The Rise and Fall of a Medical Specialty: London's Clinical Tropical Medicine

1

The necessity for ‘colonial medicine’

Many diseases which are now categorised as ‘tropical’ formerly existed in temperate parts of the world (Britain included). An excellent example is malaria. William Shakespeare (1564-1616) was well aware of this:

… he is so shaked of a burning quotidian tertian that it is most lamentable to behold. ¹ [Henry V, Act 2, Scene 1]

Thomas Sydenham (1624-89 – the ‘English Hippocrates’) was well aware of intermittent fevers which responded to treatment with the ‘bark’. ² It is also interesting to recall that infection with Plasmodium sp was indigenous in England until the early twentieth century; in fact, as late as 1860, transmission of this protozoan parasite occurred in extensive areas of low-lying ground in England. ³

John Bunyan (1628-88) was well aware that tuberculosis (which arguably remains the world’s commonest bacterial infection, and is now largely localised to tropical countries) was a major problem in Britain:

The captain of all these men of death that came against him to take him away was the consumption; for it was that that brought him down to the grave. ⁴

Fig 1.1: Sir Andrew Balfour (1873-1931): President of the Royal Society of Tropical Medicine and Hygiene (1925-7).

Fig 1.2: Scene in Nigeria in 1961, exactly one hundred years after foundation of the colony: Lagos from the harbour.

There seems little doubt that these facts were in the mind of Sir Andrew Balfour (1873-1931) (see fig 1.1) (the first Director of the London School of Hygiene and Tropical Medicine [LSHTM]) in his Presidential Address to the Royal Society of Tropical Medicine and Hygiene (RSTMH) in 1925:

…there is in one sense no such thing as tropical medicine … many of the most erudite writings of Hippocrates are concerned with maladies which now-a-days are chiefly encountered under tropical or sub-tropical conditions. ⁵

Therefore, most of the infections which now constitute serious health hazards in tropical countries were formerly prevalent in temperate ones also. It is the prevention and management of these which have formed the major thrust of the activities of the RSTMH for example, since its foundation in 1907. At the Society’s inauguration, The Lancet announced: ‘The Society of Tropical Medicine and Hygiene was formed on Jan. 4th of this year [1907] at a meeting held at the Colonial Office for the purpose of the study and discussion of diseases met with in tropical countries …’. ⁶ The Society’s objectives were clearly laid down in 1907:

The objects of the Society are specially directed to the stimulation of enquiry and research into the causes, treatment and prevention of human and animal diseases in warm climates … by promoting social intercourse among scientific workers in all parts of the tropical world [my italics]. ⁷

West Africa in the late nineteenth century

West Africa up to the nineteenth century was essentially a black man’s ‘country’ (see fig 1.2). The climate was inhospitable; a combination of heat and humidity, in addition to infection, contrived to make it the ‘white man’s grave’, for both morbidity and mortality – especially amongst newly arrived individuals – were intense. Malaria and yellow fever were the chief culprits, although there were many other infectious diseases which afflicted the non-immune. It was in fact, still doubted that white-skinned individuals could ever exist healthily there. ⁸ The mortality rate amongst British troops was, for example, the highest in the Empire. In the late nineteenth century convicted criminals were sentenced to carry out garrison duty in what can best be described as a delayed death sentence. Even around 1900, a tour of duty for British officials in coastal West Africa lasted a mere twelve months, so devastating were the environmental conditions. However, for those in northern Nigeria, with a far less demanding climate, an eighteen month stint was the rule.

Therefore, for most of the nineteenth century, the majority of Britain’s West African colonies were virtually derelict outposts as far as the white man was concerned. The Gambia and Gold Coast (now Ghana) were mere relics of the Atlantic slave-trading era and barely viable, whereas Sierra Leone which was a major coaling station for the Royal Navy (RN), was largely manned by Africans. Lagos colony which had been acquired by the British in 1861, as a base for anti-slaving operations ⁹ was about the only area in West Africa to attract British commerce, palm oil – used in soap and candle manufacture – being the chief attraction. The Liverpool entrepreneurs, later headed by (Sir) Alfred Jones ¹⁰ – backed by naval patrols, some of which penetrated the Niger and Benue rivers – were dominant in this trade. The traders, in turn, sold gin, in substantial quantities, to Nigerians and to a lesser extent other West African countries. The palm oil – gin equilibrium was to some extent disturbed in the latter years of the century by the French – whose politicians and soldiers became obsessed with the idea of creating an empire of their own – stretching from west Africa across the western Sahara, and a railway from west Africa to the Red Sea, the latter being inspired by the American Union Pacific Railroad, and in many ways comparable to Cecil Rhodes (1853-1902)’ ambition to build a railway from the Cape to Cairo. The British fear was that the French would seize major tracts of inland territory, leaving the coastal possessions – especially in the Gambia, Sierra Leone, and the Gold Coast (Ghana) – more or less isolated on the west African coast, thus strangling inland trade. ¹¹

The West African colonies were therefore a considerable focal point for British politicians. Although not dominant in the mind of Lord Salisbury (1830-1903) – the British Prime Minister (1885-6, 1886-92, and 1895-1902), it was of considerable interest and importance to Joseph Chamberlain (1836-1914) (see fig 1.3 and preface) – British Secretary of State for the Colonies from 1895-1903 ¹² – who decided that Britain would take a tough line, the 2,000 strong (Royal) West Africa Frontier Force – with Lord Lugard (1858-1945) as its commander – being on the offensive.

By 1901, the mode of transmission of both malaria and lymphatic filariasis were largely understood. Ronald Ross (1857-1932) had carried out his researches on malaria at Secunderabad and Calcutta, India ¹³, and before that Patrick Manson (1844-1922) (see fig 1.4) had shown that mosquitoes were involved in another ‘tropical’ disease, elephantiasis – a complication of filariasis. Furthermore Manson, now home from China, was giving lectures on ‘tropical disease’ at various institutions in London, including St George’s Hospital and the missionary institution, Livingstone College. What a marvellous idea, Chamberlain felt, if colonial medical officers serving in tropical locations, especially West Africa – where so much morbidity and mortality existed amongst the British contingent – could attend Manson’s lectures.

With so much taking place in West Africa, and recognition that there was enormous morbidity and mortality in that locality, Chamberlain thus became aware that some form of medical intervention was urgently required to protect British personnel from the major health hazards, dominated by malaria and yellow fever.

Fig 1.3: Joseph Chamberlain (1836-1914): British Secretary of State for the Colonies (1895-1903): Courtesy National Portrait Gallery, London.

Fig 1.4: (Sir) Patrick Manson (1844-1922): ‘father of modern Tropical Medicine’, and the first President of the Royal Society of Tropical Medicine and Hygiene (1907-9).

Fig 1.5: Cartoon in Tropical Life (April 1926): a contemporary appeal for funding tropical medicine.

‘Colonial’ medicine

Chamberlain therefore arranged for Manson to be appointed to a senior medical position (Medical Advisor) at the Colonial Office. It was from that point that the formal discipline arose (see Chapter 2). ¹⁴ It was to expand rapidly, not only in Britain but in all those European countries with possessions in a warm climate.

In 1922, Manson, by now hailed as the ‘Father of Tropical Medicine’, died. However, colonial medicine in Britain remained an extremely viable enterprise, which still attracted major funding from the British population at large as was made clear in a cartoon in an issue of the magazine Tropical Life, dated April 1926. Funding was also sought for the ‘Ross Institute’ ¹⁵ (see fig 1.5). Subsequently, in 1951, and after a series of removals from its place of origin, which will be outlined in this book, the Hospital of Tropical Diseases (HTD) (the ‘flagship’ hospital of the discipline in Britain) was transferred to St Pancras Way, London NW1, UK. ¹⁶

The formal (‘colonial’) discipline of tropical medicine was thus founded in 1899 when the British Empire and Raj were at their height. As this book will reveal, this specialty was only to last for about a century.

References and Notes

1 W J Craig (ed). The Complete Works of William Shakespeare London; Oxford University Press 1954. [See also: C Singer, E A Underwood. A Short History of Medicine (2nd ed). Oxford: Clarendon Press 1962: 854; M Honigsbaum. The Fever Trail: the Hunt for the Cure for Malaria. London: Macmillan 2001: 333; N MacGregor. Shakespeare’s Restless World. London: Allen Lane 2012: 320.]

2 K Dewhurst. Dr Thomas Sydenham (1624-1689): his Life and Original Writings. London: Wellcome Historical Medical Library 1966: 101-25, 131-9.

3 D Guthrie. A History of Medicine. London: Thomas Nelson and Sons Ltd. 1945: 204, 357; Op cit. See note 1 (Singer, Underwood) above: 455.

4 J F Forrest, R Sharrock (eds). Bunyan, J. The Life and Death of Mr Badman: presented to the world in a familiar dialogue between Mr Wiseman, and Mr Attentive. Oxford; Clarendon Press 1988. [See also: Note 1 (Singer, Underwood) above: 720; R Dubos, J Dubos. The White Plague: Tuberculosis, Man, and Society. London: Rutgers University Press 1952: 277; F Ryan. Tuberculosis: the greatest story never told. Bromsgrove, Worcestershire: Swift Publishers 1992: 446.]

5 A Balfour. Some British and American pioneers in tropical medicine and hygiene. Trans  Soc Trop Med and Hyg 1925-6; 19: 189-231. [See also: G C Cook. Twenty-six Portland Place: the early years of the Royal Society of Tropical Medicine and Hygiene. Oxford: Radcliffe Publishing. 2011: 230-7.]

6 Anonymous. Lancet 1907 i: 605. [See also: Ibid (Cook 5-23).]

7 G C Cook. From the Greenwich Hulks to Old St Pancras: A History of Tropical Disease in London. London; Athlone Press 1992: 338; G C Cook. Evolution: the art of survival. Trans R Soc Trop Med and Hyg 1994; 88: 4-18. [See also note 5 (Cook) above: 559.]

8 C E Woodruff. The Effects of Tropical Light on White Men. London: Rebman Ltd 1905: 358.

9 M Crowder (ed). Nigeria Mag: Lagos Centenary Issue 1961; 69: 91-194. [See also: G C Cook. National Service 50 years ago: life of a medical conscript in West Africa. 2014 (in press).]

10 P N Davies. The trade makers: Elder Dempster in West Africa 1852-1972. London: George Allen & Unwin Ltd 1973: 526; P N Davies. Sir Alfred Jones: shipping entrepreneur par excellence. London: Europa Publications Ltd 1978: 162.

11 L James. The Illustrated Rise and Fall of the British Empire. London: Little, Brown and Co. 1999: 178-91. [See also: T Allan (ed). The Illustrated History of the World: the Age of Imperialism – 1870-1905. London: The Reader’s Digest Association Ltd 2007: 192.]

12 P T Marsh. Joseph Chamberlain: Entrepreneur in Politics. New Haven: Yale University Press 1994: 725; P T Marsh. Chamberlain, Joseph (Joe) (1836-1914). In: H C G Matthew, B Harrison (eds). Oxford Dictionary of National Biography. Oxford: Oxford University Press 2004; 10: 923-34.

13 G C Cook. Ronald Ross (1857-1932): 100 years since the demonstration of mosquito transmission of Plasmodium spp – on 20 August 1897. Trans R Soc Trop Med Hyg 1997; 91: 487-8. [See also: Chapter 2.]

14 G C Cook. Disease in the Merchant Navy: a history of the Seamen’s Hospital Society. Oxford: Radcliffe Publications 2007: 415-34; G C Cook. Origin of a Medical Specialty: the Seamen’s Hospital Society and Tropical Medicine. St Albans: Tropzam 2012: 182. [See also: note 7 above (Cook 1992; 33-67).]

15 G C Cook. Aldo Castellani FRCP (1877-1971) and the founding of the Ross Institute & Hospital for