SUMMARY.

What measures should be instituted to keep an expeditionary force fit for service in the Tropics?

1. Moderation in all things when possible-drills, athletics, marches, etc.

2. Avoiding exposure combined with exertion during the heat of the day, unless unavoidable. The natives have shown that the siesta is of value.

3. The food should be nutritious and well cooked, with an abundance of fruit.

4. A water-boiling detail should be routine in camp or field.

5. The insistence on the use of mosquito nets and careful nightly inspections by the sentries will show results in a low malarial incidence.

6. Insistence on a follow-up treatment for every case of malaria, so that every known source of infection is eradicated.

7. Cooperation between the provost marshal and the medical officers in the eradication of venereal disease.

8. Insistence on antityphoid and cowpox vaccinations for the command.

9. That a regular schedule of transport sailing be instituted. Hope deferred maketh the heart sick," certainly applies here, not only to the enlisted personnel but to officers as well. Homesickness is a very real disease, and how many of the suicides which occurred in the brigade since it first took up its duties here, in the last analysis might be traced to it I am unable to say, but my belief is that it was one of the compelling reasons. The knowledge that, during a peaceful occupation, a soldier can see the date for his departure, gives him a mental anchorage that should not be disturbed.

10. That the easiest, best, and quickest method of transporting patients in a tropical country is by airplane, and future hospitals, if possible, should be located near a landing field or have a landing field of their own.

The year has passed, and now to the history of the marines in Santo Domingo can soon be written the word " finis."

The medical history of the men composing it can only be concluded when taps is sounded over the last survivor in some vast cemetery of a busy city or in the seclusion of a country graveyard, and what the toll from known or unknown diseases contracted here will be, is known to the angel of death, and his records are not open to our inspection.

Our memories of the island will not be clouded by remembrances of deadly epidemics, but of a country to which nature was kind, and where a rational mode of living made existence easy.

NOTES AND COMMENTS.

The long, narrow, tropical island of Java has a population of some 35,000,000 people. By far the greater part of this great aggregátion of human beings is made up of peasants, simple folk, untroubled by intellectual turmoil, living always on the bare verge of existence, and utterly unfitted, either individually or collectively, to resist or survive the great epidemic diseases. In November, 1910, plague gained a foothold in that populous country, but the spread of the disease has been slow. The principal affected areas have been the mountain districts.

Three species of rats were found by the Dutch civil medical service in definite association with the native population. Mus rattus griseiventer, the gray-bellied black rat, is the house rat proper of Java. Its normal habitat is in the roofs, bamboo timbers, and other harborage afforded by the native methods of house building. This rat can not live in the open in competition with the other prevailing species. Once got out of the houses, and kept out, the species rapidly disappears. It is a highly effective plague carrier, and its flea is the Xenopsylla cheopis, the plague conveyer par excellence.

In contrast to Mus rattus griseiventer is the field rat of Java, Mus rattus diardii. It is partly dependent on man, in that it feeds mainly on his rice crops, but it does not come into houses. It is capable of being infected with plague, but is not an important factor in its dissemination. Its flea is the Pygiopsylla ahalae, a large, slow-moving flea, which is not an active plague carrier.

The third rat in Java is Mus concolor. Normally a field rat, it invades the native houses when Mus rattus griseiventer has been driven out. It is an active plague carrier, as its flea is the Xenopsylla cheopis.

The problem which confronted the officers of the Dutch civil medical service was to break the contact between the plague-carrying rats, their fleas, and the native population. It was assumed as a basis of operation that all native houses in the infected area should be so modified in respect to structural conditions that Mus rattus griseiventer or Mus concolor could not occupy them unobserved. One familiar with the bamboo house of the Tropics can readily understand the difficulty of making it ratproof. How the medical officers of Java solved this problem is told in an article on "Plague control

in Java," by Doctor Elkington, which appeared in a recent number of Health, a monthly journal issued by the Commonwealth of Australia. Speaking of the method of ratproofing employed, Doctor Elkington says:

"The vast majority of peasant houses in Java are built with bamboo plates, studs, and rafters, a grass ('Atap') roof, and walls of woven bamboo laths. At one end of the single apartment is an elevated platform-the 'bali-bali '-on which the inmate sleeps. It is usually composed of the omnipresent bamboo. A few simple presses and shelves complete the furnishing. The house rats live in the roof and the large bamboo timberings, gnawing out the joints of the bamboo to secure passageways or harborage. In a few hill districts houses are built of mud bricks, with tiled roofs, but these are relatively infrequent.

"The principal nesting places are above the ridge pole, in the hips of the roof (where a peculiarly shaped structure known as a 'squirrel tail' is inserted to shed the rain), in the rafters and plates, and about the bali-bali. The grass roof is thick and stout, a necessary feature in this country of heavy rainfall, and provides unending nesting space and nest material. It was necessary in effect to reconstruct the houses, and by last advices about three-quarters of a million houses have been so reconstructed.

"Grass roofs being obviously inconsistent with plague control, the native industry of tile making was encouraged by the Government and extended on a large scale. House timber is a rare and costly commodity in Java. A series of careful experiments were therefore carried out in order to discover methods of employing bamboo in a manner which would prevent its use by rats. It was found that by cutting a slot in the top joints of studs the resulting opening enabled rat passages to be detected at once. This seemingly minor detail is in reality one of the most important features of the whole work, for it prevents the rats from forming covered passageways to the roof. By plugging the ends of rafters and exposing their undersurfaces their use as harborage or runways was prevented. The ridge pole was shaped off to an inverted V to permit observation from below. After removal of the grass roof the new tiled roof was whitewashed underneath and lighting spaces were left to allow the whole undersurface and roof timbers to be viewed clearly. The 'bali-bali' supports were slotted, the front removed, the platform kept away from the walls, and presses raised from the ground to permit access underneath. If insufficient tiles were available at the time the grass roof was stripped down, cleaned of rats and fleas, the framework reconstructed, and the cleaned roof material replaced as a temporary measure. For mud houses similar ingenious methods were adopted. The use of bamboo for certain timbers in new houses was forbidden.”

The appearance of the Atlantic Medical Journal marks a new era in medical journalism in the East. It combines and continues the journals of the medical societies of Delaware and Pennsylvania. We trust it will receive the support deserved by the worthy Pennsylvania Medical Journal, which it supplants. The first issue contains the following on bismuth in the treatment of syphilis, a subject which should be of interest to many naval medical officers:

"Sazerac and Levaditi in 1921 and 1922 reported the results of their experiments on bismuth compounds-bismuth ammonium citrate, lactate, subgallate, oxyiodogallate, and sodium and potassium tartro-bismuthate, in the treatment of rabbit syphilis. They observed that these salts of bismuth possessed a spirocheticidal action. The least toxic and most effective was sodium and potassium tartro-bismuthate, which they proposed for treating human syphilis, and were the first to employ, using it in an oil suspension by intramuscular injections.

"Subsequent to this study they reported equally favorable results in the treatment of rabbit syphilis with precipitated bismuth as with sodium and potassium tartro-bismuthate. The compound was injected in oil suspension. It, therefore, appears that the metal bismuth is the active spirocheticidal agent in bismuth compounds employed in the treatment of syphilis.

"As a result of the elaborate researches of Sazerac and Levaditi the clinical use of bismuth as an antisyphilitic drug has been made possible. The favorable results reported by them in the treatment of human syphilis with sodium and potassium tartro-bismuthate were confirmed first by Fournier and Guenot, who reported on its employment in the treatment of 200 syphilitic patients in different stages of the disease. Other reports, mostly French, have since appeared, until now a considerable number of syphilitic patients in all stages of the disease with diverse manifestations have been reported treated with the drug. In most of these reports, sodium and potassium tartro-bismuthate in an aqueous solution and in oil suspension were used.

"The foregoing reports show that bismuth is therapeutically active when employed in the treatment of human syphilis.

"Sodium and potassium tartro-bismuthate is administered solely by intramuscular injection. The drug is very toxic when administered intravenously in rabbits. It is administered either in an aqueous solution or an oil suspension; the former in doses of 0.1 gram in 1 cubic centimeter every other day, the latter in doses of 0.2 gram in 2 cubic centimeters of oil every fourth day. Most French writers favor the oil suspension of the drug, since it is considerably less painful.

"A course of treatment consists of a total administration of 2.5 to 3 grams of the drug given in the course of six to eight weeks. A rest period of about one month is instituted, then a repetition of this treatment until the Wassermann test is maintained negative.

"Spirochetes disappear from the surface of open syphilitic lesions usually 24 hours after the administration of 0.2 gram of the drug. Lesions of primary, secondary, and tertiary syphilis involving the skin and mucous membranes involute after a total administration of the drug ranging in amounts from 0.4 to 1.5 grams.

"The 4-plus Wassermann reaction of most patients in early secondary syphilis, previously untreated, and in the late secondary stage becomes negative following the total administration of bismuth in amounts ranging from 1.5 to 3 grams. The 4-plus reaction of primary syphilis becomes negative after a lesser amount of the drug and is somewhat proportional to the duration of the chancre. The 4-plus Wassermann reaction of tertiary syphilis requires varying amounts of bismuth treatment and can not arbitrarily be stated. "The initial untoward reaction of bismuth is a foul breath and gingival blue line which is indistinguishable from that seen in plumbism. These reactions may appear following a total administration of 1.5 gram of bismuth. This, however, is exceptional. They usually appear following the administration of about 2.5 grams. Depending upon the intensity of bismuth therapy, the foul breath. and the gingival blue line forecast the appearance of stomatitis and are associated with it. The incidence of stomatitis is intimately associated with the intensity of bismuth treatment and the hygienic condition of the mouth of the patient treated.

"Other untoward reactions are chills and fever occurring soon after an injection of bismuth, loss of weight, anorexia and malaise which may appear after prolonged treatment with bismuth. Less common reactions are polyurea, enteritis, and cutaneous reactions. Bismuth, as employed in the treatment of syphilis, apparently does not exert a nephrotropic action.

"It is known that relatively enormous doses of bismuth can be taken by mouth without producing signs of intoxication. This is probably due to the fact that very little is absorbed by the digestive tract. Although at times following oral administration of large amounts of bismuth signs of intoxication may occur, these signs also occur following absorption from wounds and when injected in the form of Beck's paste. Absorption is more rapid following the therapeutic use of bismuth by intramuscular injection. It is logical to believe that following this treatment any of the symptoms of bismuth poisoning with which we are familiar may appear. There is doubtless much to learn regarding the untoward reactions from the prolonged administration of bismuth by intramuscular injections.