are some indeed, who would tell you that the scientific man is illfated for anything but science; that he cannot be punctual, business-like, a plain speaker, pious, or I know not what else." "It would be difficult to find greater nonsense in any of the books of journals on a modern book-stall." "There is nothing that a man may not be at the same time that he is scientific." (Paget.)

Failures in practice are by no means limited to the scientific. This fact requires no extended argument. Did Schoenlein's practical work in Berlin suffer because of his scientific attainments or because he became the pioneer in Germany in the introduction of physiological methods, the microscope, and chemical analysis, in the study of his clinical material?

Haller had made the attempt one hundred years before but the scientific fundament supplied by pathological anatomy was wanting. Hippocrates auscultated, and one hundred years before Lannec, Auenbrugger attempted to introduce percussion as a diagnostic agent. These attempts bore no fruit; pathological anatomy was needed to make clear the meaning of physical signs. It is by no means to be considered an accident that among the greatest advances in medicine made during the century just closed, the introduction of pathological anatomy and auscultation into the clinic, both were introduced by the same clear mind, Lænnec. He is one of the greatest physicians in history. Allbutt has said "He deserves to stand by the side of Hippocrates, Galen, Harvey and Sydenham. His work was a revelation of the morbid anatomy of the internal organs during the life of the patient."

The physician who is truly successful in practice must depend in a great degree upon the good opinion of his fellow practitioners. Laymen have not the positive means of gauging our ability which those possess who are fitted to judge. Nothing commends itself to the professional mind as does the thorough scientific investigation of individual cases. Certainly there are among those who have no medical education some who judge reasonably of the physician's worth, but the number of these is few. Of the majority, we may say they are the most ignorant who are most positive and loudest in their praise or denunciation, and these are often the most influential.

Herbert Spencer has well said, "Had we time to master all subjects, we need not be particular."

"Could a man be secure

That his days would endure

As of old, for a thousand long years,
What things might he know!

What deeds might he do!

And all without hurry or care."

Bearing in mind our limited time for acquisition and action, the question which is of such transcendent moment is whether the methods recently introduced are of sufficient benefit in the study of disease to claim our attention and time. We must determine in other words, "The relative values of knowledge." If we consider the relative worth of these methods to the clinician from an unbiased standpoint, we must conclude in favor of the adequateness of the advantages. There is certainly a proportion between the required labor and the probable benefit. The young man needs the knowledge and training which the thorough study of disease develops while those who have grown old in the treadmill must take advantage of modern methods and ideas to retain their standing in the profession.

Sir James Paget in his memoirs recently published, writing on the "Ways into Practice," and the "Various Ways out of Practice," speaks candidly on the conditions which effect success and invite retrogression. Between the lines one can read the thoughts of this clear-minded gentleman physician and the appreciation by him of the importance to the honest worker of receiving, after a sufficient period of probation, the methods which were included in the armamentarium of his juniors and pupils.

To those who are practicing at a distance from centres where men are devoting themselves to the accurate methods in medicine, a word of warning may not be misplaced at this time. Your influence will not endure if you persist in ignoring methods which have been tried and found useful. You will finally hold only a remnant of your public clientèle. In spite of the fact that the public has never been more credulous or more ready to encourage quackery, the services demanded from the physician were never before expected to be of so high an order. His search

must always be after the end of science. "The real and legitimate goal of all sciences is the endowment of human life with new inventions and riches." The individual has a right to demand of his physician accurate recording of all facts relating to his condition with a painstaking investigation of every detail which the case offers, by every method needed for accurate observation and ultimate diagnosis. Believing that modern methods of diagnosis lead to trustworthy interpretation of symptoms with a firm belief in the superior ability of those who have adopted these methods, the lay world is fast removing its former prejudices against hospitals where medicine and surgery are practiced rationally. The consulting rooms of those who are known to employ the most thorough methods are filled with all classes of clients. There is a feeling abroad which calls for thoroughness from those charged with the recognition and treatment of disease.

The period has not yet been reached when we can truthfully deny that our art is in advance of scientific direction and explanation. Now as always we need common sense, as well as knowledge, with ready decision and resourcefulness. This no college or teacher can supply. We must never allow our critical faculties to exceed the practical. It has been truly said that "Practice without scientific re-edification soon degenerates into stereotyped and sterile routine." No amount of extra labor bestowed on the study of disease will prove irksome to him who possesses the true scientific spirit; on the other hand, the consciousness of a duty thoroughly and consistently performed, will prove an ample reward.

Out of the clinical laboratory "The new medicine is to comethe medicine which penetrating into the intimate processes of Nature, learns to turn Nature to her own correction—the clinical laboratory is to be the scene of the study of the origins of disease."

"A life full of Work and Labor is no burden, but a Boon, an Enjoyment." This served as the text of Virchow's original thesis. His life has been sweetened by the conscientious and scientific application of his great powers, and it is this spirit which will continue to inspire the physician.

The moral force of scientific methods in medicine is the greatest factor in modern medical practice.

TROPICAL DISEASES AS OBSERVED IN THE

PHILIPPINES.*

By R. W. ANDREWS, M. D.,

Late First Lieutenant and Assistant Surgeon, 46th Infantry Volunteers.

Concluded from January ANNALS, page 23.)

ANKYLOSTOMUM DUODENALE

In July last year I went to the hospital in Manila with diarrhoea and fever, and while there saw many cases of dysentery, one case of ankylostomiasis, and several due to benign parasites. The benign cases were those of tricomonas and circumonas intestinalis. These are said to be benign, but when they occur in such numbers as were reported it was thought very probable that they might cause diarrhoea. This parasite, ankylostomum duodenale, causes a profound anaemia, called ankylostomiasis. It is known by various names, in the French West Indies as cachexia aqueuse, in Colombia as tuntun; in Europe it is known as miner's anaemia, in Egypt as Egyptian chlorosis. The normal habitat of this parasite is in the small intestine of man, particularly the jejunum, rarely lower in the tract, sometimes it is found in the stomach. Its action is purely mechanical, it is a blood sucker. It attaches itself to the mucous membrane of the gut and thus obtains a plentiful supply of blood for its nourishment, absorbing only the plasma, and passing the red corpuscles through its alimentary tract unchanged. It shifts its hold from time to time, and the wounds then continue to ooze blood. There are generally three females to one male ankylostomum. The male measures six to eleven mm. in length by four to five mm. in breadth. The female measures seven to fifteen mm. in length by one mm. in breadth. Both sexes are cylindrical in form and white in color when alive, gray when dead. In both sexes the posterior end is the broadest, and the body then tapers forward to a narrow neck ending in a powerfully armed distinct mouth, the margin of which has four strong claw like hooks. The female produces a large and never ending stream of eggs, which pass out in

Read at a meeting of the Dutchess County Medical Society, Vassar Brothers' Hospital, Poughkeepsie, N. Y., April 10, 1901.

the faeces. While in the body of man the development of the embryo does not advance very far, but on leaving the body it proceeds so rapidly that in one or two days the embryo is born. This organism is very active, devouring what organic matter it can find, and for a week growing very rapidly. During this time it moults twice. After the second time it passes into a larval state, in which it ceases to eat and its growth stops. In this state it may live for months moving about in water or in mud. It may enter the human body by the drinking water, or by earth on the hands of the person, or in some similar manner. When it gets into the body it moults again, and then acquires sexual characters and permanent form. The symptoms are progressive anaemia generally associated with dyspeptic troubles, but not causing a wasting of the body; serous effusions in different cavities may result in an unchecked case, also fatty degeneration of the heart. There may be dozens of ankylostoma in the intestines without causing any anaemia, or any symptoms whatever; in fact grave symptoms in this disease are the exception. In the tropics many of the people are half starved, or live on innutritious food, they are therefore prone to dyspeptic disorders. In these cases the addition of ankylostoma may prove serious, and especially where coolie or native labor is employed. One of the earlier symptoms of an ankylostomum invasion is pain or uneasiness in the epigastrium, increased by pressure, and somewhat relieved by the taking of food. The appetite is usually ravenous. The patient suffers from dyspeptic trouble, colic, borborygmus, and diarrhoea of imperfectly digested food. They also have a perverted appetite much the same as girls with chlorosis. They desire to eat such things as clay, earth, slate pencils and the like. The stools of the patients sometimes show a reddish tinge from the admixture of half digested blood. Some little fever, irregular and intermittent in type, is common. All the common symptoms of anaemia are present when the disease is well advanced: lassitude, breathlessness, tinnitus aurium, palpitation, vertigo, depression of spirits, etc.

In all cases of anaemia in the tropics it is well to examine the faeces microscopically in order to make a diagnosis early, for it is probable that ankylostoma are at the root of the