. Bodies of uncertain significance found in the salivary glands of anophelines. 2. Alleged transmission of malarial infection through the eggs of the mosquito. 3. Conditions determining the successful infection of anophe- lines fed on infected blood. 4. Number of persons one anopheline can infect. 5. Does the percentage of infected anophelines vary from month to month, and, if so, to what extent ? 6. How long does an anopheline once infected remain so ? 7. Penetration of red cells by sporozoites. 8. Properties of the salivary secretion of mosquitoes. Happily some of these questions have been tackled. Thus, Bruce Mayne has shown that one anopheline can infect as many as five persons, while Wright has worked at the functions of the oesophageal diverticula, the contents of which mingle with the saliva, and Yorke and Macfie have carried out researches on the salivary secretion, and have found that it does not contain an haemolysin. As to the other questions, however, knowledge 358 Dr. Andrew Balfour?Vistas and Visions: is still either lacking or defective, so that there is plenty of scope for the anxious enquirer, though it is true that Sinton in India would seem to have confirmed Rowley Lawson's view that the sporozoites do not enter the red cells, but plaster themselves, as it were, upon the outside of the envelopes of the erythrocytes. We still do not know precisely how quinine acts on the malarial parasite, and the employment of the latter as a therapeutic agent in general paralysis of the insane is revealing the incom- pleteness of our conceptions as regards certain relations of the Plasmodium to the disease it produces. Another mosquito- borne malady lurks on the littoral, and every now and again flares into activity, slaying both white men and black. It is yellow fever. Again, those not fully intimate with its mysteries may exclaim, "What more has to be learned about Yellow Jack?" We understood that the Americans had solved its problem of conveyance, that Noguchi had unearthed its parasite, the Leptospira icteroides, that a preventive vaccine and a curative serum had been prepared, that it was moribund, if not actually extinct, in the New World. Very true, but we have still much to learn regarding this deadly malady on the African West Coast. We do not yet know for certain that it is the same disease which once spread terror throughout the ports of South America, the West Indies, Bermuda, and the Eastern seaboard of the United States. We believe it is the same. Dr. Carter, of the United States Public Health Service, who has constituted himself its historian, is, indeed, of opinion that it is of African origin, but the Leptospira icteroides has not yet been demonstrated in West Coast cases. Moreover, we do not know if more than one species of stegomyia or aedes is operative as its vector in Africa, we are not yet sure if any of the lower animals may serve as a reservoir for its parasite, we find great difficulty in distinguishing it from that Weil's disease, the Spirochcetosis icterohcemorrhagica, which, only the other day, played havoc in a Scottish coal mine. Quite recently, however, Hoffmann, of Havana, has made a discovery which, if confirmed, is of great importance. He examined old pathological material, the organs of yellow fever patients who died in Cuba during the outbreaks of 1906-1908, and he found that the kidneys harboured lime casts. His experimental work would appear to show that Some Aspects of the Colonial Medical Services. 359
their occurrence is pathognomonic, that they are found only in yellow fever, and that their presence will serve to distinguish post-mortem that disease from those other febrile maladies associated with jaundice which are so easily mistaken for it. At the present moment bubonic plague is taking toll of human lives in the Gold Coast, in Ashanti, and in Nigeria. You will say plague is one of the oldest known diseases in the world; we understand that the Philistines and the Israelites knew a great deal about it. Kitasato isolated its bacillus, its pathology has been fully worked out, the role of the rat and of other rodents has been established, the flea has been incriminated, there is a plague vaccine and a plague serum. Surely there is little fresh light to be thrown upon plague! Well, the mere fact that despite all our knowledge, plague persists, that it slays millions in India, that the great majority of those infected die from it, that it dislocates trade and traffic, and that the rat, its carrier, defies our efforts to cope with him, shows that there is still much work to be done on the plague. For one thing we want a cure. Plague serum is too often a broken reed, and our drugs are usually powerless to stay the destroyer. It is said that in Uganda the intravenous injection of neokharsivan has given good results. This requires confirmation, and, believe me, one of the most urgent needs of the day is to find a remedy for plague. It is curious that it has eluded us, plague being a bacterial disease and most of the bacterial diseases having been conquered, but the fact remains that in our Colonial Office returns we read again and again entries like the following:? Plague cases for the Week ending so and so, 62; deaths, 60, or it are we to do about the rat ? We may even be 62. Again, what have poisoned and trapped him, we have built him out, we have tried to starve him, we have chased him with dogs, cats, and ferrets, we have encouraged his natural enemies, which are legion. Here and there, though not sufficiently frequently, we have tried to master him by Rodier's method of killing all females caught and letting loose the males, a plan successful in the case of Australian rabbits, and used to good effect against rats in some limited areas; we have attempted to find some its and means of interfering with the rat's family life, fertility fecundity, and, speaking generally, we have failed. We are 360 Dr. Andrew Balfour? Vistas and Visions: only beginning to realise the importance of certain factors in connection with plague. French observers on the African West Coast have drawn attention to the possible presence of healthy human and healthy rat carriers of the disease. Dr. Norman White, of the Health Section of the League of Nations, has thrown fresh light on the nature of pneumonic plague, but much still remains obscure. Hence you will see that, taking the very first group of British Colonies which we reach, and considering only three of the diseases found therein, there is plenty to engage the attention of a keen and trained observer. Needless to say, there is much besides. There may even be, there almost certainly are, new diseases to be discovered?that is to say, there are maladies at present mistaken for disorders with which we are more or less familiar, and which have to be separated and worked out. When one considers how encephalitis lethargica was recently recognised for the first time as a specific entity in Europe, and how it was " " only the other day that tularaemia, the rabbit disease of the United States, was brought to light, it is reasonable to suppose that there are half a dozen unknown pathological conditions awaiting exploitation in these vast territories where the climate ranges from the steamy, languorous heat of the coast to the dry stimulating atmosphere of the desert regions of the hinterland. Let us speed across these to other sand stretches flanking that mighty river of antiquity, the Nile. It is true that the Sudan Medical Service is not under the aegis of the Colonial Office, but the Anglo-Egyptian Sudan is very much in the public eye at present, and in any case it possesses a Government service well worth the attention of the young medical graduate. Do not imagine that the Sudan is nothing but a sandy waste. It is true that sand is the predominating feature of its northern territories, but there are fertile strips along the Atbara, the Bahr-el-Azrak, and the Bahr-el-Abiad?the Blue and the White Niles, with here and there oases in the wilderness, and in certain parts most interesting hill ranges and vegetation of a kind. Follow the line of either of the Niles to the south, taking the aerial pathway of countless squadrons of migratory birds, and you will see the desert give place to forest, and anon, in the case of the White Nile, you will speed, like Dr. Chalmers Some Aspects of the Colonial Medical Services. 361
Mitchell of the London Zoo, over the wide belt of papyrus swamp, the famous Sudd. If, happier than he, you escape the dangers of a forced descent amongst reeds and water cabbages and hippopotami and crocodiles, you are free to travel hither and thither over a vast territory of forest, grass plain, morass and hill ridges, a happy hunting ground.both for the sportsman and the tropical pathologist. Some may be tempted to say the Sudan is played out as a place for medical research. The laboratories there have been hard at it for years. So they have, and they will be hard at it, let us hope, long after we are dead and gone. If not, it will never be for lack of material. To many of you the name of Sir William Leishman, a Glasgow man, the distinguished Director-General of the Army Medical Department, must be familiar, and probably a goodly number know that an important tropical malady has been called after him, Leishmaniasis, even if they are not acquainted with its Indian name, kala-azar or black fever. Well, it is many a long year since Leishman discovered the protozoal parasite of that disease, a disease found in certain parts of the Sudan, and yet we are ignorant of how its parasite effects a lodgment in the human body. Here is a fine field for work, but any amongst you who feel disposed to exploit it, had better make haste, for the Calcutta School of Tropical Medicine is inaugurating a determined onslaught, and when Colonel Megaw waters it and his merry men go abuccaneering in pathological is a slim parasitic craft, be it protozoon, bacillus, or spirochete, which can evade them. I am inclined to think that we are on the eve of the solution of a problem which has hitherto baffled every enquiry. What we may call a new disease exists, or at least has existed, in the Northern Sudan, and requires particular attention. It is associated with the presence of a peculiar bacillus which I found long ago in the throat and mouth of a British officer in Khartoum where it produced ulceration. Its toxin has a markedly depressing effect upon the heart. Unfortunately, I lost my culture of this organism, though, I am glad to think, through no fault of my own, and so was unable to study it fully. During the war, however, I met in Egypt a Canadian medical officer who had been stationed in 36*2 Dr. Andrew Balfour?Vistas and Visions:
Khartoum, and who, when investigating an outbreak of sore throat amongst British troops, had rediscovered the bacillus before he knew anything of the previous work on the subject. He made useful clinical observations, and I believe he incor- porated his findings in a thesis, but no paper by him has ever been published on the subject, and, as I say, this peculiar condition which I found associated with diphtheria, but which would appear to be a distinct disease due to a specific organism, still awaits full elucidation. So does a very well-known malady in the Southern Sudan, for those who imagine that because we know the trypanosomes which cause African sleeping sickness, and the tsetse flies which act as their intermediate hosts, and can cure many cases by atoxyl, antimony, Bayer "205," or tryparsamide; those, I say, who think we have thereby exhausted the old negro lethargy are very greatly mistaken. Why, we are not yet certain as to whether Trypanosoma gambiense and T. rhodesiense are the same parasite or different species; we still quarrel, politely and scientifically, over the vexed question of the big game, or perhaps one should say the wild animals as reservoirs of infection ; we know precious little about immunity to the disease; we are not at all sure as to the feeding habits of Glossinse and we are still trying to discover which is the best drug and how we can best prevent this mysterious complaint to the fascination of which two such distinguished novelists as Seton Merriman and John Masefield have fallen victims. As in the case of the West Coast, so in that of the Sudan, I have mentioned three diseases, but, of course, there are many more concerning which our knowledge is defective and amongst them the ubiquitous malaria. However, it is convenient to associate certain maladies with certain countries if only to give a little variety to our narrative, to vary the visions as we vary the vistas. We pass almost imperceptibly from the Sudan to Uganda, for there is no sharp dividing line, and there is little change in scenery till perchance we catch a glimpse of the Victoria Nile hurtling itself in froth and spume from chasm to basin at the Falls of Murchison, or suddenly see far below us the long gleaming trough of Lake Albert with the mountains of the Belgian Some Aspects of the Colonial Medical Services. 363
Congo piled one above another on the west, the wooded heights behind Butiaba on the east, and, far away to the south, the giant, snow-clad peak of Ruwenzori glistening through clouds and mist. It is a wonderful sight. Surely the vast immensity of Africa and the noble proportions of its mountain scenery must always thrill the observer. We sail over dense forest, the primaeval stretches of Budongo, most sonorous of names, course above the swampy complexities of lake Chioga, and, finding the Nile again, follow it as guide, till, at Jinja, we mark the Ripon Falls, and beyond them, that huge inland sea, the Victoria Nyanza. Uganda is not lacking in medical problems. Apart from some already mentioned, for plague, malaria, and sleeping sickness are rife in the Protectorate, there is work to be done on that cerebro-spinal meningitis which continues to take toll of the native. Does there exist a chronic meningococcaemia, like that recently described by Dock in the United States, and which had been previously noted here and there ? Syphilis is one of the curses of the country, and, despite all that has been accom- plished in the way of working out its etiology and pathology, there is still much to be discovered, specially in relation to its ravages amongst native populations, and as regards the life- history of its parasite. As a third disease in Uganda, let us take tick fever, also due to a spirochete. Having said this, there is scarcely need to say more, at least to those who have studied spirochetosis in any of its forms, for they know full well that we are still in the dark as to the morphology and development of these corkscrew-like organisms which appear to occupy an intermediate place between bacteria and the protozoa, and which every year are shown to play a much greater part in human pathology than was formerly suspected. Uganda is like a garden, a garden under hot-house conditions, but the scene changes, as, crossing a corner of Lake Victoria, we strike Kisumu at the head of the Gulf of Kavirondo. Ere doing so, however, we see the Sese Islands, green gems, famous, or should we say infamous, in sleeping sickness history, and still more or less desolate though repatriation has begun. Who can fail to be interested in places where the Sitatunga 364 Dr. Andrew Balfour?Vistas and Visions:
antelopes, from being the shyest and most water-haunting of horned game, became land animals, free from the fear of man, and, as a result, now exhibit hoofs of a shape quite different to those they sported when they were wont to live a semi-aquatic existence ? Again, is it not entrancing to know that, since the islands were depopulated, young crocodiles are rarely seen upon them, simply because the big varanus, the monitor lizard, the iguana of these regions, no longer molested by the native, has multiplied exceedingly, and thriven in part upon a diet of crocodile eggs ? But we have reached Kenya, somewhat sterile and forbidding about Kisumu, but, further east, a wonderful and beautiful territory of valleys and mountains and lofty tablelands. Plague, again, presents its puzzles here, but, in addition, there is a strange complaint simulating pneumonic plague, examples of which from Nairobi I saw at the quarantine island of Dar-es-Salaam during the war, and the real nature of which has not been determined. Again, cases of a condition recalling typhus fever, but apparently not lice-borne, have been encountered and require elucidation, while, to turn for once from medicine to hygiene, there is the whole important and deeply interesting question of the acclimatisation of the white settlers in the Highlands to be settled. That German legacy, Tanganyika Territory, enormous, wild, full of variety as regards its scenery, its peoples, and its climates, presents a promising field for enquiry. The German, though he worked hard there and accomplished a great deal, has by no means exhausted its possibilities for the British student. Take leprosy. We remain ignorant of its mode of spread, despite theory after theory. Take a disease allied to it bacteriologically and far too common in the coastal towns, no other than our old enemy, tuberculosis. He who thinks tuberculosis is a completed chapter in pathology and therapeutics is far from the mark, and more especially if he is considering it from the tropical standpoint. There are certain points about tuberculosis in Africa and elsewhere very urgently requiring solution, and that although it kills more people than any other disease and is caviare to the practitioner. Can we find a third disease here in Tanganyika ? Assuredly, for dysentery is Some Aspects of the Colonial Medical Services. 365 common in both its forms. But you will say, Surely the last war taught us all we need know about the bloody flux ? Did it ? I am inclined to think it showed us how ignorant we yet remain. So far as bacillary dysentery is concerned, there are undoubtedly facts to be unearthed regarding its relation to flies. Why is it that in some places there is very little dysentery when flies swarm ? The infection is there, but the flies do not seem to act as aeroplanes for the bacilli. In the chronic amoebic type, can anyone affirm that we have reached finality in treatment ? Assuredly not. The man who discovers how to cure chronic amoebic dysentery will earn the gratitude of many a hapless sufferer. We will skim over Nyasaland, for the world is our oyster to-day and time presses, but we may pause a moment as Rhodesia, youngest of Crown Colonies, spreads below us, and, afar off, drifting columns of spray proclaim the Victoria Falls of the Zambesi, while the thunder of its waters rises on the air. At the present moment Northern Rhodesia is disturbed by the occurrence of cases of splenic abscess amongst natives. Abscess of the spleen is a rare disease, and, in Rhodesia, its etiology, so far, remains obscure. Here is opportunity for research! In Southern Rhodesia black water fever, that grim and too often deadly condition, the first signs of which are apt to strike terror into the heart of the tropical resident, is attracting much attention. Even if we admit that it is intimately bound up with malaria, we have yet to learn the precise relationship, and we have yet to find out how really bad cases can best be saved. There is little, perhaps no, finality in tropical medicine. We had an idea that we knew all about undulant fever, since Bruce, a great Scottish worker, isolated the Micrococcus melitensis, and since the Commission under his guidance incriminated goat's milk, yet it was only the other day that, in Southern Rhodesia, Bevan gave us the first inkling of a link between the organism of Malta fever and that of the contagious abortion of cattle, the Bacillus abortus of Bang. A new field of enquiry has been opened up which will require much exploitation. Some of you may be in time to enter it. Having dealt with our three diseases in the Rhodesias, we may direct our course overseas, and, sweeping above Madagascar, 366 Dr. Andrew Balfour?Vistas and Visions: where the French, believe me, could teach us a thing or two, we come to earth in one of the finest and smallest of British Colonies, the famous island of Mauritius. It is a land of waterfalls and rainbows, of remarkable mountains, of extreme fertility, set in a wonderful sea, blessed with a wonderful climate, but for many years past cursed by disease. It is a continent in miniature, and it would be easy to find more than three diseases in it furnishing food for thought, even apart from any already mentioned. Why is there no yaws there? Yaws, as some of you may know, is a spirochetal disease, which, in the main, attacks the skin, and is most disfiguring and crippling. It is first cousin to syphilis, and yet is not a venereal complaint. It has undoubtedly been introduced into Mauritius, but it has not spread. Why has cholera, the water-borne disease par excellence, which has played havoc in the island on several occasions, disappeared from it entirely, although, to all appearance, everything was there to favour its continuance and extension ? Why has that annoying creature, the chigger flea, which burrows into the skin of the feet, never gained a footing in the colony ? Mauritius is a tempting place to the tropical pathologist, but we must leave it and hie to another island, perhaps as beautiful, certainly much larger and quite as interesting. Safely in Ceylon, with Adam's Peak towering above us, and the light and colour of the East about us, we may ask ourselves how we stand as regards sprue, that malady of frothy stools, sore mouth, emaciation, and anaemia, which hurries many a tropical sojourner to the grave. If Scott is right, and there is good reason to credit his findings as regards calcium metabolism and the control of the parathyroids, then one more puzzle will have been solved, but, even so, there are points about sprue which will require solution. The hookworm, which has afforded such happy hunting for the Rockefeller Foundation on British and other territory, causes much mischief in Ceylon, and though, thanks to the Rockefeller workers and to others, it has been tracked and can be treated, someone has yet to tell us definitely the nature and the action of its toxin. Lastly, despite the work of Castellani and of Chalmers, there is at least one skin disease in Ceylon, that home of cutaneous mycoses, requiring classification with a view to cure, Some Aspects of the Colonial Medical Services. 367
We rise above the fringing belt of graceful coco-palms, amongst whose fronds mosquitoes may be breeding as they breed in the palms of Tanganyika, and we speed over the Indian Ocean to Singapore, gateway of the Far East, and visit also those Federated and Unfederated Malay States where a son of Glasgow, who returns to his native city this very day, earned the spurs of knighthood. Sir Malcolm Watson is a household name in Malaya, and with good reason, for by his anti-malarial work, his energy, pertinacity, and enthusiasm, he has saved thousands of lives and many thousands of pounds sterling. Malaya has a fine record of research and the practical applica- tion of results, but I make bold to say that we have not heard the last about beri-beri, either there or elsewhere. Perhaps there is beri-beri and beri-beri?that is to say, there may be, there probably is, more than one disease masquerading under that rather attractive name. Diet deficiency, the lack of anti- neuritic vitamin, will explain much, but I doubt if it will explain all. There may be a toxic factor so far merely suspected, but which may be left for some of you to clear up. Malaya well exemplifies our opportunities, for it was only recently that Stanton and Fletcher determined the cause and worked out the pathology of what they call melioidosis, formerly described by Whitmore as morphia injector's disease. One would fain linger in Malaya and explore not three, but thirty, avenues of research, yet, as time presses, we will climb once more into our world cruiser, and this time, journey far and wide, ignoring Borneo and New Guinea, perhaps more fruitful fields than any, for they are little known, giving Hong Kong the go-by, but tarrying for a space amongst the South Sea Islands, where Robert Louis Stevenson found a haven of rest. Here, where the palm sways in the trade wind, and the long combers burst upon coral reefs, we find ourselves faced by the mysteries of filariasis. Bancroft and Manson first shed light upon the life-history of the blood worm, and Low completed the tale. All that is an old story, yet the disease it causes, or appears to cause, remains incurable, save where the surgeon's knife can give relief. In Fiji we have yet to find out why there is practically no syphilis, and in parts of Melanesia, we have to learn how 368 Dr. Andrew Balfour?Vistas and Visions:
best we may save a fine, but dying race, a race dying because they have abandoned interest in life, in a life imposed upon them bv the white man, and which has lost its savour. There is work to be done in these distant isles, and Dr. Buxton is hard at it now, but be very sure he will leave some- thing for successors to accomplish. Again we get under weigh, and crossing the Isthmus of Panama, with Americans on it busy as bees in a hive, we take a line across the Carribean and effect a landing without difficulty on the flats of Demerara. There we will encounter several of the maladies we have mentioned, notably, perhaps, filariasis, but, in addition, you will here find every now and then epidemics of dengue. Dengue, dandy or breakbone fever, is one of those partly explored diseases, and we are still none too certain about its exciting cause, though there is little doubt that a blood spirochete is to blame, as is the case with the very similar sand-fly or phlebotomus fever, common in Palestine and Mesopotamia, two countries, which, like the Levite of old, and unlike the Samaritan, we have passed by. I scarcely like to touch upon the West Indies, that chain of fair islands, so redolent of romance, so full of history, for, under existing conditions, I would hesitate to recommend any medical graduate to take service there under the Crown, except perhaps in Trinidad, the land of the humming bird, where there is some chance of a career. At the same time, from the medical and scientific standpoint, both the Leeward and Windward Islands are mines of wealth. " Pellagra, skin seizure," is the meaning of the two Italian words which make up the name, is far from uncommon, and though there is little doubt that pellagra is a dietetic disease, we are not yet certain as to its precise etiology, despite Goldberger's valuable work. Barbadoes, little England beyond the seas, is, unlike her great namesake, free of anopheline mosquitoes. Why is this the case ? Is it wholly attributable to the presence of the tiny, larvivorous "millions" fish? I doubt it. We want to be informed, and doubtless someone will tell us one of these days, but the question remains open. In Jamaica there is a peculiar form of peripheral neuritis, about which we know very little, but which is a serious Some Aspects of the Colonial Medical Services. 369 thing for those afflicted. Everywhere there is a burden of disease, everywhere there is work to be done. Finally, we will pay a visit to Bermuda, which we must clearly distinguish from the West Indies, or we shall get into serious trouble. Has it not its own pavilion, a very good one, at Wembley, and is it not a very old and very proud little " colony ? It remains, however, a still vext Bermoothes," so far as mosquitoes are concerned, yet, here again, anophelines are lacking. Though but a tiny spot in the Atlantic, it is as full of medical and sanitary problems as an egg is full of meat, and I could linger upon it for quite a space as it is a pleasing place in many ways, though, unfortunately, not in the fore-front of the sanitary battle. We appear to have well-nigh circled the globe, so we may complete our flight by crossing the Atlantic, and, if the weather be favourable and visibility good, wing our way up that beautiful Firth of Clyde which lies at your doors. We may effect a landing, provided we can find an open and level space, in, let us say, the Cowcaddens, and we shall soon realise, from sundry sights and scents and sounds, that we are home again. Have I tempted you ? Perhaps you will complain that I have dealt with research work, that research can only be properly carried out in a labora- tory, and that you cannot all be laboratory workers. The first statement is true, the last is true, but the one in the middle is far from the truth. What kind of laboratory do you think had Laveran, when, an army surgeon at Constantine, he discovered the parasite of malaria ? Dr. Patrick Manson was a busy practitioner in Amoy when he embarked upon that filariasis work which was to lead the way in the conquest of tropical disease. Sir David Bruce wandered about in Zululand with precious little equipment, when he found the trypanosome which bears his name and which is the cause of the nagana, so fatal to cattle and horses. I might multiply examples culled not only from the tropical field. What you do want, however, is a microscope, and you must know how to use it. In the tropics a microscope is as valuable, if not more valuable, than a stethoscope. Students, I think, rather love their stethoscopes. This aural apparatus is a kind of doctor's hall mark. In the old days it was closely connected No. 6. Z Vol. CII. 370 Dr. Andrew Balfour?Vistas and Visions: with his top hat, also a distinguishing feature of the Faculty. The top hat, costly, unhygienic, perhaps hair-destroying, has, let us be thankful, to a large extent, vanished, but, of course, the stethoscope remains, in new and varied forms, and doubt- less is still beloved by the budding medico. It would be well, however, if the microscope also shared his affection. It and its appurtenances constitute a little laboratory in themselves. It may at any time save his own life, and it will certainly be the means, if properly used, of saving the lives of many of his patients. "Cherish your microscope" would be a good motto for every man and woman when entering the portals of the profession. However, being I hope cautious if not actually dour, you may still have your doubts, so let me wind up what have been truly rambling remarks by two clinical adventures?one surgical, the other medical?taken from my own experience. They will serve to show you the kind of thing you may be up against in the tropics, and they possess useful lessons for any medical student, for any doctor. A good many years ago I was on my way to visit the sleeping sickness camp at Yei, in that part of the Southern Sudan which had just ceased being the Enclave leased to the Belgians. With me was a distinguished Colonel of the Army Medical Service. We reached the port of Loka and there found the British officer in charge busy recruiting amongst the natives for a special battalion which was being raised. He was somewhat concerned, for his Syrian medical officer had reported that a promising new recruit had been admitted to hospital very seriously ill, was, indeed, suffering from acute intestinal obstruction, and would probably not recover. The Commandant was anxious, for if this man died in hospital the success of his recruiting would be detrimentally affected, and it meant a great deal to make a good start now that British rule had superseded that of the Belgians. The Colonel and I at once visited the thatched hospital and were shown the case. The Syrian doctor, considerably flustered by the presence of his superior officer, explained that he could find no cause for the condition, that he did not know what to Some Aspects of the Colonial Medical Services. 371
do, and stated that he feared the worst. The patient was a fine young black, but was obviously in a bad way for the condition had persisted for some time. The Colonel pulled the blanket off him, and almost at a single glance we saw what was the matter. There could have been no proper or careful examination. The man had a bubonocele, which, as some of you know, is an incomplete form of inguinal hernia. The loop of bowel had become strangulated. No wonder he was in danger. We had to proceed to immediate operation, and moved the sufferer into the operating shed hard by. It was 12 p.m., very hot and very still. I was no surgeon, so the Colonel rolled up his sleeves and I prepared to assist him as best I could. The Syrian gentleman was instructed to administer chloroform. We were soon ready, but the patient would not go under. He passed into a curious state of semi-anaesthesia, and was rather restless and trouble- some. For a few minutes we could not make out what was the matter, and then the Colonel, sniffing the air, asked me to see what the anaesthetist was doing, as the smell was the smell of ether and not of chloroform. Sure enough the hapless Syrian, having by this time completely lost his head, was administering ether by the open method. In his agitation he had got hold of the wrong bottle. We remedied things and proceeded, but his mistake had not improved matters, and soon the patient was violently sick, and the sickness rapidly assumed that dangerous form which in cases of this kind too often heralds the end. I need not be more explicit, but surgeons and those of you who have studied surgery will understand. There was need of haste, and I shall never forget how the Colonel, despite lack of practice, for he was an administrative officer, rose to the occasion and worked swiftly but deftly. Happily he managed to relieve the constriction with a result such as was to be expected, and which, combined with the sickness, produced a state of matters that under the primitive conditions prevailing, could only be described as appalling. The Colonel, he was a very fine man, never turned a hair though the sweat poured down his face. He merely hastened his work, for time meant everything, and in a few minutes we had the patient back in bed, still breathing, but well-nigh pulseless. We waited till he had rallied, and then had to leave him and push on to Yei, 372 Dr. Andrew Balfour?Vistas and Visions:
having laid down the law to the medical officer as to care and treatment. We were back in a week or ten days and found the patient sitting up on bed with a grin on his face and an unholy desire for food, while the delighted Commandant told us that, as the result of his recovery, recruits were pouring in and the situation had been saved. Although I had very little to do with it, 1 confess I felt quite proud and pleased. So much for surgery; now for medicine. You will find, if you have not already found, that nowadays certain observers decry the value of the differential leucocyte count?that is to say, the enumeration of the white cells of the blood according to their class or type. Well, I can only say, that I have found the procedure of signal value on several occasions, and believe in it, provided?and this is all important? that it is properly carried out. One year, when returning to the Sudan from leave, I learned on arrival in Cairo, that a British Medical Officer, a very good friend of my own, was seriously ill in Khartoum. When I got out of the train there, I enquired anxiously as to his condition, and was told he was dying. I was startled and distressed. I could not, and would not believe it. "No man is dying till he is dead," I cried, parodying someone who invented this epigram. I asked what was wrong, and was told that the diagnosis was in doubt. The patient had suffered from amoebic dysentery and was known to harbour amoebic cysts, so it was feared he might have hepatitis, and perhaps a liver abscess. At one time there had been a focus of tubercle in his lung, and there was a possibility that this had lit up and spread, and that his case was one of miliary, and hence hopeless, tuberculosis. Lastly, he had cut himself some little time before, when performing an opera- tion upon a septic case; hence he might have septicaemia. His symptoms, however, were obscure. One thing only was certain ; he was desperately ill. I asked if a differential leucocyte count had been made. I was answered in the affirmative, but told it had not helped the diagnosis. How many cells had been counted, I asked. About 200, was the reply. About 200 and a valuable life at stake! I fear my language was unparlia- mentary, or, perhaps, considering present conditions, one should say parliamentary! Well, the patient was seen?sadly Some Aspects of the Colonial Medical Services. 3?3 changed, undoubtedly very ill. A proper count of 500 cells was made, for a physical examination revealed nothing definite. From that count it was possible to exclude the liver condition and the miliary tuberculosis. I came to the conclusion that the case was one of septicaemia, and, from the character of the breathing and some other signs, it seemed not unlikely that pus was forming in the pleural cavity, that an empyema was developing. Well, the very next day there were certain indica- tions which justified immediate operative interference (you see we cannot quite exclude surgery), a rib was resected, and sure enough we found a limited empyema, the root of the trouble. Moreover, by examination of the pus it was possible, owing to the fact that the cells were found to be actively phagocyting the causative staphylococcus, to hazard an opinion, that he, the patient, who was very weak, would probably not require vaccine therapy. Such proved to be the case?careful treatment and skilled nursing, especially the latter, gained the day, and that officer is alive at this moment, and doubtless doing good work in the world. Anyhow, he has been married since those days, and that is something. Well, gentlemen, I ask again, have I tempted you ? If not, let us see what a poet?what two poets can do. We began with Robert Burns. Let us end with Robert Louis. We can trust him so far as vistas go, for he had the soul of the romancist. Are we not all children of a larger growth, and did he not write these lines for children ??
" I should like to rise and go Where the golden apples grow, Where below another sky Parrot islands anchored lie."
? ???????
" Where in sunshine reaching out, Eastern cities miles about Are with mosque and minaret Among sandy gardens set, And the rich goods from near and far Hang for sale in the bazaar."
When we come to visions, however?medical visions?we may 374 t)R. Andrew Balfour?Vistas and Visions. turn to Sir Ronald Ross, who last year fulfilled the duty I have tried to discharge to-day. At Bangalore in 1890 he wrote?
" Hour by hour I labour without stress or strife To gain more knowledge, greater power, A nobler, longer life. By thought alone we take our stand Above the world and win command." And again, "... But see The standards of Advance unfurled The buds are breaking on the lea, And Spring breaks thro' the world. Tho' we may never reach the Peak God gave this great commandment, seek."
And it was he, after long and arduous toil, who in 1897 could exclaim? " I know this little thing A myriad men will save, O Death where is thy sting ? Thy victory, 0 Grave 1"
? Yet, after all, Stevenson may be left to sum up the whole argument. It is true that it is the spirit of enquiry which has made medicine, and of late years, tropical medicine, great. Yet enquiry alone, enquiry pure and simple, will not lead us very far. Let us recall the Spaewife?
" Oh, I wad like to ken?to the beggar wife says I?- The reason o' the cause, an' the wherefore o' the why. Wi' mony anither riddle brings the tear into my e'e, It's gey and easy speirin', says the beggar wife to me."