ON MEDICINE AND WARFARE IN THE TROPICS

By DR. C. M. HASSELMANN

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SINCE hostilities in the Pacifio oom­menced, by far the largest war areabaa been made up of the tropics or

of adjacent territories where allied olimatesand maladies exist.

The tropics proper comprise the beltbetween the Tropio of Cancer and theTropio of Capricorn, but this geographicallimitation falls far short of embracingother vast regions with similar climateand diseases. In our map we have in­cluded approximately the regions withpathology representative of the tropics.

The primary duty of an army medicalservice is to determine the physical andmental fitness of draftees and volunteers;to make all preparations humanly possible

to keep the personnel healthy and fullyable to perform required duties withminimum time on the sick list; to restorethe wounded aa quickly and completelyaa possible; and to determine impartiallythe degree of incapacity of invalidedoaaualtiee for purpoeee of compensationand rehabilitation in civilian life.

We are not aware of any disea8e whichaffects certain races only. although thestudy of comparative pathology revea1athat variations in the course of diseasesare discernible in diJJerent races. Itlikewise becomes evident that some racespoese88 a distinct susceptibility to certaindi8eaaee. But the major problems ofpresent warfare in the tropics are, on.

ON MEDICINE AND WARFARE IN THE TROPICS

the one hand, the vastness of the combattheater with the difficulty both of ade­quate supply and proper care of the sickand wounded, and, on the other, copingefficientl-y with the fOUT ~Tamoun.t tTO"P­ical d.i.seases - malaria, enteric fevers,impetigo and ringworm, and nutritionaldeficiencies, apart from ordinary diseasesand problems of hygiene.

find water, and enough of it, besides foodand proper clothing. As for diseases,malaria and the dysenteries took th&heaviest toll. They were the same ob­6t8.clet!. 'Which fa.ced the builders of thePanama Canal, who mastered them onlyat enormous cost in money and men andwith every conceivable help at their­command.

Malaria's peculiar mode of infection.requires the anopheles mosquito. Onlya few races of this species are vectors­(disease carriers) of any consequence, andonly against these must effective controlbe directed. However, whereas one anoph­eles type is a most dangerous vector'in one country, it may be quite harmless

PAST EXPERIENCES M.A.LARIA.

The exigencies of war with its massing More than any other single healthof large bodies of men have boosted pre- problem in tropical warfare, malariaventive medicine from the bleachers to- demands the lion's share both in control'the reserved box in the grandstand. effort and in treatment. To conquer this­Many of the Crusades failed because premier malady of the hot countries is·of pestilence, mainly malaria, bubonic not yet possible, but effective control is­plague, and enteric fevers. In 1348, the indispensable in order to maintain theyear of the "Black Death," probably one combat power of the troops. Malariaquarter of the entire population of Europe has often had a hand in changing history.died of bubon- The decline ofic plague. In x .. - , both G re e kthe Crimean and RomanWar the Brit- culture w a s-ish lost 4,600 pre cip i t a-killed inbattle tedbymalaria.and 17,500 The native'from disease, pop u I a t ionthe French could offer20,240 killed little resist-and 75,000 ance, whereas-from disease. the slaves-As late as in from Africathe Boer War, . and the East

ore men RegiOnl with pathology repl'8lJllhtative of the tropiCS. They are highlm approximately bordered in the north by the yearly mean ~ere ydied of ty- isotherm of 59° F., in the 80uth by that of 68° F. shown on our lIDIDune. Yet.phoid f eve r map Fate spared.than in battle. For the first time in the neither side: it was also malaria that felledhistory of protracted warfare, medical Alaric on his victorious march to the'science triumphed in the years 1914 to south; he had just conquered the Eternal'1918, when disease claimed fewer victims City and was carrying the might of thethan did weapons. Visigoths to North Africa. And more than

.. once did malaria turn the tide against.An outstanding ac.hievement of World the proud Ghibelline emperors who had

War I was the heroIC stand of the Ger- been victorious in the battlefield.man Colonial Corps in East Africa underGeneral von Lettow-Vorbeck. Cut offfrom all supply routes, the replenishmentof ammunition and vital medical supplieswas attempted by raids on enemy basesand stores. In some regions even cin­chona trees were planted with a view toeventual quinine production. The chiefproblem in the field of operations was to

160 THE XXth CENTURY

in another. InYugoslavia,malaria is chieflytransmitted by Anophele8 maculipen:nia,a species that becomes progressively rarerto the south, where the prevailing tem­perature is already above its optimum oflife. In the Philippines the principalcarrier is Anophele8 minimU8, which breedsin the foothills' slow-running streams andsluggish brooks banked by weeds andleaf-debris. But the lowlands are con­spicuously free, in spite of rice fields andtheir irrigation canals. Hence controlmeasures are comparatively simple, nordo they conflict with established agri­oultural habits. In neighboring Java andin the Malay Peninsula, however, themost dangerous species is Anophele8 Zud­lowi, which breeds not only in rice fieldsbut even in the brackish water of fishponds. Here effective control is boundto interfere with the customs and waysof life to such a degree as to be incom­patible with the established manner oflivelihood of the population.

Branding the enormous harm done bythe myriads of insect pests, the greatentomologist Howard has passed themournful judgment that we flatter our­selves to be living in the era of Man butare aetually still enslaved in the era ofinsects. This applies to malaria morethan anything else. Although the pas­sages through the Suez and PanamaCanals are now kept safe, control of thefecund mosquito is a continuous gargan­tuan task. In the forests of Madagascar,in the oases of North Africa, in thejungles of Malaysia, in the disembarka­tion camps at Basra, in the oil fields ofthe Caucasus and along the vital railroadsof Soviet Central Asia, malaria is thechief health impediment. It can bechecked, where the cost is worth themoney-in saved lives or in terms ofcrops and commerce. But continuouscontrol measures permit no slip.

Control measures vary according to theaoil and the peculiar breeding conditionsof the responsible anopheles vector. Intropical .warfare, advance study is re­quired of the malaria peculiar to the areaunder consideration and of the habitatof the pertinent transmitter. Under field

conditions, and especially in a war ofrapid movement, effective measuresagainst the mosquito are extremely dif­ficult. It is rarely possible to accomodateadvancing troops in adequately screenedquarters or to provide and enforce theuse of individual mosquito nets. Only insome instances will commanders be ableto select camping pIaoes where anophelesare likely to be absent.

So medicinal prophylaxis is often theonly remaining means of prevention.But this must be rigidly enforced, sincethe careless attitude of officers and menhas often been responsible for greatlosses. The individual soldier, shunningthe unpleasant accompanying side-effectsof the medicament, too often lacks suf­fioient insight. During the Great War,for instance, medical officers could onlymake sure of the men really taking theirquinine dose by lining up officers andmen, giving them quinine dissolved inwater, and letting each say his nameafter he had swallowed the bitter fluid.

The new German synthetio antimalarialdrugs mean progress of the first magnitudeand, notwithstanding their high cost andtheir side-effoots, open up a new avenue tothe quickest cure of that perfidious malady.

In the Great War the incidence ofmalaria on the Balkan front near Salonikarose to nearly a hundred per cent. Noless may be expected today in somemalaria-ridden districts unless preventivemeasures have been effectively carriedout. As in many other fields, war againprovides a mass experiment on a scalehitherto unparalleled. But resultsinvariousareas can only be compared if similarconditions prevail and if prophylactiomedication has been rigorously enforced.

THB ENTERIO DVlm GROUP

Seen as preventable diseases, the enteric(intestinal) fevers must be dealt withfrom the standpoint of epidemiology,which considers the mass aspect of thedisease, not the sick individual. It reck­ons with the group, or herd, as the unitof observation.

Though their apposite microbes arewidely at variance, cholera, typhoid fever,

OK IlEDICIKE AHD WARFARE IN THE TROPICS 161

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the paratyphoid leven, aDd botII. dy.!l8ll­teries can all be cl"...d under ODe heedingfrom the point of view of preventh'eepidemics. They have muoh in oommon.No animal host is required. Infectioninvariably means a short circuit betweenthe excretions of one person and the mouthof another, however indirect that routemay be. Ae a matter of fact, direct con­tact transmittal is rare, but infection isbrought about in great part by mouththrough food and drink. A surreptitiousdraught of polluted water or from acontaminated cup may have dire con­eequenoee, especially in the case ofcholera. Osler's triad of three "F's"ranks first among routes of transmittance:

Feces - Fingen - FoodFeoee - Fomites (Rubbish)- FoodFeces - Flies - Food

To avoid defects in sanitary organiza-tion is particularly diffioult when largetiroOP movements are neoeesary. Properdispoeal of human excreta, of garbageaDd rubbish is perplexing enough incivillaD life wherever large numbers ofpeople are gathered. Human d.isease car­nen play a very important part in thecausation and recurrence of epidemics,whether they are convalescents or chroniccarriers. The outbreak of explosive epi­demics is greatly enhanced by a combina­tion of facton such as the arrival of new81l8oeptible individuals (troops from otherregions, for example) in an area of lowBOCiological and hygienic culture favoringthe eventual intake of the pertinent micro-organism.

In the Boer War enterio fevers werestill far more fatal than shells and bullets.In the years 1914 to 1918 they werealmost negligible. In no other realm ofhealth has preventive medicine triumphedto such a degree, partly through thediligent enforcement of general hygienicmeuures and partly owing to the properpophyJactic inoculations.

IMPBTIGO AJ.~D RINGWORM

Sweat and humidity promote the soften­ing up of the skin on which pyogenic(pus-producing) bacteria and fungi then

thrive. Healthy skin is greatly imper-­mus to both. But the manifestationsof either frequently follow upon a break­down, at leaa~ looa1ly, of natural resist­ance &I wen 'M upon massive contamina­ting contact with .prms. The latterabound in military Camps ~ in theopen, and the former often 0000I'8 whengeneral personal hygiene becomes diffioultor impossible to pursue, with bathing andeoap M a premium. Now conditions areideal for microbes to hunt Man, and anarmy may suffer seriously from this per­secution.

The superfioial pus-filled blisters andblebs of impetigo are caused by pyogenicbacteria. They are the marks of a dirtd.i.sease which affects principally children.But, given favorable circumstances, theimpetigo pustules may spread like wildfireon the adult's skin, too.

In susceptible skin certain fungi mayproduce various skin eruptions. Theyhave nothing to do with "worms," bu~

the colloquial term "ringworm" alludesto the occasional serpiginous configuration(ring-shaped, progressive patches on theskin) caused by them. Fungi are a lowspecies of plant. Some of them areyeasts and molds; others are apt to invadethe superficial layers of the human skinor even attack inner vital organs.

Moist, s9ftened skin is especially suitedfor such an invasion. Hence the skinfolds, the groin, and the spaces betweenthe toes and fingers of most people be­come affected by one or another fUD«UBinfection, though gross subjective symp­toms may remain absent for a long time."Athlete's Foot" refers to the infectionacquired on out-of-door tracks and inshower-rooms when no shoes are worn.In the tropics, ringworm is often trans­ferred through contaminated laundry:"Dhobie Itch," Dhobie being the verylow Hindu caste entrusted with thowashing of clothes.

The priokly heat of the tropios in itssimple form is not a ringworm affectionbut a form of eczema many people sutleras a result of profuse sweating on hotand humid days, often after taking alcohol

162 THE x..~tb CENTURY

and hot and spicy food. But 88 a resultof chafing and scratching due to the itchi­De88 of prickly heat, ringworm infectionmay well 8upenede.

Under active-service conditions in warmclimates, particularly in a war of move­ment, it is usually impossible to procureadequate bathing, much less laundering.Marching through lowland jungles, legsand feet never get dry, and the spacesbetween the toes become an ideal placefor fungus growth. An army marcheson-but not when it is footsore.

NUTRITIONAL DEFlCIENOIX8

Although distinct nutritional diseaseslike beriberi, scurvy, and keratomalaciawill hardly occur frequently among theselected healthy manpower of a modemarmy, the quartennaater corps faoea amajor task in the tropics in providing adiet with what.are known 88 "protectivefoods." Except in a frozen state and inlarge cities, meat is seldom availablelocally in sufficient quantity and faultlessquality. Dairies are small, few, and farbetween. Minimum requirements for thenecessary vitamins in food become hardto meet. Among them, Vitamin C isprobably the most vital yet the leaststable. Vegetable and fruit are its mainsource. Even in peace time, such anagricultural country 88 the Philippineshad every month to import over threethousand tons of vegetables and abouttwelve hundred tons of fruit and nutslWith the Herculean problem of transportin war time, it is well-nigh impossibleto secure these needs for large bodies oftroops. Yet any organized feeding ofarmies designed adequately to maintainhealth must nece8880rily be based uponsound nutritional considerations ratherthan on the daily swallowing of tabletsof alphabetical portraiture.

OTHER DMrOBTANT DISEASES

Occasionally one or the other of theubiquitous diseases may assume a positionof the first magnitude in the tropics.Among them is dengue fever, which canincapacitate great numbers of men, a.sanyone who has ever su1fered the splitting

headache and excruciatingly painful spineit causes will tell you. With the pertinentmosquito carrier omnipresent, humansand even monkeys seem to form the res­ervoir for the causative virus of ex­plosive flare-ups in epidemic form. As arule, no one dies of dengue, thoughduring an epidemic in Greece a few yearsago many people are said to have 8UC­

cumbed. Pappataci fever is a similarmalady, also caused by a virus, and trans­mitted by sandfties.

The spirochete of Weil's Disease (in­fectious jaundice) is usually plentifulwhere urine of rats soils toilet floors, andin certain creeks and swimming pools.Especially in Egypt and the Far East,flukes of the schi8t08omum species arewidespread; their intermediary hosts arespecifio snails. From these snails, cer­cariae (larvae) emerge during the hothours of the day. They penetrate theskin of men swimming in the infestedpool or wading through irrigation ditches.

Hookworm is the plague of all militarycamps in the tropics where the groundbecomes infested through the indiscrim­inate disposal of human excreta. Thelarvae soon hatch in moist soil and infectthe human h08t through the skin, usuallywhen he is barefooted. By the installa­tion of proper latrines, German medicalpioneers succeeded in doing away withthis soourge in the plantations throughoutthe Dutch East Indies. In a world·widecampaign supported by large funds, theRockefeller Foundation followed suit andliberated millions of people from thispestilence. Infestation with the commonroundworm is much more widespreadthan with hookworm, but usually lessserious. Like dysentery, infection gen­erally takes place by eating raw vegetablesor fruit (such as strawberries) from gar­dens where human excrements have beenused for ferti.lWng.

In some of the dry, hot, dust·riddencountries such 88 Egypt and partB ofChina, trachoma of the eye is a seriousproblem, with no known preventive ex­cept the control of flies. Herded to·gether under poor sanitary conditions,large troop contingents are also widely

ON ~.EDIC1XE A~D WARf·..\RE IN TH.E TROPICS lli3

expoeed to relapsing fever; it is trans­mitted in Africa by certain ticks and herein China by body lice. Though it ismostly acquired in childhood, infectionmay loom in heavily infested areas whennutrition is inadequate and other diseaseshave lowered general resistance.

In dry sandy ground and on the clayfloor of huts, chiggers may abound.Boring into toes and soles by the score,this flea species can disable whole detach­ments. And men marching through someof the wet jungle forests of southern Asiaand the Paci1io Islands run the gauntletof bloodthirsty leeches teeming in thefoliage and sodden graas.

Ymally there is the host of insects tobe found in hot. humid countries with alow hygienio level and a poor standardof living. Foremost among them ranksthe nuisance from the common mosquito,even when not transmitting disease; butthe annoyance from bedbugs, fleas, andtiob J:D&Y also be considerable and afiectthe strained nerves of fighting men.

Sunstroke, with excessively high feverand dangerous unconsciousness, as well88 its less serious preliminary stages, canbe prevented by rigorously forcing thetroops to wear proper helmets. Strangelyenough, sunstroke may be common inone country and quite absent in anotherof the same latitude and sunshine.

Heatstroke is largely a matter of thebody's faulty heat conditioning. Wht'nthe heart is not above par, and particularlyin closed rooms with stale hot air of highhumidity, the regulation mechanism ofcertain persons breaks down. To protectagainst such an event, proper ventilationmust be provided in tanks, engine rooms,and workshops; ample fluids must be8upplied with enough salt to make upfor the loss through sweating; and anypossible heat congestion during marchingdue to unnecessarily heavy or too tightlyfitting garments must be avoided.

But, by force of circumstance, diseasesof the respiratory tract are still theprimary problem of aU diseases and onall theaters of war. Throat troubles,inJIuenza, bronchitis, and pneumonia are

aU uppermost in the public's appreciation,but unsung is the sinister rhapsody of thecommon cold. It seriously impedes doingeffectively SU8tained work, it reducesgeneral resistance, and paves the way toother maladies. The fighting men haveusually suftered severe hardships-long,forced marches with insufficient shelterand sleep, with a lack of adequate waterand food. With all this, and crowdedtogether, they are an easy prey to con­tagion. The same applies to trainingcamps, where explosive epidemics ofchildren's diseases like measles and mumpsare favored by the presence of manysusceptible recruits.

More than any other single infectiOU8disease, bubonic plague and cholera havein the past swept our globe in explosiveepidemic form at various times. Todaycholera still claims many victims in largeparts of Asia and South America. Inoc­ulations and isolation of cases can con­trol a flare-up of epidemic proportions.

Bubonic plague h88 always spread fromone of the five or six endemic centers inthe world along the trade routes of grain.It is primarily a disease of rodents; whenthey die, their fleaa seek other hosts.Coolies unloading grain cargoes, peoplohunting and handling small rodents andtheir furs, and inhabitants of denselypopulated waterfront districts, where ratsabound, are t.he ones most frequently tofall ill. The control of bubonic plaguemust still be carried out through erect­ing ratproof buildings and periodicallyfumigating ships and grain silos ratherthan by attempts at mass vaccination.

VENEREAL DISEASES

Soldiers are not yet plaster saints.After having faced death, they are proneto overindulge in food, alcohol, and otherdissipations. In the tropics, and espe­cially under mobilization conditions, suit­able sexual partners are few and farbetween, if one excepts prostitution inits narrower sense. Here promiscuitymay make each infective case the focusfor an explosive epidemic. For troops,the control of venereal diseases rests uponindividual prophyluis as well as on

1M THE XXtb CENTURY

preventing the diseased female carrierfrom spreading the infection. But sexcannot be abolished.

During the summer of 1917 the BritishExpeditionary Forces in France had, attimes, 88 many 88 23,000 hospital bedsoccupied by venereal-disease patients.That represents the manpower of twowhole infantry divisions. Their averagehospital stay was 46 days, so that the1088 in fighting power reached the stagger­ing total of 70,495,000 soldier-days peryear. The American forces lost 6.5 mil­lion soldier-days during the Great Wardue to hospitalization of venereal-diseaaecases. In the American ExpeditionaryForces in France, the venereal-diseaaemorbidity in the disembarkation port ofSaint-Nazaire W88 sometimes 88 high astwenty per cent. Similar examplescould be given from. most of the armiesin the Great War. I vividly recall anumber of instances where highly skilledand valuable men under my commandfell ill, entailing serious 1088 to thecombat units.

To give a present-day example: Vonder­lehr of the US Public Health Service re­ports that among 1,070,000 volunteersand selectees recently examined therewere altogether 48,600 active cases ofsyphilis, with only 1.85 per cent amongwhites but the enormous proportion of24.12 per cent among Negroes. Thisshows that the sociological standard great-

. ly affects the incidence of venereal dis­eases among different population groups.

"SPOT1'Y lllA.LA.DIBS"

One of the curious riddles of medicineis the regional ocourrence of some dis­eases. Rabies (hydrophobia), for exam­ple, does not occur in Bomeo or on theisland of Bali. Kala-Azar, a protozoaninfection of dog and man causing fever,enlargement of the spleen, and progressiveemaciation, is widespread in British Indiaand North China. But, mysteriouslyenough, it has never gained a footholdsouth of the Yangtze River, althoughsoldiers and refugees have carried itwith them.

Elephantiastic enlargement of the legsis often observed in persons sufferingfrom parasitic worms in the blood (filaria­sis) in New Guinea, the South Sea Islands,and certain regions of Africa. Yet it isabsent for all practical purposes in ad­jacent tropical countries. where apparent­ly the same blood parasites abound andare transmitted by the same mosquitocarrier.

Human sleeping sickness (trypanoso­miasis) is endemic to Central Africa only.The malady called oroya fever or VaTUfIItJperuviana, important from the days whenPizarro conquered Peru up to the mostrecent warfare in the Chaco, is restrictedto deep, hot valleys in the northernAndes. Yellow fever, whose mosquitotransmitter, Steg&mya /lUCiala, is probablythe most common mosquito in all hotclimates, is strictly limited to a beltcomprising the tropical parts of Southand Central America-including the is­lands of the Caribbean-and the Atlanticborder of Africa. To the esoteric cognate,President Roosevelt's order of over ayear ago to inoculate the personnel of theUS Marine Corps against yellow feverwas of presageful significance.

COMPARATIVlllLY BARB TBOPIOALAILMENTS

In justice to the tropics we mustmention that some diseases are compara­tively rare in those parts. Among themis typhus (Typh'U8 exanthtmaticuB). Itacause is the Rickettsia prowauki, which istransmitted by body lice. But the 101186

feels ~ppiest at a temperature of be­tween 82 and 91 degrees Fahrenheit,which is that usually prevailing betweenthe skin and the clothes in a cool climate.The louse does not care for the highertemperatures of the tropics. Thisis one of the re880na why typhusmay show an increase in Shanghai andplaces with a similar climate when hotweather eets in: the louse feels uncom­fortably hot inside and seeks otherfeeding grounds.

Diseases due to streptococci are thedaily bread of any surgical dispensary incool northern Europe or America, but the

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ON lIEDICJNE AND WARll'ARE IN THE TROPICS

army surgeon of any outfit in the tropicswill probably be bothered far lees bythem. In fifteen years I saw fewer casesin Manila than I saw every month inGermany during my years as an interneand as a staff surgeon. The same appliesto scarlet fever.

PROBLEMS OF DISTANCE Aloo'"D SUPPLY

Because of the vast distances involvedin World War 0, vaster than in anyprevious war in history, the problem ofsatisfying the demands for all kinds ofvital supplies is a never-ending challengeto the quartermaster corps. The staminaof fighting men is tremendously impairedif they lack sleep and are not adequatelyIIbeltered. But, in order to survive, wateraudfood are more vital than arms, shelter,or clothing. Only those who havetnveled in Africa, the Middle East,Burma, and such places can realize themagnitude of this task.

Far from the principal manufacturingcenters of Europe and America, and partic­ularly in the tropics. essential medicaland dental supplies are as hard to re­plenish as other indispeD8&ble goods; andto repair medical apparatus properly isas difficult as repairing optical instru­ments, tanks, and guns. The require­ments of modem methods of diagnosisand treatment further complicate thecare of the sick or wounded soldier. Airtransport has, in some instances, helpedmaterially.

In th18 war it is essential to have largostocks of transfusion blood ready fortreating shock and severe hemorrhage.This blood ill mOM difficult to AtoM in t.hetropics than in a moderate climate. Noless than fifty per cent of the blood lostthrough injury should be replaced. Thegreat demand for it is shown by London'sfigure of about 165 pints of fluid for ahundred air-raid casualties. Satisfactorymanagement of wounds, burns, and frac­tures makes heavy demands upon med­ical and auxiliary personnel as well ason hospital space, so difficult to procurein primitive tropical areas. The sameapplies to radiology and elementarylaboratories.

WKlGBING BVlDDOBCOLLECTING DATA

War often wonderful opport ....'masa experiments. When the individuallife does DOt count, when money is of noimportance, and when large-scale testsbecome compulsory for the commongood, progreea advances by leaps andbounds in every field.

In the Great War, the greatest advancewas made by the technical sciences.Apart from diseases alone, in the sphereof Man and human relations chances ofunparalleled dimensions are afforded forthe study of human behavior underforced conditions, a study which wouldbe strongly opposed in civilian life by allconcerned, either because of sheer igna.rance or ill-conceived ideology.

As was the case with cholera and ty­phoid fever during World War I, it ishoped that the protective value of pre­ventive immunization against other dis­eases will be clarified.

Bacillary dysentery, even more thanthe amoebic form, is the great scourge ofthe hot countries. In the Philippines,prophylactic injections have been used byus for years with undoubtedly good re­sults. The incidence from bacillary dys­entery among the personnel of the US.Asiatic Fleet going up to Chefoo in the .summer was infinitely lower among thosemen who had previously been vaccinatedwith antidysenteric vaccine than in anonvaccillAted lluga r.ont.Nll group ofsailors and marines. This led to theAdoption for 89nClrtl.1 UIIO of Il mix9d vac­cine containing germs of cholera, typhoidfever, the paratyphoid fevers, and dysen­Wry cuWlJillOO. In Sha.ughai thia mixedvaccine has not yet been adopted.

The French in Indo-China have re­ported excellent results from the ora).administration of specially prepared anti­cholera vaccine. Since the giving of prep­arations by the mouth is a great dealeasier than by injection, the advantagein immunizing large numbers of peopleis obvious. Oral immunization againsttyphoid fever has so far been a failure. Iknow a good number of patients who

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166 THE XXtb CENTURY

contracted it in spite of previous oraladministrations, but I have hardly everseen a case where the disease was con­tracted after proper injections.

The fairly strict surveillance of largenumbers of men fighting in the tropics,and the possibility of a later check-up,&fiord further opportunities of studyingthe influence of malaria on syphilis.Beyond that, and generally speaking, theinfluence of any co-existing malady, andthe effeot of superinfection with anotherdi.sea.se, upon the primary one are of con­siderable practical importanoe. Thoughsurgery has always benefited most, warlikewise affords for other fields ofmedioine the most severe test on thelargest possible scale.

But let us state most emphatioally thatproper food and medioine are not enough.The maintenance of adequate healthamong troops in the extensive tropicalwarfare of today is possible only if asufficient number of intelligent soldiershas been educated in the principles ofhow to keep healthy. It is futile to givesimple instructions concenling the dangersof contaminated water and inadequate ortainted food, of mosquitoes and clandes­tine habits derogatory to well-being, ifthe morale of each soldier is not such asto keep unbroken vigilance. And cautionis a virtue that soon stales.

TOTEMS AND TABOOS

There are many superstitions among allpeoples and in all countries of the world.Troop contingents of difterent rMie8 andreligions are a headache, partioularly incertain tropical regions. To carry outthe law of the Koran entails observingvarious restrictions. Neither food oon­taining any flesh of swine nor any in­toxicant is allowed. During the periodof Ramadan, no taking of medicine be­tween dawn and sunset nor even theminute cutting of the skin for a drop ofblood for malaria examination is per­mitted. Another task is to provideenough water for ablution of hands,

mouth, and nose before eating and pray­ing. No orthodox Hindu will eat ordrink from containers touched by handsless exalted than of his own caste. The"untouchables" may not draw waterfrom the same well as other castes. Onlythe Brahman touch is pure for all.

Officers of the British Plague Com­mission were assaasinated not long agowhen helping to control the rat pestduring an outbreak of bubonic plague inIndia. They had dared to affront theHindu god Ganesha, whose earthly vehicleis the destructive rat. And the dogmatiorule against killing any animal whatsoeverin Hindu and Buddhist faith applies toall disease transmitters and poisonoussnakes alike. Since the cow is particular­ly sacred, my orthodox Sikhs would neverlet me inject them with liver extractsmade from the livers of cattle, so potentagainst the pernicious form of anemia.Many are the inhibitions man has placedupon man at times and in places.

CARE OF THE CIVILIAN POPULATION

Most cities in the tropics can scarcelymeet the problem of air-raid shelters.The care of refugees and bombing vic­tims becomes a crucial task. Famine,together with poverty and overcrowding,paves the way for disease. "Scorchedearth" policy adds to the misery. Yet aminimum standard of health must bemaintained among the general populationat home and in occupied territories sothat the health of the troops may not beendangered and in order that food andother supplies be produced and secured.

• • •Tariff barriers and passport quotas can

strangle commercial and social inter­course between nations, but they canrarely control epidemics. The people onboth sides of the fence should demand aspecial seat forPublio Health and Sociologyat the table of any future peace conference,and with some extra votes at that, lestthe painful lessons from the years follow- .ing the first World War a·re set at naught.