2361 
 
 5547 
 
A REPORT 
 
 OF AN INYESTIGATION INTO THE CAUSES OF THE 
 DISEASES KNOWN IN ASSAM AS 
 
 KiU-iZiE Am BERI-BEEI 
 
 BY 
 
 GEO. M. [GILES, m.b., f.r.c.s., san. sci. cert. univ. London, 
 
 J^L'KGFON, T AI.S., ON SPECIAL DUTY, AsSAM. 
 
 ^i r -.I .-r^K tit 
 
 SHILLONG: 
 PRINTED AT THE ASSAM SECRETARIAT PRESS. 
 
 1890. 
 
 Price One Kupee. 
 
A REPORT 
 
 OP AN INVESTIGATION INTO THE CAUSES OF TEE 
 DISEASES ENOWN IN ASSAM AS 
 
 KilA-iZAR Am BEEI-BEEI 
 
 BY 
 
 GEO. M.^; GILES, m.b., f.r.cs., san. sa. cert. univ. London, 
 Surgeon, I.M.S., on special duty, Assam. 
 
 SHILLONG: 
 PEJKTBD AT THE ASSAM SECBETABIAT PKESS. 
 
 1890. 
 
 Qj 
 

 EXPLANATION OF PLATES 
 
 ivi361851 
 
PlaJ 
 
 G.M.G.deTiat.dsl. 
 
 Lith: "by J C Chucl^rb 
 
PLATTE I.~Ova and other Bodies found in Dejecta. 
 
 Fig. 1. Unsegmented ovum of Dochmius duodenalis expressed 
 from a dead worm. 
 
 " o* I Segmented ova Dochmius duodenalis from dejecta of 
 " A \ f^ala azdr patients. 
 
 „ 5.^ 
 
 „ 6. f Subsequent stages of Dochmius ova met with in cultiva- 
 
 „ 7. j tions. 
 
 „ 8.) 
 
 „ 9. Ovum Trichocephalus dispar as met with in dejecta. 
 
 „ 10.^ 
 
 „ 11. f Various stages of segmentation of Trichocephalus ova 
 
 „ 1 2. J met with in cultivations. 
 
 » 13.) 
 
 „ 14. Ovum of Oxyuris vermicularis, as met with in dejecta. 
 
 „ 15. Ovum of Ascaris lurabricoides, as met with in dejecta. 
 
 „ 16. Line measuring j^(y^''' drawn to the same magnification as 
 the preceding figures. 
 
 17 1 
 
 " 18* \.C<^^<^^^i^ containing psorosperms from the dejecta of 
 
 " 19* ( ^a?a a^a?^ patients. 
 
 „ 20. A small specimen of the same simulating a Dochmius 
 ovum. 
 
 „ 21. Line of 5 yo*(7Tf'' t^i'awn to same scale as figures 17-20 
 inclusive. 
 
 „ 22. Immature Pediculus sp. often found in dejecta. 
 
 „ 23. Line jj^''' long, drawn to same scale as fig. 22, 
 
PLATE II.— Tlie Male Rhabditls of " Doclimius duodenalis " 
 in various Stages. 
 
 Fig; 1. Recently hatched embryo. 
 
 „ 2. Rhaditis five days old (in the pre-exual stage). 
 
 „ 3. Aboral extremity of a male rhabditis in earliest state of 
 sexual differentiation. 
 
 „ 4, Hinder half of a male rhabditis further advanced. 
 
 a. Rudiment of testis. 
 
 b. Copulatory spiculse. 
 
 c. Intestine. 
 
 d. Copulatory bursa. 
 
 „ 5. Mature male rhabditis, viewed laterally. 
 
 0. Mouth. 
 
 a. Anterior bulb. 
 
 6. Posterior ditto. 
 
 g. Central ganglion, 
 
 h. Hepatic cells, 
 
 i. Intestine. 
 
 L Lemniscus. 
 
 t Testis. 
 
 c. -Copulatory bursa. 
 
 8, Copulatory spiculae, 
 
 „ '6. Line representing j^J/ on same scale as preceding 
 figures. 
 
 „ 7. Aboral extremity of mature male rhabditis viewed 
 vertically. 
 
 „ 8. Line representing yjjvg'^ ^^ same scale as figure 7. 
 
 „ 9. Mouth parts of mature rhabditis, 
 
 g. Ganglion cells. 
 . p. Papillae. 
 
 „ 10, Line representing yooo" ^^ same scale as figure 9. 
 
Plate II. 
 
 'A G. de na.l. del. 
 
 Li"tjh"by J. C. Chuclcerhutty". 
 
G. M.G, deTiat-del. 
 
 LilKHvJ. C CKuc 
 
PLATE III— Stages of Female Rhabditis. 
 
 Fig. 1. Female rhabditis in earliest stage of sexual dififerentiation. 
 
 „ 2. Further advanced specimen, the ovary forming a promi- 
 nent organ, but still histologically indeterminate. 
 
 „ 3. Aboral extremity of advanced female rhabditis showing the 
 blunt extremity of the oviduct containing germs. 
 
 „ 4. Advanced female rhabditis almost at the end of the process 
 of depositing her eggs. One embryo has hatched out 
 within her body. 
 
 „ 5. Middle portion of the Fame more liighly magnified. 
 
 „ 6. Mouth of immature parasitic form from intestine of 
 monkey. 
 
 „ 7. Line representing jj^^" on same scale as figures 2, 3, 5. 
 
 „ 8. Line representing 5 j^^jj'^ on same scale as figures 1 and 4. 
 
PLATE IV.— Changes in the Gastro-intestinal Mucosa. 
 
 Fig. !.• Portion of a vertical section of upper part of Ilium from 
 a ease of anchylostomiasis, showing the space between 
 .» two villi filled up with blood clot, in which is imbedded 
 an immature Dochmius (the worm is cut twice by the 
 section, so that two sections are seen). At the highest 
 part of the recess filled with clot, may be seen a deep 
 erosion of the mucous membrane, x about 40 diams. 
 
 „ 3. Vert, section mucous membrane of stomach, thickened, 
 showing the mouths of the tubular glands blocked by a 
 fibrinous cicatricial layer, x about 200 diams. 
 
Plat.e IV. 
 
 Liih:"bY J. C. Chuclcerbulty. 
 
ABSTRACT OF THE REPORT, 
 
 Section I. — Introductory Kemarks, page 1; the word beri-heri has 
 been applied to several distinct diseases, ib.; its want of vernacular 
 signification in any language, ib.; the diseases described originally 
 by Malcolmson in Madras, and afterwards, by Pekelharing in Achin, 
 are alike epidemic peripheral, neuritis, and have no connection with 
 the beri-beri of Ceylon and Assam, which are alike anchylostomiasis, 
 pages 3-7; reference to Leichtenstern's discoveries in Dr. Kynsey*s 
 pamphlet on beri-beri of Ceylon pages 7-8. 
 
 Section II. — The General Course and Kesult of the Investiga- 
 tion, page 9 ; preparatory measures, ib. ; general appearance of kdla-azdr 
 cases, page 10; temperature in kdla-azdr, page 11; its most prominent 
 symptom is ansemia, ib.; points of distinction between the anaemia of 
 anchylostomiasis and that of malarial cachexia, page 12; discovery of 
 anchylotomes in a case oi kdla-azdr, page 13 ; hostility of the natives to 
 European medical treatment, pages 13-14; inefficiency of native methods 
 of cooking prevents recovery, pages 14-15; the disease as seen in infected 
 villages, page 15; evidence of the prevalence of anchylostomiasis in 
 kdla-azdr villages, page 16; tour in the tea districts, pages 16-17; 
 negative results of bacteriological investigations, page 1 8. 
 
 Section III. — The Prevalence of Kala-azar as judged by availa- 
 ble Statistics, page 19; data are scanty, -16. ; effect on general vital 
 statistics, pages 19-20; effect on revenue returns, page 21; table of 
 mortality in kdla-azdr villages, pages 22-25 ; table of villages with a 
 mortality exceeding 200 per thousand, pages 25-26; table of villages 
 with mortality from 150 to 200 per thousand, page 26. The distribu- 
 tion of kdla-azdr is that of a communicable disease, page 27. 
 
 Section IV. — Facts relating to the Spread of Kala-azar, page 28. 
 First appearance in 1869, medical relief operations 1884, ^6.; appear- 
 ance in Kamrup, ib.; rate of progress of disease, page 29; deductions 
 from the progress of the disease : incompatibility of the facts with 
 the theory of a malarial origin, -i^.; instances of Paru and Maligaon, 
 page 30 ; table of analyses of water from localities affected with kdla- 
 azdr and beri-beri, pages 32-37 ; kdla-azdr not necessarily a terai 
 disease, 38 ; Dr. Russell on the Chaygaon th^na, ib. ; Dr. P. M. Gupta 
 on communicability of kdla-azdr, page 39 ; further arguments as to 
 the non-malarial origin of kdla-azdr, pages 40-41 ; has never yet 
 affected Europeans, page 41. 
 
 Section V. — The Symptoms of Kala-azar as illustrated by Cases, 
 page 42 ; cases taken from Dr. Dobson's reports, pages 43-50 ; Dr. Dobson 
 on the prevalence of enlarged spleen in apparently healthy subjects, page 
 50; cases taken from Mr. Macnaught's reports, pages 50-55 ; cases taken 
 from Mr. Nandi's reports, pages 56-58 ; cases noted in Charitable Dispen- 
 sary, Gauhati, pages 59-62 ; Deputy Surgeon General Clarke on the pro- 
 minence of ansemia in the symptomology oi , kdla-azdr, page 62 ; Dr. 
 Borah on symptoms of kdla-azdr, ib.; Dr. P. M. Gupta on the symptoms 
 oi kdla-azdr, page 63; comments on the cases: the dependence of the 
 increased mortality on anchylostomiasis : the inadequacy of malaria to 
 account for the cases, pages 63-66. 
 
( ii ) 
 
 Section VL — The Life History- of the Parasite, page 67; early 
 changes in deposits, ib,; method of instituting cultivations, ib.; period 
 at which embryos hatch out, page 67 ; measurements of ova, ib,; points 
 of distinction between Dochmius, and other ova found in dejecta, 
 page 70 ; changes in ova previous to hatching out, ib.; the newly- 
 born embryo, page 71; encapsuling and calcification of embryos, as 
 recorded by Lutz, a fallacy, page 72 ; method of examination of culti- 
 vations, pages 72-73 ; the process of ecdysis, page 73; changes in embryos 
 while still of indeterminate sex, page 74 ; meaning of term rhabditis, 
 page 75 ; the development of the male rhabditis, pages 75-78 ; the 
 development of the female rhabditis, pages 79-80 ; reproduction of the 
 rhabditis, pages 80-81 ; experiments with monkeys, pages 81-85 ; 
 the question of encystment of the parasite, pages 85-87 ; duration of 
 life of the parasite, pages 87-88. 
 
 Section VII. — Effect of Various Conditions on the Life of the 
 Free Stage, page 89; effect of food-supply, ib-.; if limited, only a single 
 generation is produced, ib,; if fresh supplies are furnished, a large number 
 of generations may succeed each other, in the free state, page 90 ; experi- 
 ment illustrating these points, pages 90-91; infectiveness of soil may 
 continue indefinitely, page 92; effect of supply of oxygen, ib, ; therhab- 
 dites can only live on the surface, ib.; live but do not flourish in water, 
 i6. ; deprivation of oxygen kills, page 93; experiments illustrative of 
 this, ib.; influence of moisture, page 94; most favourable degree of, 
 ib,; can survive moderate dessication of some duration, but not chemical 
 drying, 'i6.; the dessicating influence of sun in dry weather is capable 
 of killing them, ib, ; the bearing of these facts on disinfection and on 
 the distribution of the disease, influence of heat, page 95; temperatures 
 exceeding 140°F. kill the rhabdites and ova : influence of chemical agents, 
 page 96 ; influence of light, ib. 
 
 Section VIII. — The Method of Infection by the Parasite, page 97 ; 
 auto-infection by ova impossible, ib.; infection probably only by rhab- 
 ditis' progeny, ib,; drinking water an improbable vehicle of infection, 
 pages 97-98 ; infected earth introduced into food is probably the usual 
 vehicle, pages 99-102 ; frequent re-infections are probably the rule, page 
 102 ; danger of infection through the agency of milk, page 103. 
 
 Section IX. — Remarks on the Pathology, Diagnosis, and Treat- 
 ment, &c., OF Anchylostomiasis, page 104 ; importance of early diagnosis 
 and treatment, ib.; lesions in the stomach, page 105; the importance of 
 dyspepsia in the production of the fatal train of symptoms, page 106; 
 Cobbold on predisposition in helminthiasis, page 107 ; Kynsey on the 
 symptoms of anchylostomiasis, ib.; the diagnosis of anchylostomiasis by 
 " microscopic me^thods, pages 108-109 ; Coccidia in dejecta of Ma-a^ar 
 patients, pages 109-111; method of searching for expelled parasites, 
 pages 111-112; the importance ef systematic medical inspections of 
 coolies, pages 112-113; earth-eating, pages 113-115; remarks on treat- 
 ment, pages 115-120 ; complications of anchylostomiasis, other parasites, 
 page 121; Trichocephalus dispar, ib,; Ascaris lumbricoides, -page 123; 
 Oxyuris vermicularis, page 124; Amphistoma hominis, ib,; Distoma 
 crassum, page 125; cestode parasites, ib,; pedeculi, page 126; intestinal 
 coccidia, page 127 ; malarial complication, ib,; mode of death in anchy- 
 lostomiasis, ib. 
 
( iii ) 
 
 Section X. — ^Preventive and Remedial Measures, page 129; the 
 obvious necessity of measures of conservancy and the futility of other 
 sanitary measures in anchylostomiasis, ib.; trench latrines, page 130; 
 dry earth latrines, pages 131-133; the disinfection of infected sites, 
 pages 133-135; purification of drinking-water, pages 135-136; futility 
 of medicinal, remedial, measures, page 136; abstract of recommenda- 
 tions, pages 137-138. 
 
 Section XL — Anchylostomiasis in Tea-gardees, page 139; in 
 gardens long on the black list, the cause is generally anchylostomiasis, 
 ib.; absence of exact statistics as to the prevalence of the disease, page 
 139; total mortality of gardens, page 140; steady rise in number of 
 black-listed gardens, page 141; table illustrating this, page 142; wide 
 diffusion of the disease among garden hands still at work, page 143; 
 instance of Chunsali tea-garden, pages 143-145; the general sanitary 
 condition of coolies on tea-gardens, (a) housing, pages 145-149, (6) 
 clothing, page 149, (c) food, pages 149-152; " the hotel system," page 
 150, {d) water-supply, page 152, (e) conservancy, pages 153-156, 
 
REPORT ON KALA AZAR AND BERI BERI. 
 
 I. — Introductory Eemarks. 
 
 For reasons that will appear in the sequel, it will be in 
 no way necessary to enter into any separate description of 
 the maladies indicated by the above popular terms, as the 
 main result of the investigation has been to establish their 
 identity. 
 
 Tt is unfortunate that the word "beri-beii" should have 
 acclimatized itself as firmly as it appears to have done 
 in Assam. I refer of course to its use among Europeans, 
 because the word is unknotvn to the other inhabitants of the 
 province, whether Assamese, or imported Indians. The 
 fact is that " beri-beri" the " kakke " of Japan, " hald-azar" and 
 another word, equally evil-sounding to English ears, in 
 popular use in South America, but which I am unable at 
 present to recall, all may refer to the same disease ; while 
 each has the added disadvantage of being popularly apphed 
 to any disease that may bear a rough resemblance to what- 
 ever malady may be the commonest cause of epidemic 
 mortality in the particular region affected. 
 
 The confusion has been greatly enhanced by the efforts 
 of scientific men, who were conversant with a disease in 
 some one country, to identify the malady they had themselves 
 observed with diseases of other countries, of which they 
 had no personal experience. The word " beri-beri" however, 
 seems to have the widest acceptance, at least among 
 Europeans, but it is a curious fact that it has not even the 
 defence of being in popular use in the vernacular of any part 
 of the world. 
 
 On this point Dr. John Grant Malcolmson,* who wrote 
 
 a prize essay on " ben-beri," as observed in Madras, more 
 
 than fifty years ago, remarks — 
 
 ** As to the appellatiou *' Ben-beri'' it appears to me perfectly unac- 
 countable bow it could ever have crept into such general use as it has, for 
 
 *■ A Practical Essay on the History and Treatment of ** be>i-heri, '* by 
 Assistant- Surgeon John Grnnt Malcolmson, Madras Medical Establish- 
 ment. Vepery Mission Press, Madras, 1835. 
 
 B 
 
( 2 ) 
 
 it is perfectly unintelligible to the natives from wliom it is said to have 
 originated. Though the word **B'hay-ree" does really mean a sheep 
 in the Hindustani dialect, and by repeating it (making allowances for 
 the orthographical error in persons unacquainted with the language, and 
 consequently of the proper sound of the word), we may form such a name 
 as beri-heri ; yet, after the most particular enquiries on the subject, 
 I find the natives are totally ignorant of any disease under that title." 
 
 A disease, endemic in Ceylon, of somewhat similar 
 character, came to be called by European medical men by 
 the same name, from the supposed identity of the two 
 maladies, though, it need hardly be remarked, the word 
 has no more vernacular signification in Cingalese than in any 
 other dialect. This endemic, we now know from Dr. Kynsey's 
 pamphlet,* is estabUshed without doubt to be anchylostomiasis, 
 though it is quite possible that cases belonging to another 
 category may be found in that island in addition. We hear 
 much too of the ravages of " heri-heri " in the Dutch Indies, 
 but perhaps here with more justice, if we confine tlie term 
 to the disease as originally described in Madras. It will 
 be desirable to refer more fuUy to this point further on, but 
 no one can, I think, compare the descriptions given by 
 Malcolmsonf and Pekelharing,J without being convinced 
 that they are describing the same disease ; and that this 
 disease is not anchylostomiasis, but an entirely distinct malady. 
 At the same time I think it more than probable that in both 
 instances a certain percentage of cases of anchylostomiasis 
 are to be found. 
 
 I know, from personal observation on coolies freshly 
 imported thence, that anchylostomiasis does exist, at the 
 present day, in the northern part at least of the Madras 
 Presidency, and it is hardly likely that the disease is at all 
 a recent introduction. Indeed, some few of Malcolmson's 
 cases appear best referable to that cause. On the other hand, 
 Professor Pekelharing actually found anchylostomes in a few 
 cases in Achin. In climates so favourable to the development 
 of the parasite as those of the Madras Presidency and Achin, 
 the spread of the parasite wiU be merely a question of the habits 
 of the natives, and while I doubt if such habits could anywhere 
 
 * " Eeport on Anaemia, or Beri-beri of Ceylon," by W. E. Kynsey. 
 Government Press, Colombo, 1877. 
 
 f Op cit. 
 
 I " Kecherchea sur la nature et la cause du beri-beri et sur les moyens 
 de le combattre," par L. A. Pekelharing et C. Winkler, Utrecht, Kremnik 
 et fils, 1888. 
 
( 3 ) 
 
 afford more favourable opportunities for its propagation tlian 
 in Assam, we well know that the sanitation of semi-civilized 
 communities is everywhere so backward that, given the 
 presence of the parasite among such communities, it can 
 hardly fail to find a considerable number of hosts. 
 
 Again, it seems possible that at any rate some of the cases 
 included under the name of " kakke " in Japan may be exam- 
 ples of anchylostomiasis. 
 
 In "Yirchow's Archiv.," Vol. XXL, page 290, for 1877, 
 Wernick wrote a paper on the Japanese variety of heri-heri, 
 which, as I gather from Pekelharing, was devoted to proving 
 beri-heri to be a pernicious anaemia. Pekelharing devotes 
 several pages to demolishing this view, pointing out that anae- 
 mia is by no means a necessary, or even common, symptom of 
 beri-beri (as he had seen it), never apparently suspecting that 
 he and Wernick may have been observing two entirely 
 distinct diseases, and that their differences might be accounted 
 for by the dissimilarity of what they had to observe rather 
 than to errors of observation on either side. Now, pernicious 
 anaemia is, clinically, by far the most salient symptom of 
 anchylostomiasis. 
 
 That the disease described by Malcolmson in Madras is 
 identical with that observed by Pekelharing in Achin is a 
 matter wflich hardly admits of doubt. Nothing can show 
 this better than to place side by side the cases and symptoms 
 recorded by the two authors. First, let us compare their 
 accounts of the symptoms in general. Malcolmson says — 
 
 " The disease presents such a variety of symx^toms that it will be 
 more instructive to consider them in detail than to attempt any elaborate 
 general description. It will be sufficient to describe the most remarkable 
 characters. 
 
 " It usually commences gradually with a feeling of numbness, sense 
 of weight, and slight weakness and stiffness below the middle of the thighs, 
 sometimes preceded by muscular pains. There is slight oedema of the 
 feet and legs, especially along the tibiaB, often found to come on after the 
 other symptoms. The walk is unsteady and tottering, even when the 
 patient is not aware of weakness in the limbs, which are occasionally 
 tremulous ; spasms occur in the calves and soles of the feet, sometimes 
 becoming general and occasionally shooting to the chest and larynx, 
 obstrncting respiration and speech. The want of power often rapidly 
 increases to almost total palsy, especially of the extensor muscles, and in 
 a few cases, the patient, after slight indisposition, suddenly loses the use 
 of his legs. Eigidity and various painful affections of the nerves accompany 
 the paralytic symptoms, and there is sometimes pain along the spine, 
 commonly at the two last lumbar vertebrae. In some cases the disease 
 goes no further, and a cure is effected ; but more frequentlv, the numbness 
 
 B 2 
 
( 4 ) 
 
 extends upwards towards tlie abdomen, there is a general sense of lassitude 
 and aversion to motion, and the hands, arms, and chest (and in a few 
 cases even the neck and lips) are gradually benumbed. There is oppres- 
 sion and weight at prsecordia, dyspnoea on slight exertion, diffused and 
 irregular pulsation in the cardiac region, and the face and hands are puffy 
 and cedematous. The patient is often found dead in bed, or sinks after 
 several fainting fits or throbbings at the heart ; or the csdema rapidly 
 increases and extends up the trunk, violent dyspnoea and inability to lie 
 down in bed comes on, with anxiety, cold sweats, cold extremities, 
 rapid feeble pulse, urgent thirst, and partial suppression of urine. 
 At the commencement the urine is always scanty, of a deep red colour, 
 without cloud or sediment, and possessing very peculiar properties ; in 
 some old cases it becomes copious, turbid, and pale, with a large white 
 deposit, and is passed with pain from an irritable bladder. The stomach 
 is irritable in many bad cases, and pain and tenderness in the epigas- 
 trium is sometimes complained of; there is, in a few, pain in the abdomen, 
 or a sense of lieat is diffused over it and the chest. Effusion takes place 
 into the chest, and more rarely into the abdomen, and there are now and 
 then some signs of inflammation of the pleura or bronchi. In the early 
 stage the pulse may be full, hard, and frequent or little altered ; when the 
 face is puffy and there is weight and oppression at the praecordia, it is quick, 
 often irregular, and usually small, although it is occasionally strong. 
 
 "Various dyspeptic symptoms occur ; the bowels are often costive, the 
 stools green and variously disordered, and the eyes are often tinged yellow. 
 The skin is rather cold, unless there is pyrexia, which is often present in 
 the evening. The disease is sometimes fatal in a few hours, but is often 
 chronic, and in these the patient is liable to sudden death, to rapid aggra- 
 vation of the symptoms, or supervention of new and more formidable ones, 
 by which he is soon carried off; and if he survives these, he may live for « 
 long time bedridden, dropsical, and a true paralytic." ^ 
 
 Pekelharing gives the generally described earlier symp- 
 toms as follows : — 
 
 *' At first a slight oedema along the crest of the tibia, the face puffy 
 and doughy, diminished motor power in walking or going up stairs, &c., 
 paraesthetic and anaesthetic symptoms affecting the lower extremities ; 
 palpitation of the heart ; a pulse somewhat accelerated, or perhaps normal 
 during repose, but which rises to 90—100 on the least exertion ♦ * ♦ 
 * * * Beri-ben always comm ces gradually aud without fever, but in 
 a later stage there may occur a sujuen exacerbation of the malady, accom- 
 panied with fever ***** * ^^^ acute exacerbation may 
 bring about a sudden termirjation of the case, from the nerves of the 
 heart becoming involved, or become the cause of dropsical complications. 
 Brri-beri does not always commence with cramps, but, during a certain 
 stage, an acute exacerbation affecting a large number of motor nerves 
 may be accompanied with the phenomena of irritability of the muscles. At 
 first parasthesia :'s not a prominent symptom; but an acute exacerbation 
 maybe accomppnied^by neuralgic pains, and cause the terrible sufferiug 
 known as ana-tiitsia dolorosa." 
 
 Both authors, too, remark on the circumstance that 
 residence within an endemic area of some duration is necessary 
 before the disease can definitely manifest itself, and are equally 
 
( 5 ) 
 
 agreed as to its depending primarily on nervous lesions. The 
 comparatively rude methods of clinical and patliological 
 investigation available fifty years ago naturally prevented 
 Malcolmsdn's recognizing the peripheral origin of these lesions, 
 but he describes clearly enough, from advanced cases, lesions 
 of the spinal cord and larger nerves, which we know now to 
 be of a secondary character, and entirely similar to the 
 advanced lesions described by Pekelharing. Compare, too, 
 the following two cases, extracted, almost at random, one 
 from each author. 
 
 The case I extract from Malcolmson is reported as 
 follows: — 
 
 " James Hicks, Iiido-Briton, April 24th, for sometime ill of beri-heri; 
 limbs cold, moist, and nninb ; oedema of back and logs, partial loss 
 of power of lower extremities ; tendons in bams sbnietiraes contracted, 
 and legs are extended with difficulty ; spasms of calves ; urine pale, depositing 
 earthy phosphates. 26th.— Heat of feet nearly restored ; numbnessmuch the 
 same. 27th— Feet mostly warm, when they sweat they get cold. May 4th — 
 Less numbness, and cannot bear the heat of sand in which he lias been 
 w^alking at noon for some days ; coldness of toes and heels only, cold sweat 
 of forehead. 19th— Legs to-day cold and covered with sweats. Vespere. 
 Skin very hot all day. Pulse 100. Thermometer in axilla and palms 
 of hands 101°; between^olcs of feet, which, like the rest ot the benumbed 
 parts, donot,feel hot, 77°, and nbove the knees a little higher. Temperature 
 of- the air 89°. Barometer 30'. 20th. — Fever left with sweating. Temperature 
 of axilla and hands 98"', feet 91°, and says they are not so coid as before. 
 Temperature of the atmostphere 86°, Barometer 29' 58*. Hardness of the 
 flesh over the lower part of calves, and a cold sweating covers the part. 
 Internal feeling of heat in right leg. Says the 'veins are now getting a 
 colour from the blood, and that before the}*^ were empty.' After this, 
 while the temperature of the air varied from 8'.)° to 93^ (Barometer 29' 
 48*), the feet were of the same temperature as the air, and the hands 97,^ but 
 when that of the air fell to 83° and it was loaded with sensible moisture, 
 the feet v»^ere at 87° and the hands at 94°. The numbness was not* 
 complete, and slight oedema extended apparently into the interstices of 
 the muscles. In the progress of the case, burning sensations in the feet and 
 calves of legs came on, but the surgeon into whose care he pass-d did not 
 ascertain the temperature. The arterial action did not seem to have been 
 weakened in the cold uaits, but the colour of the blood in the veins, as far 
 as could be judged from that of the vessels, was not of the usual dark 
 hue." 
 
 The case extracted from Pekelharing is that reported on 
 page 23 of his paper : — 
 
 "• Mang, aged apparently about 21, born at Batavia, has served for four 
 months as a sailor on board the HydroiiriKif, off the island of Onrust. 
 There were several cases of heri-berl on board. He had never been ill 
 before. According to his own account, which there is no reason to doubt, 
 he became ill on 4th December 1887. In a few days his legs became 
 
( 6 ) 
 
 swollen ; next, he experienced an unbearable tingling, but what occasioned 
 him the greatest suffering was acute pain in the calves. He described this 
 pain as being in the bones. In the meantime movement, and especially 
 •walking, had become difficult. On the 13th December he was admitted 
 to hospital at Batavia. The swelling of the legs diminished rapidly, the 
 paresthetic symptoms lasted a few days longer ; the pain disappeared as 
 long as he remained quiet, but re-appeared if he attempted to walk. He 
 was not quite paralysed, and never had been, but his walk was tottering. 
 
 " The patient stated that he had never had any fever, nor had he had 
 any difficulty in obeying the calls of nature ; he ate, drank, and slept well. 
 
 " Condition on 31st December. — The patient is strongly built and mus- 
 cular, and does not look as if suffering. There is no apparent anasmia or 
 blueness of the mucous membranes. He enters with interest into what 
 is going on around him, and describes his condition from the commence- 
 ment of his illness with considerable vivacity. Pulse 94, rising to 116 
 after very little exertion, moderately tense ; neither sharp nor dichrotic. 
 Respiration 26, of abdominal type. The heart's impulse is strong, and can 
 be made out as far as the 5th intercostal space in the nipple line. The 
 heart's dullness extends beyond the left border of the sternum, but does 
 not reach the middle line. The sounds of the heart are sonorous, and 
 pure, with reduplication of the second sound and intensification of the 
 pulmonary disastolic sound. 
 
 ''No' other abnormalities could be discovered in either the thoracic 
 or abdominal organs. His face is doughy and somewhat puffy, but 
 does not pit on pressure. Along the crest of the tibia the skin 
 pits distinctly, but the ankle is not oedematous. The pupils act promptly, 
 and evenly, both to direct light and for convergence^ The higher senses are 
 unaffected. He sees well, hears the tick of a watch at a long distance, and 
 distinguishes at once between salt and sugar. Organs of motion. — The 
 muscles are well developed, hard to the touch. Some of them, for example, 
 those of the calf, are very tender on pressure, and seem to have become more 
 resistant ; when they contract, one meets with circumscribed swellings ; 
 mechanically, they were not irritable to the stroke of the percussion hammer. 
 They present no ideomuscular contraction. 
 
 ** Most movements, whether active or passive, can be performed. 
 However, when the patient is on his back, he cannot flex the ankle, and 
 plantar flexion can be easily prevented. 
 
 " If the patient rises, considerable locomotor disturbance is observable. 
 He lifts his foot with difficulty from the ground, raises it high ; he cannot 
 stand upon one leg, nor raise himself on his toes. If he try to crouch, 
 he does so clumsily, and is in danger of falling. When lying on his back 
 he can bend and extend the trunk, and perform all movements of the upper 
 extremities, as well as those of the eyes, face, and tongue. When 
 standing with closed eyes, he totters, but no distinct disturbance 
 of muscular coordination can be made out. • Lying with the eyes closed, 
 he can place the toes of one foot on the other knee slowly, but without 
 blundering." 
 
 Allowing for the different ways of describing similar facts 
 incidental to the advance in the methods of medical inves- 
 tigation that has taken place during the interval of more than 
 fi^ty years which has elapsed between the dates at which the 
 two descriptions were written, I do not think that any one can 
 
( 7 ) 
 
 doubt, after reading tlie above extracts, that botli authors are 
 describmg the same disease. 
 
 Now, this epidemic affection of the nervous system presents 
 not the least similarity with anything met with in Assam. 
 Compare these accounts with the symptoms of anchylostomiasis 
 as given in Dr. Kynsey's pamphlet (page 5, paragraph 26), 
 which, being readily accessible to all interested in the diseases 
 o? Assam, I will not occupy unnecessary space by extracting. 
 In the one disease the prominent character is paresis, and 
 anemia is an after and unessential complication ; in the other, 
 the leading symptom is angemia, and no true paralysis ever 
 occurs. , 
 
 Seeing then the confusion that has been caused by the 
 use of the word, and the fact that it has nowhere any ver- 
 nacular signification for the patient affected, but is used only 
 by Europeans, it would, I think, be in every way preferable 
 to entirely drop the use of the word and to adopt some 
 such words as anchylostomiasis or parasitic anasmia for the 
 heri-heri of Ceylon and Assam, and specific peripheral neuri- 
 tis, or endemic palsy for the disease described by Malcolmson 
 and Pekelharing in Madras and Achin respectively. 
 
 Before closing these introductory remarks, I would wish 
 to point out that, situated as I am at the*^ time of writing, far 
 from all medical libraries, it is quite impossible for me to do 
 justice to those who have worked at the question before me, or 
 to attempt to give any bibliographical references whatever. 
 
 I have not even been able to gain access to Leich- 
 tenstern's paper, briefly referred to in Dr. Kynsey's compila- 
 tion, though it is possible that he may have followed the 
 rhahdites already described by many previous observers to the 
 adult condition, in which case much of my work may have 
 been forestalled by him. However, not having seen the paper, 
 it was necessary to work out the whole question anew, and 
 I am necessarily ignorant of how far his results go, or to what 
 extent they coincide with my own. There must, however, be 
 some mistake in either the original paper or its translation. 
 .The paragraph to which I refer is to be found near the bottom 
 of page 52 of Dr. Kynsey's pamphlet, and is worded as 
 follows : — 
 
 '* The work of Leichtenstern announces the discovery of a rhabditic 
 form, the segments of which have an independent life when separated, and 
 are able to propagate the species." ^ 
 
( 8 ) 
 
 Now, to speak of the " segments " of a nematode worm, 
 which is not a segmented animal in either the biological or the 
 popular sense of the word, is a zoological absurdity, as egre^ 
 gious as would be the description of a vertebrated molusc o^ 
 an eight-legged insect. The description would apply well 
 enough to a tapeworm, although it would hardly be, strictly 
 speaking, correct to speak of the proglottides of a cestode a^ 
 " segments," a term which, in biology, is properly restricted t^ 
 the externally visible somites of arthropods, but, taken as it 
 stands, the statement is utterly unintelligible. If we substitute 
 the word " individuals " for " segments," and strike out me 
 words " when se})arated " altogether, it becomes not oily 
 intelligible, but in accomance with the facts of the case ^s 
 I have observed them ; but it is difficult to understaild 
 how even the most careless translator could make such a 
 combination of mistakes, unless, indeed, he mistranslatecf the 
 word corresponding to " segments " and, on his own authority, 
 inserted the words " when separated " in order to explain it. 
 
 On this account I have been much disappointed th^t, up 
 to date, my correspondent in England has not forwardfed me 
 the original paper. It is, of course, possible that the note in 
 question ma}'- be a translation of an abstract originally made 
 by an unskilled hand, or may even have paissed tlirough 
 several hands before assuming its present form, but, in the 
 absence of the original, it is difficult to say where the very 
 obvious errors took their origin. 
 
 Before coming to Assam, I took the opportunity of search- 
 ing for references to beri-beri and anchylostoiniasis in a file 
 of the Medical Eecord, but came across very few. Those that 
 I found referred exclusively to ca-es of beri-beri, which come 
 under the heading of endemic peripheral neuritis. My file did 
 not, however, extend back for more than a few years. 
 
( 9 ) 
 II. — The General Course and Eesults of the Investigation. 
 
 Leaving the Central Provinces on tlie 1st November 1889, 
 Calcutta was readied on the 4th. Though well provided with 
 microscopes and microscopical accessories, I possessed no 
 bacteriological plant, apparatus of this kind being too bulky 
 to form part of the kit of a medical officer engaged in his 
 usual routine work. 
 
 In view of the fact that the cause of kdla-azdr was quite 
 unknown while the researches of Pekelharing and others 
 indicated a bacterial origin for heri-beri, it was clearly- 
 necessary to be provided with sufficient bacteriological 
 apparatus to start laboratory work of that kind. I accord- 
 ingly obtained permission from Deputy-Surgeon-General C. 
 P. Costello, F.R.C.S., Sanitary Commissioner of Assam, to halt 
 a sufficient time in Calcutta to procure what might be neces- 
 sary. Apparatus of this kind is of course not kept in the 
 very limited stocks of the purveyors of scientific appliances 
 in any Indi'an town, so that it was necessary to get- many of 
 the requirements made, and some other articles, through the 
 kindness* of the Superintendent, Dr. Wood-Mason, were pur- 
 chased from the Laboratory of the Indian Museum. I also chose 
 at the -Telegraph Maintenance Company's establishment a medi- 
 cal battery, in case I should afterwards require one. The 
 disease observed by Pekelharing in Achin depends essentially 
 upon nerve lesions, and for its investigation electrical appara- 
 tus is absolutely necessary ; but, from what I had already read, 
 it appeared tolerably certain that the disease described by 
 him was quite distinct from that known by the same name 
 in Ceylon and Assam, so that in all probability it 
 would be unnecessary to spend Government money in 
 the purchase of one. As, however, in no instance have 
 cases been met with exhibiting symptoms pointing in 
 any way to nervous lesions, it has never been necessary 
 to buy the apparatus chosen. While such of the articles 
 were being made as required personal supervision, I 
 employed myself in preparing a stock of tubes of culti- 
 vating media, which I was enabled- to do much more 
 quickly and easily in Calcutta than could have been done 
 elsewhere, bccaiffee there, by the courteous permission of Dr. 
 Warden, the Chemical Examiner to Government, the resources 
 of the well-equipped laboratory of the Medical College were 
 entirely at my disposal. 
 
( 10 ) 
 
 Owing to tlie unavoidable delay so caused, it was not 
 until late in November tliat I reached Gaulidti, which had been 
 indicated as the best point from whence to commence 
 operations. Here I found a most zealous and obliging 
 coadjutor in the person of Dr. Mullane, the Civil Surgeon, 
 who not only set aside for my use a room in the dispensary, 
 but found accommodation in. his house for myself and labora- 
 tory, but for which, owing to the entire absence of other 
 suitable accommodation, it would have been very difficult to 
 proceed with the work at all. There were five or six in- 
 patients in the dispensary suffering from kdla-azdr, as well as 
 a daily casual attendance of out-patients suffering from the 
 disease, and the first step was clearly to make a careful exami- 
 nation of the cases at my disposal. 
 
 The greater number certainly presented more or less 
 prominent symptoms of malarial poisoning, but it was 
 equally apparent that, in by far the larger proportion, the 
 malarial symptoms were quite inadequate to account for 
 the gravity of the mischief. On casually enquiring the history 
 of a case, the patient would generally say that it had commenced 
 with " fever," and he had it off and on for months. On a more 
 and more close interrogation, however, so as to distinguish true 
 ague from other maladies, it generally came out that there had 
 been comparatively little true fever, and that what the patient 
 really meant was merely that he had been feeling ill for a long 
 time. There is of course nothing new in this, because every- 
 where in India, nearly all disease is ascribed by natives to 
 " fever," and it is only by the most patient enquiries as to the 
 exact symptoms actually experienced that one can get any other 
 history for nine diseases out of ten. 
 
 Then, again, most of the cases had more or less enlargement 
 of the spleen, many of them exhibiting a regular " ague cake ;" 
 but when we remember how rare it is in post mortem exami- 
 nations to find any Indian with a spleen of the normal weight, 
 it will readily be seen that too much importance should not 
 be attached to the presence of a symptom which is well nigh 
 universal, and is by no means incompatible with fair general 
 health. A much enlarged spleen may of course do damage 
 by its pressure on the other abdominal organs, but otherwise 
 it is important only as a sign of malarial poisoning. It is 
 that poisoning, and not the splenic enlargement caused by 
 it, that is the cause of malarial cachexia, for we know that the 
 spleen can be entirely removed without, to all appearance. 
 
. ( 11 ) 
 
 affecting the general health. Hence it is a mistake to attach 
 any great importance to an enlarged spleen, unless its pre- 
 sence be accompanied by other symptoms of malaria. It is 
 a matter of common experience to find men doing their full 
 day's work, and quite healthy to casual examination, and yet 
 having a spleen so large that it may extend down to the iliac 
 bone and across the middle line. Such subjects are in con- 
 stant danger of death from rupture of the organ, caused by 
 comparatively slight injuries, but otherwise do not appear 
 much worse off than their fellows. Indeed, spleens as large as 
 this nuiy be found liidden under tlie folds of fat covering sturdy 
 Banniahs, whom no one would considej- cachectic. 
 
 Now, the cases in the dispensary, though in a terrible state 
 of cachexia, gave no other evidence of malarial poisoning 
 than a very variable amount of splenic enlargement. The 
 temperature charts, far from forming the well-known malarial 
 trace, exhibited, as their most marked character, a subnormal 
 temperature, indicative of a profound depression of the vital 
 forces. At first I could not, and would not, believe the ther- 
 mometric observations to be correct, but repeated and care- 
 ful observations with several thermometers which were tested 
 by comparison with thoroughly reliable instruments of non- 
 clinical make, showed that this low temperature was an actual 
 fact in all advanced cases. 
 
 I have observed the temperature as low as 94°F., and this 
 in cases by no means absolutely dying. A temperature of 
 95° rising to 96° in the afternoon was often persistent for 
 several days together ; such low temperatures are almost un- 
 known except in tlie case of profound traumatic shock or in 
 articulo mortis^ and are certainly unknown to persist for any 
 length of time in any other disease than anchylostomiasis. 
 This and the profound anaemia were the most marked clinical 
 characteristics of the disease with which I had to deal. 
 
 Putting aside cases of ordinary sickness of all sorts, 
 which were freely brought me as kdla-azdr, this ansemia was 
 the one constant symptom. As has been repeatedly noted 
 by previous observers of kdla-azdr, it is the earliest symptom 
 to appear, and its intensity advances pari passu with the 
 disease. Its characteristics easily distinguish it from the 
 anaemia that accompanies malarial cachexia. In the latter, " 
 anaemia is a late and secondary symptom, whereas here it 
 
( 12 ) 
 
 appears from the first, and nearly all of the other symp- 
 toms are merely its results. Then, again, in the anasmia 
 of malarial cachexia, specially when accompanied by 
 enlarged spleen and consequent venous and portal obstruction, 
 the conjunctiva, though deficient in blood, is nearly always of 
 a dirty yellow tint, often accompanieil by distinct icterus. 
 The absolute dead white, rather blueish than yellow, coloration, 
 met with in the larger proportion of kdla-azdr cases is never 
 met with in uncomplicated malaria. There is something 
 peculiarly pathognomonic about this appearance of the con- 
 junctivas which, once thoroughly appreciated, is not easily 
 forgotten. 
 
 At this time, however, I had no idea as to what might 
 be- the cause of the symptoms observed, and, while await- 
 ing an opportunity of making a post-mortem examination, 
 proceeded to make a series of cultivation experiments by 
 inoculating a considerable series of tubes of nutrient jelly 
 with blood from several patients. With the exception of a 
 few tubes, which developed accidental colonies of well-known 
 mildews, &c., such as will occur in any such series of 
 observations, these experiments gave entirely negative results. 
 These observations, and the fact that none of the cases 
 showed the least sign of paralysis, or disturbance of sensory 
 power, clearly showed that, whatever it might be, kdla-azdr 
 had no connection with the endemic palsy described by 
 Pekelharing under the name of heri-heri. I may here 
 mention that neither in kdla-azdr nor in the heri beri of 
 coolies have I met with any truly paralytic symptoms 
 or any trace whatever of nerve lesions. Hebetude and an 
 excessive weakness which may simulate paralysis, are of 
 course the common characteristic of the last stages of these 
 maladies, as they are in other similar states of low vitahty, but 
 it would be as erroneous to speak of this state as . paralytic 
 as to so characterize the weakness of a man tired out by 
 severe exertion, for it depends, not upon any lesions of the 
 nervous system, whether central or peripheric, but upon 
 want of nourishment for brain and muscle. 
 
 After about ten days, the death of one qf the in-patients 
 enabled me to make an autopsy. The examination showed 
 that the immediate cause of death was an exacerbation of a 
 state of chronic dysentery from which she had suffered during 
 the whole of the time she had been under observation. The 
 other changes were oedema and ascites, excessive anaemia of 
 
( 13 ) , 
 
 all tissues, and an obviously thin and watery condition of the 
 blood. In the duodenum and upper part of the jejunum 
 were a number of anchylos tomes. In this case, then, the pri- 
 mary cause of death was plainly enough anchylostomlasis, 
 and this led me to examine the dejecta of my other patients, 
 and in every instance enormous numbers of the ova of the 
 parasite were found. A rough estimation was made of the 
 numbers passed in a few cases by diluting a known Aveight 
 of fasces, and counting the number of ova in a small weighed 
 portion of the diluted material, with the result of showing 
 that the number passed daily must often exceed a milHon. 
 Other post-mortem examinations followed, and proved 
 incontestibly that, whatever kdla-azdr might b6 elsewhere, the 
 disease so called in Gauhdti was undoubtedly anchylosto- 
 mlasis . Such being the case, my next step was to gain 
 some preliminary familiarity with the appearances of the free 
 embryonic forms of the parasite, and, while stiU observing 
 such . cases as presented themselves at the dispensary, 
 sufficient sets of preliminary cultivations were instituted to 
 ensure the ready recognition of the embryoes wherever they 
 might then be encountered. It may be well here to anticipate 
 an objection which might well be raised, namely, that embryonic 
 nematodes of different species resemble each other so closely 
 that one might readily confound rhabditic anchylostomes 
 with anguUlulce and other nematodes found commonly enough 
 in the soil. The characters, however, of the bursa of the male 
 rhabdites are quite sufficient to distinguish our species from 
 any other nematodes likely to be met with in such situations. 
 Having made these preparations, I went into camp, proceecling 
 first to the Chaygaon district, which had been pointed out as 
 the most favourable base of operations. I visited a large 
 number of kdla-azdr villages, but was much disappointed 
 in the opportunities they offered for* clinical observation. 
 I saw, of course, crowds of cases, but the people could not be 
 persuaded to come to the dispensary for either treatment or 
 observation. There is a branch dispensary at Chaygaon, and 
 there must be hundreds of cases of kdla-azdr within a radius 
 of a couple of miles of. the building; but, in spite of this, only 
 three or four cases attend daily, and the number of new cases 
 was quite insignificant ; and even if one carried a supply 
 of medicine with one, it was difficult to induce the sick to take 
 it. They have such a firm belief in the incurability of the 
 malady, that they are free to confess that even charms and 
 sacrifices to the gods are quite unavailing. 
 
( H ) 
 
 The remark recorded by Dr. Dobson of one of his patients 
 well illustrates the position they take up on this point. 
 
 He was trying to persuade an old woman to submit to 
 treatment by impressing upon her that kdla-azdr was but neg- 
 lected fever, the view of the malady which has hitherto been 
 universal with the profession. Eeplied she — " If I have got 
 fever I shall get well sooner or later anyhow, but if I have 
 kdla-azdr nothing can cure me, so what is the good of bother- 
 ing me with medicine ? " From the point of view I take of the 
 disease, there was a great deal of justice in the old lady's 
 remarks. Nothing that has been hitherto tried has had any 
 effect on kdla-azdi\ and even thymol is as a rule of no use, 
 because cases seldom if ever come to us sufficiently early to 
 be relieved of the parasites before they have inflicted fatal 
 damage upon the system. 
 
 It is little use stopping the drain of blood from the 
 patient's veins, when his digestive powers have become so 
 utterly wrecked as to be quite unable to assimilate food to 
 replace the loss. The inefficiency in advanced cases of mea- 
 sures merely directed to expel tlie parasites is only too well 
 known to all tea-garden medical officers, who have much 
 experience in the treatment of anchylostomiasis. Even in 
 early cases, they are, I find, agreed that the expulsion of the 
 parasites, is but the first step of the treatment, and is effica- 
 cious only as a preparatory measure to careful feeding up 
 on the " hotel system." An advanced case rarely recovers, 
 whatever one may do. It is just possible that such cases 
 might be conducted to recovery, could one place them in 
 the wards of a London liospital and feed them hourly with 
 peptonized liquid nourishment, but such measures are quite 
 impracticable amongst Indians, whose caste prejudices forbid 
 their touching any f 00^1 save such as has been prepared by a 
 caste-fellow, even if one had the apphances for providing any- 
 thing more suitable. Even in our dispensaries, the cooking is 
 of the rudest, and, amongst themselves, no native has the faintest 
 ■notion of sick-room cooking. What is food for the healthy 
 must serve for the sick also, and he who cannot diijest half- 
 cooked dal and ill cleaned, sodden rice must necessarily die. 
 
 In the course of this investigation I must have micro- 
 scopically examined the dejecta of many hundreds of subjects, 
 sick and healthy, and nothing impressed me so much as the 
 inadequacy of native methods of cookery which it brought to 
 light. The rice is commonly so badly cleaned that one finds, 
 
( 15 ) 
 
 on washing away the finer particles, an enormous quantity 
 of whole rice-husks. Xow this is a very different matter 
 from the comparatively finely-ground particles of husk to 
 to be found in our own brown bread, yet even this is so 
 irritating that the article has a well-known purgative action. 
 How much more irritating then must be the unbroken husk 
 of rice, which is more siliceous than tliat of any other grain, 
 and has extremely sharp points. In the case of dal it is 
 common to find it passed quite undigested, the cooking having 
 quite failed to soften the grain, w^liich, if thoroughly cooked, 
 is one of the most digestible of foods. In jails, where we put 
 into practice on a large scale these imperfect native plans of 
 cookery, which at the best are only fitted to deal with small 
 quantities, this is even more marked than among the free 
 population, and is, I strongly suspect, one of the most import- 
 ant factors in causing the disproportionate amount of bowel- 
 complaints found in such estabhshments. 
 
 However, although it was quite impossible to make a 
 very minute clinical study of the disease, there was no diffi- 
 culty whatever of satisfying oneself of its enormous preva- 
 lence, for the people were ready enough to bring out their 
 sick and to converse about the disease, when one visited them 
 in their villages, however unwilling they might be to adopt 
 our methods of cure. 
 
 By making daily excursions from Chaygaon, a large number 
 of villages were visited, in some instances naif depopulated, 
 in others with only a few cases, and while, as wiU be more 
 fully pointed out further on, cases of sickness of all sorts 
 were confounded with the epidemic cause of additional 
 mortality, by the panic-stricken villagers, it soon became 
 evident that by far the greater proportion were cases of 
 anchylostomiasis, and that it was this alone that was respon- 
 sible for the enhanced mortality. 
 
 One strongly confirmatory fact was that large numbers 
 of the villagers who did not as yet consider themselves as 
 absolutely ill, showed unmistakable symptoms of the disease, 
 and, after a little practice, it became easy to pick out from the 
 group around one, a number of such cases at a glance. 
 
 The diagnosis of the disease can only be made a matter of 
 certainty by the discovery of the ova of the parasite in the 
 dejecta, and even this test cannot be considered final until after 
 careful and repeated examinations. 
 
( 16 ) 
 
 It was, of course, impossible to induce the people to bring- 
 specimens of their dejecta except in the very small number of 
 cases one niet with in hospital. Owing to this, it was found 
 necessary to test the question of the prevalence of the disease 
 by collecting specimens of the dejecta of the inhabitants at 
 random ; but as they never go more than a few yards from their 
 own doors to perform the offices of nature, there is no diffi- 
 culty whatever in finding specimens, for, filthy as are Indian 
 villages in general, I never elsewhere have found the people 
 60 thoroughly careless in this respect as in Assam. 
 
 Close by the houses are always to be found a number of 
 small, shallow pits, from which mud has been taken for 
 plastering the walls. As the Assamese has a constitutional objec- 
 tion to unnecessary exertion, these excavations are never more 
 than 10 or 20 yards from the house, and they are fond of utilizing 
 them as latrines, forming miniature, but horribly offensive, 
 open cesspits close to the dwellings. Of course, there is much 
 fouling of the general surface, as they will often defile tlie 
 ground absolutely beneath. the eaves of their huts, to save 
 themselves going out in the rain, and are too utterly careless 
 about the matter to use any one place systematically, but 
 these pits are certainly their favourite place for the purpose. 
 By examining thus sptichnens taken at hapliazard, it was often 
 found that, in badly-stricken villages, three specimens out of 
 every four would contain the ova of the parasite. Further, it 
 was found that the severity of the outbreak and the proportion 
 of specimens showing ova was generally proportionate. In 
 these pits, in the soil about the houses (though often show- 
 ing no signs of recent defilement) in the puddles in the streets, 
 and in the filthy shallow hhils, I repeatedly discovered the 
 free or rhahditis phase of the parasite, in all stages of growth. 
 Strange to say, however, in only one instance has a trace 
 of it been discovered in any specimen of ostensible drinking 
 water, and even this instance was a doubtful one. The worse 
 a village is affected with hdla-azdr the more easy is it to 
 discover evidences of the prevalence of the parasite. 
 
 After some stay in the kdla-azdr districts, I proceeded to 
 Upper Assam, and visited the tea-growing districts, where 
 anchylostomiasis has recently been shown to be so prevalent 
 under the name of beri-beri. 
 
 Nothing here struck me so strongly as the absolute 
 identity of the clinical pictures presented by these cases of 
 acknowledged anchylostomiasis with those I had just been 
 
" ( 17 ) 
 
 seeing so much of, under the name of kdla-azdr. Probably, one 
 of the reasons that has prevented the earUer recognition of 
 their identity is owing to the fact that no one medical officer 
 has had any very extensive opportunities of observing both 
 diseases. Godlpdra, e.g.^ has been continuously under the charge 
 of Dr. Dobson, but that officer . has never served in the tea 
 districts, while the tea cultivation about Gauhdti is too hmited 
 to afford much opportunity of studying the diseases of coolies 
 to the Civil Surgeon there. Surgeon-Major Borah, on the other 
 hand, has had comparatively little opportunity of observing 
 kdla-azdr. 
 
 Owing to the very extensive drainage operations that 
 have been carried out on the level tea lands in the Lakhimpur 
 district, the malariousness of the localities inliabited by the 
 garden coolies must necessarily have been much diminished, 
 and they are much less obnoxious, in this respect, than any part 
 of either Kdmriip or Godlpdra ; and for this reason, alike among 
 the victims of anchylostomiasis, and among the apparently 
 healthy, enlargement of the spleen is much less commonly met 
 with. Nevertheless, it is easy to find numbers of cases, which 
 exhibit as large spleens combined with anchylostomiasis, as 
 in the worst cases of kdla-azdr^ and no one, in these cases, 
 appeared to consider the malarial complication as of other 
 than secondary importance. 
 
 Probably, we shall never hear of kdla-azdr in the tea 
 districts about Lakhimpur, because the cases will be at once 
 identified, and it will be said that heri-heri has spread to 
 the indigenous population, as, indeed, it already haj, in the 
 instance of some villages near Dibrugarh. For the same reason, 
 when anchylostomiasis appears in the tea-gardens of the 
 Kdmriip district, it will be called, not beri-ben but kdla-azdr* 
 and, as in that district, the deep drainage cuttings found in 
 the tea-gardens about Dibrugarh are not required, these will 
 no doubt be found to possess as large a proportion of enlarged 
 spleens as is found among the ordinary population. 
 
 What I found most noticeable in my tour in the tea dis- 
 tricts was that, while a great deal of money had been spent 
 upon improving w^ater-supply, the provision of suitable Hues, 
 and other sanitary projects, the matter of conservancy was 
 
 * It is a curious circumstance that, since the above lines were -written, 
 the forecast therein made has iDioved to be a true one in the instance of the 
 Chunsali tea-garden near Gauhati, where, though the management re- 
 turned the mortality as due to " anaemia ;" the Civil Surgeon describes the 
 outbreak as " kdla-azar,'' exactly like that met with in the district, vide 
 Section XI. 
 
 C 
 
( 18 ) 
 
 everywhere entirely neglected. It further appeared that, 
 while these improvements have undoubtedly resulted in a con- 
 siderable improvement in general health, as far as anch^dosto- 
 miasis is concerned, they seem to have been generally ineffec- 
 tual. These tours, including a week's visit to the immigra- 
 tion depots at Dhubri, which resulted in the discovery that the 
 disease is already present in 2^ per cent, of the newly- arrived 
 immigrants, occupied my time fully until the end of March. 
 
 Having thus satisfied myself that, in both diseases, the 
 mortality was alike due to anchylostomiasis, my duty clearly 
 resolved itself into making a careful investigation of the 
 life-history and method of infection of the parasite. A great 
 deal was already known, but many points were still doubtful, 
 more especially it was important to ascertain the best way 
 of destroying the infective embryos. 
 
 This task has occupied the greater part of my time 
 during the remainder of the period, but another, and very 
 tedious, business was the systematic examination of the 
 pathological material that had been collected. With the view 
 of supplementing the cultivation experiments made with the 
 blood of Mla-azdr patients, and which gave purely negative 
 results, I made and examined, under a high power, immersion 
 objective, many hundreds of sections of the organs of the 
 subjects of post-mortem examination. These sections were 
 stained in every possible way likely to reveal the presence of 
 bacteria, but without bringing to light anything specific, though, 
 in cases that had died of lung comphcations, I found the now 
 often described cocci, and made some other observations of a 
 similar character. Had any specific bacterium been present, it 
 could scarcely have escaped notice. The greater part of each 
 day, for over two months, was occupied in this work, so that 
 the examination was in no sense perfunctory. 
 
 This result forms a strong piece of negative evidence in 
 favour of the view that anchylostomiasis is the one and only 
 cause of the enhanced mortality, for nearly all epidemic 
 diseases have one by one been shown to be due to the action 
 of parasitic organisms, vegetable and animal, and, where the 
 cause cannot be shown to be due to the action of vegetable 
 parasites {bacteria), the probability must be in the direction of 
 an animal parasite, so that, wherever we meet with an epide- 
 mic of hitherto unknown character, we may fairly expect to 
 be able to refer it to one or the other category. 
 
 The examination of old records, and the preparation of 
 this report have also necessarily occupied a considerable time. 
 
( 1^ ) 
 
 III. — The Peevalence of Kdla-azdr as Judged by 
 Available Statistics. 
 
 That the mortaHty from kald-azdr has been very serious, 
 is a matter about which there can be no doubt, but unfortu- 
 nately it is quite impossible to gain any exact idea of the 
 absolute number of deaths it has caused. It is certain that it 
 has, in many cases, nearly depopulated whole villages, and 
 caused such panic among the survivors that they have fled and 
 left the place entirely abandoned. Several places were pointed 
 out to me during my tour in the Chhaygaon district, where, 
 in some instances, the ruined habitations of families, which 
 had been practically exterminated by it, exceeded the number 
 still inhabited. In such instances, enquiries among the sur- 
 viving inhabitants would generally elicit the tale that most of 
 the inhabitants of these ruined houses had died, and that the 
 one or two survivors had taken to flight. It would not be 
 difficult to .collect from the- reports of district officials a 
 number of such instances, but their collection could serve no 
 useful purpose, as we should be still as much as ever in the 
 dark as to the extent of the prevalence of the disease. 
 
 The provincial vital statistics throw no light on the 
 subject. Taking the Kdmriip district as the best for our 
 purpose, because kdla-azdr has only appeared within its limits 
 during the last few years, one would expect to find the annual 
 mortality for these years markedly increased ; but, whatever 
 be the extent of the fatality, it does not show itself in the 
 returns. During 1889, the total mortality of the Kdmriip district 
 per milk was 27*20, which is only 0*29 per mille in excess 
 of the average death-rate of the preceding five years, an 
 amount well within the ordinary limits of annual varia- 
 tion, as may be seen by an inspection of the annexed 
 table, which gives the death-rate for each year from 1882 
 inclusive, during which period the conditions and efficiency 
 of registration has been fairly uniform. The birth-rates are 
 also given, as the proportion they bear to the death-rates 
 gives one a rough test of the comparative efficiency of 
 registration during the years in question : — 
 
 C2 
 
( 20 ) 
 
 Mortality of the Kdmrup district from 1882 — 89, 
 
 
 
 
 
 Total death- 
 
 Total birth- 
 
 ' 
 
 Year. 
 
 
 
 rate jier 
 
 rate per 
 
 
 
 
 
 mille. 
 
 mille. 
 
 1889 
 
 
 
 
 27-20 
 
 21-63 
 
 1888 
 
 
 
 
 27-64 
 
 23-18 
 
 1887 
 
 ... 
 
 
 
 22-83 
 
 24-27 
 
 1886 
 
 .. 
 
 
 
 29-18 
 
 2502 
 
 1885 
 
 ... 
 
 
 
 27-59 
 
 26-00 
 
 1884 
 
 .. 
 
 
 
 27-39 
 
 24-95 
 
 1883 
 
 ... 
 
 
 
 25-60 
 
 22-66 
 
 1882 
 
 ... 
 
 
 
 82-88 
 
 27-65 
 
 The great annual fluctuations, and their capricious rela- 
 tionship to the birth-rate indicate of course that registration 
 is as yet in its infancy in Assam, a fact which indeed is ad- 
 mitted, and adverted to, in each successive annual report. Still, 
 however defective registration may be, and however mislead- 
 ing as a measure of absolute mprtahty, the figures must have 
 some comparative value, and strongly suggest the conclusion 
 that the mortality from hdla-azar has been somewhat 
 rated. 
 
 exagge- 
 
 We hear nothing of kdla-azdr in the Kdmrup district up to 
 the year 1884. Then, creeping gradually up through the Goal- 
 para district, A^a/a-a^^Jr first appeared in Kdmrup in 1885, and, 
 since then, has spread through the whole district, and is now 
 commencing to attack that of Nowgong. In spite of this, there is 
 no marked increase in the registered mortahty. The year 1886 
 has, it is true, a mortality considerably higher than 1885, but 
 this is followed by a year of abnormally low mortality, in spite 
 of the fact that reports show that kdla-azdr was steadily on the 
 increase. The years 1888 and 1889 again return closely to 
 the average of preceding years. 
 
 In the Godlpdra district, the death-rate has always been 
 higher than in Kdmrup, a fact accounted for, in successive 
 annual reports, as due to more efficient registration, but the 
 appearance of kdla-azdr is so nearly coincident with the in- 
 troduction of an improved system of registration that the 
 figures are valueless for our purpose. 
 
( 21 ) 
 
 The fact appears to be tliat Mla-azdr enhances the 
 €ick rate more than of mortality. As to the number of sick, we 
 have no direct means of judging, but it must be very large, as is 
 shown by the serious decrease in the revenue of the affected 
 districts, owing to a considerable area having fallen out of 
 cultivation from want of hands to till it. 
 
 A man, so ill as to be unfit to work, is just as unable to 
 cultivate the land as a dead man, so that no doubt incapacity 
 as well as death accounts for a share of this abandoiiment 
 of cultivation, and may explain why it is that the revenue 
 returns are so much more affected than the vital statistics. 
 
 During the past year, in the district of Kamriip alone, 
 the falling off in the revenue attributed to Mla-azdr^ amounted 
 to Es. 12,896, and as the separate holdings are as a rule very 
 small, few paying more than a few rupees per annum, this must 
 represent many hundreds of families either dispersed, or so 
 diminished by sickness and death as to be unable to cultivate 
 the land they had hitherto held. Wliile, however, the in- 
 creased mortality has not been sufficient, at any rate in 
 Kdmrup, to make its mark in the very imperfect vital 
 statistics of the w^hole district, there can be no doubt that, in 
 individual villages the increase has been so enormous as 
 to attain a truly pestilential character. The fact is that 
 the distribution of the disease is extremely capricious, while the 
 individual outbreaks are sharply circumscribed ; one village 
 being decimated, while another, close by it, remains unaffected, 
 but, wherever the disease makes its appearance, in the course 
 of a few months, large numbers of people are attacked, and 
 the mortality of the place is enormously increased. This is 
 illustrated by a table, prepared in 1884, by the Civil Surgeon, 
 Dhubri, in which an approximation to the mortality from kdla- 
 azdr is obtained by tabulating the recorded mortality from 
 " fever " in the alffected district. In the registers, all cases of 
 kdla-azdr are of course included under this term, and it is 
 well to remember that, in Indian vital statistics, the heading 
 really stands for nearly all diseases except bowel-complaints, 
 violent deaths, small-pox, and the small percentage of cases 
 seen by medical officers. Wlien tested by actual medical 
 investigation, as I have seen done- in the Central Provinces, the 
 number actually due to malarial fever is found to form a 
 comparatively insignificant percentage of the whole, but, as 
 a general rule, in all parts of India, somewhat the larger half 
 of all deaths recorded will be found to be included under this 
 
( 22 ) 
 
 very elastic heading. Now the probable (not the recorded) 
 mortality of the Goalpdra district may be taken as nearly 
 50 j^.9a» annum per mille, and we shall not be far wrong if we 
 assume that 28 j)er mille of this total are cases which would 
 ordinarily be returned under the head of " fever," so that any 
 excess over this number in any given village may fairly be 
 ascribed to the epidemic. In the above-mentioned table, re- 
 produced below, Dr. Dobson gives the population and numbers 
 of death from fever in 266 villages. 
 
 Name of Tillnge. 
 
 <3 5o 
 
 J3 - 
 
 Rangjuli Outpost. 
 
 Amjonga 
 
 Pulana Chita 
 
 Kakomapura 
 
 Rangpur 
 
 Kashumario 
 
 Bangpiira 
 
 Shupuku 
 
 Shilabania 
 
 Dorakpura 
 
 Chormureo 
 
 Allibario 
 
 Kaniarpotta 
 
 Budanang 
 
 -Darrangeeri 
 
 Rangjooho 
 
 Rahaniaheo 
 
 Bhomrapather 
 
 Rangpather 
 
 Kutakoothea ..., 
 
 Dhikdhok 
 
 Deegboho 
 
 Pipmebareo 
 
 Maoang 
 
 Atheabareo 
 
 Mamagao 
 
 Ambook 
 
 Katalmooree 
 
 Gatiapara 
 
 Arimari 1 
 
 Monbari Khamar . ) 
 
 Dhontola \ 
 
 Gora Chatka \ 
 
 Banioonigao 
 
 Tipnai 
 
 Potpara 
 
 583 
 
 20 
 
 440 
 
 11 
 
 188 
 
 11 
 
 91 
 
 10 
 
 232 
 
 20 
 
 257 
 
 15 
 
 375 
 
 10 
 
 137 
 
 10 
 
 139 
 
 16 
 
 180 
 
 22 
 
 376 
 
 24 
 
 734 
 
 51 
 
 896 
 
 46 
 
 3,397 
 
 284 
 
 3,497 
 
 326 
 
 486 
 
 42 
 
 91 
 
 11 
 
 111 
 
 11 
 
 1,806 
 
 72 
 
 388 
 
 9 
 
 1,280 
 
 19 
 
 970 
 
 35 
 
 1,302 
 
 63 
 
 1,243 
 
 45 
 
 470 
 
 9 
 
 598 
 
 27 
 
 555 
 
 14 
 
 498 
 
 25 
 
 286 
 
 5 
 
 794 
 
 19 
 
 400 
 
 15 
 
 680 
 
 32 
 
 1,293 
 
 47 
 
 34 
 25 
 68 
 
 109 
 86 
 58 
 26 
 73 
 
 115 
 
 122 
 63 
 69 
 51 
 83 
 93 
 86 
 
 120 
 99 
 39 
 23 
 14 
 36 
 48 
 36 
 4 
 45 
 25 
 50 
 
 17 
 
 23 
 
 37 
 
 47 
 36 
 
 Name of yillage. 
 
 \ 
 
 to 
 
 
 ^a^j 
 
 c 
 
 
 
 
 
 "O 
 
 c3 
 
 
 
 «-■ Li 
 
 
 
 I 
 
 as 
 1- 
 
 s 
 
 Rangjuli Out- 
 post. — (Concluded.) 
 
 Fakirpara 
 
 Khootabario 
 
 Ambareobeemdri ... 
 
 Khakapara 
 
 Masalain 
 
 Ghillabario 
 
 Shikajooho 
 
 Maniskpur 
 
 Sachapanee 
 
 Deulgooree 
 
 Kharashinook 
 
 Cliakbaree 
 
 Sal^Kira Outpost. 
 
 Mandalgrdrn 
 
 Ulortala 
 
 Kharaoram Tala- 
 
 baree, 
 Khamarshialmarie... 
 
 Diirurah 
 
 Hapangeeree 
 
 Hadeerarapara 
 
 Kangchee 
 
 Ghorapota 
 
 Uporparah 
 
 Habanipara Bongao 
 Bamonpanie Khata. 
 
 Khamarie 
 
 Bambooputa 
 
 Borapather 
 
 Chetnipeareo 
 
 Bakharpara 
 
 Dainrahat 
 
 Boralurnpara 
 
 Hatibanda 
 
 Chansmareo 
 
 313 
 459 
 333 
 299 
 455 
 550 
 1,123 
 699 
 528 
 552 
 583 
 
 741 
 655 
 805 
 
 49 
 282 
 557 
 
 57 
 136 
 168 
 189 
 190 
 184 
 138 
 117 
 268 
 219 
 
 66 
 345 
 143 
 314 
 233 
 
 78 
 8 
 9 
 
 59 
 46 
 10 
 
 135 
 40 
 
 40 
 
 4 
 33 
 39 
 
 5 
 
 - 8 
 
 21 
 
 7 
 26 
 
 9 
 
 19 
 12 
 21 
 50 
 
 6 
 
 9 
 20 
 
 4 
 
 3 
 
 47 
 48 
 39 
 56 
 35 
 
 14 25 
 
 69 
 11 
 17 
 106 
 78 
 
 182-1 
 61-0& 
 49-6 
 
 816 
 117-2 
 
 70-01 
 
 87-7 
 
 58-8 
 125 
 
 37-03^ 
 136-8 
 
 40-9 
 137-6 
 102-5 
 
 78-3 
 228-3 
 
 90-9 
 
 26-08 
 139-8 
 2-11 
 
 12 08 
 
( 23 ) 
 
 Name of village. 
 
 
 
 
 
 c 
 
 
 .2 
 
 goo 
 
 a 
 
 ^a 
 
 3 
 
 •ss 
 
 m 
 
 !■! 
 
 
 
 s 
 a) 
 
 
 ^•^ 
 
 o 
 
 Salpara Out- 
 post. — (Concluded.) 
 Bogalamarie, Khae- 
 
 repara. 
 
 Badershee 
 
 Kharapara 
 
 Salpara 
 
 Falpanee 
 
 Guruah 
 
 Satapara 
 
 Boramatiah 
 
 Hatimara 
 
 Pepiraphar 
 
 Pddfan Poozahori- 
 
 parah. 
 
 Arrimari 
 
 Ashu Churee 
 
 Chamgiapara 
 
 Shonan Doobi 
 
 Shiaine 
 
 Kishnai hdt 
 
 Kouripara 
 
 Khokan 
 
 Chinapara 
 
 Belpara .. 
 
 Kashpara 
 
 Nokshar 
 
 Yeia ;. 
 
 Karkalichachapani . 
 
 Barigram 
 
 Ddman 
 
 Ning Yanee 
 
 Nahadon 
 
 Dhaigram 
 
 Khoruapiira 
 
 Kailumostra 
 
 Sardarpara 
 
 Sianmari Jonaimari 
 
 Daboho 
 
 Nananonubasa 
 
 Degohe 
 
 Shaiknatu 
 
 Ranasara 
 
 Odeahpara 
 
 Salmara Station. 
 
 Ghoramara 
 
 Shimlabari 
 
 Bara Ghoriah 
 
 Chaklapara 
 
 415 
 
 154 
 142 
 389 
 69 
 565 
 
 154 
 
 360 
 
 61 
 
 753 
 
 265 
 136 
 
 40 
 179 
 293 
 142 
 
 71 
 559 
 219 
 178 
 
 69 
 
 82 
 228 
 257 
 166 
 217 
 359 
 196 
 240 
 
 28 
 
 87 
 246 
 239 
 446 
 279 
 292 
 429 
 
 99 
 128 
 
 268 
 
 52 
 
 327 
 
 140 
 
 41 
 
 11 
 
 26 
 
 46 
 
 3 
 
 9 
 
 "29 
 36 
 17 
 55 
 
 10 
 
 7 
 
 1 
 
 51 
 
 5 
 
 1 
 
 6 
 
 4 
 
 15 
 
 18 
 
 4 
 
 10 
 
 46 
 
 10 
 
 32 
 
 70 
 
 13 
 
 23, 
 
 14 
 
 4 
 
 11 
 
 36 
 
 38 
 
 9 
 
 33 
 
 9 
 
 19 
 
 5 
 
 16 
 
 71-4 
 
 183-09 
 
 118-2 
 
 50-8 
 
 15-9 
 
 188-3 
 100 
 278-6 
 73 04 
 
 37-7 
 
 51-4 
 
 25 
 284-9 
 
 17-06 
 704 
 
 84-5 
 7-1 
 
 68-4 
 1011 
 
 67-7 
 121-9 
 201-7 
 
 389 
 192-7 
 322-5 
 
 362 
 117-3 
 
 58-3 
 112-8 
 126-4 
 146-3 
 158-9 
 
 20-1 
 118-2 
 
 30-8 
 
 44-2 
 
 50-5 
 125 
 
 37 
 
 76 
 24 
 
 7 
 
 Name of village. 
 
 
 M 
 
 
 
 
 cico 
 
 
 
 
 Ti r-l 
 
 
 
 c3 
 
 a 
 
 
 
 S 
 
 
 ft 
 
 s 
 
 a 
 
 
 
 S-" 
 
 
 
 -2 a 
 
 
 
 I.& 
 
 Salmnra Station. — 
 
 (Continued.) 
 Shimlabari II. 
 
 Rnpaah 
 
 Uzarparah 
 
 Kirtonpura 
 
 Bezupara 
 
 Haldibari 
 
 Kaltapara 
 
 Narabhita 
 
 Kokila 
 
 Noniborpara 
 
 Tainbulbari 
 
 Harigapanee 
 
 Lengtisinga 
 
 Noah Shasroh Be- 
 joypiir. 
 
 Margao 
 
 Golapara 
 
 Tilpukhri 
 
 Anishury 
 
 Peradhora 
 
 Duinuriah 
 
 Kliudvo Narikola ... 
 
 Jolakhara 
 
 Dholagao 
 
 Daiiiorshurie 
 
 Boragirigao 
 
 Nodipori 
 
 Arimara 
 
 Bora Narikobe 
 
 Rohumarie... 
 
 Sonanioobe 
 
 Malaygorh 
 
 Jhitkibario 
 
 Pochamiah 
 
 Hooramara 
 
 Charupooniah 
 
 Jaldhapara 
 
 Chakro Bhum 
 
 Kakoijala 
 
 Kuchea Kata 
 
 Shiporphila 
 
 Sikkagao 
 
 Dolaigao 
 
 Birjhara 
 
 Boshongao... 
 
 Mulagao 
 
 Bongaigao 
 
 Majgao 
 
 Baniongao 
 
 117 
 
 1 
 
 227 
 
 9 
 
 49 
 
 9 
 
 90 
 
 5 
 
 100 
 
 6 
 
 125 
 
 6 
 
 54 
 
 10 
 
 63 
 
 2 
 
 1,095 
 
 18 
 
 373 
 
 13 
 
 59 
 
 1 
 
 312 
 
 11 
 
 1,409 
 
 36 
 
 39 
 
 1 
 
 32 
 
 1 
 
 90 
 
 2 
 
 205 
 
 3 
 
 111 
 
 9 
 
 489 
 
 20 
 
 776 
 
 10 
 
 229 
 
 4 
 
 197 
 
 10 
 
 844 
 
 21 
 
 135 
 
 9 
 
 273 
 
 19 
 
 272 
 
 5 
 
 131 
 
 10 
 
 1,066 
 
 41 
 
 1,805 
 
 74 
 
 333 
 
 33 
 
 287 
 
 13 
 
 194 
 
 1 
 
 651 
 
 21 
 
 338 
 
 5 
 
 205 
 
 16 
 
 64 
 
 7 
 
 38 
 
 1 
 
 1,962 
 
 90 
 
 496 
 
 26 
 
 792 
 
 29 
 
 520 
 
 42 
 
 747 
 
 24 
 
 1,701 
 
 50 
 
 785 
 
 34 
 
 881 
 
 24 
 
 956 
 
 16 
 
 503 
 
 14 
 
 273 
 
 19 
 
 8 
 39 
 
 183 
 55 
 60 
 48 
 
 185 
 31 
 16 
 34 
 16 
 28 
 25 
 25 
 
 31 
 22 
 14 
 81 
 40 
 12 
 17 
 50 
 24 
 66 
 69 
 18 
 76 
 38 
 41 
 99 
 45 
 5 
 32 
 14 
 78 
 109 
 26 
 45 
 62 
 36 
 80 
 32 
 29 
 43 
 27 
 16 
 27 
 69 
 
( 24 ) 
 
 Name of village. 
 
 Salmara Station.- 
 (Continued.) 
 
 Madaleemari ... 
 
 Khongdon 
 
 Kali L>oba 
 
 Chakepara 
 
 Khokorpura 
 
 Shalmara 
 
 Deohalty 
 
 Tulon^a 
 
 Choutaki 
 
 Dompara 
 
 Balubaiio 
 
 Chandaparah 
 
 Chiikani 
 
 Maniarpara 
 
 Pakhru Ghoori ... 
 
 Jogiighopa 
 
 Kakoitaree , 
 
 Udashirlitta 
 
 Chalondapura ... 
 
 Katuslibari , 
 
 Bagrabari 
 
 Udobi , 
 
 Boalinari , 
 
 Kerkhabari 
 
 Khoragao 
 
 Alloknagar 
 
 Chappara 
 
 Kaimario 
 
 Balapani 
 
 Koriagao 
 
 Birpara 
 
 Amshooree 
 
 Shooiirmukha ,.., 
 Kheloorapara .... 
 Baripookhoori .... 
 
 Bongao .%.. 
 
 Neeinagao 
 
 Barakhata 
 
 Beziemari 
 
 Talshurie 
 
 Moobeegao , 
 
 Raghoonandanpur 
 
 Sal Bari 
 
 l^asharpara 
 
 Bbishnoopur 
 
 Borakhola 
 
 Kumsakuta 
 
 Ghihishoorio 
 
 «M '^ 
 
 aa 
 ^ g 
 
 S5^ 
 
 144 
 236 
 254 
 
 1,600 
 768 
 
 1,116 
 
 1,411 
 390 
 541 
 210 
 168 
 56 
 24 
 120 
 107 
 729 
 666 
 112 
 
 1,569 
 777 
 270 
 154 
 149 
 374 
 848 
 109 
 130 
 60 
 340 
 119 
 208 
 580 
 91 
 52 
 433 
 100 
 141 
 519 
 204 
 255 
 560 
 856 
 353 
 263 
 835 
 60 
 78 
 761 
 
 2 
 21 
 
 11 
 69 
 30 
 47 
 42 
 13 
 18 
 
 6 
 14 
 
 3 
 
 2 
 28 
 
 1 
 34 
 28 
 
 8 
 
 65 
 36 
 14 
 
 4 
 12 
 18 
 31 
 15 
 19 
 
 2 
 11 
 
 1 
 
 1 
 44 
 
 I 
 
 1 
 51 
 
 4 
 11 
 29 
 
 4 
 13 
 17 
 39 
 
 9 
 12 
 44 
 
 4 
 
 1 
 49 
 
 13 
 89 
 43 
 43 
 39 
 42 
 29 
 33 
 33 
 29 
 83 
 53 
 83 
 
 233 
 9 
 46 
 42 
 71 
 41 
 46 
 51 
 26 
 80 
 48 
 36 
 
 137 
 
 146 
 33 
 32 
 8 
 4 
 75 
 11 
 19 
 
 117 
 40 
 78 
 55 
 19 
 50 
 29 
 45 
 25 
 45 
 52 
 66 
 12 
 64 
 
 Name of vUlage. 
 
 is 
 
 
 Salmara Station.- 
 (Concluded.) 
 
 Singimara ;, 
 
 Bhootkoori , 
 
 SakhChor , 
 
 Slionkorkbola ..... 
 
 Shoznabbitu , 
 
 Basbbari 
 
 Dewangao 
 
 Bashigao 
 
 Dhontola 
 
 Barnipari 
 
 Bazikpara 
 
 Poschagao 
 
 Paknabari 
 
 Kaetpara 
 
 Shakbotiegram 
 
 Napatpara 
 
 Tanglamari ........ 
 
 Sheejorgao... 
 
 Chabiechira 
 
 Godlpdra Station 
 
 Garkuta 
 
 Falpanee 
 
 Kokonga 
 
 Kukoria 
 
 Karipara 
 
 Laliibarie 
 
 Tongabari 
 
 Bbozmahi 
 
 Thalpara 
 
 Bamunpara 
 
 Nowhata 
 
 Baraparaniatia 
 
 Jugupara 
 
 Manikpore , 
 
 Dbandipora 
 
 Bhalakhamar 
 
 Khalmohora , 
 
 Boramohara 
 
 Bhakorbhita 
 
 Poncha Raton 
 
 Makorie 
 
 Khorboza 
 
 Bbahekdubi 
 
 Doshakatol 
 
 Rohatie 
 
 Garmari 
 
 667 
 274 
 111 
 
 1,144 
 291 
 
 1,351 
 523 
 
 1,057 
 282 
 104 
 246 
 882 
 299 
 315 
 861 
 215 
 
 143 
 
 .178 
 
 539 
 
 348 
 
 1,202 
 
 216 
 
 1,241 
 
 433 
 
 137 
 
 191 
 202 
 
 79 
 176 
 
 97 
 360 
 117 
 485 
 310 
 112 
 181 
 
 85 
 
 458 
 
 713 
 
 1,102 
 
 78 
 
 25 
 
 3 
 
 10 
 
 45 
 
 11 
 
 72 
 
 53 
 
 23 
 
 14 
 
 2 
 
 22 
 
 24 
 
 4 
 
 24 
 
 32 
 
 1 
 
 1 
 
 1 
 
 r 
 
 1 
 
 8 
 31 
 
 14 
 44 
 35 
 1 
 8 
 15 
 
 "l 
 
 1 
 
 7 
 
 28 
 
 7 
 
 11 
 
 26 
 
 39 
 
 3 
 
 1 
 
 2 
 
 1^ 
 
 20 
 
 10 
 
 49 
 
 3 
 
{ 25 ) 
 
 Name of village. 
 
 
 m 
 
 
 r^ 
 
 c 
 
 s- 
 
 •2 
 
 '§2 
 
 a 
 
 fi 
 
 53 
 
 
 P. 
 
 ° s 
 
 a 
 
 3 
 
 
 § 
 
 g 3 
 
 
 
 Q 
 
 » 
 
 Godlpara Sta- 
 ■ <^o?^, — (Continued.) 
 
 Bhardobi 
 
 Sheinlitbla 
 
 Balipura ...#. 
 
 Shatorpara 
 
 Takora 
 
 Bhukpara 
 
 Dakoidol Teriko- 
 riahparah. 
 
 Doreemornai ( 
 
 Dobola ^ 
 
 Oaobari ( 
 
 84 
 
 42 
 
 548 
 
 3 
 
 223 
 
 4 
 
 349 
 
 2 
 
 492 
 
 32 
 
 751 
 
 30 
 
 263 
 
 53 
 
 694 
 
 
 964 
 
 61 
 
 303 
 
 ... 
 
 500 
 
 5 
 
 17 
 
 5 
 
 65 
 
 39 
 
 210 
 
 30 
 
 Name of village. 
 
 Godlpara Out- 
 post— {Conchided.) 
 
 Mornai 
 
 Dalgao 
 
 Bagooah 
 
 Bakaitari 
 
 Badur Chor 
 
 Hadagram 
 
 Mozkubi 
 
 Kakhoshuhi 
 
 Aoorkakuchee 
 
 Kokorin 
 
 as 
 
 836 
 636 
 122 
 1,169 
 624 
 502 
 307 
 106 
 556 
 164 
 
 81 
 21 
 11 
 49 
 24 
 30 
 11 
 12 
 14 
 7 
 
 96 
 33 
 90 
 41 
 38 
 59 
 35 
 113 
 25 
 42 
 
 The total population of the villages included in this table 
 is 117,912, and the number of recorded deaths 5,848, equal to 
 49-1 per mille. Subtracting from this the 28 per mille as- 
 sumed as the normal proportion of deaths recorded as " fever," 
 we are left with a mortality of 21*1 per thousand, equivalent to 
 2,488 deaths, due to some unusual cause, in a single year, and 
 that in only a- portion of the Godlpdra district. As may be 
 seen, in forming this estimate, all tendency to arrive at an 
 exaggerated estimate has been avoided by taking the recorded 
 mortality from " fevers " as being exact, while assuming the 
 normal mortality of the district to be considerably above that 
 recorded ; but, in spite of this precaution, the rates from 
 individual villages are something appalling, as will be seen from 
 the selection from the preceding table given below : — 
 
 List of villaf/es in Kdla-azdr stricken portions of the Godlpara district in 
 which the mortality from ^^ Fever'' alone exceeded '^00 per thousand in 1883. 
 
 Name of village. 
 
 .2 
 
 Deaths 
 frora 
 fever. 
 
 Mortality 
 per thou- 
 sand. 
 
 Champeani 
 Eeperagbor 
 
 219 
 61 
 
 50 
 17 
 
 228-3 
 
 278-6 
 
( 26 ) 
 
 Name of villages. 
 
 Population. 
 
 Deaths from 
 fever. 
 
 Mortality per 
 thousand.. 
 
 Shoran Dubi 
 
 Jira 
 
 Daman 
 
 Mamarpara 
 
 Khal Moharer 
 
 Bhardoki 
 
 Dakaidol (Jarporlahpara) 
 
 179 
 
 228 
 217 
 120 
 117 
 84 
 263 
 
 51 
 46 
 70 
 
 28 
 26 
 42 
 53 
 
 284-9 
 201-7 
 822-5 
 238 
 222 
 500 
 201 
 
 Averages 
 
 148-8 
 
 88'8 
 
 257 
 
 List of villages in which the mortality from ** fever'' alone exceeded 150 per 
 thousand in 1888 in Goal para. 
 
 Name of village. 
 
 Population. 
 
 Deaths from 
 fever. 
 
 Mortality per 
 thousand. 
 
 Mandagrain 
 
 741 
 
 185 
 
 182-1 
 
 Kharapara 
 
 142 
 
 26 
 
 183-09 
 
 Boramatiah 
 
 154 
 
 29 
 
 188-8 
 
 Bangrain 
 
 166 
 
 '82 
 
 192-7 
 
 Senamari Jonaimari 
 
 289 
 
 88 
 
 158-9 
 
 Azarpara 
 
 49 
 
 9 
 
 188 
 
 Kallapara 
 
 54 
 
 10 
 
 185-2 
 
 Lalabario 
 
 216 
 
 85 
 
 162 
 
 Manikpur 
 
 176 
 
 28 
 
 159 
 
 Averages 
 
 215-2 
 
 88-0 
 
 176-6 
 
 There is no particular reason to believe that similar 
 statistics for the present year would exhibit any great change 
 from those obtained six years ago, but, at any rate, no im- 
 provement can be expected, as there cannot be the least doubt 
 that the disease is now far more widely spread than it was in 
 1884, so that such a list would now probably exhibit an even 
 larger proportion of villages with heavy mortalities. At any 
 rate, no more recent statistics are available. 
 
 A glance at the above tables will show one notable point. 
 This is that, with but one exception, the villages thus remark- 
 able for so pestilential a'"mortality are of small size, and the 
 worst instances occur in very small villages. On the assump- 
 tion that the disease producing this mortality is communicated 
 
( 27 ) 
 
 from man to man, this can be easily understood. A village^ 
 e.g.^ such as Bhardoki, where half the entire original popula- 
 tion of 84 souls died in this one year, would consist of but two 
 or three families, in the Indian sense of the word ; in other 
 words, the inhabitants would be in close and constant associa- 
 tion; and the high mortahty, assuming the deeply-seated 
 popular conviction of the communicability of the disease to be 
 well founded, would be inevitable. 
 
 Thus, the average population of the villages having a mor- 
 tality of over 200 per thousand is 148, that of the villages with 
 mortalities between 150 and 200 per thousand is 215, while the 
 average population of the whole number of villages, of all 
 mortalities is 443. It seems to me that it is impossible to explain 
 this fact, save on the assumption of communicability, for it is 
 perfectly inexplicable that malarial poisoning, or any other non- 
 communicable malady should thus single out the small villages 
 for a disproportionately large mortality, scattered as they are, 
 amongst the large ones, over all parts of the affected district ; for 
 the number of small villages exhibiting exceptionally high 
 rates of mortality is too large to admit of the explanation of 
 its being due to the fallacy of drawing statistical ratios from a 
 small number of data. Thus, the deductions derivable from 
 such statistics as are available all point to the conclusion that, 
 whatever it may be, kdla-azdr is a disease which affects intense- 
 ly scattered local centres. That while the mortality of such 
 places is so. serious as to cause a widely-spread and well jus- 
 tified panic, the total number affected, while sufficient to render 
 unfit for work a number adequate to seriously affect the reve- 
 nue of the affected districts, is yet insufficient to make any 
 distinct mark on the vital statistics of large areas, even when 
 they are as seriously affected as the Kamriip district is at 
 present. Finally, the distribution of the malady points strongly 
 to the conclusion that kdla-azdr is a communicable disease. 
 
( 28 ) 
 
 IV. — Facts relating to tpie Spread .of Kala-azar. 
 
 In Appendix A to the Annual Sanitary Eeport of Assam 
 for 1882, Dr. Clarke, the then Sanitary Commissioner, gives 
 a short abstract of what was then known as to kdla-azdr. Ac- 
 cording to this report, the disease had attracted attention as far 
 back as the year 1869, and appears to have been, up to the 
 date of the report, confined to the G4ro Hills and those por- 
 tions of the Godlpdra district bordering on them. During the 
 next three years, it spread widely through the Godlpdra district, 
 affecting first those portions nearest the Gdro Hills, and gra- 
 dually spreading till almost the whole district became dotted 
 with affected villages. In 1884, the disease became so serious 
 a matter, in this district, that Government organized special 
 measures of medical relief, by starting dispensaries at several 
 suitable centres, and employing a number of medical subordi- 
 nates to travel about and visit the people at their houses. 
 Accounts of these operations figure in several succeeding reports, 
 but they appear to have been attended with but little success. 
 This was mainly owing to the difficulty of inducing the people 
 to submit to European medical treatment, and their impatience 
 for an immediate cure even when persuaded to give our 
 methods a trial. They expected to be cured by a single dose 
 of medicine, and seldom could be induced to take a second.' The 
 disease being a very chronic one, no method of treatment 
 could be expected to yield any appreciable results at once, and 
 I have found that the same difficulty exists at the present day. 
 The . treatment, however, was entirely devoted to combatting 
 malaria, and hence, from the point of view of the disease deve- 
 loped in the prevent investigation, it is by no means surprising 
 that success was so wanting, as it would only be in cases of 
 true malarial cachexia, such as are always to be abundantly 
 found in Assam, that success could be expected. In such 
 cases, no doubt, considerable good was effected, but, for all 
 practical purposes, the spread of the disease was in no way 
 affected by the relief operations. 
 
 In the sanitary report of the Kdmriip district for 1886, 
 we find Dr. MuUane noting the appearance of the disease in 
 the western portion of liis district, where it marches with the 
 Goalpara district, and year by year we find the Civil Sur- 
 geons of Kdmriip speaking in stronger and stronger language 
 of the ravages caused by the disease. In 1888 the disease 
 
( 29 ) . 
 
 had become most serious in Cliaygaon, 30 miles from Gauhdti, 
 having taken, as is remarked by Mr. A. C. Campbell, the Deputy- 
 Commissioner of the district, in his comments on Dr. Borah's 
 annual report for 1888, four years to travel 36 miles, and during 
 the latter part of this year, and during 1889, cases began to ap- 
 pear in Gauhdti itself. At present it is undoubtedly increasing 
 in the town, and there are numerous villages, close by it, which 
 are as badly stricken as any of those in the Chaygaon district. It 
 is now to be found well to the eastward of Gauhdti, and is said 
 to have invaded the portion of the Nowgong district contiguous 
 to Kamriip. On the northern bank of the river it has spread 
 to Barpeta and Mangaldai, and is very severe in some of the 
 villages just opposite Gauhdti. 
 
 It is a noticeable fact that, once the disease has made its 
 appearance in a district, it never leaves it, the weekly returns 
 of the prevalence of epidemic disease showing it to be present 
 to-day in every part of the country where it has been hitherto 
 reported. 
 
 It will thus be seen that the progress of the disease is 
 pecuhar. It does not appear suddenly and inexplicably over 
 a large area, like influenza or cholera : it does not spread 
 rapidly from man to man like small-pox, and other specific 
 fevers ; but it creeps slowly from village to village, holding what 
 it has seized, but progressing so slowly that it has taken seven 
 years to reach Gauhdti from the Gdro Hills, a distance of not 100 
 miles. It must, I think, be admitted that these facts are in no way 
 compatible with the theory of a malarial origin. Assam always 
 has been extremely malarious ; but if, as has been suggested, 
 kdla-azctr be due to waves of " periodic epidemic intensity " (of 
 malaria), how is it that we hear of no such periods of intensity 
 before the appearance of this disease ? and how is it that once 
 it has appeared, the intensity remains intense, but ceases to be 
 periodic ? Again, if Mla-azdr be but malarial cachexia inten- 
 sified by the proximity of uncleared jungle, the habits of the 
 people, and so forth, it is clearly incumbent on the advocates 
 of this theory to show that these conditions and habits have been 
 intensified in affected villages coincidently with the outbreak of 
 the disease, but, in point of fact, no one pretends that any such 
 change has taken place. Further, I would ask, how is it that it is 
 common enough to find villages quite unaffected by it in the midst 
 of villages badly stricken, which may be less than a mile distant ? 
 And yet, that such is the fact, is a matter on which any one may 
 
*( ao ) 
 
 satisfy himself by visiting the affected districts. To take a con- 
 crete instance. About six miles from Gauhdti is a village called 
 Paru, which is most seriously affected with Mla-azdr. The village 
 stands on alluvial ground, on the river bank, but the site is some- 
 what elevated above the general level of the plain by the detritus 
 washed down from the Kamakliia hill, the river bank being here 
 exceptionally liigli. To the east, the close but isolated 
 patch of jungle, clothing Kamakliia hill, reaches nearly down 
 to the village, but is separated from the habitations by a belt 
 of cultivation. On the north is the river Bralnnaputra, and 
 the remaining sides look on to extensive open cultivated j^lains. 
 The houses are, for an Assamese village, closely placed, the 
 place boasting of two quite distinct streets, and there is compara- 
 tively Httle jungle within its precincts. The supply of drinking- 
 water is taken from the river, which is so absolutely at every 
 one's door that it involves less trouble to do so than to seek for 
 it elsewhere. The river here sweeps by the village in a strong 
 deep current, and there is no backwater to be found nearer 
 than Gauhdti. On account of its proximity to Gauhdti, I 
 visited the place many times, and have been into every corner 
 of the village, and am positive that there are no wells to be 
 found in it. Between the village and Kamakhia hill is a small, 
 very filthy bhil. It is evidently used for watering cattle, 
 but the water is so filthy that I doubt if even an Assamese 
 could be persuaded to drink it ; and it is further from the houses 
 than the river is, so that it would involve additional trouble to 
 take drinking-water from it. It does not appear to contain 
 any fish. The neighbourhood of the houses is of course filthy 
 in the last degree, but in this matter it differs in no way 
 from every other Assamese village I have entered. The 
 other village, that of Maligaon, is almost three-quarters of a mile 
 from Paru, and is situated on the Trunk Eoad not far from 
 the spot where the path to Paru diverges. It is thus a long 
 distance from the river, and the ground on which it is placed lies 
 somewhat lower, but it is about the same distance from tl;e 
 jungle of the Kamakhia hill. The hills to the south of the road 
 are nearer and shut it in more than Paru, so that there is quite 
 open country to the north and west only. The water-supply 
 is from two or three shallow hutcha wells, which contained, at 
 the time of my visit, only a little brown, evilly-smelhng water. 
 It, too, has one or two pools, the counterparts of that at Paru. 
 In the matter of filth, it is neither better nor worse than the 
 other place, and, on the whole, it must be admitted that, 
 owing to its more open and sHghtly drier site, and its pos- 
 
( 31 ) 
 
 session of an excellent water-supply, Paru is by far the more 
 desirable place of residence. Yet Paru, as we have seen, is 
 being decimated by kdla azdr, while I could not find a single 
 case of it at Maligaon, either described as such by the inhabit- 
 ants, or in the shape of early cases diagnosable by anaemia, 
 but not yet sufficiently affected to consider themselves ill. 
 Why then should a wave of " periodic epidemic intensity " pass 
 over the one place and not involve the other, so close by it, and 
 so similarly situated ? Another illustration of the want of con- 
 nection between the incidence of the epidemic and ordinary 
 sanitary conditions is to be found in the water-supply. 
 While on tour, I searched large numbers of specimens of 
 drinking-water microscopically for dochmius embryos, but 
 without success, and, after I reached Shillong, I determined 
 to make a further attempt to find them, and accordingly, by 
 the kind aid of Dr. Costello, the Sanitary Commissioner, obtained 
 from the district medical officers a considerable number of 
 specimens of drinking-water from infected localities. Having 
 the conveniences now at hand, I supplemented the micro- 
 scopical, hj a rough chemical analysis. The results show 
 the greatest variety, from really good drinking-water to the 
 most horrible filth imaginable. In only one instance were 
 anything like dochmius embryos discovered, and, for many 
 reasons, even in this case, the exact character of the single 
 nematode observed is very doubtful. The results of these 
 examinations of drinking water are given in the subjoined table. 
 The analysis of the Shillong pipe-water, which is really 
 excellent, examined on the same plan, is given as a means of 
 comparison : — 
 
( 32 ) 
 
 Results of analysis of Specimeiis of Water from 
 
 Name of place. 
 
 Smell. 
 
 Colour. 
 
 Reaction. 
 
 o S 
 
 Oxydiable matter as 
 oxygen required lo 
 oxidize mgs. per litre. 
 
 Shillong pipe-water 
 
 Nil. 
 Nil. 
 Foul 
 
 Disagree- 
 ble. 
 
 Veiy foul 
 Foul 
 
 Slight ... 
 
 Little or 
 more. 
 
 Nil. 
 
 Foul 
 
 » • 
 
 Nil 
 
 Nil 
 
 Very foul. 
 
 Disagree- 
 ble. 
 
 Nil 
 
 SHght ... 
 
 Foul 
 
 Cle a r and 
 
 sparkling. 
 
 Good 
 
 Fair 
 
 Neutral ... 
 
 Ditto ... 
 
 Acid 
 
 1 
 
 2-9 
 17 
 
 1-6 
 
 7-1 
 
 1-7 
 
 2-6 
 
 20 
 
 4-0 
 
 1-2. 
 1-2 
 
 1-4 
 1-6 
 1-6 
 
 1-4 
 
 0-9 
 1-8 
 
 1-4 
 
 0*5 
 
 hkiix well 
 
 1-2 
 
 Label illegible (probably also from 
 Bara Jalinga). 
 
 Nagadum tea-garden river- water... 
 
 Chunsali tea-garden well in coolie 
 lines. 
 
 Bara Jalinga tea-garden tank-water 
 
 Well at Kalapani, Salpara outpost. 
 
 Well, village Dighi, Darangiri 
 jurisdiction, Rangauli outpost. 
 
 Well of Lakhipur, label nearly 
 illegible. 
 
 Bojni outpost, laljel otberwise ille- 
 gible. 
 Label quite illegible 
 
 3-6 
 
 Good after 
 settling. 
 
 Brown 
 
 Good 
 
 Neutral ... 
 Acid 
 
 0-7 
 4*8 
 
 Slightly acid 
 
 Ditto ... 
 
 Ditto ... 
 Alkaline ... 
 Acid 
 
 31 
 
 Very brown 
 
 Good 
 
 Fair 
 
 2-8 
 1-6 
 2-5 
 
 Good 
 
 S'Q 
 
 
 
 3-0 
 
 Biini outnost Dine-water 
 
 
 Neutral 
 
 Acid 
 
 Mar k e d 1 y 
 acid. 
 
 Acid 
 
 Neutral 
 
 Acid 
 
 0-8 
 
 Darrangiri jurisdiction, label 
 
 otherwise illegible. 
 Biini outoost Dond-water 
 
 
 0-8 
 
 Brownish... 
 Good 
 
 12-0 
 
 Laokhoa bhils, Gauripore ............ 
 
 . 1- 
 
 Well Manicpore, Salpara outpost... 
 
 Pond- water, Naipara, Godlpdra 
 police-station. 
 
 0-8 
 
 ■ 
 Fair 
 
 1-8 
 
 
 4-0 
 
 
 
 
 
( 33 ) 
 
 >taces afected with Kdla-azdr and Beri-heri, 
 
 Ammonia by 
 
 Nestless test 
 
 qualitative. 
 
 Microscopical appearances, &c. 
 
 Quality. 
 
 1-0 
 3-8 
 1-4 
 
 1-4 
 
 2-4 
 
 4-9 
 
 4-7 
 4-9 
 
 15- 
 2-4 
 6-7 
 
 1-9 
 
 1-4 
 21 
 
 2-4 
 
 A slight trace... 
 
 A trace 
 
 Strong re-action 
 
 Ditto 
 
 Ditto 
 
 Very strong 
 re-action. 
 
 Ditto 
 
 A trace 
 
 Distinct reaction 
 
 Very strong 
 ro action. 
 Ditto 
 
 A trace 
 
 Ditto 
 
 Marked re-action, 
 
 Distinct 
 
 A trace 
 
 Distinct 
 
 Very strong 
 reaction. 
 
 Scarcely any sediment, some algsB, copepods, and Excellent. 
 
 diatoms. 
 A very small amount of brownish yellow sediment, Good. 
 
 mainly mineral, no evidence of pollution. 
 A moderately copious, brownish white, flociilent Very bad, 
 sediment, consisting mainly of decomposed 
 vegetable matter, cotton fibres, rice, husk, &c. 
 Copious gray sediment, consisting mainly fino Bad. 
 Siind, diatoms, human hair, and some decomposed 
 vegetable matter. 
 Sediment very copious, composed mainly of Very bad. 
 decomposed vegetable matter wiih mud, cotton 
 fibres, epithelia, <S:c. 
 A moderate amount of floculent sediment, consist- Ditto, 
 ing almost entirely of decomposed vegetable 
 matter, copeuods, diatomaceas algre, fibres, hair, 
 epiihelia, evidently much polluted. 
 Small amount of red brown sediment, consisting Bad, 
 almost entirely decomposed vegetable matter, 
 copepods. No evidence of human pollution. 
 Small sediment, mainly decomposed vegetable Good, 
 matter, copepods, a setigerous annelid, diatoms 
 algae. No evidences of human pollution. ' 
 Moderate sediment, mainly decomposed vegetable Doubtful, 
 matter, cotton fil)res and other evidences 
 pollution, desmids, diatoms, infusorians. 
 Scanty sediment, mainly organic, with a fewhving Very bad. 
 
 copepods. 
 Scanty sediment, consisting of about equal parts Bad. 
 sand and organic matter, a small cattle tick, 
 copepods, <S;c. 
 A very small sediment consisting almost entirely Good. 
 
 of desmids and diatoms. 
 Scanty sediment mainly consisting of organic Ditto. 
 
 matter, with infusorians. 
 Considerable sediment, almost entirely organic Very bad. 
 remains of copepods; cotton fibres, and other 
 evidences of human pollution. 
 Small sediment, consisting almost entirely of Doubtful, 
 filamentous algsB, living and decomposed ; cotton 
 fibres, &c. 
 Scanty sediment, mainly organic, with clayey Good. 
 matter, filamentous algae, ostracods and copepods. 
 Moderate sediment, almost entirely decomposed Doubtful, 
 vegetable matter with fibres, hairs, and other 
 evidence pollution. 
 Copious sediment consisting almost entirely of Bad. 
 organic matter; filamentous algae and diatoms 
 extremely abundant. 
 
 D 
 
( 34 ) 
 liemUsof Analyses of Specimens of Water from 
 
 ~ 
 
 
 
 
 
 S S3 £ 
 
 
 
 
 
 
 5 
 
 5d 
 
 n^ll? 
 
 
 
 
 
 
 ^ 
 
 tJ-= ^ 
 
 
 
 
 
 
 
 = ^s, 
 
 
 Nftine of place. 
 
 Smell. 
 
 Colour. 
 
 Re-action. 
 
 
 Oxydiable 
 oxygen r 
 oxidize, 111 
 
 Backwater of Brahmaputra at 
 Chowdoniah. 
 
 Well, Pykan, Salpara outpost 
 
 Banishpara well, Goilp4fa police 
 
 hit 
 Label illegible 
 
 Well, Darrangiri, Hanguli ontpost 
 
 Label partly illegible, Bijni out- 
 post, well water. 
 Label illegible 
 
 Ditto ,. 
 
 Well, Chihari village, Ranguli 
 
 outpost. 
 Well, Kota Kuti village, Punjab 
 
 outpost. 
 
 Lakhipur ('* Radha para " well) ... 
 Chigknagoal 
 
 Silchar Dispensary 
 
 „ coolie depot 
 
 Katalgouri Tea-garden "kacha well.. 
 EohlangaoD 
 
 Darangiri village 
 
 Gabul „ 
 
 Baringiri „ 
 
 Faint 
 
 Slight .. 
 
 Disagree- 
 
 ble. 
 II(.rribly 
 
 fi.ul. 
 
 Faint ... 
 
 Nil. 
 Slight ... 
 
 Nil. 
 Slight ... 
 ,, ... 
 
 Hardly any 
 
 SFight ... 
 
 Distinct 
 Foul . 
 
 A^7. 
 Bad 
 Nil 
 
 Fair 
 
 Brownish... 
 
 Rather brown 
 
 Good 
 
 Fair 
 
 Good 
 Fan- 
 Brownish ... 
 
 Good 
 
 Fair 
 
 Brownish 
 Brown 
 Fair 
 
 Acid 
 
 Alkaline ... 
 
 Acid 
 
 >» • 
 
 Neutral ... 
 Slightly acid 
 
 Aeid 
 
 Slightly acid 
 
 M a r k e dly 
 acid. 
 
 Ditto ... 
 Acid 
 
 Neutral ... 
 Acid 
 
 Acid 
 

 
 ( 35 ) 
 
 
 places affected toith Kdla-azdr and Beri-beri. 
 
 
 Ammonia by 
 
 
 
 
 Nestless test 
 
 Miscroscopical appearance, &c. 
 
 Quality. 
 
 So 
 
 CO 
 
 e5^ 
 
 qualitative. 
 
 
 
 30 
 
 Slight trace 
 
 Moderately abundant sediment consisting almost 
 entirely of fine sand, with a little decomposed 
 vegetable matter. 
 
 Good. 
 
 21 
 
 A trace... 
 
 Scanty sediment, mainly decomposed vegetable 
 matter; diatoms, desmids, and other algae very 
 
 Ditto. 
 
 
 
 
 
 
 abundant. 
 
 
 12-2 
 
 Ditto 
 
 Scanty sediment mainly inorganic, with some 
 decomposed vegetable matter. 
 
 Fair. 
 
 
 
 
 4-2 
 
 Strong re-action. 
 
 Copious sediment of tenacious clayey matter, 
 containing much decomposed matter, vegetable 
 and animal; desmids, copepods, fibres, and other 
 evidences (»f pollution. 
 
 Very bad. 
 
 21 
 
 Very marked re- 
 
 Scanty sediment of inorganic matter, mixed with 
 
 Doubtful. 
 
 
 action. 
 
 decomposed vegetable matter, copepods, amoebsB. 
 
 
 10-3 
 
 A truce 
 
 Small amount sediment, ujainly inorganic, with 
 some decomposed vegetable matter, algse, Sic. 
 
 Good. . 
 
 1-6 
 
 Distinct re-action 
 
 Scanty sediment, mainly inorganic, infusorians ; 
 an ovum (not of any known human parasite, 
 but probably nematode.) 
 
 Doubtful. 
 
 07 
 
 MarkedTe-action 
 
 Scanty sediment, m;iinly decomposed vegetable 
 matter, large numbers of infusoria and diatoms. 
 
 Bad. 
 
 28 
 
 Distinct re- 
 
 Scanty sediment, mostly inorganic, with a few 
 
 Fair. 
 
 
 action. 
 
 copepods and diatoms. 
 
 
 2-3 
 
 A trace 
 
 Scanty sediment, almost entirely decomposed 
 vegetable matter, containing infusoria, with fibres, 
 and other evidences of pollution. 
 
 Ditto. 
 
 24 
 
 Marked re-action 
 
 Much sediment; decomposed vegetable matter 
 mixed with fine sandy particles, infusoria, cotton 
 fibres, and evidences of pollution. 
 
 Doubtful. 
 
 1-6 
 
 A trace 
 
 Scanty flocculent sediment consisting entirely of 
 zooglcea entangling grains of ralher coarse 
 sand. The zooglcea has probably developed since 
 the collection of the specimen. 
 
 Good. 
 
 3-6 
 
 Ditto 
 
 Scanty sediment, mainly inorganic, diatoms, des- 
 mids, &c. 
 
 Fair. 
 
 5-8 
 
 Ditto 
 
 Considerable sediment, mainly decomposed Vege- 
 table matter. 
 
 Doubtful. 
 
 3-6 
 
 Distinct re- 
 
 Much sediment, clayey matter, with evidences of 
 
 Very bad. 
 
 
 action. 
 
 human pollution. 
 
 
 
 Marked ditto ... 
 
 Very scanty sediment, consisting almost entirely 
 of fibres, particles of rice husk, «&c., looking in 
 fact as if a pinch of house dust had been added 
 to the watur. 
 
 
 ... 
 
 Strong ditto ... 
 
 Of the same character as above. 
 
 
 ... 
 
 Distinct ditto ... 
 
 Diito ditto. 
 
 
 ... 
 
 felight ditto ... 
 
 Ditto ditto but in addition a specimen 
 of a rhabditis, possibly dochrnius, was found. 
 
 
 D 2 
 
( 3t5 ) 
 
 Eesult of AtKilyses of Specimens of Water from 
 
 Name of place. 
 
 Smell. 
 
 Colour. 
 
 Re-action. 
 
 o 
 
 Z J 
 
 Oxydiable matter as 
 oxygen required to 
 oxidize mgs. per litre- 
 
 N^gaghooli tea-garden No. 2 coolie 
 lines. 
 
 NAgaghooli tea garden No. 3 coolie 
 lines. 
 
 Hilika tea garden, Bengali lines ... 
 hospital 
 
 Nil 
 Foul ..*.. 
 
 Nil 
 
 >j 
 
 Faint 
 
 Disagree- 
 able 
 Nil 
 
 i> 
 
 » 
 
 M • 
 
 f> 
 
 » 
 
 „ .c... 
 
 } " 
 
 \ 
 
 . f> •• ••• 
 
 ,, ...... 
 
 ■ 
 
 „ ...... 
 
 ,, ...... 
 
 » 
 
 Fair 
 
 » 
 
 Good 
 
 Faintly acid. 
 Nil 
 
 33 
 
 4-1 
 
 2-1 
 1-2 
 41 
 
 2-3 
 1-4 
 
 0-9 
 5-3 
 
 7-4 
 
 37 
 M 
 
 3-7 
 1-7 
 31 
 
 0-9 
 
 10 
 1-4 
 0-5 
 1-4 
 
 08 
 2*2 
 
 Faintly 
 acid. 
 Ditto 
 
 Ditto 
 
 Acid 
 
 0-4 
 0-4 
 20 
 
 36 
 
 >> • 
 
 » • 
 
 Fair 
 
 „ „ jungle lines, 3... 
 ,, new lines, 3 
 
 Talap tea-garden, Poolibari lines 
 well. 
 „ „ Dhangori lines 
 
 2nd well. 
 ,, „ northern side 
 
 Good 
 
 M • 
 
 » 
 
 Fair 
 
 Good 
 
 Faintly 
 acid. 
 Ditto 
 
 Nil 
 
 08 
 
 0-4 
 
 0-4 
 
 well, old lines. 
 
 „ „ northern side 
 
 well, new lines. 
 
 Talap new lines, southern side well 
 
 Doom Doona, Muthik lines 
 
 Disti n ctl y 
 acid. 
 
 Faintly 
 
 acid. 
 Acid 
 
 F a i n t 1 y 
 
 acid. 
 D i 8 tinctly 
 
 acid. 
 
 Nil 
 
 04 
 04 
 
 Deep brown 
 Fair 
 
 5-4 
 
 Bisakbpi tea-garden, Buch well 
 No. 2 lines. 
 
 Pipe-well 
 
 No 3 lines. 
 
 „ „ Jungle 
 
 side well No. 6 lines. 
 
 „ „ Big well 
 
 No. 6 lines. 
 
 well No. 7 
 
 04 
 
 Good 
 
 1% ...... 
 
 Slight 
 
 Pale brown 
 Slight ... 
 Fair 
 Slight ... 
 
 0-7 
 10 
 
 Acid ., 
 
 0-4 
 
 Nil 
 
 10 
 
 lines. 
 
 No. 9 
 
 lines. 
 
 „ „ No. 2 lines. 
 
 „ tea-house well 
 
 Faintly 
 
 acid. 
 Nil 
 
 Distin c 1 1 y 
 acid. 
 
 04 
 
 0-3 
 0-5 
 
( 37 ) 
 
 places affected ivith Kdla-azdr and Beri-heri. 
 
 
 
 
 
 S 00 
 
 Ammonia by 
 
 
 
 Is 
 
 Nestlesa test 
 
 Miscroscopical appearance, Ac. 
 
 Quality. 
 
 ^3 
 
 qualitative. 
 
 
 
 
 « 
 
 - 
 
 
 51 
 
 Faint re-action ,. 
 
 A copious brown sediment, consisting mainly of 
 claj'ey matter, with gome decomposed vegetable 
 debris, infusoria, &c. 
 
 Fair. 
 
 3-8 
 
 Strong 
 
 A moderate amount of floculent sediment, almost 
 purely organic and showing plain evidences of 
 human pollution. Some large ova, possibly 
 treinatode. 
 
 Bad. 
 
 3-5 
 
 Trace 
 
 Scanty brown sediment, consisting almost entirely 
 of deconipQsed vegetal)le matter. 
 
 Good. 
 
 35 
 
 Ditto 
 
 Sedinient somewhat less copious, but otherwise of 
 the same character as the preceding. 
 
 Ditto. 
 
 
 
 32 
 
 Strong 
 
 A n)oderately copious sediment, almost entirely 
 
 Bad. 
 
 
 
 decomposed vegetable matter, but showing some 
 
 
 
 
 evidences of pollution. 
 
 
 35 
 
 Distinct 
 
 Sediment less copious, but otherwise of the same 
 character as the preceding ; monads. 
 
 Ditto. 
 
 
 
 38 
 
 mi 
 
 Scanty brown i«edimont, mostly decomposed vegeta- 
 ble matter, insect larvae, monads, and infusorians. 
 
 Good. 
 
 28 
 
 Nil. 
 
 Very scanty sediment, n)ainly vegetable matter ; 
 but fibres, &c.. of suspicious character. 
 
 Ditto. 
 
 n3 
 
 Trace 
 
 A very scanty brown stdiment, consisting almost 
 entirely of decomposed vegetable matter. 
 
 Doubtful. 
 
 
 M^\J\A %^%0^\AA» 
 
 5-3 
 
 Ditto 
 
 A very scanty sediment, consisting almost entirely 
 of fine san<l, with a little decomposed vegetable 
 
 Ditto. 
 
 
 
 
 
 
 matter. 
 
 
 49 
 
 Ditto 
 
 A very small sediment, mainly inorganic, with 
 
 Good. 
 
 
 
 some decomposed vegetable matter. 
 
 
 3-8 
 
 Doubtful 
 
 Colour too brown for reliable NHg determination. 
 A copious dark red peaty deposit consisting 
 
 Bad. 
 
 
 
 
 
 mainly of decompt)sed vegetable matter, and 
 
 
 
 
 containing filamentous algae, copepods, &c. 
 
 
 6-3 
 
 Distinct 
 
 Copious orange-coloured sediment, consisting 
 almost entirely of an oval bacterium. 
 
 Doubtful. 
 
 
 
 3-8 
 
 Marked 
 
 A scanty dark brown sediment, consisting of little 
 else than decomposed vegetable matter. 
 
 Fair. 
 
 
 
 4-0 
 
 Slight 
 
 An exceptionally small sediment of the same 
 character as the preceding. 
 
 Ditto. 
 
 3-5 
 
 Nil, 
 
 Scanty greenish sediment of the same general 
 character as the preceding, but with some doubt- 
 ful evidences of pollution. 
 
 Good. 
 
 3-5 
 
 Trace 
 
 A very small black sediment, consisting entirely of 
 
 Ditto. 
 
 
 
 living and dead vegetable matter. 
 
 
 2-8 
 
 Trace 
 
 Scanty brown sediment consisting of clayey matter, 
 
 Very 
 
 
 
 filamentous algae, &c. 
 
 good. 
 
 31 
 
 Distinct «. 
 
 An exceptionally small, flocculent sediment, consist- 
 ing entirely of living and dead vegetable matter. 
 
 Fair. 
 
 4-6 
 
 Ditto 
 
 Scanty sediment, consieting almost entirely of 
 
 Ditto. 
 
 
 
 filamentous algae. 
 
 
( 38 ) 
 
 Nor are these by any means isolated instances. Far from 
 being so, cases sucli as that of Paru and MaUgaon may be de- 
 scribed as typical of the distribution of the disease, especially 
 in the Chaygaon district, where the villages, though small, are 
 very numerous, and placed at small distances from each other. 
 
 In the earlier reports on the subject, and in support of 
 a malarial origin for the disease, much stress is laid on the 
 assumption that kdla-azdr is necessarily a terai disease ; and, no 
 doubt, as long as the disease remained confined to the G^ro 
 terai, this was a fact, but the spread of the disease shows that 
 the connection, then so confidently asserted, was quite casual, 
 being merely due to the circumstance of the disease, at that 
 time, not having spread beyond the terai regions. Now, how- 
 ever, the disease is common in portions of the Province which 
 are in no sense terai, and as far distant from the hills as any 
 portion of Assam can be. For example, the Chaygaon thdna 
 is now the portion of Kamriip most seriously affected, and the 
 disease is as rife there as anywliere in the Province, so 
 much so, indeed, that it was at once suggested as the most 
 favourable centre for my enquiries ; yet this very region 
 was, previously to the appearance of kdla-azdr^ considered 
 the most salubrious portion of the district. Commenting 
 on the comparative im:nunity from cholera enjoyed by the 
 thdna during the year 1882, Dr. Russell, the then Civil 
 Surgeon, remarks : — 
 
 " Its natural features should make Chaygaon thana the healthiest 
 region of the district. Its southern portion consists of hills and highlands, 
 timber covered, and well watered by hill streams (branches of the Singra 
 and Kulsi rivers). Its northern half, though lying low, and containing a 
 large extent of swamp, yet is well tapped by watercourses, and consequent- 
 ly fairly well drained. It is rarely subject to inundations, and, if these 
 occur, they quickly subside." 
 
 Nor is Dr. Russell alone in his opinion, for Dr. MuUane, 
 in his annual report for 1884, remarks in much the same 
 terms on the comparatively greater healthiness of the Chay- 
 gaon thdna over the rest of the Kdmrup district. Added to 
 this, by far the greater part of the population live far from 
 hilly or terai portion of the thdna, and are so closely settled 
 that the land is almost continuously under cultivation, and 
 exceptionally open and free from jungle. If malaria be the 
 source of- kdla-azdr, how is it that a district possessing such 
 comparatively favourable features should be now devastated 
 by the latter disease, while many truly terai portions of 
 Kdmnip remain untouched. It will be thus seen that the 
 
( 39 ) 
 
 f^cts relating to the spread and distribution of the diseased 
 are entirely at variance with a malarial origin. 
 
 In connection with the spread of the disease, another 
 point remains to be considered, and this is the strong popu- 
 lar belief in its contagiousness. This belief is founded on 
 the undisputed fact that, when once a case of Mla-azar 
 has appeared in a village, others soon appear, or, in other 
 words, that the disease appears to spread. Moreover, this 
 tendency is especially often noticed in members of the same 
 household, who, one after another, contract the disease until 
 occasionally all may fall victims to it. So far as I know, no 
 one has ever disputed that such are the facts of the case, and 
 during my enquiries I found that if one person in a family 
 was affected, it was common to find that many other members 
 would be found in various stages of the disease ; while other large 
 families remained quite free from the disease, though living in 
 a badly-stricken village. Now, these facts certainly point 
 strongly to contagion. They may, or may not, be capable of 
 some other explanation, but in the face of their admitted 
 genuineness, it appears to me quite unjustifiable to state, as is 
 done in so many reports, "There is not a particle of evi- 
 dence in favour of contagion." Nearly all the reports I have 
 read confidently assert that there is no evidence to support 
 the popular view ; but it is evident, on reading them, that 
 the conclusion has been based rather upon a systematic 
 ignoring the facts of the case than upon a patient consideration 
 of them. Dr. P. M. Gupta, for example, in his report on the 
 Gdro Hills for the year 1888, says :— 
 
 "The belief that it is contagious is founded in the fact that tvhen one 
 is seized with an attack of this fever in a village, there are others soon to 
 follow'' (the italics are mine) ; "but this is no doubt due to the same climatic 
 influences under which they all live ; and that the fever ceases to be less 
 virulent, and less liable to attack others when the inhabitants shift from one 
 village to another" ( as they not unfrequently do when this disease is very 
 bad amongst them), "only goes to prove my contention" (of a malarial origin) 
 "beyond doubt." 
 
 I select this report because it contains, in a few words, 
 the leading arguments, over and over again repeated, in 
 other reports, as to the malarial origin of kdla-azdr. 
 
 The second sentence is somewhat involved, but I take the 
 writer to mean that removal from an infected site is effica- 
 cious in checking the spread of the disease. 
 
 It is perfectly obvious that the facts, which are admitted 
 by the writer, really warrant quite the opposite conclusion. 
 
( 40 ) 
 
 It Is perfectly clear that, from tlie nature of the case, in all 
 instances of communication of disease from man, to man the 
 subjects must be under the " same climatic influences," and that 
 the argument might be appHed with equal cogency to small- 
 pox, or any other admittedly infectious disorder. If, moreover, 
 these outbreaks of kdla-azdr in villages be due to climatic in- 
 fluences, it is clear that the outbreak should attack a large 
 number of people simultaneously, or nearly so, whereas, instead 
 of this, we find that the disease always attacks but few of the 
 inhabitants of a village at first, and then spreads with excep- 
 tional slowness. Accompanied, as it is among the Gdros, by 
 desertion of the sick, it is obvious that migration is a most 
 efficient measure in the case of any communicable disease, 
 whereas the breaking up of new ground would, as is well known, 
 tend to intensify malaria instead of checking its ravages, so much 
 so, indeed, that other writers have, on this very ground, advanced 
 the migratory habits of the Gdros as one of the causes of kdla- 
 azdr, so that while one observer points out that migration 
 checks the disease, another gives it as one of its causes, both, 
 in different ways, twisting the facts to support a connection 
 between kald-azdr and malaria. 
 
 If analyzed, all the arguments in favour of malarial origin 
 amount to this. Kdla-azdr closely resembles malarial cachexia. 
 Therefore they are identical. Malaria is not contagious. 
 Therefore all facts that point to contagion must have some 
 other explanation ; which, as will be seen, is but arguing 
 in a circle. 
 
 It is never safe to entirely ignore a widely-spread 
 popular conviction of this kind, and I know of no instance of 
 a disease popularly believed to be communicable ultimately 
 proving to be otherwise, for the popular mind is much more 
 apt to overlook contagion than to believe in it. Ten years 
 ago, the medical profession were practically unanimous on the 
 belief that tuberculosis was never contagious, and this in spite 
 of a strong popular impression to the contrary. Yet, quite 
 recently, the communicability of tubercular phthisis has 
 become an established fact, and the methods and vehicles of 
 communication have been clearly made out. As will be seen, 
 when the method of transmission of anchylostomiasis is dis- 
 cussed, the fact that migration accompanied with desertion of 
 the sick is efl&cacious in checking kdla-azdr entirely fits in 
 with the facts relating to the method of communication of this 
 parasitic disease, and is a strong argument in favour of their 
 identity. Indeed, if the arrangements for excluding the 
 
( 41 ) 
 
 sick could be made thorough, it would be absolutely 
 effectual, and the reason why kdla-azdr often springs up 
 again amongst the migrated community is because the 
 advance of the diseases is so insidious, that they necessarily 
 included among their number many infected, but unsuspected 
 persons. 
 
 Another point in connection with the spread of kdla- 
 azdr is that there is no recorded or even hearsay instance 
 of an European becoming infected. Europeans, of course, 
 suffer much less than natives from malarial cachexia, 
 but they nevertheless enjoy no complete immunity from 
 it. The number of Europeans living in the affected districts is, 
 it is true, but small, but, in spite of their small number, 
 their escape would be indeed remarkable if malarial in- 
 fluences were abroad sufficient to account for the terrible 
 ravages of kdla-azdr. For these Europeans were certainly 
 exposed to the same climatic influences, and the conclusion 
 seems inevitable that, as their climatic surroundings were 
 the same, the source of thei^ immunity is to be found in 
 a difference of habits, and, be it observed, that it is only 
 among such Europeans whose habits assimilate them to the 
 semi-civilized inhabitants of Assam that anchylostomiasis has 
 ever spread. It is only among the lowest class of miners and 
 brick-makers that the disease has been ever known in Europe, 
 never among the class who migrate to Assam to serve as 
 officials, tea-planters, and missionaries. 
 
( 4-2 ) 
 
 Y. — The Symptoms of " Kala-AzAr " as illustrated by 
 
 Cases. 
 
 What then is kdla-azdr f 
 
 The best method of answering this question will be to 
 give the notes of a number of cases, as described by 
 different observers, commenting on whatever may appear 
 most remarkable in each or all. 
 
 I will first quote some cases described by Dr. Dobson, 
 Civil Surgeon of Goalpdra, in a special report on Mla-azdr, 
 furnished by him, when the disease first reached an epidemic 
 importance in that district. These 'cases a -e convenient for 
 our purpose, because, while occupying but little space, 
 whatever is recorded is so much to the point, that it is 
 generally easy to make a diagnosis of the true nature of each 
 case, and they illustrate, in a most typical manner, the sort of 
 cases that are brought to one, when visiting a kaia-azdr- 
 stricken village. 
 
 That Dr. Dobson did not then recognise the greater 
 proportion of them as instances of anchylostomiasis is due 
 to the fact that the disease is one which is never encountered 
 in English medical practice, and that for this reason we 
 are at the best familiar with it only by occasional extracts 
 from the foreign medical press. At the date of Dr. Dobson's 
 report, the connection between the anaemia of coolies and 
 anchylostomiasis was not even suspected. I had the pleasure 
 of many discussions with Dr. Dobson during my stay at Dhubri 
 in March last, and, since then, he has made renewed obser- 
 vations on the subject, and appears to have come to much 
 the same conclusion that I have, for while "opposed to 
 admitting all kdla-azdr is anchylostomiasis," in his remarks 
 on the Damra Charitable Dispensary he says^ " I have no 
 doubt many of the so-called cases of Mla-azdr are cases 
 of anchylostomiasis ;" and notes, too, that malarial cachexia 
 and anchylostomiasis appear to complicate each other in 
 Damra, which is entirely in accordance with my own 
 observations elsewhere. This, it appears to me, is as near 
 a coincidence of opinion as can bo expected so shortly 
 after the promulgation of my views in the preliminary note 
 appended to last year's Sanitary Eeport, and I feel sure 
 that a few more visits to kdla-azdr-siri(iken districts will 
 bring Dr. Dobson's views into entire accordance with my 
 own. 
 
 That people brought low by anchylostomiasis should more 
 
( 43 ) 
 
 readily become the subjects of malarial poisoning is only natur- 
 al, and a very large proportion of cases undoubtedly do present 
 this complication ; but, apart from some amount of increase on 
 this score, I see no reason for believing that malarial cachexia 
 is commoner now than it always has been. From first to last, 
 as much before Mla-azdr was heard of as after, the ravages of 
 malarial poisoning form a prominent subject of annual and 
 other reports. Indeed, the malariousness of Assam is notorious 
 now, and always has l)een, so that it would be indeed astonishing 
 if Mla-azdr cases failed to present this complication. 
 
 Case No. 1 " was that of a Gdro woman, who had been 
 ill for over a year. It had begun with strong fever. She had 
 tried village medicines, which consisted of leaves mixed with 
 mud ; but as she got worse and emaciated, she was told she had 
 *^ldla-azdr' and nothing further was done for her. When seen 
 by me, she had a temperature 103° F. ; she had a troublesome 
 cou^h, with httle or no expectoration, dullness over both lungs, 
 especially about their apices, and all the physical signs of phthi- 
 sis were present. Her pulse 65, and very weak ; her tongue pale, 
 conjunctivse deadly white; eyes far sunk in their sockets ; cheek- 
 bones prominent, cheeks hollow. Appetite almost 7iiL She was 
 80 weak that she could not sit up, and, when raised, we had to 
 put her down. Her spleen and liver were not enlarged : if any- 
 thing, they may have been slightly atrophied. She was passing 
 her stools involuntarily, and had done so for four or five days. 
 There was no dropsy or oedema of any kind present, nor could 
 I learn that she ever had either. Such then was a case of kdla- 
 azdr, but which was in reality a typical case of phthisis. The 
 woman's complexion was of the ordinary brownish colour. No 
 one would come near her, she was alone in a miserable hut, 
 which was tumbling down. Her food and drink were handed 
 in at the door, none of the villagers would touch her : even her 
 husband had taken another house in the village, and the 
 children (varying in ages from three to seven) called out to the 
 Hospital- Assistant and myself, and warned us not to touch her : 
 when they found we had, they immediately called out * you 
 will get Mla-azdr .' 
 
 " This is the popular idea among the Gdros, and it is one that 
 is early impressed on the young mind. The odour within this 
 poor woman's house was very trying. It was difficult to 
 get even these few particulars about her iUness, as every one 
 shunned her : even these particulars, such as they are, must be 
 received with caution." 
 
 e2 
 
( 44 ) 
 
 In this case the most prominent symptoms, at the time of 
 examination, were those of lung mischief. There can, how- 
 ever, be Httle doubt that the case was primarily one of anchy- 
 lostomiasis, low broncho-pneumonia, such as exists in one 
 form of phtliisis, being one of the commonest terminations of 
 the disease, and actual phthisis a common complication.* It is 
 to be observed that there are no signs whatever of malarial 
 cachexia, neither spleen nor liver being enlarged. 
 
 Case No, 2 " was that of a very healthy-looking girl, 
 aged nine years, who was brought to me by her grandfather 
 saying she had Mia azdr. It seems she had fever a year 
 ago, which lasted for two or three months steadily, coming 
 on at evening usually. From the description given of it, it must 
 have been an ordinary case of quotidian ague. For the last 
 two months she had no more fever. Three months ago, for 
 about ten days, but at intervals of two or three days, her 
 nose bled, but to no great extent. At this time also she had 
 occasional attacks of diarrhoea. At present she is very well 
 nourished, with a good appetite, a clean tongue, no pains, no 
 pigmentary deposits of any kind ; her spleen extends down 
 to her groin, and her liver is also enlarged. She is toler- 
 ably dark in complexion. The grandfather is aware of her 
 enlarged spleen, and imagines she had Mia azdr, but does not 
 think she has become blacker than usual." 
 
 This is evidently a case of ordinary malarial fever of a 
 mild type. Observe that, in spite of very large spleen and 
 enlarged liver, her general health is comparatively little affected, 
 as so often happens in such cases, when tending to cure. 
 
 Case No. 5, " a Rabha man ; fever for four months, which 
 comes on every third or fourth day. He had no fever when 
 I saw him. He is well nourished, but slightly anaemic. His 
 appetite is good. Spleen is slightly enlarged. He is darker- 
 skinned than most of his neighbours, but if anything slightly 
 clearer than his own brother, who is in good health. He has 
 been told he has Mla-azdr^ but does not believe it, as he does 
 not think he is likely to die for some time to come. He 
 has never had diarrhoea or oedema of any part of his body." 
 
 Probably a case of early anchylostomiasis complicated 
 with malaria. 
 
 Cases Nos. .4, 5, and 6 " are those of a Kachari man 
 and his two sons, aged five and seven years. They have all 
 
 Vide Dr. Kinsey's pamphlet, already quoted, pages 52-53. 
 
( 45 ) 
 
 been ailing for four months only. A son, aged about four 
 years, died six months ago of the same disease. Their illnesses 
 began with strong fever, which still attacks them every now 
 and again. [The fever is intermittent from the description 
 given]. These three unfortunates are at present very ema- 
 ciated and very anasmic. The father has oedema of both feet 
 (very marked) and puffiness about his eyes. The youngest 
 boy has also oedema of both feet and a collection of fluid in 
 his abdomen and scrotum. The abdomen is so much distended 
 that he is scarcely able to stand. The superficial veins of his 
 abdomen are markedly distended. Both boys have very large 
 spleens. The father's spleen is not enlarged. The livers in 
 all cases are normal. The father alone has suffered from diar- 
 rhoea at times during his illness. At present the bowels of all 
 three are irregular, and they all complain of great weakness and 
 loss of appetite. They have noticed nothing abnormal about their 
 urine, which seems right in colour and quantity. The man 
 has lost all virile power for over two months. I failed to find 
 any pigmentary deposits about this family, in fact, they are all 
 of a light brown tint. They have never had any bleeding from 
 the nose. The father and youngest boy are scorbutic. Their 
 food consists of dhal and rice, and, from what I could gather, 
 very littk of it. The hut they occupied was a miserable 
 one, low and dark, and thickly surrounded with jungle and 
 rank vegetation. This family is in very needy circum- 
 stances." 
 
 These are all three typical cases of anchylostomiasis 
 in an advanced condition. In the case of the two children, 
 it is complicated with malaria, but the father is free from 
 it. Here, too, is an instance of the way in which the disease 
 spreads through a family. 
 
 Case No. 7 "is that of a Gdro woman, said to have 
 had fever for the last four or seven months every now 
 and again. She is slightly emaciated, but very anaemic. 
 Her tongue is pale and flabby, appetite pretty good. Has 
 never had diarrhoea, oedema, or bleeding from the nose. Her 
 spleen is not enlarged. Her great distress seems to be due 
 to an intensely severe pain over the left half of her head. 
 This has troubled her for six weeks^ and is scarcely ever 
 absent. She is at present suckling an infant seven months old." 
 
 A typical case of anchylostomiasis moderately advanced, 
 and without a sign of malarial complication. 
 
( 46 ) 
 
 Case No. 8 " is that of the Agia school-master. He 
 has had fever (intermittent) almost daily ior the last four 
 months. He frequently feels feverish and out of sorts, 
 although no fever is actually present. When I saw him, his 
 temperature was 100'2F., pulse normal, never had diarrhoea, 
 is very scorbutic, his gums were bleeding. Bled from the nose 
 fifteen days ago, and again after three days : on both occasions 
 the bleeding was profuse. His spleen was normal. His appetite 
 bad, his bowels somewhat constipated. His conjunctivaB were 
 very white. He is rather a dark-skinned individual." 
 
 Clearly a case of anchylostomiasis, again without any 
 signs of malarial cachexia. 
 
 Case No. 9 ''is that of a gir! aged 14 years, who had 
 been ill for ten months or more with fever, which she gets 
 rid of for a time only, as she suffers from it off and on. She 
 had diarrhoea, but no dropsy or epistaxis. She is slightly 
 scorbutic. Her spleen is much enlarged. Appetite good. 
 Bowels regular for some time past. Tongue clean. Her 
 complexion is light brown, and she is intelligent and cheerful. 
 She had attended the dispensary two mornings, with long 
 intervals between the two visits, but, as she did not improve, 
 the father informed me there was no necessity for her doing 
 so any more. I attempted to show him the absurdity of his 
 ideas, but he held to his own opinion on the subject." 
 
 An ordinary malarial case, but which hardly can be 
 said to have reached a cachectic condition. 
 
 Case No. 10 "was that of a man, agfed about 23, who 
 had suffered from fever for the past eighteen months. He does 
 not get it near so frequently of late, nor is the fever so severe 
 as it used to be. He is weakly. His gums have bled some 
 months ago, but he hag no scorbutic symptoms at present. He 
 has a fair skin, a huge liver and spleen, and oedema of both 
 feet. His pulse is slow and weak. He is anaemic. His appe- 
 tite is very good. He usually eats dhdl and rice, and only 
 rarely does he eat fish or fresh vegetables. He will not go to 
 dispensary. He is at present being treated by a 'Kobiraj.' 
 The treatment consists in keeping a spot on the crown of his 
 head (about the size of a rupee) shaved, and into it daily is 
 rubbed some preparation, the object being ' to cool the 
 blood.' The application does not burn or smart in the least." 
 
 Also a malarial case, but which is in all probability 
 complicated with anchylostomiasis. 
 
( 47 ) 
 
 Case No. 11, "was that of a young man aged 23, who 
 was greatly emaciated. He had suflered from fever for 
 several years, but only during the last eight months has 
 become very ill. His spleen is enormous, his abdomen is 
 greatly distended, both by his spleen and dropsical fluid. 
 Very marked dropsy of both lower limbs as far up as 
 the knees. The superficial veins of his abdomen are very 
 prominent. He has frequently, at different times of his illness, 
 suffered from diarrhoea, but it has clung to him with great 
 pertinacity for the last six weeks. His urine is of a reddish 
 brown colour, and he passes the usual quantity. He has never 
 bled from the nose. He is scorbutic, and his gums have bled at 
 times. On his trunk are purpuric spots and extravasations- of 
 blood. The mucous lining of his mouth shows a black pigment- 
 ary deposit. He is very anaemic, has no appetite. Now passes 
 his stools involuntarily. Is not able to stand. His complexion 
 is of a light brown colour. His brother says he has become 
 black, whereas, in point of comparison, I remarked he is very 
 fair for a native, and much fairer than this own brother of his." 
 
 A case of anchylostomiasis in its last stage, complicated 
 with malaria and scurvy. 
 
 Case No. 12 " was that of a boy aged five years, who has 
 been ailing for eighteen months. It began with fever, but after 
 about four rilonths the fever left. He is now in tlie same state 
 very nearly as when I saw him on the 8th December last, the 
 only change being a slightly greater enlargement of his 
 spleen, which is truly enormous. His liver is also enlarged. 
 His conjunctivae are yellow. His abdomen is so greatly enlarged 
 owing to the state of his viscera and dropsical effusion, 
 that the poor little fellow, on being made to stand began 
 to cry, lest he should fall down, as he was not able to 
 support himself. When allowed to be seated on the ground, 
 he was perfectly happy. The superficial veins of his abdo- 
 men were distended and prominent. There was no oedema 
 of legs or feet. There was great emaciation. Complexion was 
 of a rich brown colour." 
 
 A case of pure malarial cachexia. Observe how, in this 
 case, ascites precedes oedema of the lower extremities. In 
 anchylostomiasis oedema usually precedes ascites. In mala- 
 rial cachexia of course, oedema often appears later on, but 
 naturally ascites appears first, due, as it mainly is, to mechani- 
 cal obstruction to the portal circulation by the pressure of the 
 
( 48 ) 
 
 enlarged spleen and liver on the vessels. In ancliylostomiasis, 
 on the other hand, the dropsy is of hasmic origin, and naturally 
 commences in the parts most distant from the heart. 
 
 Case No. 13 "is that of a policeman whose home is in 
 North Salmara. His present illness dates four months back, 
 but there is an old history of fever. He says he is unfit to do 
 his work. He is emaciated and has an enlarged spleen ; occa- 
 sionally suffers from diarrhcea, but has never had dropsy or 
 bleeding from the nose. The least amount of work quite 
 knocks him up. He is anaemic, but not scorbutic." 
 
 A case probably of anchylostomiasis and malaria, but it 
 is difficult to say which factor predominates. 
 
 Case No. lU " is that of a Eabha man, age not known, 
 who has been ailing for fourteen months. His illness began 
 with a strong fever (intermittent) which lasted for three months. 
 At the end of this time he had diarrhoea for ten days. At pre- 
 sent he complains of having a great disinclination to do work 
 of any kind, and, should he do any work, he finds a trifling 
 amount quite fatigues him. His spleen is slightly enlarged, 
 and his conjunctivse are very white. Pulse 70, but not 
 strong." 
 
 This, again, is clearly a case of anchylostomiasis in a 
 moderately early stage, with trivial malarial complication. 
 This man's sister was also ill, but Dr. Dobson wag. not allowed 
 to make any proper examination of her case. 
 
 Case No. 15 " is that of a Kabha man aged about 30 
 years. He was somewhat fairer in colour than his neighbours, 
 and was suffering from oedema of both feet and seemed very 
 weak. I was told by his friends that he had been ailing for 
 a long time and that he had kdla-azdr. This man at the time 
 of my visit was busy making a sacrifice." 
 
 This too is pretty certainly a case of anchylostomiasis, 
 though the data are rather scanty. 
 
 Case No. 16 "is that of a boy aged 12 years. He has 
 had fever for over a year. Fever present when I saw him. 
 Very anaemic, liver and spleen both enlarged, the latter very 
 much so. Conjunctivae very yellow. Never had diarrhoea. 
 No other symptoms noticeable ; complexion is of the usual 
 brown colour. The peculiarity about this case is, he is said 
 to have kdla-azdr and yet reputed to have got a yellower colour 
 than he was when in health. His father asserts ' he has not got 
 blacker, but fairer.' " 
 
( 49 ) 
 
 Appears to be a case of ordinary malarial cachexia, perhaps 
 complicated with anchylostomiasis. 
 
 Case No. 17 "is thsit of a Eabha man aged 40, although, 
 according to his own statement, he is not more than 20. 
 Hehassiifleredfrom fever for ten days. IX is intermittent in 
 type. He is altogether a debilitated subject and anemic, his 
 chief complaints being weakness and total loss of virile power, 
 during the last three days only. He further stated this is usual 
 in kdla-azdr, and that when the women get kdla-azdr their 
 menses cease." 
 
 There is nothing here to account for the anasmia, but 
 anchylostomiasis especially as the condition of the spleen is not 
 stated, but enlargement cannot have been very marked, or it 
 would have been noticed, as in the other cases. 
 
 Case No, 18 "is that of a Eabha man who has had fever 
 for over two years. For the first four months he suffered most, 
 and then he found he had a large spleen. The fever still 
 attacks him occasionally. He now suffers from great weak- 
 ness, and is quite unable to move beyond his door. He is 
 extremely emaciated, his conjunctivae are very anaemic. He 
 has suffered from diarrhoea for the past two months. Never 
 bled from nose. Is scorbutic. Belly greatly distended with 
 fluidjthe superficial veins of abdomen are prominent, spleen enor- 
 mous. Liver seems normal. Great oedema of both feet. 
 Pufhness about the face and eyes. Complexion light brown, 
 but on the mucous lining of his cheeks there is a" fair amount of 
 bluish black deposit, which is very distinot. This man has 
 two children aged about four and two and a half years of age. 
 Both these youngsters have large spleen, and are thought to be 
 healthy. The father has lost all virile power for the past four 
 months only." 
 
 A case of anchylostomiasis in the last stage, the oedema 
 affecting even the face. There is malarial and scorbutic com- 
 plication. 
 
 Case No. 19 "is that of a chaukidar in charge of the Public 
 Works Department rest-house. He has had intermittent fever 
 daily for the last three months. He has become very thin and 
 weak, and has no desire to do anything. He is very ansemic. 
 His spleen is not yet enlarged. His appetite is very poor. 
 He says he has ' kdla-azdr.' He is of a light brown colour. He 
 objects' to take our drugs. I saw this poor fellow again some 
 days ago, and he then had strong fever, 103°F." 
 
( 50 ) 
 
 A case of aAcliylostomiasis, with an intercurrent attack 
 of malarial fever, Lat m the absence of any signs or history 
 of chronic molarial disease, Le certainly cannot be said to be 
 a subject of molarial cachexia. 
 
 Case No. 20 " was a child eight years old who had fever 
 two years ago, which lasted for several months, and which left 
 the child very weak and emaciated and with a large spleen. 
 The weakness is daily getting worse, and a few days at most will 
 see the end. No further symptoms discernible, nor could I 
 obtain any further history relative to this case." 
 
 This, on tlu other hand, is probably an ordinary malarial 
 case. 
 
 While on this tour, Dr. Dobson, apparently mistrusting the 
 sufficiency of malarial poisoning to account for what he had 
 seen, examined 42 cliil< ' -en to all appearance quite healthy and 
 reputed to be so, and found that 21, or half the number, had 
 enlarged spleen, the organ in some cases being very large. This 
 accords with my own experience in the Chaygaon district, 
 where I examined the spleens of a large number of people repu- 
 tedly healthy. The proportion was about the same, but unfortu- 
 nately I have lost the slip on which the notes were made. If 
 then half the reputedly healthy population show more or 
 less spier* c enlargement, is it surprising that it should be 
 found also in kdla-azdr f The reverse would indeed be as- 
 tonishing, and in the face of such a fact it is obviously 
 absurd to attach any pathognomonic importance to this 
 symptom in connection with the etiology of kdla-azar. 
 
 The next cases are from Mr. McNaught's series, but, 
 owing to the detailed mass of daily notes, it is impossible 
 to insert them in full, so that an abstract only is given : — 
 
 Case No. 21^ Mantang, cultivator, age about 30, living 
 at Kalputa in the Garo Hills. Father died when he was a 
 child, mother about a month ago. Is married, and has two 
 children, said to be healthy. His village consists of about 
 16 houses, all inhabited by Gdros. A large number of people 
 had died of kdla-azdr in neighbouring villages, but his 
 village was not attacked till about a year as^o. The disease 
 was believed to have been brought from Khilonbari, which 
 is within sight of Kalputa. A man called Thodang was the 
 first person attacked, and, though ill, he still lives. This 
 man's grown-up niece, and some of his children have since 
 
( 51 ) 
 
 become affected. After this, a man called Melcha took the 
 disease. Then Illal 's household became affected, and four of 
 his people are still ill. Two men died of the disease in 
 separate houses, but the' family of one of them were not 
 affected. This illness commenced about a month ago with 
 feverish symptoms and diarrhoea, then his spleen became 
 enlarged and he began to lose flesh. 
 
 Present condition is weak, thin, and anseniic. Has slight 
 anasarca, appetite bad, slight looseness of the bowels ; spleen 
 enlarged to 10 ^gers below the ribs. Abdominal pain. 
 
 The man remained 3^ months in hospital, and, in spite of 
 continuous anti-malarial treatment, grew steadily worse, had 
 repeated bowel attacks, and died from an attack of pneu- 
 monia. 
 
 He is recorded as having fever pretty regularly at 
 some portion of the 24 hours. In spite of this, his tempera- 
 ture, with one or two shght rises, remained subnormal during 
 the whole of his stay in hospital, often not reaching the nor- 
 mal for a week too^ether. Durinoj the last fatal attack of inter- 
 current pneumonia, it ran up to 103°, and remained above 
 normal for some days. It had, however, been again subnormal 
 (9§-8°.) for some days before his death. The Hospital- Assistant's 
 puzzlement at having to do with a case of fever, which the ther- 
 mometer persistently belied, is betrayed by such phrases as ^'N"o 
 fever now, but had fever during the night," never apparently 
 suspecting that the man had no fever at all, and that his saying 
 he had had it, merely meant that he felt ill, and that, like most 
 sick people, he felt worse at certain periods of the 24 hours 
 than at others. Anti-malarial treatment had a fair trial in this 
 case. Quinine in 16 grains doses, arsenic, iron, and iodine were 
 all tried, and persevered in ; but, in spite of the fact that the 
 man 's case was at first by no means serious, and had only 
 lasted a month, under this treatment the man steadily grew 
 worse instead of better. Considering that the only symptom of 
 malarial poisoning in this case was a moderately enlarged 
 spleen, such as is found in immense numbers of Indians, to 
 all appearance enjoying very fair health, this result is by 
 no means surprising. 
 
 Post-mortem examination tibelve hours after death. — 
 Body emaciated, not darker than usual. Feet oedematous. 
 Section of tissues anaemic. 
 
 Thorax left plural cavity contained fluid of a slightly 
 turbid character, pleura congested and rough. Posterior 
 
( 52 ) 
 
 part left lung in a state of gray hepatization, no fluid in right 
 pleural cavity. 
 
 Heart contained P. M. clots ; structurally healthy. 
 
 Abdomen contains a moderate amount of pale serum. 
 
 Liver of normal size, not congested, of firm consistence, 
 " otherwise of normal appearance." Spleen enlarged to three 
 times normal size, lobulated, section firm, capsule thick and 
 corrugated, no infarcts. 
 
 Kidneys — right congested, medullary portion slightly 
 granular ; left of similar appearance. Suprarenal capsules 
 appear normal. • 
 
 Stomach contains thick white mucous adhering to 
 mucous membrane, the surface oj which is brownish and cor- 
 rugated, but not ulcerated ; mesenteric glands of normal size ; 
 section anaemic. 
 
 Intestines — the duodeiium and about 2 feet of the jejunum 
 were of somewhat slaty colour, ivhich became lessened gradually in 
 the lower parts. — Lower down the bowels were considerably 
 thinned with patches of dotted congestion, sometimes extending 
 through Peyer's patches in streaks, but not over the whole 
 surface, but no ulceration, and there were other Peyer's 
 patches quite healthy. 
 
 Here we have described a typical case of anchylosto- 
 miasis alike in symptoms, progress, and termination. Post- 
 mortem — the appearances found after death in such cases 
 are all described, except the worms, which, as I well know, 
 are much more easily overlooked than found, even when 
 one is actually searching for them ; but the condition of 
 the stomach, and of the duodenum and upper part of 
 the jejunum are most typical, and a similar combination will 
 hardly be found in any other disease than anchylostomiasis. 
 
 The thinning of those parts of the intestine not the seat 
 of active irritation from the parasite, is of course only a part 
 of the "general emaciation, while the reddish streaks found were 
 probably only patches of hypostatic congestion. 
 
 Case No. 22, Khejan, a Grdro cultivator, M%. about 15 
 years, came from Kerapara in the Gdro Hills. "The usual 
 history " of illness for some time, with enlarged spleen, fever, 
 gradual wasting, and inability to work. 
 
 Present condition is aneemic, thin, and weak, but can still 
 get about. Gets fever irregularly. Bowels regular, chest 
 healthy, pulse quick, tongue pale, appetite fair, spleen sfightly 
 enlarged. None of his relatives have had kdla-azdr. 
 
( 53 ) 
 
 The after history of this case closely resembles the preced- 
 ing. He was submitted to anti-malarial treatment, under 
 which the spleen diminished in size ; but, in spite of this, he be- 
 came steadily worse, and died from a violent intercurrent attack 
 of diarrhoea, after a stay in hospital of a little less than three 
 months. 
 
 A temperature of 10 1* 8° is recorded once only, and with 
 this single exception, there was never any pyrexia during his 
 whole stay in hospital, and, as in the preceding case, the 
 temperature is often sub-normal. 
 
 The poci-mortem examination showed the death to be 
 immediately due to enteritis. The same peculiar appearances 
 are recorded in the duodenum, and he also describes a large 
 number of " deposits of pigment of an inhy hue varying in size 
 from that of a millet-s^ed to a split pea, many of them being quite 
 firm to the feel!' 
 
 These are of course the well-known "bites " made by the 
 parasite, and consist of extravasations of blood into the mucous 
 and submucous tissues. It is instructive to note that, whatever 
 malarial element may have at first been present in this case, it 
 was in a fair way to cure at the time of his death. 
 
 Case No. 23, Nausi, a Gdro cultivator's wife, aged 26. 
 Kald-azdr had appeared in her village two years ago. She 
 has been ailing for a year, her child took the disease and died, 
 and her husband ran away from her, from fear of contracting 
 it. Her illness commenced with pain in the head and discharge 
 of blood from the bowels. She stated that her skin had become 
 darker. Her appetite is bad, she complains greatly of head- 
 ache. Her spleen is somewhat enlarged. She is thin and weak, 
 face and eyelids puffy, conjunctivae of a " muddy" colour, 
 tongue pale and flabby. Base of lungs oedematous. 
 
 This woman remained nearly six months in Hospital, 
 during which time she had repeated severe attacks of diarhoea, 
 the bowels being loose the greater part of the time. She grew 
 decidedly better, the diarrhoea ceased, and she was discharged 
 apparently in a fair way to cure. 
 
 This case is less clear than the preceding, but the 
 degree of enlargement of the spleen will not account for 
 the oedema, &c., and the general severe symptoms, and it 
 is probably one of anchylostomiasis also. It seems probable 
 that the violent and repeated attacks of diarrhoea may have 
 dislodged the worms. I am strongly inclined to believe that this 
 sometimes takes place, though I have not as yet been able to 
 
( 54 ) 
 
 find worms in such a cas3. My opportunities, liowever, have 
 been small, as I have' nearly always given thymol after but 
 few days' observation. 
 
 Case No. 2i, Dachi, a girl aged 12, daughter of a culti- 
 vator ; was driven away from the village, because she had 
 kdla-azdr. Her parents had both died of it. She was found 
 on the road, and brought into Tura in a state of semi- 
 starvation. 
 
 Present condition. — Body thin, feet and face oedematous, 
 anaemic, bowels loose. Her spleen is very large. 
 
 This patient rallied at first, but suffered almost conti- 
 nuously from diarrhoea and severe abdominal pain. Her tem- 
 perature;, though not of a malarial type, remained at one time 
 continuously between 101° and 102°. It is only recorded, how- 
 ever, for a few days, and the pyrexia was probably connected 
 with a severe attack of enteritis. She lingered on for three 
 months, and finally died from a fresh bowel-attack. 
 
 Post-mortem examination. — Body much emaciated, section 
 of tissues anaemic. 
 
 A little serum in pericardium and pleura, but thoracic 
 organs otherwise healthy. 
 
 Liver large, somewhat congested. 
 
 Spleen very much enlarged. 
 
 ^Duodenum somewhat chickened and large. Jejunum has 
 a darkened appearance caused by a remarkably fine dotted 
 pigmented deposit not ulcerated. There were arborescent 
 patches of congestion in the ilum, but Beyer's patches were 
 healthy, and so were all other remaining organs. 
 
 There can be of course no doubt as to the gravity of the 
 malarial complication in the case of this poor waif, but i\\Q post- 
 mortem -appearances leave no doubt as to the case being one of 
 anchylostomiasis, and, as she died from the irritation to the 
 small intestine caused by the parasites, it was evidently this, 
 and not the malarial complication, that caused the fatal issue. 
 
 Case No. 25 a Gdro woman, aged 28, wife of a cultiva- 
 tor. Lives at Marapura, where three people had already 
 been attacked by kdla-azdr^ one of whom has since died. She 
 was taken ill about a year ago, and since then, her husband 
 has become ill, and her child has died. The illness commenced 
 with fever, followed by enlargement of spleen. Has had 
 diarrhoea for two or three months, severe pain in the head, 
 lost fiosh, and has become unable to work. 
 
( 55 ) 
 
 Present condition. — Is still able to stand and walk, but 
 is very weak and emaciated. Her appetite is now fair. She 
 is anaemic, her feet are oedamentous, and her spleen is enlarged 
 to six fingers breadth below the ribs. Her skin does not 
 appear to have grown darker. 
 
 This patient seems to have improved somewhat ; she does 
 not appear to have had any fever a hatever during her stay in 
 hospital, which extended to two months and a half, but the 
 termination of the case is not i eccrded, as she appears to have 
 been still under treatment when the collection of cases was 
 sent in. This, too, is in all probability a case of anchylos- 
 tomiasis, at any rate the amount of splenic enlargement is 
 quite inadequate to account for the anaemia and anasarca. 
 
 The remaining 25 cases of Mr. McNaught's series include 
 several which there can be no doubt were instances of anchy- 
 lostomiasis. They also include one case of acute pneumonia, 
 two of acute dysentery, several cases of ordinary or remittent 
 fever, which of course yielded to treatment, and one or two 
 cases in which the evidence points to malarial cachexia, besides 
 some cases in which apparently anchylostomiasis and mala- 
 rial cachexia coexisted in various proportions. In some cases 
 from the police and jail hospital there is nothing to show that 
 the patients believed themselves to hsive kdla-azdr, and they seem 
 to have been classed as such, simply because they had fever. 
 
 It is quite evident that Mr. McNaught was on the verge 
 of discovering the true nature of the cases with which he had 
 to deal. The careful examination he made of Peyer's patches 
 in each case shows that he suspected some connection with 
 typhoid fever, but in place of the lesions characteristic of that 
 disease, he found changes in the upper part of the gastro-intes- 
 tinal canal which he saw were quite peculiar, but which, 
 owing to the non-discovery of the worms that cause them, 
 remained inexphcable. The preliminary washing necessary 
 for a careful examination of the mucous surface necessarily 
 washed away the worms, and left him only the changes pro- 
 duced by them to observe. All his dissections were made 
 several hours after death, or, in other words, at a period when 
 the worms would have become detached from the mucous mem- 
 brane, and so enveloped in the glairy yellow mucous of the 
 duodenum as to be quite invisible except to closest scrutiny, 
 directed especially to their discovery. Had he chanced to 
 have made one of his examinations immediately after death, 
 while the parasite is still fixed to the mucous membrane, he 
 could scarcely have failed to have found them and to recognize 
 
( 56 ) 
 
 the causal connection between them, and the pecuUar, and 
 otherwise inexphcable lesions he had found in those portions 
 of the bowel occupied by them. 
 
 Case No. 26 (Dr. Nandi's series). — Manara, an Assamese 
 Muhammadan, aged 25. For the last five years has lived in 
 Gauhdti as a domestic servant in a native family. Before this 
 he served as water-carrier, on a tea-garden for about two years. 
 
 About six months ago suffered from fever, and since then he 
 has got steadily worse, suffering mainly from dyspeptic 
 symptoms. 
 
 Present condition. — Is markedly anaemic and emaciated, 
 with a much enlarged spleen and slight anasarca of the feet. 
 Can walk a little. Urine s. p. 1,010, acid, no sugar or albu- 
 men. As he was suffering from diarrhcea, no purgative was 
 given, but he was at once placed upon slop diet and thymol 
 administered, four doses of 30 grains being given at 6 a.m., 
 8 a.m., iO a.m., and noon. He passed one stool at 9*30 and 
 another at noon, and both were examined for anchylostoma, 
 as well as one passed at 4 p.m., the previous day, before the 
 administration of thymol, but no worms could be detected. 
 
 This and the following four cases are interesting, because 
 they are not originally contributed as examples of kdla-azdvy 
 but in compliance with a circular of the Sanitary Commis- 
 sioner, requesting an investigation as to whether or not anchy- 
 lostomiasis existed among Native Assamese as well as among 
 imported coolies. That the case was one of anchylostomiasis 
 there cannot be the slightest doubt, and the way in which the 
 discovery of the worms was missed is a good illustration 
 of the way in which misleading evidence has accumu- 
 lated. It will be observed that the last stool examined 
 was one passed about the same time as the administration 
 of the last dose of thymol, and only six hours after the first. 
 Food and badly soluble drugs such as thymol introduced into 
 the stomach remain there, as a rule, about four hours, so 
 that only two hours are left for the intestinal contents to 
 pass from the duodenum to defsecation, a time entirely 
 inadequate, even supposing the worms to be destroyed by the 
 first contact of the drug. 
 
 I have seldom, if ever, found any worms until some eight 
 hours after the last dose, and it would have been truly 
 surprising if they had been found in this case. The next case, 
 in which Dr. Nandi succeeded in discovering the worms, illus- 
 trates this point. 
 
( 67 ) 
 
 Case No. 27 . — Domolio, an Assamese Hindu convict, age 
 about 32, lias been in jail about a year, previously to which, with 
 the exception of a month, during which he served in Gauhdti 
 as a servant, he had resided at Nomati in the Nalbari thdna. 
 About four months ago, had fever and cough, and has not 
 been well since, suffering much from palpitation of the heart, 
 dyspepsia, occasional diarrhoea, alternating with costiveness, 
 with rumblings, and occasional abdominal pain. 
 
 Present condition. — Marked ansemia and weakness, with 
 some emaciation. Feet just pit on pressure. After the ad- 
 ministration of a preliminary saline purgative, the patient 
 was given three 30-grain doses of thymol at 7 a.m., 9 a.m., 
 and 11 a.m. followed by a second saline purge. 
 
 At 5-30 p.m. (z.^., 6|^ hours after the last dose), he passed 
 a stool containing 25 anchylostomes. 
 
 At 6 a.m. a stool containing only two as car ides. 
 „ 8 p.m."] passed stools, which were collected in a single 
 „ 9 „ > vessel, and found to contain a number of 
 „ 10 „ ) anchylostoma and one ascaris. 
 
 It will be observed that it is not till nine hours after the 
 last dose that the bulk of the worms appear. It is improbable 
 that he contracted the disease in jail, so that it was probably 
 contracted in his native village, a fact which would seem to 
 point to a somewhat prolonged period of incubation, during 
 which the worms were slowly growing to maturity. My 
 experiments on monkeys, though not conclusive, would seem 
 to point to a similar conclusion. 
 
 Case No. 28. — Kikhor, aged 20, a resident of Gauhdti, 
 but in the habit of making trips to upper Assam in pursuance 
 of his caUing, as a boatman. For the last six months 
 has been suffering from abdominal pain, alternating diarrhoea 
 and constipation, with palpitation of the heart. Is anaemic and 
 weak, feet oedematous, face to a less extent so. Has enlarged 
 spleen, and the hepatic region is rather full, with pain in left 
 hypochondriac and umbilical regions, and winces on pressure 
 over hepatic region. Urine high coloured, no albumen. 
 
 Treatment — Calomel, grains ii., every four hours, for four 
 times, followed next morning by thymol, grains xxx, at 
 6 a.m., 8 a.m., and 11 a.m. He passed one stool at noon, and 
 a second at 1 p.m., which were examined, but no anchylostoma 
 were found. 
 
 The patient died four days after, and a» post-mortem exarai- 
 ination was made. The description of the changes recorde'd 
 
. ( 58 ) 
 
 reads mucli like some of Mr. McNaught's cases, with the addition 
 that nearly the whole length of the intestinal mncous mem- 
 brance was closely scrutinized, but no anchylostoma found. 
 
 Here, again, the last examination of the stools was made 
 only an hour after the last dose of thymol, and however many 
 worms may have been ejected by it, they would not be dis- 
 coverable in the stools until many hours after. After such 
 a thorough dosing with thymol and purgatives, the close search' 
 for anchylostomes was hardly likely to be rewarded, as all 
 would be, almost infallibly, cleared out of the intestine. 
 
 Case No. 29. — Jugil Kachari, aged 13. Has served 
 for the last three years on a tea-garden, whence he 
 was admitted to the charitable dispensary, Gauhdti. About 
 a year ago suffered from fever, and two months after this his feet 
 commenced to swell, and he gradually became very weak. 
 
 Present state. Is anaemic, suffers from palpitation of the 
 heart, pulse 100. Spleen enlarged, feet oedematous, face slightly 
 swollen. Appetite bad. Suffers from alterating diarrhoea and 
 constipation. Liver shghtly enlarged. Thymol was given in 
 15 grain doses (a quantity I have personally found inade- 
 quate), and the last stool examined was passed five hours after 
 the last dose. 
 
 Under the circumstances, it is not surprising that no worms 
 were found. Here is a regular case of tea-garden beri-beri, yet 
 observe the identity of the symptoms with those recorded in 
 kdla-azdr, even to the fever and hepatic and splenic enlarge- 
 ment, and notice the double fallacy involved in the assumption 
 that no anchylostomes were present.* 
 
 Case No. 30. — Shaik Hyat, an Assamese Muhammadan, 
 aged about 40. Has served off and on in tea-gardens, was in 
 hospital five or six months ago with syphiHs. Has lately become 
 weak, and has, for a long time, suffered from diarrhoea and 
 dyspepsia. A little while ago had an attack of melasna, lasting 
 two or three days, during which he passed much blood, quite 
 unaccompanied by pain or tenesmus. 
 
 Present condition — Emaciated, weak, and anaemic. Feet, 
 legs, and scrotum oedematous ; a little ascites. Breathing 
 laboured, appetite bad. No enlargement of liver or spleen. 
 He was given thymol at 6 a.m., 8 a.m., and 10 a.m., and stools 
 passed at 9 a.m. and 11 a.m. were examined for worms, but 
 naturally enough none were found. The case, of course, is a 
 typical one of anchylostomiasis. What other disease indeed 
 will account for the painless melaena ? 
 
( 59 
 
 To this collection I add two of my own cases observed in 
 the charitable dispensary, Gauhdti, which illustrate certain 
 points which are not noticed in any of the preceding cases. 
 
 Case No. 31. — Api, aged 4, an orphan, can give no account 
 of herself, but is a Kachdri, a class whose diet is of a mixed 
 character, and in fact will eat almost anything. 
 
 The child is extremely weak ; cannot stand without assist- 
 ance ; there is general oedema and ascites ; and the face is 
 very puffy, but there is no special prominence of oedema along 
 crest of tibia. There is no sign of paresis or of diminished 
 sensation, and the special senses appear normal. Complexion 
 moderately dark, skin dry and hard. She is anaemic to the 
 last degree, tongue clean, but deadly pale, pulse 102, very 
 weak. Bowels loose, but motion not dysenteric. The lower 
 part of the chest contains fluid, but the lungs and heart are 
 otherwise normal. The liver dulness extends barely to the 
 costal margin : above, its limits are masked by the presence of 
 fluid in the chest. The spleen appears much enlarged, but, 
 owing to the presence of ascites, and much flatus, it is difficult 
 to define its exact limits. The blood was very watery, and poor, 
 in red corpuscles, which did not exhibit the normal uniformity 
 of size. No micro-organisms could be detected in it, and 
 attempted cultivations gave negative results. 
 
 A few days after she came under observation, the post 
 mortem in which anchylostomes was first found, occurred, 
 and, on examining her dejecta, large numbers of ova were 
 discovered. She was given thymol, and a large number of 
 anchylostomes and a few lumbrici were expelled. No good, 
 however, resulted, and I am even inclined to think that the 
 fatal termination may have been accelerated. She gradually 
 sank, and died about three weeks after she came under my 
 observation. There were a few irregular elevations of tempera- 
 ture, but otherwise the temperature was constantly subnormal. 
 
 Post-mortem examination, made three hours after death. 
 Total weight, 30 pounds. Body emaciated, but extremely oede- 
 matous, the distended cellular tissue being an inch deep over 
 the chest, and, like all the other tissues, excessively anasmic. 
 Abdomen, plur^ and pericardium full of fluid. Brain 2 pounds ; 
 some fluid in ventricles, otherwise healthy. Heart 2^ ounces ; 
 muscle rather oedematous, right side contains a large ante-mor- 
 tem clot, a tail of it extending into the pulmonary artery. 
 Valves healthy, witli the exception of three small hard granu- 
 lations (old) on posterior flap of mitral. • 
 
 f2 
 
( 60 ) 
 
 Lungs — Eight 4 ounce, left S}^ ounce. Both very oede- 
 matous ; a few scattered mihary tubercles on surface of right ; 
 none on left. 
 
 Liver, 1 pound 5 ounces, of normal appearance, gall blad- 
 der much dilated, containing, greenish, glair}^ bile. 
 
 Spleen, 9 ounces, dense, and harder than normal ; no 
 adhesions on the surface. 
 
 Kidneys, weigh together 4 ounces. Capsule peels easily in 
 both, right with convex border congested, interior pale. Left 
 pale throughout, cortex somewhat atrophied. 
 
 Stomach shows scattered petechias. Greater curvature of 
 a dull bluish red colour. 
 
 Intestine, duodenum and upper part of jejunum of a 
 peculiar slaty hue, closely spotted with marks of old and recent 
 bites. In duodenum and upper part jejunum ten anchylosto- 
 mes were found (eight females and two males) adherent to the 
 mucous membrane, most being found about three feet down 
 jejunam. Besides these, a number of shred-like bodies contain- 
 ing ova (probably dead, half -digested parasites) were found 
 in the intestine. The ileum contained a number of lumbrici^ and 
 trichocephali were found in the coecum, some lying coiled up 
 within ulcerated surfaces. Near the anus a number of oxyu- 
 rides. 
 
 Case Xo. 3^2. — Jagat Das, a Hindustani, vrlio had lived 
 for some years in the neighbourhood of Gauhati. Age about 30. 
 Much emaciated. Height 5 feet 6 inches, weight 901bs. Can 
 scarcely stand, and is too apathetic to give any clear account 
 of his past history. 
 
 Face puffy, legs oedematous. No modification of sensory 
 or motor power, apart from extreme weakness and hebetude. 
 Is frightfully anaemic, and the tongue is very pale, but furred. 
 Skin dry and cold. 
 
 Area of cardiac dulness somewhat increased, but difficult 
 to define, on account of being merged below in the dulness 
 extending over the lower pulmonary area. A weak systolic 
 murmur, marked ascites, but no other abnormality of abdo- 
 minal organs. He is constipated, but complains of no pain. 
 Some kaladana was given to relieve the bowels, and the 
 dejecta were found to contain large numbers of ova, but the 
 food was passed mainly undigested. 
 
 This man hved only three days after admission. Thymol 
 could only have precipitated matters, and so was not given, 
 TJie temperature was persistently sub-normal, and, two hours 
 
( 61 ) 
 
 before death, was only 90° in the rectum, the lowest tempe- 
 xature I have ever seen recorded in a living human being. 
 The blood was repeatedly examined at different periods of 
 the day, but no micro-organisms could be discovered. 
 
 Post-mortem examination four hours after death. — Ema- 
 ciated and anaemic, but very oedematous. 
 
 Chest. — A small quantity of fluid in each pleura, the 
 pericardium contained much fluid. 
 
 Lungs. — Eight l^lb., left l^lb. Both extremely oedema- 
 tous throughout, congested below, extremely pale above. The 
 larger branches pulmonary arteries contained ante-mortem clots. 
 
 Heart. — Eight side filled with an enormous ante-mortem 
 clot, which extended into the auricular appendix, and into 
 the pulmonary artery and its branches. Muscular substance 
 thin and pale. Mitral valve and adjacent endocardium some- 
 what thickened. Left ventricle empty. 
 
 Abdomen. — Contained a quantity of ascitic fluid. Liver 
 lib. 15|oz., pale, but otherwise normal, gall-bladder moderately 
 full. 
 
 Spleen 5oz., tissue of normal appearance, very firm. 
 Kidneys each 4oz. Pale, but otherwise healthy. 
 
 Intestinal canal. — (Esophagus pale, but normal. Stomach 
 dilated, pale, with a few reddened patches and petechioe, the 
 walls of the organ are so thin as to be nearly transparent. The 
 bowel was loaded with alvine secretion throughout the upper 
 part, containing mucous streaked with blood. The ascending 
 colon containing soft fa3cal matter, while the lower bowel is 
 filled with a hard mass. No ova could be found in the mucus 
 from the upper part of the bowel; they were extremely 
 numerous in the soft faecal matter in the ascending colon, 
 wiiile they were comparatively rare in the hardened •mass. 
 The upper end of the small intestine must have contained 
 about a thousand anchylostomes. The first specimen was 
 found adherent immediately below the pylorus, and they 
 were adherent in great numbers to the whqle of the duodenum, 
 and upper third of jejunum. The greatest numbers to be 
 found in the commencement of the jejunum, where 65 were 
 counted adherent to a piece of bowel eight inches in length ; 
 on this piece only 10 more recent bites than adherent worms 
 could be counted. About 3J feet along the jejunum, only 
 30 could be counted in a similar length, while at 5 feet 
 only unadherent specimens could be found, and a few such 
 could be found throughout the greater part of the length 
 of the small intestine. No other entozoa were present. The 
 
( C2 ) 
 
 aorta and larger veins, as well as the tlioracic duct, were 
 examined, but presented nothing abnormal. 
 
 At first sight, it might appear, from a perusal of this collec- 
 tion of cases, that we were as far as ever from being able to de- 
 fine what kdla-azdr is. 'It will be observed that it includes cases 
 of the most diverse character. For the most part, however, all 
 are chronic cases, whose common leading characteristic is ca- 
 chexia. Even this characteristic, however, is not universal, for, 
 as we have seen, cases of acute maladies, such as dysentery 
 and pneumonia, are included. 
 
 Putting these aside, however, the common symptom that 
 characterizes the greater number of the cases is anaamia, and tlie 
 prominence and importance of this symptom has been noted 
 by all observers, in illustration of which we may now with 
 advantage add some of the remarks as to the general symptoms 
 oi the disease that have been made, from time to time, by 
 medical officers who have given special attention to the subject. 
 Deputy-Surgeon-General Clarke (Annual Sanitary Eeport, 
 1882), epitomizing the accounts he had received from various 
 sources, says " a disease commencing with pyrexial attacks, 
 ushered in with rigors, and followed by sweating frequently 
 recurring, accompanied by pains in the joints and continued 
 headache, resulting in a condition oj general ancemia with 
 splenic and hepatic enlargement. This is followed by extensive 
 anasarca of haemic or renal characters affecting the face, eyelids, 
 abdomen, and feet; occasionally by melanasma, epistaxis, diar- 
 rhoea, melsena, aphonia, and symptoms of laryngeal and bronchial 
 catarrh. The disease generally terminates by death from gene- 
 ral asthenia. * ♦ * Nearly all the preceding symptoms 
 seem to depend on one other symptom not yet mentioned. 
 That symptom is an intense anasmia, which shows itself at an 
 early period, and continues to increase in* intensity as the 
 disease progresses." 
 
 Now, I have strong reason for believing that anchylosto- 
 miasis does often commence in a pyrexial attack, but putting 
 aside the pyrexial onset, could one possibly have a better 
 account of the symptoms of anchylostomiasis than is here given ? 
 
 Dr. Borah (Appendix to Annual Eeport of 1888) says 
 — " The train of symptoms appear in the following order : — 
 Anasmia, enlargement of the liver, loss of appetite, emaciation, 
 oedema of the feet, diarrhoea, ascites, and, in a very few cases, 
 cancrum oris (due to poverty of the blood), also enlarged 
 spleen and phtliisis pulmonalis." 
 
( 63 ) 
 
 Here again, the description will apply well to cases of 
 ancliylostomiasis and to no other disease. The order of appear- 
 ance of the dropsical symptoms, too, is given quite definitely 
 and accurately, and is, as I have already observed, the reverse 
 of what is found in malarial cachexia. The very small promi- 
 nence given to enlargement of the spleen in this description 
 is another indication of the carefulness of the observations 
 that underlie it, especially when we remember that the writer 
 was fully convinged of the malarial origin of the disease, 
 and, but for this predisposition, must have recognised that, 
 though anaemia may result from chronic malaria, it is a sequel, 
 and not a premonitory symptom, of the disease, as here 
 described. It is evident, indeed, that Dr. Borah strongly 
 suspected the true cause of 'the malady, for he states that he 
 used thymol in some cases, but failed to discover any worms. 
 That he did not find them is probably due to the fact that 
 •it is quite useless attempting to find them by a mere inspec- 
 tion of the dejecta, unless they be present in quite exceptional 
 numbers, though it is equally possible that the cases on 
 which he happened to try the drug, may have been instances 
 of ordinary malarial cachexia, or other wasting disease. 
 
 Dr. P. M. Gupta, speaking of the disease, as seen jn the 
 Gdro Hills, in the same appendix, describes the symptoms as 
 follows : — " Obstinate diarrhoea and dysentery, inflammation, 
 affections of the respiratory organs, enlarged spleen and 
 liver, epistaxis, with a general tendency to hoemorrhage, dread- 
 ful angemia, dropsy, and general anasarca are the most pro- 
 minent complications." Here there is no attempt to describe 
 the order of appearance of the symptoms, but the general 
 description answers most thoroughly to the complications 
 that appear in the anaemia of anchylostomiasis. 
 
 To these pictures of the disease. I can add but Httle, and, 
 as I shall have to refer more fully to this point when writing 
 of anchylostomiasis as such, I will not here insert observa- 
 tions, which would necessarily have to be repeated. It is 
 obvious that acute cases of ordinary tropical maladies, differ- 
 ing, as they do, in no way from cases met with aU over India, 
 can have nothing whatever to do with the enhanced morta- 
 lity, and the same remark applies to chronic cases, such 
 as the instances of caries of the spine, of phthisis, and of 
 lardaceous disease which were brought me as kdla-azdr. 
 
 Eeally, the only common character of the cases is that 
 they believed themselves to be suffering from kdla-azdr, and, 
 in point of fact, it will be found in visiting a M/a-a^ar-stricken 
 
( 64 ) 
 
 village that any and every case of illness, alike chronic and 
 acute, will be brought out and exhibited to one under that 
 name. Nor is this unnatural. Even the most highly-civilised 
 natives of Europe can hardly be trusted to diagnose their 
 own diseases ; and I would submit that if, in all cases, as has 
 been done in this instance, we left the diagnosis to the patient, 
 there are few diseases in which we should not be in equal 
 confusion, and that, for example, in India at least we should 
 draw no distinction between small-pox, measles, and vj^ricella ; 
 for it is notorious that, in most parts of India, natives return all 
 three as small-pox : yet "either of the three might be the cause 
 of a widely-spread epidemic, and to argue that an epidemic of 
 measles must necessarily be one of small-pox, because the latter 
 disease had always been common in the affected district, and 
 the general populace saw no difference between them, would be 
 obviously fallacious, and none the less so, because it would 
 be necessarily easy to find plenty of cases of true small-pox to* 
 support one's contention. 
 
 To account, however, for a malady which causes a 
 mortality so rapidly increasing, so severe, and so different 
 from our previous experience of the diseases - of the country, 
 we must seek some newly-introduced cause : some disease 
 which has not been always endemic, and not a malady like 
 malaria, which has always been rife in Assam, and which 
 depends on conditions which have remained entirely un- 
 changed. We are, it is true, still much in 'the dark as to the 
 exact causation of malaria, but, if this enormous increase 
 of sickness be due to it, we ought to be well on our way to 
 a certainty, as to some at least of its effective causes, for 
 these causes should be in prominent action in the affected 
 villages to an extent seldom before realised. Nothing of the 
 sort, however, can be found. I am aware that the disturbance 
 of the drainage lines of the country by newly-constructed em- 
 banked roads, and also the extension of forest reserves, have 
 each been suggested as the possible cause of the assumed 
 intensification of malaria ; but neither sus^orestion will bear 
 even the most casual examination. 
 
 To begin with, the distribution of the malady bears no 
 relation whatever either to roads or reserves. Further, if 
 an embanked road, by stopping the outflow of water, render 
 the ground above it damper, it is perfectly clear that it 
 must necessarily render that below it drier. Water cannot, 
 flow in more than one direction. If such a road be placed 
 in the line of the gradient of the land, it can exert no 
 
( 65 ) 
 
 influence in either direction. If, however, it be placed more 
 or less parallel to the lines of contour, it must render the 
 contours above it damper and those below it drier. Most 
 of the great roads do, in point of fact, run parallel with the 
 contouring of the country, or, in other words, between the 
 hills and the river, and must, in so far, tend to render the 
 land between the hills and the road somewhat damper than 
 before their construction. I doubt, . however, if they are 
 adequate to produce any very appreciable effect, for they seem 
 very fairly provided with openings, and hJiils, and other col- 
 lections of standing water seem just as common on the one 
 side as the other ; moreover, if they really did interfere much 
 with drainage, it is perfectly certain that they would not 
 stand long. 
 
 However, assuming them even to have such an effect, 
 and so to enhance the malariousness of the country, on one 
 side of the road, it is perfectly clear that the general health 
 ought to be proportionally bettered on the other side, but 
 no one has even suggested that this has taken place. 
 
 In a country like Assam, where so large a proportion 
 of the total area is virgin forest, I have never been able to 
 understand how any one could soberly suggest that the 
 petty amount of afforestation effected by man can have any 
 influence on disease. It seems like accounting for the grimi- 
 ness of Newcastle by the importation of a few baskets of 
 charcoal. 
 
 In the absence, then, of any intelligible cause for intensi- 
 fication of the well-known malariousness of the affected districts, 
 it seems as great a mistake to attach any importance, in the 
 production of the increased mortality, to such cases of mala- 
 rial cachexia as one meets with, as to the cases of dysen- 
 tery, pneumonia, and spinal caries. 
 
 Personally, I have not found cases of uncomplicated 
 malarial cachexia at all commoner than I have in certain parts, 
 for example, of the Central Provinces and Punjab. What I 
 have, however, found is that, wherever a village is seriously 
 affected with kdla-azdr, the larger proportion of serious illness 
 will be found to consist of cases of anchylostomiasis. That a 
 very large proportion of the cases will be found to be 
 complicated with enlargement of the spleen is quite beside 
 the question, for, as we have seen, this condition nearly as 
 often complicates apparent health. Malaria doubtless accounts 
 now for as much sickness and death as it always has, and 
 that, we well know, is no small amount ; but it is entirely 
 
( 66 ) 
 
 inadequate to serve as the efficient cause of the terrible death- 
 rate of kdla-azdr-stricken villages, and the true cause of this will 
 be found to be neither more nor less than anchylostomiasis. 
 Of course, it is perfectly intelligible that a man brought low 
 by anchylostomiasis should more readily fall a victim to 
 malarial influences. In the closely-analogous case of famine, 
 we know this to be the case, but it is to shortness of food, and 
 not to malaria, that we ascribe the high death-rate of periods 
 of famine, in spite of the fact that many poor, half-starved 
 wretches might have survived but for attacks of fever and 
 enlargement of the spleen. Conversely, a man, already the 
 subject of malarial cachexia, will die much more rapidly from 
 anchylostomiasis than an originally healthy subject. 
 
 As will be se^en, I am far from asserting that any and 
 every case that will be produced as kdla-azdr is necessarily 
 anchylostomiasis, or that cases of malarial cachexia are 
 otherwise than very common, for such cases are very common 
 now, always have been, and it will be long ere they cease 
 to be so. All I wish to convey is that the increased morta- 
 lity is due to the anchylostomiasis, and to no- other cause, and 
 hence the answer to the question propounded at the com- 
 ^lencement of the section must be that if we take kdla-azdr 
 to be anything brought as such, kdla-azdr may be anything, 
 but that if we confine ourself to the cause of the present 
 pestilence, the reply is that it is anchylostomiasis. 
 
 If, as it is to be sincerely hoped will not be the case, the term 
 kdla-azdrhe retained at all, it should, I think, be confined to the 
 cause of increased mortality, which has given rise to the term. 
 The preferable course, however, will be to classify our cases 
 under the headings of ordinary medical nomenclature, and 
 to avoid entirely the use of such misleading terms as kdla- 
 azdr and beri-beri. 
 
( 67 ) 
 
 YI. — The Life History of the Parasite. 
 
 The immense numbers of ova which are to be found in 
 the dejecta of patients suffering from anchylostomiasis has 
 already been adverted to. We must now attempt to follow 
 what happens to these a.fter they have been deposited on the 
 ground. 
 
 If we watch a deposit, we shall find that, in warm, damp 
 weather, by the next day there will be little or no offence, and 
 little to be seen of the faecal mass. In its place we shall find 
 the ground turned up into minute heaps of granules. This has 
 been mainly efiected by the agency of several species of beetles 
 which feed on the excrement, and carry much of it down into 
 their burrows. 
 
 In spite, however, of the destruction of the greater part of 
 the mass by these little animals, if we examine the soil, the 
 next day, i.e., two days after deposition, we shall find it absolutely 
 swarming with minute nematode embryos. In three or four 
 days, the place where tlie fseces were deposited will be difiicult 
 to make out, and by the end of ten days no trace of its presence 
 will remain to the naked eye, but the microscope will reveal 
 the presence of the embryos, in even increased numbers. During 
 the cold season, when many of the species, which thus act as 
 scavengers, are sluggish, or perhaps hybernating, the deposit 
 will remain longer on the ground, and its traces will be discern- 
 ible for a long time, but the ultimate result, tliough deferred, 
 will be the same. 
 
 As will afterwards appear, when we come to discuss the 
 methods of infection, this rapid disappearance of the offensive 
 matter, and the persistence of the embryos on the site it 
 occupied, has an important bearing on the transmission of the 
 disease. In the case of the small pits, which have been already 
 mentioned, where there is a considerable accumulation of faecal 
 matter in one place, the efforts of the scavenger beetles are in- 
 sufficient, indeed they will not be found except at the edges of 
 such accumulations, and hence in this instance the greater part 
 of the faBcal matter remains at the disposal of the nematodes, 
 which are thus enabled to flourish even more vigorously than 
 iif the case of isolated deposits. 
 
 For purposes of investigation, however, it is better to insti- 
 tute a regular cultivation, but nothing but fsecal matter will 
 serve for the proper nourishment and development of the 
 worms, so that the course of events as seen in nature must be 
 followed as closely as possible. 
 
( 68 ) 
 
 I liave transferred embryos to the ordinary nutritive 
 media, used in bacteriological investigation, to meat juice and 
 other fluids that, it appeared, might offer a suitable and in- 
 offensive cultivating material, but, though the embryos often 
 contrived to live in these for several days, all growth and 
 development was at once stopped. From the circumstance 
 that the intestinal contents of the embryos change to a purple 
 hue under the action of Pettenkofer's test, it may be consi- 
 dered probable that the worms find their nourishment mainly 
 in the biliary matter found in the fiEces, and, as far as my 
 experiments go, they show that it is quite useless attempting 
 to observe the development of the worms except they be 
 provided with faecal nutriment. 
 
 However, by utilizing the deodorizing powers of earth, 
 we may obtain cultivations of the worms, which if not abso- 
 lutely free from ofTence can yet be dealt with without any 
 great amount of personal annoyance. After trying a great 
 many plans, I find the method most favourable to the develop- 
 ment of the worms is to place the suspected faeces in a lightly- 
 covered vessel, such as a cjamlah tied over with muslin, for a 
 day or two, and then to add sufficient water to render the 
 mass quite fluid. 
 
 A shallow crystallizing glass is then about half filled 
 with clean white sand, which should not be too fine, and a suffi- 
 ciency of the diluted faecal matter is poured over this, without 
 touching the sides, solas to thoroughly wet the sand without 
 causing obvious pools on the surface ; and, finally, the whole is 
 covered with a piece of clean window glass. From time 
 to time (every day or two) the glass cover must be raised so 
 as to renew the air within the chamber, as I find that the 
 worms can only develop in the presence of a free supply of 
 oxygen. Freshly-collected faeces may be employed in the 
 same way, but I am inclined to ^think, as a result of many 
 experiments, that the development is rendered more sure by 
 the ova being allowed to remain from 24 to 48 hours in their 
 natural habitat. 
 
 A certain amount of dampness is important in ensuring 
 the best result, and the degree of this may be best expressed 
 by stating that the grains of wet sand should still hold a 
 certain amount of air entangled amongst them. No doubt, 
 this is connected with the necessity the worms, in common 
 with other animals, have of obtaining a free supply of oxygen. 
 The length of time taken in hatching out varies greatly with 
 the temperature of the air. At what degree development 
 
( 69 ) 
 
 altogether stops I am unable to state, as, owing to the impos- 
 sibility of obtaining ice, I was unable to institute any experi- 
 ments on the point. As far, however, as Assam is concerned 
 this is unimportant, as the temperature here, even in the cold 
 weather, never falls sufficiently low to do more than retard the 
 hatching process. 
 
 In December, at Gauhati, the temperature in my labora- 
 tory ranging a little above 60° F. during the day, and falling 
 to about 54° at night, the embryos do not commence to 
 hatch out until the fifth day, and then only a very small 
 number, the greater proportion not appearing until the sixth 
 day. On the other hand, in an observation made at Dhubri 
 late in March, the temperature being about 84° in the 
 room where I was working, the embryos hatched out the 
 day after the deposition of the excrement ; while in Shillong, 
 at an intermediate temperature of about 70°, they usually 
 did not appear till the third or fourth day. I made some 
 attempts at ascertaining the effects of a higher temperature, 
 but my constant temperature apparatus proved a failure, and 
 the experiments that were attempted in it were necessarily 
 inconclusive. They showed, however, that the embryos can 
 live for a considerable time at a temperature of 120° F. 
 
 The ova, as met with in the fgeces, have a very charac- 
 teristic appearance, and once seen cannot well be mistaken 
 for anything else. As the average of a large number of 
 micrometric observations, I find they measure ^^^-g- inch in length 
 by -^^Q inch in breadth. As far as can be made out from the 
 very rough figure in Dr. Kinsey's pamphlet, this coincides 
 pretty closely with Perroncito's measurements, but his figure; 
 to judge from the varying size of the ova represented, can only 
 be a free-hand production, and therefore cannot be taken as 
 exact. I can find no statement as to the measurements of 
 the ova in the papers of either Dr. Adolpli Lutz or Dr. 
 Schulthess. 
 
 In the last edition of Dr. Bristowe's " Theory and Practice 
 of Medicine," the measurements are stated as ^^^^ inch by y-jyVo- 
 inch. The statement is of course, not original, as the author 
 could have had no opportunity of personal observation, and 
 the authority for it is not given, but if it be based on correct 
 observations, it must refer to a distinct species from that 
 observed in Assam^ as the measurements of the ova of any 
 one species vary within such narrow limits only, that it would 
 be impossible to find any two ova differing by as much as 
 ■^^■^ inch and ^-i^ inch, so that either the ova referred to belong 
 
( 70 ) 
 
 to different species, or some mistake has been made by the 
 authority from which Dr. Bristowe took his description. 
 
 The exact measurement, however, is of great importance 
 in the diagnoses of cases by microscopical examination of the 
 faeces, especially when it is attempted for the first time, before 
 one has become familiar with the general appearance of the 
 ova ; and hence this statement in Bristowe gave me a great deal 
 of trouble in the early stage of the investigation, and, mistrust- 
 ing the exactness of my stage micrometer, I sent for a new 
 one, but both instruments give the same readings, so that the 
 above measurement may be accepted as exact. 
 
 In fresh fieces the ova are usually 2-4 segmented, but I 
 have often met with unsegmented ova. The yelk is of a 
 greyish colour, and is separated from the shell by a compara- 
 tively* wide zone of perfectly clear, transparent fluid. As this 
 fluid and the egg-shell are alike quite white, it is by this 
 character alone perfectly distinguished from the ova of Ascaris 
 lumbricoides, which are yellow, and from those of Trichoce- 
 phaltis dispar, which are deep red brown. This clear zone is 
 usually wider at the poles than elsewhere, and is not found 
 to the same extent in any other human parasite. Another 
 pe'culiarity is that the egg has a tendency to a cylindrical 
 form ; in other words, its outline is not truly elliptical, but has 
 its longer. sides somewhat flattened. 
 
 The only human parasite with whose eggs it can possibly 
 be confounded is the Oxyuris vermicularis^ but this latter is 
 somewhat smaller, being only -^\-q inch in length, its outline is 
 iinsymmetrical, being flattened on one side only, and, lastly, it 
 always contains a well-advanced embryo. Now the most 
 advanced DochmiiLS ova which can be found in fresh faeces 
 are in the morula stage of development, so that the mistake 
 could only arise in examining faeces that have been passed 
 some time, though, as we have seen, in hot weather 18 or 20 
 hours would be sufficient. 
 
 . After reaching the morula stage, the first indication of 
 the embryo appears as a slight groove, rather to one side of 
 the pole of the morula. This groove deepens until the em- 
 bryo can clearly be made out as a tadpole-shaped body bent 
 on itself. The embryo now rapidly increases in length, at 
 the expense of the thickness of the larger end, until a distinct- 
 ly worm-like body results. Before this process is completed 
 even, slow movements begin to be observable in the mass, 
 until at length the embryonic worm can be seen in constant 
 motion coiling itself about in the egg with such rapidity that 
 
( 71 ) 
 
 it is very difficult to obtain a correct drawing. The movements 
 become more and more violent, tlie creature appearing to 
 struggle to straighten itself out, till at last the shell ruptures, 
 as a rule, a little to one side of one of its poles. The little 
 worm soon wriggles itself free from the empty shell, and at 
 once begins to move about actively in the fluid in which it 
 finds itself. 
 
 Immediately after emerging from the egg, the embryo 
 measures 0-085'^ in length by 0*005'^ in diameter. It tapers a 
 little towards the head, which is rather blunt, and terminates 
 in a finely-pointed tail. The whole length is marked with fine 
 transverse striations as close as those of muscle fibre. Under 
 a high power, the intestinal canal can be clearly made 
 out, but is not as prominent anobject as it becomes a few hours 
 later, when its endothelial cells have become plumped out with 
 granular matter. 
 
 The commencement of the intestine proper is about one- 
 fifth of the entire body length from the oval end of the body. 
 Immediately in front of this is a small chitinous bulb, which 
 is armed with certain chitinous ridges, so disposed as to 
 appear like the mouth of a leech, when seen in optical section. 
 When first escaped from the egg, this bulb is in a continuous 
 state of pulsation, its strokes being about 60 per minute, 
 but not absolutely regular, sometime pausing for a while. It 
 is no doubt by this means that the large supply of nourish- 
 ment required for its growth is drawn into the body. After 
 an hour or so, these pulsations become slower, and finally 
 cease. In front of the bulb, the oesophagus can be traced as a 
 faint outline, broadening somewhat at about half its length, 
 and extending to the mouth. The little animal grows at first 
 with extreme rapidity. Within the next 48 hours, at an 
 average temperature of 70°, they have increased to three times 
 their original length. During this time, they have undergone 
 several ecdyses, but the exact number of changes is difficult 
 to state, as it is impossible to keep any individual worm con- 
 tinuously under observation. Eepeated experiments have con- 
 vinced me that observation of these embryos, under laborat- 
 ing conditions, are quite valueless. The nature of the mediimi 
 in wliich they will alone flourish quite precludes microscopi- 
 cal observation, and, in water, development is at once modified 
 and soon arrested. I have made many attempts to induce 
 them to grow in transparent media, but quite fruitlessly. In 
 nutrient beef jelly, such as is used for bacteriological work, 
 whether acid, neutral or alkaline, they soon die, whether it 
 
( 72 ) 
 
 be allowed to solidify or kept fluid by heat or dilution. Tliey 
 live longer, but will not flourish, in urine, and the nearest 
 approach to success was obtained by mixing fgecal matter with 
 water, and filtering through nainsook, whereby a fluid is ob- 
 tained which, in thin layers, is still clear enough for micros- 
 copical observations ; but even in this I have quite failed to 
 observe continuously, from birth to the adult rhabditis stage, 
 to be described below, any individual embryo. 
 
 It is no doubt owing to too great trust in observation 
 conducted under purely laboratory conditions, that the des- 
 cription of the life history of the worm given in Dr. Adolpli 
 Lutz's paper is full of fallacies. As those who have read that 
 otherwise very able paper will remember, a great feature is 
 made of what he terms the encapsuling and calcification of the 
 embryonic parasites. I can emphatically assert that in their 
 life history there is no such phase, under any conditions what- 
 soever ; and that what has been so described is not life, but 
 death history, in other words, they are but the changes that 
 occur in dead worms when left in water. I have kept dead 
 embryos which presented all the changes figured by Lutz 
 under observation for long periods, and I have never witnessed 
 the least sign of returning life ; further I have followed the 
 further change of decomposition into mere granular matter. 
 The only way to successfully observe the normal life history 
 of the parasite is to make a large cultivation and remove small 
 specimens at frequent intervals for microscopical examination 
 in water. It is here that the use of coarse sand as a basis^ 
 proves so useful, as the sand entirely does away with the tena- 
 ciousness of the original material, and a specimen removed 
 to a glass tray, and plaj^ed upon by a jet of water, falls 
 to pieces, and is ready for observation at once. It may 
 be well, before proceeding further, to describe more 
 minutely the process employed in examining the cultivations. 
 The best size of tray is about 3 inches by 2 inches, internal 
 measurement, and about ^ inch deep. Such tray can easily be 
 made by any one as follows : — 
 
 Cut a strip of window glass ^ inch wide, and as thick as 
 can be obtained. Cut ofi it two pieces, each 3 inches, and two 
 pieces 2 inches long. Cut also, from a thinner piece of glass, as 
 free as may be from flaws, a plate, 2^ in. x 3^ in. Now make one 
 of the long strips hot in a si^irit lamp, and smear one edge with 
 shellac, or, better, a mixture of equal parts shellac, yellow bees- 
 wax, and resin : now heat one of the long sides of the larger 
 plate, and then apply the cemented strip, so that it is fixed 
 
( 73 ) 
 
 along the edge of tlie plate, standing upriglit. Next, in the 
 same way, apply the cement to one edge and one end of each 
 of the shorter strips, and fix them in position in the same way 
 one by one. Lastly, cement one edge and the end of one face 
 of the f onTth side, and place it in position, and the tray is com- 
 pleted. I describe the method of making these trays thus 
 minutely, as their use is of some importance in the diagnosis of 
 doubtful cases, as, owing to the lively movements of the embryos, 
 it is much more easy to detect them in a cultivation than 
 to find the ova in the fasces. Moreover, a simple pocket 
 lens, of one inch focal length, affords quite sufiicient 
 magnification, so that a comparatively large amount of 
 material can be searched over in a few minutes. A good light 
 is necessary, however, so that, unless a regular dissecting stand 
 be available, it will be necessary to improvise one, to do which 
 the tray should be plac^l over a hole in one side of a cigar-box, 
 the lid being removed, and a shaving-glass, arranged at a suit- 
 able angle, placed within the box. The lens may be sup- 
 ported on a pen-holder fixed in a hole in the back of the 
 box and thrust through the small holes which are found in 
 the sides of the horn case of pocket lenses of the .usual 
 pattern. Such an apparatus can be constructed by any one, 
 however little of an amateur mechanic he may be, and forms 
 by far the most certain method of diagnosing the presence of 
 the parasite, when present in only small numbers, and by its 
 means I have again and again detected the presence of a few 
 parasites where repeated careful examination of the fasces for 
 ova had failed. For a reason that will presently appear, the 
 cultivation should be allowed to stand for six or eight days 
 before condemning it as sterile. 
 
 On account, then, of the impossibility of keeping the 
 embryos under continuous observation, I am unable to afford 
 any exact information as to the number of ecdyses, but where 
 development is rapid, I estimate the changes of skin at not 
 less than twice a day. I have often watched the process, and 
 some very curious appearances occasionally present them- 
 selves, as the w^orm often remains for a considerable time 
 partially entangled in the old skin. 
 
 In every instance that I have watched, the old skin is' 
 ruptured near the head, a small cap of the anterior part of 
 the chitinous investment being forced off, while . the rest of 
 it is cast off entire, the worm drawing itself out like the finger 
 from a glove, the tail being the last part freed. 
 
 Even in one and the same cultivation, the rate of growth 
 
 G 
 
( 74 ) 
 
 varies greatly, depending no doubt on variations of the amount 
 of available food supply in different portions of it. In experi- 
 ments conducted at Sliillong, under conditions as nearly as 
 possible approaching those found in actual practice, the whole of 
 the stages from ovum to the adult rhabcfitis stage, to be presently 
 described, occupied six days. In this case the faecal matter 
 was simply spread over a patch of garden soil enclosed with- 
 in four planks. In experiments conducted in glass vessels, 
 with a necessarily somewhat restricted supply of air, the de- 
 velopment takes a trifle longer. The most important factor, 
 however, is the proportion of fascal matter, or, in other words, 
 of nutritive material used. In large foecal masses, in the 
 temperature of the plains, fully developed rhabdites may be 
 found as early as the fourth day. On the other hand, imma- 
 ture forms may still be found as late as the tenth or even 
 twelfth day after hatching out. • 
 
 The first change that takes place is that the cells lining 
 the intestinal canal proper swell out and become granular, 
 bulging out into the lumen of the channel, so that its course, 
 as seen in optical section, appears zigzag. Certain of the ceUs 
 at its commencement, i.e., immediately below the hinder bulb, 
 take on a special development, and remain larger tlian the 
 rest throughout life. They probably function as a liver. 
 After one or two clianges of skin, the anterior dilatation of 
 the oesophagus becomes much more distinct. Between it and 
 the liinder bulb, a nervous centre, consisting of four or five 
 ganglion cells, encircling the oesophagus, makes its appear- 
 ance, and lastly, about midway along the ventral aspect of the 
 body, there appears a single hyaline cell, the rudiment of the 
 future generative organs. In these early stages, the mouth 
 is a simple, somewhat funnel-shaped opening, without either 
 Ups or armature of any kind. The anus opens on the ventral 
 side of the body, a little in front of the pointed end of tlie tail. 
 
 Almost up to the assumption of the adult rhabditis stage, 
 the changes occurring at each change of skin are very gradual, 
 and consist merely of growth of the parts that have already 
 appeared, no further change taking place in the development 
 of the generative organs until this great and final stage. 
 
 In these final changes the worms become adult male and 
 female organisms, and immediately commence to propagate the 
 species. 
 
 For the benefit of such of my readers as may be unac- 
 quainted with the details of nematode terminology, it may be 
 well here to explain what is meant by a rhabditis stage. 
 
( 75 ) 
 
 Its meaning is that certain parasite nematodes* present the 
 phenomenon of alternations of generations, the ova laid by 
 worms in the parasitic stage, developing, not into animals like 
 themselves, but into a form which no naturalist would place 
 even in the same genus. In fact, if we were ignorant of their 
 origin, these forms would find their place, for purposes of classi- 
 fication, in Dujardin's genus Rhahditis. The worms in this 
 stage live free, and are in no sense parasites, but when they 
 reach sexual maturity, they give birth to a generation which 
 again takes up a parasitic mode of life, or, at any ratej is capable 
 of doing so, while, as far as can be seen, the first generation 
 would be incapable of becoming parasitic. 
 
 Thus, the worms of such species, in the parasitic stage, 
 are not the children, but the grandchildren of parasites. In 
 the present instance, the free or rhabditis stage fits with some 
 difficulty into Dujardin's definition of the genus Rhahditis as 
 its strongyloid origin is indicated, in the male, by a distinct 
 copulatory bursa supported by chitinous rods, much resem- 
 bling, though not identical with, that -of the parasitic stage. 
 As, however, Dujardin's definition includes certain species, 
 the males of which have the " tail provided with membranous 
 wings," its limits are not much forced, and there is no need to 
 institute a special term for the free stage of our present species. 
 As far as can be made out, the commencement of the sexual 
 difierentiation of the male rhabdites takes place in the last ecdy- 
 sis, but one preceding that in which completely adult characters 
 are assumed. At this period, the worm measures about -^^ inch 
 in length l^y about yo^o" ii^chat the thickest part of the body, 
 opposite the still rudimentary sexual gland, which is placed 
 rather nearer the caudal than oral extremity, the middle of the 
 fusiform rudiment being about y-J-Q inch from the caudal extre- 
 mity. At this stage the generative gland consists of only one 
 or two hyaline, multinucleate cells. The copulatory spiculse 
 however, are well developed, and do not change to any extent 
 during the remaining ecdyses. There is, however, no sign of 
 the copulatory bursa, which appears after the next change of 
 skin, the tail being very long, and tapering so as to form a 
 sort of flagellum. Even after the next ecdysis, there is but 
 little change in the generative gland, which, at this period, con- 
 sists of a hyaline, fusiform body, containing a few clear nuclei, 
 
 -'' The number of species in which such a life history has been proved 
 is constantly increasing. Only lately the fact has been made out in the 
 case of Stronqylus itriyosus and S. retortm fonnis by Prof. A. Kailliet, 
 Bull. Soc. Zool. France, XIV. (1889) page 375-7. 
 
 G 2 
 
( 76 ) 
 
 placed ventrallv, and measuring ^Jo "^^li long by ^gV^incli in 
 diameter. Tlie'caudal extremity is ratlier abruptly conical, and 
 now shows a well-developed copulatory bursa, consisting of a 
 delicate transparent membrane, shaped hke a finger -nail, and 
 projecting laterally a good deal more than it does beyond the 
 point of die obtusely conical tail. It is supported on either 
 side by three simple chitinous rods of uniform diameter, which, 
 takincr their origin in the cuticle of the tail, pass from it, outwards 
 and backwards, quite to the edge of the membrane. Tlie 
 width of the entire organ barely equals that of the greatest 
 diameter of the body, and it extends up its sides only ^i-^ mch 
 from the extreme point of the tail. Just above this point, on 
 either side of the middle hne of the body, may be seen the 
 copulatory spicula?, consisting of two pointed chitinous rods, of 
 a deep yellow-brown colour, and about y^oo "^^^^ ^^^^S- Their 
 bases are placed at some distance apart, but their points, when 
 retracted, touch, so as to form a V, each being contained 
 within a separate sheath, the two sheaths, however, joining to 
 form a comiAon opening, which receives also the mouth of the 
 duct of the generative gland, and together open into intestine 
 close to the anus, to form a short cloaca. The form of these 
 spicules differs greatly from the copulatory organ of the entozoic 
 stacre of the worm, in which it is, proportionally, much longer, 
 ancl as it does not greatly exceed it in actual thickness, is a 
 much slenderer structure. In the entozoic stage, too, the two 
 spicula are kept in habitual contact, so that they can only be 
 separated ])V dissection, appearing to be, in some way, locked 
 together, aiid they end in a very minute but distinct hook. 
 These spicula^ are protrusible, and may be seen in different spe- 
 cimens in a varietv of positions, and when seen in profile, often 
 appear hke a couple of hooks projecting from the ventral 
 aspect of the tail. In other respects the worm as yet differs 
 but Uttle from the younger embryos already described, 
 almost the entire body cavity being filled by the intestinal 
 canal, the excretory gland, which forms so prominent an 
 object in the mature stage, being not yet sufiiciently developed 
 to be easilv made out. 
 
 When fully developed, the mature male rliabdites measures 
 ^Vinch - J^ inch in length, but little exceeding in this matter 
 the size of the worm during its two preceding changes of skin. It 
 has, however, become markedly thicker, its greatest diameter, 
 which is stiU placed in the same situation, reaching from 
 1 inch- 3-^ inch. The structure of the nutritive organs 
 remains unchanged, but, lying beneath the ventral aspect of the 
 
( n ) 
 
 intestinal canal, may be seen a glandular body of considerable 
 relative size, measuring -j^-q inch in length by ^woiy ^^^^ i^^ ^i^~ 
 meter. Behind it ends in a blunt rounded extremity, while in 
 front it tapers off to form a duct. It is lined- with an epithe- 
 lium of very small, nearly spherical, nucleated cells. In one or 
 two instances I have doubtfully succeeded in tracing the duct of 
 this gland to near the excretory pore, and have little doubt that 
 the organ has an excretory function.* It certainly forms no 
 part of the generative gland, the anterior end of which it 
 overlies. On casual examination, it appeared possible that 
 it might be a doubled-over end of the generative gland, but 
 more careful focussing showed that this could not be the case. 
 Were it a reflected position of this organ, the blind end would 
 contain the least-developed cells, and the latter would become 
 progressively advanced in development as one proceeded to the 
 assumed point of reflection, whereas the contrary is the case, 
 the blind end being filled with well-developed cells, while 
 near the point where the faintly-seen duct commences, the 
 cells become granular and degenerated. It is present* in adult 
 males and females alike, and is especially easily made out 
 where the animal has been killed by the cautious addition of 
 alcohol, just before the protoplasm becomes opaque from the 
 action of the re-agent. The histological investigation of these 
 organisms is excessively difficult, as, owing to the resistent 
 nature of the chitinous cuticle, the internal organs cannot be 
 acted upon by re-agents sufliciently soon to forestall those 
 early" putrefactive changes which are fatal to the production 
 of really instructive preparations. 
 
 Owing to their small size, it is impossible to slit them, 
 or make openings, as one would do in the case of larger 
 organisms, and the method of sectionizing is equally impracti- 
 cable, as, by the time they have passed through the various stages 
 of hardening and imbedding, nothing but a chitinous ring 
 remains. Fortunately, however, their great transparency goes 
 far to neutralize these disadvantages. 
 
 The generative gland, which has now definitely assumed 
 the characters of a testis, consists of a single tubular body, 
 commencing a little behind the second pharyngeal JDulb. 
 
 * While the above was passing through the press the August 1890 
 number of the '* Journal of the Koyal Microscopical Society " came to hand. 
 It contains (page 461) a note of a paper by Dr. 0. Hamann in the Zool. 
 Anzieg. XIII. (1890)page 210-2, in which this organ is clearly described ; and 
 it is stated that there is no doubt about the existence of an external opening, 
 and that the organ is a lemniscus homologous with those of the Acantho- 
 cephala, and therefore, as I surmised, has a probably excretory function. 
 
( 78 ) 
 
 At its anterior end, it exhibits, in optical section, a double row of 
 clear, finely granular cells, each possessing a single nucleus and 
 nucleolus. As one proceeds backwards, these cells become larger, 
 until, about half way along the length of the body, they attain 
 so large a size that they can only lie in a single row. The 
 most anterior examples of these larger cells contain only a 
 single nucleus, but further back they become multinucleate, 
 and, by careful focussing of the most developed, a distinct 
 brood of daughter cells can be made out within them. It 
 is within these latter that the spermatic elements take their 
 origin, the whole ^H'ocess being one of endogenous cell multi- 
 plication. Finally, the large cells burst, and the hindmost 
 part of the generative duct will, in perfectly mature speci- 
 mens, be found to be filled with the spermatozoa, which are 
 small rod-like bodies thicker at one end than the other, and 
 so tending to the well-known hat-shape so often seen in nema- 
 todes. They are capable of ameboid movement, but are 
 destitute of any lash. As the little creature grows older, the 
 proportion of its length filled with the large single cells increases, 
 while those arranged in double row diminish, until, at length, 
 the whole of the anterior portion of the body is filled with 
 the large mother cells only. This is, of course, owing to the 
 progressive development of the cells, and to the circumstance 
 that no new ones are formed to take up the place of those that 
 have attained complete development. When all its spermo- 
 genie cells have completed their development and discharged 
 the spermatozoa to which they have given birth, the rhabdites 
 die. The copulatory bursa of the fully-grown rhabdites, though 
 agreeing in general form, differs a good deal in detail from 
 that of the immature form found before the last change of skin. 
 In this stage, it will be remembered, there were, on each side, but 
 three simple supporting ribs. In the adult stage, there are six 
 ribs on either side, of which, counting from the front, the first,, 
 fourth, and sixth alone reach out to the edge of the membrane. 
 The second is the shortest, not reaching half its breadth, while the 
 third is a good deal longer. The fifth attains very nearly to the 
 edge of the membrane, and has the additional peculiarity of 
 being bifurcated to about half its length. 
 
 I have never succeeded in finding a pair in copula, but 
 the female is probably grasped in much the same way as in 
 the entozoic stage. It is generally supposed that, in this 
 latter stage, the grasping action of the copulatory bursa is^ 
 assisted by a viscid secretion, and this view receives support 
 from the structure of the caudal end of the rhabditis stage, in 
 
( 79 ) 
 
 which are to be seen a number of cells of unmistakably 
 glandular character, which may possibly be concerned in the 
 secretion of some such fluid. These cells are situated absolute- 
 ly in the point of the tail, and so are quite beyond the end 
 of alike the intestine and the generative duct. 
 
 In the female rhabdites the changes closely follow those 
 that take place in the male, though they are not so externally 
 prominent, on account of the absence of the copulatory bursa. 
 The generative gland is, for a long time, exactly alike in both 
 sexes, but it makes its appearance nearer the oral end of the 
 female than in the male, being placed a trifle nearer to it than 
 to the aboral extremity, but, beyond this, there is nothing to dis- 
 tinguish it from a male. At a stage corresponding to the 
 appearance of the copulatory spicul^e in the male, the female 
 external generative opening makes its appearance. It is a 
 small oval aperture placed on the ventral aspect of the 
 body, rather nearer the head than the tail, and is guarded 
 by a thickened chitinous ring. The number of changes of 
 skin between the commencement of sexual difierentiation and 
 maturity appears to be the same in both sexes, but, up to the 
 last change, the appearance of the internal generative cells is 
 closely similar ; only, at all stages, the furthest developed 
 sexual products, instead of being found, as in the male, towards 
 the caudal end of the animal, are placed opposite the opening 
 of the duct, near the middle of the body, and grow less and less 
 mature as one proceeds, on the one hand, towards the tail, and 
 on the other towards the mouth. 
 
 The single ovarian tube, in fact, extends in both directions 
 from the genital opening, and hence the least developed germs 
 may always be found in two situations near the head, and the 
 tail respectively. Instead, however, of developing into the 
 mother cells of spermatozoa, the germ cells in this case develop 
 directly, without any process of endogenous multiplication, 
 into ova. The ova produced by the rhabditic stage are in all 
 respects exactly similar to those of the entozoic, which have 
 been already described, and those first extruded are laid in 
 much the same stage of development as those met with in the 
 fasces of infected persons, viz., 2-4 segmented. During the 
 process of laying, the female remains almost motionless, and 
 does not, I am inclined to think, take any food after the 
 completion of maturity. As more and more eggs are laid, the 
 more backward germs, from either extremity of the ovarian tube, 
 advance towards the middle of the body, and develop, in their 
 turn, into distinct ova, until at length, owing to the emptiness 
 
( 80 ) 
 
 of tlie intestinal canal, she becomes from end to end little 
 else than a sausage-shaped bag of ova. The development 
 of these latter, however, proceeds at a somewhat more rapid 
 rate than the hatching process, so that soon the eggs, 
 when hatched, already contain living embryos, instead of a 
 merely segmented yelk. Finally, when the female is becoming 
 nearly emptied of eggs, they hatch out within her body, 
 and appear to feed on her organs, only gaining access to the 
 exterior by the rupture of her body-wall, by decomposition. 
 Thus, this animal presents the peculiar phenomenon of being 
 oviparous in her young maturity, and ovoviviparous in her old 
 age, and, as may be seen, the completion of the process of 
 laying necessarily involves her death also. As they do not 
 appear to require food after attaining maturity, the whole 
 process can be easily watched in a cell containing water, and I 
 have followed it throughout in several instances. The num- 
 ber of eggs produced, is considerable, but is quite insignificant 
 in comparison with the myriads produced by the entozoic 
 stage of the creature. The largest number observed to be 
 laid by any one female after isolation in a watch-glass was 70, 
 but the necessity of being sure of complete maturity prevented 
 one's being able to select them at the absolute commencement 
 of the process, so that, all considered, we sliall probably be 
 not far wrong if we double this figure as a fair average of the 
 family produced by a single female. As has already been 
 pointed out, the process of reproduction absolutely necessitates 
 the death of the female, and her whole life does not much 
 exceed seven days. 
 
 In examining impregnated females, the copulatory spicula 
 of the male may often be seen sticking in the opening of the 
 generative duct, so frequently so indeed, that this mutilation of 
 the male is probably the rule, and, if this be the case, it lends 
 strong support to the idea that the life' of the male is of no 
 longer duration than that of the female, as, after such a muti- 
 lation, his functional utihty would necessarily cease. The 
 female is considerably larger than the male, sometimes reach- 
 ing the length of -J^ inch and a breadth of 2 w ^^^^5 ^^ ^^^^* 
 with strong obhque transmitted light, they can be made out with 
 the naked eye when once their position has been ascertained 
 under a lens. The tail of the female is acuminate, a small 
 sharp process projecting from the otherwise blunt tail. In the 
 remaining points of her anatomy she exactly resembles the male. 
 ^ In both sexes, the margin of the lipless mouth is armed with 
 a circlet of very minute papillse, which, being rather sharp- 
 
( 81 ) 
 
 pointed, miglit well be mistaken for teeth. The nervous 
 system is best studied in large living specimens, which have 
 been rendered motionless by immersion in water containing 
 as much thymol as it will take up. I found this re-agent ex- 
 tremely useful for this purpose, as it stupefies without killing, 
 and it is quite sufficient to quiet the naturally sluggish adult 
 rhabdites. It is not, however, sufficiently powerful to stop the 
 violent motions of younger embryos, for which purpose, about 
 4 per cent, of absolute alcohol must be added to the mixture. 
 
 The structure and position of the central ganglion has 
 already been described, but the distribution of the nerve cords 
 issuing from it remains to be noticed. Several (6 or 8) fibres 
 proceed forwards, along the sides of the anterior pharyngeal 
 bulb, to the neighbourhood of the mouth, and on these fibres 
 are found a number of irregularly disposed ganglion cells, 
 but little inferior in size to those composing the central 
 ganglion. On each side, a single chord proceeds backwards, 
 and these, too, are provided with irregularly disposed ganglia, 
 but they cannot be traced far, as, owing to the crowding of 
 parts below the second pharyngeal bulb, they are soon lost 
 to view, but, in the clearer space near the tail, cells that seem 
 to have a ganglionic character can again be made out, and 
 there can be little doubt that these are connected by commis- 
 sural strands with the oesophageal nerve ring. 
 
 The embryos hatched out from the eggs of the rhabdites 
 are identical in size and appearance with those already 
 described as hatched out from the eggs produced during the 
 entozoic stage of the worm, and it is entirely a matter of chance 
 whether they will develop into free organisms hke their 
 parents, or become parasites like their grandparents. 
 
 In all probability, the generation immediately produced 
 from the eggs of the entozoic stage would prove harmless, if 
 introduced into the human intestinal canal, as the life cycle 
 would be incomplete, were they to develop into parasitic 
 nematodes like their parents. There can, however, be no 
 doubt of the infectiveness of the progeny of the rhabdites, and 
 it is probably universally by the agency of these that infection is 
 efiected. Attempts have already been made, by other investi- 
 gators, to infect sheep, pigs, and other domestic animals, but 
 without success, so that it was clearly useless to make any 
 experiments with these, and accordingly the small short-tailed 
 monkey [Macacus rhesus)^ very common in Assam, was selected 
 as a subject for experimentation, but, as will be seen, only 
 partial success has been met with. The first experiment con- 
 
( 82 ) 
 
 sisted in feeding a young specimen of this species with food 
 with which was mixed mud that teemed with adult rhabdites 
 and their progeny. 
 
 In the course of a few days, the httle animal became 
 obviously ill. It vomited repeatedly, was continually drinking, 
 and distinctly feverish ; its temperature being raised to 102°F. 
 It grew worse, and was obviously sinking, and, as I had to 
 leave Gauhdti to go on tour, I killed it by a heavy dose of 
 chloroform, and examined the viscera. All organs were per- 
 fectly healthy, with the exception of the intestinal canal. The 
 stomach was patchily reddened just as seen in autopsies on 
 cases of anchylostomiasis. At first sight, the duodenum seemed 
 destitute of parasites, but, on placing pieces of the mucous 
 membrane in a tray of water, under the simple microscope, 
 countless multitudes of very small nemadotes were seen adhe- 
 rent to the mucous membrane. They had attained, in some 
 cases, nearly half the length of an adult Dochmius duodenalis, 
 but were extremely slender, the generative organs being 
 still quite indeterminate, and the whole organisation of the 
 parasite more like an over-grown, immature rhabditis than an 
 entozoic dochmius, only one or two being sufficiently developed 
 to admit of the determination of sex, and these were females. 
 
 For the rest, the remainder of the intestine swarmed with 
 other parasites. These were twenty specimens of an Ascaris, 
 which I believe, is identical with the human A. lumbricoides, 
 large numbers of an Oocyuris, to all appearance, also identical 
 with that infesting the human subject, a number of Trichoce- 
 phalus dispar, and one or two specimens of a strongyle worm 
 which has not as yet been identified. Ova corresponding to 
 each of these four species had been found in the faeces, pre- 
 viously to the infection of the monkey by the Dochmius embryos. 
 The ova of the strongyle would alone have presented any 
 difficulty, had the experiment been carried further, as its eggs 
 are so like those of our species that it would have been prac- 
 tically impossible to distinguish them by microscopical exami- 
 nation. Meanwhile, a second monkey of the same species had 
 been fed in the same way. Its dejecta contained the ova of 
 the oxyurid parasite alone, so that it was better suited for our 
 purpose than the first. I had to leave Gauhati before the 
 animal showed any signs of ill-health, and it died a fortnight 
 after my departure, i.e., less than three weeks after the first 
 feeding. Unfortunately, Dr. MuUane was also absent from the 
 station at the time, and the Hospital- Assistant, in whose charge 
 the animal had been left, neglected to preserve the intestine in 
 
( 83 ) 
 
 spirit for my examination. Naturally enough, he saw nothing 
 of the worms in the duodenum, as they can only be made out 
 by careful examination under a lens, so that he found only the 
 Oxyurides^ but there can be no practical doubt that the animal 
 died from the effects of the invasion of the immense numbers 
 of embryos it had been made to swallow. The extent of 
 develojDment was quite as great as could be expected in an 
 experiment that had lasted so short a time, so that I felt little 
 doubt of being able to rear mature parasites whenever time 
 for the experiment should be at my disposal. After arriving 
 at Shillong, three more monkeys, of the same species, were 
 obtained and fed in the same way, except that a much smaller 
 amount of infected earth was administered, in order to avoid 
 the death of the animal before the parasites had had time to 
 reach maturity. No symptoms beyond occasional mild 
 diarrhoea have been observed in these animals, though they 
 have failed to get into as good condition as animals, as full}^ 
 fed as they have been, might have been expected to do. In 
 all three, the ova of Trichocephcdi were found in the fasces, as well 
 as those of the oxyurid, but none of those of Ascarides or of the 
 strongyle could be found in either. The faeces were examined 
 at intervals, but, in neither case, have the ova of Dochmius 
 duodenalis made their appearance. Three months after the 
 feeding, one of the monkeys was killed. The animal was quite 
 healthy, except that, just as in the previous case, numbers of 
 nematodes were found adhering to the mucous membrane of the 
 duodenum, though not of course in anything like the numbers 
 that were found in the first experiment. They had increased 
 a good deal in length, but were otherwise but little in advance 
 of those found in the previous experiment. The sex of all 
 specimens could, however, now be made out, and it is a very 
 curious circumstance that over thirty specimens which were 
 examined microscopically were all females, and a careful search 
 for small specimens entirely failed to bring to light a single 
 male. The remaining two monkeys, though four months in 
 all have elapsed, are still without any sign of Dochmius ova in 
 their dejecta, so that there does not appear to be any prospect 
 of the worms with which they have been infected reaching 
 maturity. 
 
 Only two interpretations can be put on these later experi- 
 ments, as far so they have gone : either the embryos of Dochmius 
 duodenalis take an extremely long time to reach maturity, which 
 is, on the whole, improbable, or else the parasites are unable to 
 find a sufiiciently congenial home in Macacus rhesus to admit 
 
( 8i ) 
 
 of tlieir attaining maturity. Personally, I incline to tlie latter 
 explanation, as it is entirely in accordance with the general 
 phenomena of parasitism, that a parasite peculiar to one animal 
 should be incapable of development in another and different 
 host. Such being the case, I fear that nothing can be hoped for 
 from further experiments on animals. The circumstance that 
 three parasites probably identical with species infesting human 
 beings, viz., Ascarus lumhricoides, Oxyuris vermicularis, and 
 Trichocephalus dispar find a congenial host in Macacus rhesus 
 shows that the latter is as favourable a species for our purpose 
 as we can expect to obtain, though it is possible that better 
 success might be met with by employing some of the higher, 
 tailless apes, the difficulty of obtaining monkeys of such 
 species here precludes the attempt being made at present. Had 
 I met with these worms, without being aware of the feeding to 
 which the monkeys had been subjected, I should certainly have 
 referred it ta a genus quite distinct from either Dochraius or 
 Ehabdites, and it might be suggested that the worms found are 
 simian parasites, having no connection whatever with the 
 Dochmius embryos introduced into the intestinal canal of the 
 monkeys experimented upon, but the evidence, I think, is fairly 
 conclusive • that this ig not the case. In the first place, the 
 specimens found in the first experiment, where only a short time 
 had elapsed between the feeding and the examination, were dis- 
 tinctly less advanced in development than those found in the 
 experiment where a period of three months had been allowed 
 to intervene ; in the next, there was an obvious relationship 
 between the number of parasites found and the severity of the 
 feeding ; and, lastly, the immaturity of all specimens found is 
 strongly against its being a separate species, as in nearly every 
 case where a parasite passes any portion of its life-cycle in the 
 intestinal canal, it is during this period that it attains sexual 
 maturity, so that it is quite exceptional ever to find large 
 numbers of immature worms free in this situation, and it would 
 be in the last degree improbable that, under normal circum- 
 stances, all should prove to be so. The most developed speci- 
 mens contained, it is true, fairly developed ova, but none of them 
 gave evidence of having been impregnated, and no ova cor- 
 responding to them -have ever been found in the dejecta of the 
 animals experimented on, so that I think it will hardly admit of 
 doubt that we have to do with a case of arrested development, 
 and that, in the worms so found, we have a phase of the 
 metamorphosis of the rhabditis embryos, so to speak, crystal- 
 lized into a permanent condition, the abnormal host affording 
 
( 85 ) 
 
 conditions sufficiently favourable to admit of the commence- 
 ment of the developmental process, but not affording sufficient, 
 or sufficiently suitable, nourishment to allow the process to 
 proceed beyond the stage we have met with. 
 
 While, however, not entirely conclusive, these experiments 
 go far to prove two points, first, that the normal method of in- 
 fection is. through the agency of rhabdites progeny, and, 
 secondly, that the worms fasten on to the intestine at once, for, 
 though the worms have as yet no oral armature like that of the 
 adult, yet they were always found actually adhering to the 
 mucous membrane. The mechanism by which this is effected 
 is not quite clear, but it must be remembered that the oral 
 end of these worms is far sharper and finer than the small- 
 est needle ever manufactured, and that the soft structures of 
 the intestinal mucous membrane can offer but little resistance 
 to such an organism, boring its way into it, simply as a sharp 
 body. That this is easily possible is shown by the way in 
 which Irichocephalus dispar bores into the mucosa of the 
 coecum, for this worm, though equally unarmed, and deci- 
 dedly larger and coarser at the oral extremity, as is well 
 known, burrows for nearly an inch under the mucous 
 membrane of the gut. Probably, like this latter worm, the 
 little nematode, at this stage, feeds upon the serous fluid per- 
 meating the tissues, and not upon the blood, as they do at 
 a later stage ; at any rate I have found no evidence that 
 blood forms any part of their food. The first experiment 
 is also instructive, in showing that the invasion of a large 
 number of the parasites may give rise to a distinct febrile 
 attack, and as, in actual practice, infection probably takes 
 place, in most cases, not once only, but repeatedly, it shows 
 how feverish attacks may form a prominent feature during 
 the earlier stage of anchylostomiasis and therefore of hdla-azdr. 
 As to the further development of the parasite, it is open to 
 doubt whether it undergoes all further changes within the 
 intestine, or effects a temporary encystment in the wall of the 
 bowel. In Dr. Schulthes's paper, translated by Dr. J. D. Mac- 
 donald in Dr. Kinsey's pamphlet, there is a note to the effect 
 that Griesinzer and Grassi have found specimens encysted in 
 the sub-mucosa. There would be nothing astonishing in such 
 a habit, as the very closely allied Sclrostonum tetracanthum . 
 Dies., which infests the large intestine of equine animals, 
 always behaves in this way, boring into the walls of the intes- 
 tinal canal soon after gaining admission to its host, and only 
 emerging from its cyst when sexual maturity has been reached. 
 
( 86 ) 
 
 In horses and mules that have died of what was said to be an 
 outbreak of " surrah," I have recently found myriads of these 
 worms so encysted, but, in spite of the familiarity with the patho- 
 logical appearances so gained, and a most prolonged and careful 
 search, I have entirely failed to find any trace of such a habit 
 in cases of anchylostomiasis. In every post-mortem exam- 
 ination, a most diligent search was made for encysted worm«, 
 not only with the naked eye, but with the simple microscope, 
 and every point that appeared at all suspicious was carefully 
 dissected. In addition to this, considerable areas of intestine, 
 in the worst case I have yet met with, were examined by the 
 method of serial sections, but without the least result. Had 
 encysted worms been present, I am positive that they could not 
 have been overlooked, and hence I feel some doubt as to such an 
 occurrence being the normal habit of the worm. Another 
 argument against it is to be found in the fact that on working 
 out the hfe history of Sclrostomum tetracanthum^ I found that its 
 infective rhabdites were provided with a distinct and peculiar 
 single boring tooth, and it is natural to suppose 'that a similar 
 structure would be found in the dochmiiLS rhabditis if 
 it were addicted to a similar habit. 
 
 Of course, it is possible that, in the cases I have had the 
 opportunity of examining, all the worms had passed through 
 the stage of encystment and regained the lumen of the intesti- 
 nal canal. All that can be said is that it is certain that no such 
 condition was present in either of these cases. With one 
 exception, however, all these post-mortem examinations were 
 on cases that had been a considerable time in hospital, and so 
 debarred from the chance of recent reinfection. The nearest ap- 
 proach to anything like encystment met with was in searching 
 over a set of serial sections, some of which showed very young 
 worms, not much larger or more developed than those found 
 in the experiments on monkeys, imbedded in blood clot which 
 filled up recesses between rugae of the mucous coat. In one 
 instance a distinct erosion of the mucous membrane was 
 found underlying the clot. This was from the case which 
 was only a few days in hospital before death. 
 
 The case in favour of encystment as a normal occurrence, 
 may be summed up as follows : — 
 
 (1) In two closely-allied species, of similar habits, it has 
 been proved to occur as a normal part of the 
 life historv. 
 
( 87 ) 
 
 (2) All worms found in the lumen of the intestine are 
 
 almost always adult and full grown. 
 
 (3) The fact of but few observers having met with en- 
 
 cystment is explicable by the fact that cases in 
 which autopsis are obtained have been usually 
 protected from re-infection for some considerable 
 time by residence in hospital. 
 
 (4) Cases not unfrequently occur in which, after all 
 
 worms living within the intestinal canal have 
 been cleared out by vermifuges, ova re-appear in 
 the faeces within a short time. I have met with 
 many such cases, but they are equally explicable 
 either by re-infection, or inefficient action of the 
 remedy. 
 
 However, it is certainly not common in ordinary post- 
 mortem examinations, and the point*, which is a comparatively 
 unimportant one, must remain open. 
 
 It is clear that, in order to observe it, one must meet with 
 the fortunate coincidence of death from other causes, in an 
 ^arly case of anchylostomiasis, or one in which recent reinfection 
 has happened ; indeed it is probable that only the former 
 class of opportunity would serve, as many clinical facts tend 
 to show that advanced cases, from their inability to afford 
 the requisite nourishment, do not form a favourable home for 
 the parasites, so that it is possible that, in such cases, newly- 
 introduced embryos may, as in monkeys, be unable to proceed 
 with their normal metamorphoses'. 
 
 On the whole, I am inclined to believe that encystment 
 •of the newly-introduced worms will prove to be a fact, and 
 greatly regret that my scanty pathological opportunities have 
 as yet failed to afford me the opportunity of observing it. 
 
 If, indeed, this wandering into the solid tissues of the intesti- 
 nal wall be a fact, it affords a ready explanation of the occur- 
 rence of pyrexial attacks in the earlier stages of anchylosto- 
 miasis, as such a wholesale wounding of so septic a surface 
 as that of the lumen of the bowel could hardly fail to cause 
 more or less septic poisoning : moreover, the analogy of 
 trichiniasis, where fever is a common accompaniment of the 
 migration of the worms, would lead us to expect it, quite apart 
 from theoretical considerations. 
 
 The duration of the life of the worm in its parasitic 
 stage is a point on which, from the nature of the case, only 
 a surmise can be formed. The failure of all experiments on 
 
( 88 ) 
 
 animals makes the production of definite facts an impossibi- 
 lity. Some authors speak of a year or years, but I believe 
 such an estimate is much beyond the truth. They have pro- 
 bably founded this opinion upon the well-known long duration 
 of individual cases of the disease, but, in so doing, have 
 quite overlooked the possibility of repeated infections. The 
 number of available ovum germs in any given worm is, however, 
 limited, and the rate of production very high, and as analogy 
 would lead us to expect that the worm would die as soon as 
 sexual activity became impossible, it can hardly be supposed 
 that its life can extend over many months. 
 
 Another strong argument against the longevity of the 
 worms is that the number met with, in post-mortem examina- 
 tions in fatal cases, is often obviously inadequate to account for 
 the mischief that has been effected, and this can only be explained 
 on the assumption that, at some period of the case, a very 
 much larger number were present. Owing to their home 
 being in the duodendum, worms dying a natural death would 
 undergo digestion in their passage through nearly the 
 whole length of the intestinal canal, and would not appear 
 in the dejecta. That this does not take place when they are 
 expelled by thymol, is owing to the fact that the worms are 
 much more often stupefied than killed outright by this drug, 
 and often still exhibit feeble motions. Those that have been 
 really killed are always found to be more or less digested. 
 
 From these considerations, I believe that the disease has 
 a natural tendency to cure, but too often the damage 
 inflicted by the worms during their life has been so serious, 
 that the patient cannot muster sufficient strength for recovery, 
 whether they be expelled in the course of nature or by the. 
 action- of* vermifuges. 
 
( 8',» ) 
 
 VII. — Effect of various Conditions on the Life of the 
 
 Free Stage. 
 
 Having thus traced what may be termed the normal 
 life history of the Dochmius rhabdites, it remains to be seen 
 how they are affected, adversely or otherwise, by external 
 conditions. 
 
 Effect of Nourishment. — Some points in this connection 
 have already been incidentally noticed, but as various consi- 
 derations of great practical importance in devising preventive 
 measures are thereby elucidated, it will be necessary to go 
 more into detail. 
 
 If the worms be supplied with but a limited amount of 
 their natural food, as happens in the method of cultivation in 
 fgecalized sand, already described, they pass through all the 
 stages already described, but only a single generation of mature 
 rhabdites appears. After this the supply of nourishment is 
 so far exhausted, that the progeny of those which have 
 reached maturity fail to do the like, and remain in the 
 undifferentiated, non-sexual stage. So far, however, from 
 shortening their lives, this deprivation of a free supply of 
 nourishment, and the attendant arrest of development appears 
 to greatly prolong it. 
 
 As we have seen, with a free supply of nourishment, the 
 whole duration of life is a matter of only a few days ; but if 
 development be arrested by exhaustion of the nutritive supply, 
 the embryos remain, without growing or changing in any 
 way, for very long periods. What the limit of this may be, 
 I am unable to say, because my experiments on this point 
 are still pending. I can only affirm that, after fully six 
 months, my cultivations seem as rich in embryos as ever. 
 When in this state, the embryos appear to rarely, if ever, 
 change their skins, they are sluggish, and move but little, in 
 fact, they are in that stage which Lutz described as encap- 
 suled. The term, however, appears alike needless and mis- 
 leading, for their structure is quite unchanged, and the so- 
 called capsule is nothing more than the ordinary chitinous 
 investment common to all nematodes. I have dissected a 
 great many specimens, and am convinced that nothing what- 
 ever of the nature of a capsule is present. When first trans- 
 ferred from damp sand to a tray of water, they are extremely 
 sluggish, but soon begin to move about actively, and after a 
 while they again become quiet, and often remain quite motion- 
 less for days ; but the addition of some stimulating agent to the 
 
 H 
 
 \ 
 
( 90 ) 
 
 water, such as a little salt or alcohol, quickly induces motiou, 
 and convinces one that they are not dead, but resting. It may 
 be that the* comparatively limited supply of air and general 
 unnaturalness of their surroundings have something to do 
 with this, for cultivations conducted by pouring the fasces over 
 an enclosed patch of garden soil behave somewhat differently. 
 Several experiments were made in this manner, four planks 
 being nailed together so as to form a bottomless box, about 9 
 inches square, and sunk in the soil of the garden. Infective faecal 
 matter, diluted with water, so as to spread easily over the whole 
 surface, was then poured on the little patch of ground so 
 marked out, and the rest left to nature. Under these circum- 
 stances, judging from the normal length of life of the rhabdites 
 and the length of time during which they continued to appear, 
 some two or three generations may be expected, but, in the end, 
 with the exhaustion of the supply of nourishment, the same 
 state of things is brought about as appeared earlier in cultiva- 
 tions carried on within the laboratory, though of course the 
 number of embryos left in the resting stage is much increased. 
 
 Development, however, is but arrested, and only awaits a 
 fresh supply of nourishment to recommence. If we now pour 
 over such a cultivation some quite uninfected fsecal matter, 
 in a couple of days, mature rhabdites of both sexes appear in 
 immense numbers and continue to appear as long as the fresh 
 nutritive supply lasts, after which, the embryos, greatly in- 
 creased in numbers, sink into the resting stage and may remain 
 so, as we have seen, for months. After which the process may 
 be repeated again, with the same result. 
 
 The following experiment will illustrate these points : — 
 
 Experiment 2J^, — May 3rd. — On visiting the Shillong dis- 
 pensary I found a man who was suffering from undoubted symp- 
 toms of anchylostomiasis. He came from a village near Nong- 
 poh, on the Gauhdti road, a neighbourhood in which kdla-azdr is 
 beginning to appear, and had never been employed on a tea- 
 garden, being in fact an ordinary villager. Dr. Campbell had 
 already recognized the nature of the case, and had treated him 
 once with thymol. Examination of the faeces, however, showed 
 that there were stiU some worms in the intestine, as they con- 
 tained a considerable number of ova. Some of the dejecta 
 were placed in a bottle and allowed to remain undisturbed for 
 two days. 
 
 May 5th. — Eggs far advanced in segmentation, but no 
 embryos. Faeces diluted with water and poured over a patch 
 of garden soil enclosed between four boards. 
 
( 91 ) 
 
 May 6th. — There is but little fascal matter to be seen. The 
 ground has been freely turned up by small beetles. A number 
 of pediculi are to be seen, also one or two other insects. . Spe- 
 cimens of these were dissected, but neither eggs nor embryos 
 could be found within them. A number of rhabdites embryos 
 have hatched out. 
 
 May 9th. — ^Well-developed rhabdites present. A setige- 
 rous annelid dissected, contained one or two embryos differ- 
 ing in no way from those which had not met with this fate, but, 
 at the same time, apparently none the worse for it. 
 
 May 27th. — Mature rhabdites still present, but not in 
 large numbers ; sluggish undeveloped embryos present in large 
 numbers. 
 
 June 5th. — Embryos plentiful, though a couple of dry 
 days has dried the surface considerably. Still one or two 
 mature specimens present. 
 
 July 8th. — Numerous sluggish non-sexual embryos 
 present, but no mature rhabdites. 
 
 July 11th. — Examined with the same result, except that 
 one or two sexually differentiated, but yet not mature, speci- 
 mens were met with. 
 
 July 20th. — A quantity of fascal matter from a healthy 
 person carefully examined, and found free from ova, mixed 
 with water and poured over the surface of the cultivation. 
 
 July 22nd. — All offensiveness has disappeared, principally 
 through the agency of small caleopetra; mature rhabdites 
 present in considerable numbers. 
 
 August 11th. — Numerous embryos in the resting stage, 
 but no mature rhabdites. 
 
 August 12th. — Again examined with the same result. 
 
 August 14th. — Again examined with the same result. 
 A fresh dressing of healthy fa3ces applied. 
 
 August 15th. — Numerous rhabdites in the stage of sexual 
 differentiation, preceding maturity, present. 
 
 August 17th. — Mature rhabdites in large numbers, also 
 very young ones, obviously just hatched. 
 
 August 20th. — Ehabdites in large numbers still present. 
 The result of the two fresh supplies of nutritive matter has been 
 to so greatly increase the number of embryos present that twenty 
 were counted in a morsel of earth not as large as a pea. 
 
 August 28th. — No mature rhabdites, but only small em- 
 bryos as yet without sexual differentiation present. 
 
 I look upon the facts established by these observations 
 as by far the most important result of my investigation. It 
 
 H 2 
 
( 92' ) 
 
 shows that a patch of ground on which faecal matter has been 
 deposited by a person suffering from the disease, may remain 
 infected for many months, and that the accident of a fresh 
 deposit of foBcal matter, even from a healthy person, may 
 enormously increase its infectiveness, and indefinitely prolong 
 it. No one who knows anything of the habits of natives will 
 doubt for a moment that the revivication of infected spots, by 
 a fresh supply of nourishment, must be an accident constantly 
 happening in practice, as each family usually confines its atten- 
 tion to a small patch of ground, every part of which must be 
 used as a place of deposit again and again, in the course of the 
 year. Further, as a spot may remain infected for months after 
 all signs of defilement have passed away, there is nothing to 
 prevent the villagers from using the infected earth for cleansing 
 eating-utensils, and for all the other numerous purposes to which 
 mud and earth are turned in native domestic economy. Most 
 important of all, it shows that there is no limit whatever to the 
 time the infection may hang about an inhabited plape, as, 
 though it is to be supposed that a time will ultimately come 
 when the resting embryos in my cultivations will succumb, 
 and pay the debt of nature, yet, at any moment before this takes 
 place, a fresh supply of faecal matter would suffice to. start it 
 off on a fresh lease of hfe ; and under the conditions of hfe subsist- 
 ing in an Assamese village, this must, as has been pointed out, 
 occur again and again. 
 
 Effp:ct of Supply of Oxygen. — ^In all stages, the em- 
 bryos exhibit a strong preference for situations in which 
 the air supply is of the freest ; if we examine a cultivation, all 
 of them will be found quite on the surface. In the deeper 
 portions of cultivations, whether in the laboratory or in the 
 open, the ova either do not hatch out, or else the embryos 
 quickly work their way to the surface. Owing to this, cultiva- 
 tions in the open are always much more fruitful than those 
 undertaken in the laboratory, because, in addition to the freer 
 supply of air, the busy operations of beetles and other insects 
 turn up the soil into a fine light powder, and largely increases 
 the depth to which air can penetrate, in this way, more than 
 compensating for the nutritive matter which they consume. 
 Owing no doubt to this cause, ova placed in water, for example 
 in a test tube, hatch out much more slowly than those spread 
 out on sand or garden soil, and when hatched out, the embryos 
 fail to undergo complete development. Lively as their move- 
 ments are in water, they are quite incapable of raising them- 
 selves in it, and, on account of their relatively high specific 
 
( 93 ) 
 
 gravity, sink to tlie bottom witli great rapidity, and remain 
 there. In spite of tliis, embryos, at any rate such as have been 
 reared in sand cultivations, will live for weeks in a considerable 
 depth of water. A depth of a foot, however, was the greatest I 
 have been able to arrange for conveniently, but even at this small 
 depth, however well supplied with nourishment, though able to 
 exist in a resting state, they will neither breed nor develop. In 
 very shallow^ trays of water they wiU continue to develop for a 
 short time, but, even here, soon come to a standstill. Evidently, ' 
 water is not their proper habitat, which indeed is to be found 
 only in defiled soil. Even in shallow trays, embryos in water died 
 out altogether in from two to three months, whereas, as we have 
 seen, the degree of longevity of embryos in sand cultivations has 
 not yet been reached. As might be expected from the con- 
 finement of the embryos to the surface of a cultivation, burial 
 of infected fceces will entirely prevent development, and not only 
 so, bufbrings about the death of the ova so that when unearthed 
 and exposed to the air, no development takes place. 
 
 The following experiments well illustrates this. 
 
 Experiment 20, — May 2nd. — A wide tube 9 inches in length 
 was taken, and closed air-tight at one end with an India-rubber 
 stopper. Some fascal matter from a patient in the Shillong 
 dispensary, which was ascertained to contain Dochmius ova 
 in large numbers, was mixed with sand and water exactly as 
 in making the usual cultivations, and placed at the bottom of 
 the tube, i.e., lying upon the stopper. Over this was placed 
 damp sand until the tube was filled to the mjDuth, and a piece 
 of coarse muslin tied over all. By this means it was easy, 
 by removing the stopper, to examine the buried cultivation 
 without disturbance, and with only a very short exposure to the 
 air. At the same -time, a check experiment of a cultivation of 
 the same faacal matter, conducted in the usual way, was made. 
 
 May 8th. — Check experiment swarming with embryos. 
 
 June 3rd. — Withdrew the stopper, and examined the 
 buried cultivation. It exhibited not a sign of nematode fife. 
 By close examination under higher powers, some bodies, 
 which appeared to be degenerated ova, were made out. The 
 tube was now inverted, and the surface, which was still 
 sufiiciently damp, was left exposed to the air. The check 
 experiment still contained abundance of embtj^os. 
 
 June 12t]i. — No embryos can be made out, nor did any 
 appear at any subsequent time, although the surface was kept 
 damp for a long time. At the date of writing, August 30th, 
 the check experiment still contains numerous embryos. 
 
( 94 ) 
 
 It was found that dry sand or earth was just as effectual 
 in preventing all development as damp sand. The practical 
 importance of these results cannot be over-rated, as it clearly 
 shows that burial in trenches, as practised in the usual plan of 
 dry earth conservancy will be quite sufficient to render the 
 infective matter absolutely innocuous, and that, once buried, 
 there is no reason to fear any subsequent infection either 
 through drinking-water, or by means of any other vehicle. 
 
 Influence of Moisture. — A certain amount of moisture 
 is essential to tlie^ well-being of the rhabdites. The most 
 favourable state of things is when the soil is moist enough to 
 hold together, but yet not sodden ; extreme conditions of either 
 dryness or moisture being unfavourable. On the other hand, 
 although their development is thereby arrested, they can retain 
 their vitality, in spite of drying, for considerable periods. I have 
 by me, a cultivation which has been repeatedly allowed to 
 become powder-dry and to remain so for weeks together, and 
 which yet, a few hours after damping, shows abundance of lively 
 embryos. If, however, the dessication be carried to an extreme 
 degree, the embryos are thereby killed. 
 
 A portion of a cultivation rich in active embryos was chemi- 
 cally dried, without the aid of heat, by being placed under a bell- 
 glass, along with a vessel containing concentrated sulphuric acid. 
 After a week, the material was removed to the open air, 
 and moistened freely with water. Many embryos could be 
 made out, quite shrunken and showing no signs of life. After 
 several days in water they had swollen out somewhat, and were 
 commencing to decompose, but showed no signs of vitality. 
 
 The direct rays of the sun, if allowed to act for a considerable 
 time seem, to have the same effect. A great proportion of my 
 earlier observations were made on an accidental cultivation 
 which existed outside the dead-house of the charitable dispen- 
 sary at Gauhati. The piece of ground in question was a steep 
 bank, which received the outflow of the mortuary drain. Over 
 this drain the washing operation involved in the search for 
 parasites was usually conducted, and accordingly the ground 
 outside had been freely irrigated with water, carrying with it 
 large numbers of ova. During the whole of the cold weather, 
 the ground remained continuously moist from the heavy morning 
 fogs, and afforded an unfailing supply of embryos, in all 
 stages of growtli. It was just at the end of the cold season 
 that I left Gauhdti, and, on my return, the bank had been 
 subjected continuously to the action of the sun during the brief 
 duration of the Assam dry season. 
 
( 95 ) 
 
 Not a trace of embryos could now be found, and, that they 
 were killed outright, is evident from the fact that, during a 
 recent visit, after the rains had been falling for months, the 
 ground was still as barren of nematodes as if it had never 
 been infected. The situation was, however, singularly exposed, 
 and received the full glare of all the sunhght that could be 
 got, so that the conditions were exceptional for Assam, where 
 the dense vegetation, which always is encouraged round houses, 
 must render a sufficently intense dessication to ensure the 
 death of the embryos a most exceptional occurrence, and it 
 is just in the shady bamboo, and plantain-groves about the 
 houses that infection is commonest and most dangerous. 
 
 This observation has an important practical bearing, as it 
 offers us a ready method of disinfecting sites, by clearing them as 
 thoroughly as possible at the end of the cold season, and leaving 
 the bare surface exposed to the sun throughout the dry hot 
 weather. It shows too, that the spread of the disease in very dry 
 climates, such as the Punjab, is extremely improbable, even 
 should it be introduced into such localities, as there would only 
 be a few months in the year duriiig which infection of the soil 
 would be possible, and the whole infected area would be 
 quickly rendered harmless, once the short period of damp weather 
 was past. On the other hand, the toleration exhibited by the em- 
 bryos for moderate degrees of drying must be the source of 
 an added danger in climates where dessication can rarely go 
 to an extreme extent, for it is evident that the partially dried 
 embryos must often form a constituent of village diist, and 
 get carried by the agency of the wind to new sites, where 
 chance may at any time find them the nourishment necessary 
 to start a new focus of infection. On the whole, it seems 
 probable that rhabditic dochmii possess the power of resisting 
 dessication in as great a degree as any nematode, for they will 
 resist ordinary drying for very prolonged periods, and I can- 
 not recall any notice of experiments on other nematodes where 
 they have been subjected to actual chemical drying. 
 
 Influence of Heat. — The extent to which the develop- 
 ment of the embryos is influenced by the temperature of the 
 air has already been touched on. It remains to notice the 
 influence of higher temperatures. ' 
 
 A series of experiments was instituted to determine the 
 temperature at which infected faecal matter would be rendered 
 sterile (as far as concerns the development of dochmius rhab- 
 dites). These experiments demonstrated that any temperature 
 exceeding 140° F. is fatal ahke to ova and embryos. At inter- 
 
( 96 ) 
 
 mediate temperatures, such as 120^-130° development is re- 
 tarded, mucli in the same way as by cold, but not put a stop to. 
 A very short exposure to a temperature exceeding 140°, for 
 example, by raising the water bath to 150°, and then removing 
 the lamp, and allowing it to cool naturally, was quite suffi- 
 cient for the purpose. It may be noted that in hot dry 
 climates, such as the Punjab, the temperature of the surface of 
 the soil must not unfrequently reach this limit during the day. 
 Throughout this series of experiments, check observations to 
 test the infectedness of the fascal matter employed were 
 uniformly carried out. 
 
 Influence of Chemical Agents. — Perchloride of mercury, 
 thymol, carbolic acid, &c., were tried, but only proved fatal 
 when employed in such considerable strength as to render 
 their employment too expensive to be practicable, except in the 
 disinfection of dejecta in hospitals, &c. Of these, perchloride 
 of mercury is by far the most efficient, the addition of an equal 
 bulk of 2 per thousand solution being quite sufficient to put a 
 stop to all development of embryos. Viewing the known 
 carelessness of sweepers and 'other hospital servants, I think 
 this precaution should always be taken in hospitals where cases 
 of anchylostomiasis are under treatment, especially as solution 
 of this strength costs so little that there can be no objection to 
 the adoption of the plan on the score of expense. . 
 
 ^ Influence of Light. — The more natural the surroundings 
 of an experiment, the more rapid and abundant will be the 
 development of the ova into embryos and mature rhabdites, 
 and I have a general impression that the influence of light may 
 have something to say in the markedly better results obtained 
 in experiments conducted in the open air, over those carried 
 out under laboratory conditions. At the same time, that 
 complete development to the adult rhahditic stage and their 
 reproduction may take place in complete darkness is a fact that 
 has been demonstrated, during the present investigation, by a 
 large number of experiments, so that the influence of light is, 
 at any rate, not essential. 
 
( 97 ) 
 
 YIII. — The Method of Infection by the Parasite. 
 
 Having now considered the life history of the parasite, and 
 the circumstances that are favourable or hostile to its develop- 
 ment, the path, or paths, by which the infection is carried to 
 human beings, remains to be discussed. 
 
 In the first place, it must be remembered that the ova 
 themselves are never the infecting agent. Apart from 
 theoretical or rather comparative considerations, which are 
 entirely against the possibility of direct infection by the ova 
 of species possessing a free stage, the circumstance . that 
 embryos are never found in the fseces, however prolonged con- 
 stipation may have been, is alone sufficient to prove this. In 
 other words, the intestine does not offer suitable conditions 
 for even the hatching out, let alone the development of the eggs 
 produced by the parasite, and, as the other conditions of food 
 and temperature are quite favourable, it may be presumed 
 that the wanting factor is a sufficient supply of oxygen, an 
 agent which, as we have already seen, exercises a most potent 
 influence on all stages of its development. 
 
 It is the hatched-out embryos, and these alone, that are 
 in a fit condition to develop into the entozoic stage of the w orm, 
 and, from the analogy of other similar parasites, it is more 
 than probable that the embryos hatched out from parasitic 
 eggs are innocuous, and that it is only the progeny of the 
 free stage that is capable of infecting. 
 
 Another matter that is certain is that the embryos must 
 gain access to their human hosts by the mouth, and so must be 
 introduced either with the food or drink, or perhaps, in certain 
 instances, by the fingers, when casually introduced into the 
 mouth for other purposes than eating. 
 
 Hitherto, it has always been assumed that the parasite 
 gained access to the intestinal canal through the agency of 
 drinking-water, but this opinion has been based rather upon 
 a priori considerations than upon the observation of actual 
 facts, and, though I have no doubt it occasionally occurs, 
 I am personally inchned to believe that drinking-water forms 
 a quite exceptional vehicle of infection. In the first place,- out 
 of the very large number of examinations of drinking-water 
 from infected places, in collecting which I in many instances 
 was at pains to stir up the mud, so as to favour the discovery 
 of embryos as much as possible, I have only once met with 
 any sign of Dochmius embryos, and even in this case, as 
 the specimen was a much-decomposed female, and not one 
 
( 98 ) 
 
 of the very characteristic males, it is quite possible that it 
 may have belonged to a harmless and non-parasitic species. 
 I can only say that it was a rhabdites, agreeing in 
 general size and appearance with those of our species. 
 Now, were drinking water the usual vehicle, it is probable that 
 it would have been met with often, in large numbers, and not 
 an isolated specimen, once only. 
 
 Again, the physical peculiarities of the embryos are entire- 
 ly unfavourable to such an occurrence. Supposing them, as 
 indeed the ynot unfrequently must do, to gain access to a well, 
 they would at once sink to the bottom of it, and become 
 entangled in the mud, and, when we remember what clear 
 water may be commonly drawn from wells very muddy at the 
 bottom, it must be seen that, unless they happen to 
 be taken during their very rapid passage to the bottom, 
 their mixture with water actually taken for drinking must, 
 in the case of wells, be a most exceptional occurrence. Infec- 
 tion by water taken from running streams must be still more 
 exceptional, for the immense dilution that infected drainage must 
 at once undergo, must render the chances against even a single 
 embryo being contained in the few ounces of water drunk 
 during the day very small, for, prolific as these nematodes are, 
 the numbers produced are in no way comparable to those of 
 bacteria, such as those of typhoid fever, where the immense 
 number and infinite smallness of the infective organisms renders 
 the infection of large volumes of water not only possible, but 
 common. In the case of large rivers, such as the Brahmaputra, 
 water carriage of infection is well nigh inconceivable, for it must 
 be remembered that the introduction of single embryos would 
 do no appreciable harm, and that, unlike the bacteria, they are 
 quite unable to breed there like within the human subject, so 
 that every worm found parasitic must have been separately 
 introduced from without. Such being the case, how can drink- 
 ing-water have been the vehicle of infection in the already 
 cited instance of the village of Paru, whose only possible source 
 of drinking-water is the river Brahmaputra, the main current 
 of which sweeps by, within a few yards of its houses. On the 
 other hand, hhib offer much more favourable opportunities 
 for the conveyance of contagion, but, even here, the natural 
 habit of avoiding scooping up more of the mud than can be 
 helped must operate to render its carriage in water taken for 
 drinking very rare. 
 
 The habit which natives have of washing out their 
 mouths with water which they have just stirred up by 
 
( 99 ) 
 
 batHng in it must, however, offer exceptional opportunities for 
 infection by the agency of water, especially as they nearly 
 always ease themselves on the very brink of the water in which 
 they propose to bathe. In pools employed for this purpose, I 
 have repeatedly met with undoubted Dochmius embryos, and 
 have little doubt that this habit is an occasional source of infec- 
 tion, although the people always stated that they did not use 
 the water for drinking. It is improbable, however, that this 
 will account for more than a very small proportion of cases, and, 
 in numbers of villages, although very badly infected, there is 
 no opportunity for its occurrence this way. For example, in 
 Paru the people bathe in the river, the rapid current of which 
 would instantly carry away embryos that might get into it. 
 If water, then, be, at best, a very exceptional vehicle of infection, 
 what, it may be asked, is the usual way in which the disease 
 is contracted ? To answer this question, we should first ascer- 
 tain in what situations infective embryos are to be found 
 in the largest numbers. These situations, I must most empha- 
 tically repeat, are neither wells nor pools, nor collections of 
 w.ater of any kind, situations which I have, moreover, experi- 
 mentally proved to be entirely unfavourable to the life of the 
 embryos, but the surface of the soil near dwellings, which, 
 as we have seen, offers by far the most favourable situation 
 for their development. 
 
 In most parts of India, the villagers, however dirty 
 their habits, make a custom of going to some little distance 
 from their houses to relieve nature. As they generally choose 
 the banks of the nearest nullah and so render inevitable 
 the defilement of their water-supply, this habit is, from 
 a general sanitary point of view, even worse than that of the 
 Assamese. One naturally expected that in this matter their 
 habits would resemble those of other Indians, but I was sur- 
 prised to find, from careful personal observation, that they 
 rarely trouble themselves to go more than a few yards from 
 their own doors. It is not uncommon to find the younger men 
 conform to the Indian habit, but old men, women, and children, 
 and especially the sick, will not move more than a stone's-throw 
 from their huts. After all, it is but natural that a man scarcely 
 able to move from the weakness brought about by anchylosto- 
 miasis, and often tormented by diarrhoea, should not trouble 
 himself to tax his strength by going to any considerable distance, 
 especially as his ideas of decency in this matter are, at the best, 
 quite rudimentary. Owing to such habits, a broad circle of 
 ground round the hut of a patient affected with anchylostomiasis 
 
( 100 ) 
 
 becomes little better than a large cultivation ground for the em- 
 bryos, and, in such situations, there is never any difficulty in 
 finding abundance of them. Assam is essentially a muddy 
 climate : even in the cold weather, the daily morning fogs keep 
 the surface of the soil continually moist, and, when it is much 
 trodden upon more or less muddy, and it is only during the short 
 dry season that the surface becomes absolutely dry, and, even 
 then, the soil will be found to be damp at a very little depth. 
 Hence, in enterin^^r his hut, and in movin<? about amonojst his 
 neighbours, the inhabitant of an infected village must always be 
 getting his feet covered with mud, which is absolutely teeming 
 with infective embryos. When we remember that a bit of 
 mud no larger than a pea may contain scores of them, it 
 is easy to see what multitudes must be introduced into the 
 house each time the occupants enter it. Once within the house, 
 there are many ways in which the embryos may gain access to 
 the intestinal canal of the inhabitants. For example, food is 
 always eaten squatting on the ground, with, at most, a bit of 
 seldom-cleaned matting as at once table and table-cloth. 
 Under such circumstances cleanly eating is impossible, and a 
 certain amount of the dirt of the floor is pretty certain to get 
 into the dish at each meal. Not only so, but, in the position 
 natives sit when eating, their hands necessarily often come into 
 contact with their feet, and, as they have no other forks than 
 their fingers, these latter must often convey into their months 
 dirt from their feet or the floor. Again, in course of time, the 
 infected mud, which must necessarily be introduced into the 
 house, w^ill become house-dust. Now the very moderately in- 
 tense drying that would take place in such a house, would be 
 quite insufficient to kill the embryos, and being, when dry, 
 very light, they must be raised into the air with the other 
 constituents of the house-dust, and descend on food and upon 
 cooking utensils, and it is quite possible that some may be 
 drawn into the nasal passages in respiration, and so gain access 
 to the stomach to<?ether with the nasal mucous, which is con- 
 stantly flowing, through the posterior nares, into the pharynx. 
 There are other native habits which also greatly favour infec- 
 tion. One of these is that of cleaning brass eating utensils with 
 earth taken up anywhere, and I have actually seen a woman 
 cleaning her platters with earth which I ascertained to be in- 
 fected, and, as an instance of their utter callousness to the most 
 ordinary considerations of niceness, I may mention that in this 
 very instance I saw her husband calmly easing himself, on the 
 same patch of ground not many yards off*. Another habit 
 
^ 101 ) 
 
 favouring infection is that of smearing the walls and floors with 
 mud mixed with cowdung, in the preparation of which compost 
 infected earth is often used. In its application no other trowels 
 than the hands are used, and the users are, we may be sure, 
 none too nice in cleansing them before employing them to 
 handle their food. In fact, the habits of the Assamese could 
 not better favour infection had they been specially devised with 
 a view to the purpose, and the only wonder is, not that so many 
 are infected, but that any escape. Nor are such habits con- 
 fined to the poor and wretched ; in fact the advantages 
 enjoyed by the educated clerk in an English office consist 
 more in better clothing and food than in any essential 
 difference in the sanitary tendencies of his domestic habits, so 
 that they in no way share the immunity from attack that is 
 enjoyed by Europeans. The longer the disease remains in a 
 village, the wider will the area of ground become, the 
 surface of which will teem with thousands of infective 
 embryos. 
 
 As far as my experiments on this point go, they tend to show 
 that the embryos do not spread very widely around the centre on 
 which the ova were deposited. They are too much entangled in 
 the surface mud to be spread very widely by ordinary rain. Stilly 
 in time of flood, especially where there exists a current of any 
 strength, the embryos must often be carried to considerable 
 distances, and, wherever they are deposited, they will lie in the 
 resting stage for months, only awaiting the accidental deposit 
 of a fresh supply of fascal matter to breed and multiply, and 
 start a fresh centre of infection. In this way, large portions 
 of the area of Mla-azdr villages may come into such a state 
 that the accidental introduction of a small portion of the 
 surface soil into the intestinal canal will be sufficient to produce 
 the disease in a new host. Unobservant as the peasantry are, 
 they have at least recognized the persistent way in which the 
 disease clings to any place in which it has once established itself, 
 and know well that no measure of prevention is so effectual 
 as the entire abandonment of such sites. 
 
 From what has already been said, it will be seen that, as 
 a rule, infection must be a very gradual matter. Cases may, 
 and no doubt do, occur in which the accidental swallowing of a 
 large dose of infective matter may suffice to introduce a number 
 of embryos large enough to cause serious mischief, and, indeed, 
 some cases of an acute character can hardly be accounted for 
 in any other way ; but usually the process must be a very gradual 
 one, and far from being a matter of a single infection, the process^ 
 
( 102 ) 
 
 more probably is a matter of almost daily small increases from 
 the beginning to the end of the case, during which I am inclined 
 to believe that often several successive sets of parasites may 
 come and go before the fatal termination. It is owing to this, 
 that treatment out of hospital is such a discouraging, and 
 indeed hopeless, matter, for, owing to the necessarily constant 
 recurrence of infection, only a temporary improvement can be 
 expected. The ground round the hut that has been occupied 
 by a case of anchylostomiasis must soon get in so highly 
 infective a condition that, if the patient is to return to it, 
 treatment can be little better than a waste of drugs. 
 
 Probably in no two cases is the rate of infection uniform 
 or similar, and the spread from man to man in a village must 
 necessarily be equally irregular and uncertain for the indivi- 
 dual, though inevitable for a considerable proportion of a 
 village population. The rate and method of spread are in 
 fact just what we find in Mla-azdr, and are necessarily 
 entirely different from the phenomena to be observed in 
 directly infective diseases, such as the specific fevers. In 
 anchylostomiasis, the infection is indirect, and mere contact and 
 Association with a patient are quite incompetent to transmit the 
 disease, whereas, in ordinary communicable diseases the infec- 
 tion is direct, and there is usually no difficulty in tracing its 
 source. It was undoubtedly with the phenomena of direct 
 contagia, such as these, alone in their minds, that previous 
 observers of kdla-azdr have so confidently stated that there is 
 no evidence in favour of its contagiousness, and, so limited, 
 their deduction was perfectly correct. In reality, however, 
 anchylostomiasis, for people in a low grade of civilization, is 
 one of the most infectious of all maladies, taking the word in 
 its broad sense of communicability, and the method of its 
 spread coincides exactly with the facts observed in connection 
 with the spread of kdla-azdr. 
 
 On the other hand, the danger of infection is almost nil 
 for Europeans, even in India. The mere fact of eating at a 
 table, with knives and forks instead of fingers, is alone almost 
 sufficient to secure immunity, and in even the most backward 
 European towns, the system of conservancy, however badly it 
 might be conducted, would suffice to prevent all chance of con- 
 tracting the disease. Were the whole of the affected popula- 
 tion in Assam suddenly transferred to London to-morrow, not 
 a single case of infection could possibly occur, as long as the 
 new-comers were forced to live under the same conditions as 
 Londoners. 
 
( 103 ) 
 
 There is, however, one danger of infection for Europeans 
 in India, about which a word of warning may not be out of 
 place. I refer to milk supply. In Gauhdti, for example, the 
 danger is a very real one. The greater part of the milk consumed 
 by the residents is brought into the town from Paru, and other 
 villages, where kdla-azdr is rife. It is conveyed in galvanized 
 iron buckets, and any morning the milkmen may be met coming 
 in, each with a couple of buckets slung on the ends of a bamboo. 
 To prevent the milk splashing and being lost, they place in each 
 bucket a wisp of reeds or grass. Now, it is perfectly obvious 
 that the reeds may have been taken from a hhil swarming with 
 embryos, and it is even more likely that the udders of the cows,. 
 and the hands of the milkers may be fouled with mud so infected, 
 and though I have met with no case where any suspicion of infec- 
 tion of a European has occurred, it behoves aU residents of such 
 neighbourhoods to be careful that all milk used in their houses 
 is thoroughly boiled, — a precaution which will certainly render 
 safe any specimen of milk, however badly it might be infected. 
 
( 104_ ) 
 
 IX. — Eemarks on the Pathology, Diagnosis, and 
 Treataient, &c., of Anchylostomiasis. 
 
 To attempt any exliaustive treatment of this subject 
 would involve writing a treatise of nearly the bulk of the 
 entire present report. Moreover; the task has already been 
 too well accomplished to make it either necessary or desirable 
 that I should do so, and all that is here attempted is to 
 emphasize some old points that appear of special importance, 
 and to notice a few new ones that have cropped up during the 
 present investigation. 
 
 The importance of an early diagnosis in cases of anchy- 
 lostomiasis cannot be overrated. If we wait till matters are 
 gone far enough for the patient to be unfit for work, the 
 chances are that the time has passed during which he might 
 have been saved. When first it was discovered that kdla- 
 azdr was actually anchylostomiasis, but having no previous 
 practical experience in treating the disease, I naturally hoped 
 that the expulsion of the parasites would be sufficient to 
 initiate a cure, and the rest would be merely a matter of 
 waiting until a sufficiency of food had been assimilated to 
 make up for what had been lost. This a priori notion would 
 doubtless have proved correct enough had the patients retained 
 the power of assimilation ; but a further experience of the 
 disease has demonstrated the fact that the mere loss of nutri- 
 tive matter required for the support of the parasites is a 
 small and quite unimportant factor in the causation of the fatal 
 symptoms produced by them. Various calculations have been 
 made as to the amount of blood actually withdrawn by the 
 parasites, and these, though differing pretty widely, agree in 
 making the amount too small to be likely to do more than 
 seriously weaken an adult. The real damage is mainly caused 
 by the destruction of the digestive powers. A large share in 
 tlie causation of this diminished power of assimilation, is proba- 
 bly to be accounted for by the^ constant recurrence of great 
 numbers of small traumatic lesions of the mucous mem- 
 brane. Should these lesions include boring, and temporary 
 encystment, the matter is the more easily understood ; but the 
 bites themselves, in spite of their small area, can account for 
 much. 
 
 Microscopical examination has shown me that the gnawing 
 of the parasite produces an erosion which extends to the sub- 
 mucosa. Now, we know that, once damage of an epi or endo- 
 thelial surface has gone to this extent, repair takes place by 
 
( 105 ) 
 
 the formation of a scar, and not by reproduction of either true 
 skin or secreting mucous membrane, so that each bite must 
 leave a small area incapable* of ever again performing its 
 natural functions. The number of bites always largely exceeds 
 that of the parasites, so that each probably inflicts several 
 small injuries in the day, and when this is multiplied by a large 
 number of parasites, acting through a long period, the total 
 area so affected may become very considerable, especially as 
 the duodenum and upper part of the jejunum are one of the 
 most important portions of the intestinal tract. Again, in the 
 examination of advanced cases, the stomach is always seriously 
 affected ; it usually shows scattered petechia and a peculiar 
 mammilated, leathery appearance of a dull slatey red hue, which 
 is most often best marked along the greater curvature, and 
 which reminds one, more than anything else, of the grained 
 appearance of morocco leather. It is undoubtedly this change 
 which is referred to in Mr. McNaught's accounts of post- 
 mortem examinations of kdla-azdr cases. This mammilated 
 appearance is so peculiar that, on first seeing it, I was con- 
 vinced that it must be due to small cysts in the mucous mem- 
 brane, and that the encysted parasite would readily be found 
 in them. Careful microscopical examination, however, failed 
 to show any sign of the parasite, but only an elevation of the 
 mucous membrane caused by inflammatory infiltration of the 
 submucous tissue, and often enclosing a small old blood clot. 
 It is very possible, however, that they may be the remains of 
 cysts, which once contained parasites, which have escaped in 
 the due course of their development. Their close resemblance 
 to the changes found in the stomachs of equine animals affected 
 with Sclerostomnm teracantlmn^ w^here there is no doubt about 
 encystment, strongly supports this view. 
 
 The ultimate result is a chronic gastritis, with thickening 
 over certain portions of the mucous membrane and atrophic 
 changes elsewhere ; the very process of repair leading ulti- 
 mately to wasting and functional uselessness of the organ. The 
 changes in the intestine are very similar, though large thickened 
 areas are rarely met with. The principal organs of digestion 
 having been reduced to this condition, proper assimilation 
 becomes impossible, and a condition of slow starvation follows, 
 under which the losses of blood, small in themselves, rapidly 
 produce the perniciously anaemic condition with which we 
 are so familiar. 
 
 Apart from this, it is well known that starvation, or any 
 condition equivalent to it, may, in itself produce, changes in the 
 
 I 
 
( JOg ) 
 
 assimilative mucosa, wliicli, tliougli difficult of exact anatomical 
 definition, are none the less quite fatal to the function of these 
 organs. The most prominent symptom *of this is usually a 
 looseness of the bowels, the well-known " famine diarrhcea," so 
 often noticed in reports referring to the great Madras famine, 
 though constipation or an alternation of these conditions were 
 sometimes met with. In such cases, recovery was practically 
 unknown, and that in spite of the most careful feeding, which 
 the digestive organs having almost lost their assimilative 
 powers, had become practically useless. Now, the condition 
 into which patients are brought by anchylostomiasis closely 
 resembles that of starvation, and no one can look at old pho- 
 tographs of the victims of the famine, without being struck 
 with the fact that a similar series taken from a kdla-azdr 
 village would be quite indistinguishable by the closest scrutiny. 
 Moreover, the symptoms of the fatal dyspepsia are closely 
 similar in both, though modified by the circumstance that, in 
 anchylostomiasis, the bowel, in place of being empty, habitually 
 contains plenty of food. It is probably owing to this that 
 constipation is a much commoner symptom in the disease we 
 are considering than in the dyspepsia of famine, the watery 
 flow being mechanically stopped by the mass of undigested 
 matter encumbering the lower bowel, until re-absorbed, and 
 which it has not the strength to expel. In spite of this, 
 attacks of diarrhoea of long duration are an almost constant 
 symptom of anchylostomiasis, but usually these attacks alter- 
 nate with shorter periods of constipation. 
 
 I am anxious to give great prominence to the primary 
 importance of dyspepsia in the production of the cachexia 
 of anchylostomiasis, because I meet with many who, from 
 failure to appreciate this fact, attach an undue importance to 
 the failure of thymol to efiect a cure in advanced cases, argu- 
 ing that, because the expulsion of the parasites fails to cure 
 the disease, they are therefore not its cause, and that there must 
 have been some antecedent cause at work, whereby the patient's 
 economy is rendered a suitable home for the parasite. Now, 
 this is an argument that, at one time or another, has been raised, 
 and abandoned in the case of every parasite that troubles the 
 human body, and its mere production argues an entire igno- 
 rance of the broad general laws of parasitism. The healthier 
 the host the better he serves the purpose of his unwelcome 
 guest, and any falling off in his health must necessarily be pre- 
 judicial to the welfare of the parasite, as, if the loss of health 
 be progressive, the ultimate result must be its destruction. In 
 
( 107 ) 
 
 connection with this Cobbold* remarks — " Most people, not ex- 
 cluding even the votaries of the healing art, following tradition, 
 regard the internal parasites or entozoa as creatures either 
 directly resulting from certain diseased conditions of their hosts, 
 or as organisms which would not have existed if their bearers 
 has been perfectly^ healthy. Nothing can be more absurd. 
 Such a conclusion is utterly at variance with all logical deduction 
 from known facts. It is, however, quite on a par with multi- 
 tudes of otlier popular delusions, which, in spite of the advance of 
 science, will probably never become wholly eradicated from the 
 public mind. People who hold these notions cannot or do not 
 desire to reject a view, which has for them a dominating power 
 almost equal to that of any known rehgious dogma." Yet these 
 same people, who would at once recognize the absurdity of insist- 
 ing on the necessity of a predisposition, to permit of the action of 
 the deprivation of food, in the production of starvation, still 
 would assume such a necessity to account for what is prac- 
 tically the same state when brought about by the action of 
 parasites. The fact is that fallacies of this description die hard. 
 , Dr. Kynseyf divides the symptoms of anchylostomiasis into 
 3 stages, — (1) the dyspeptic ; (2) the anaemic ; (3) the dropsical — 
 and though the arbitrary division of the gradual processes 
 of disease into distinct stages is rather to be deprecated, his 
 classification recognizes the truth of the primary importance of 
 the dyspepsia, and the manner in which it actually underlies 
 the angemia. Its disadvantage is that it does not sufficiently 
 emphasize the fact that dyspepsia, besides being the earliest 
 symptom, is continuous throughout the case, that, far from 
 diminishing when the anasmic stage is reached, it increases 
 in severity with the progress of the case, from first to last, and 
 that it is largely the cause of the anaemia, and not entirely 
 its effect, though the actual loss of blood caused by the 
 depredations of the worms has also an important share in 
 the resulting bloodlessness. Practically speaking, however, we 
 rarely, if ever, get the opportunity of recognizing the disease 
 previously to the supervention of ansemia, at any rate in 
 Assam, where cases will, as a rule, run into the dropsical stage 
 before they apply for medical assistance, and rarely indeed 
 seem to consider themselves as ill, until matters are very far 
 advanced. When once the ansemia has declared itself, how- 
 ever, the diagnosis, after a little practice, becomes very easy. 
 
 * "Parasites: a Treatise on the Entozoa of Man and Animals." By 
 T. Spencer Cobbold, m.d., f.r.c.s. J. & A. Churchill, London, 1879, page 1. 
 f Op, Cit.y page 5. 
 
 i2 
 
( 108 ) 
 
 The peculiar character of this anasmia and the way in which 
 it may be distinguished from other cachexies have already been 
 described on a previous page, and so need not be repeated 
 here. Even laymen soon become expert in recognizing the 
 condition, and I was much struck with the way in which a 
 gentleman managing a tea-garden in the Lakhimpur district, 
 while walking over his estate, picked out early cases at a 
 glance, and at once sent them off to hospital for treatment. 
 The coohes, I may remark, seemed in no way to resent being 
 treated in this way, and the undoubted success that has 
 attended this gentleman's attempts to cope with the disease, 
 serves as a ready answer to the objection that always meets 
 one when .systematic medical inspection and treatment of early 
 cases is proposed. Nearly always the reply is that the coolies 
 would not submit to such treatment, and would desert if one 
 attempted to deal with the disease in this way ; but here, as 
 in the case of conservancy, the objection is purely a priori, 
 and the objectors have never troubled themselves to test the 
 soundness of their theory by giving the system a practical trial. 
 But, even supposing the objection a real one, though I doubt 
 if it has the least foundation in fact, it would be surely better 
 to risk the chance of the loss of the services of a few men by 
 desertion, than to face the certainty of the entire loss of a large 
 number of men by death, and the diminution of working 
 power of perhaps half the remainder. In the instance, however, 
 which I have mentioned, I was assured that the popularity of 
 the garden had in no way suffered, and that, on the contrary, 
 the coolies seemed rather to appreciate the care taken of them. 
 Once the anaemic stage is fairly entered, there is no diffi- 
 culty in making a diagnosis, which is certain enough for all 
 practical purposes, but in very early cases some doubt may be 
 felt, and in such cases, before submitting the patient to the 
 ordeal of treatment with thymol, it is always well for the me- 
 dical attendant to make sure of his diagnosis by microscopical 
 examination of the dejecta, ^he examination is a very easy 
 one, and requires neither the use of high magnification, nor 
 anything more than a most rudimentary acquaintance with 
 microscopy. The easiest plan is to dip the end of a strip of 
 bamboo into the specimen to be. examined, and with it to 
 smear a minute quantity on an ordinary glass slide. A drop 
 of water is then placed on the smear and a thin cover applied. 
 By gently moving the cover to and fro on the slide, the water 
 and the material for examination become intimately mixed 
 together, and the slide is then placed on the stage of the 
 
( 109 ) 
 
 microscope and systematically examined. Care must be taken 
 that only a very small quantity is placed on the slide, as recog- 
 nition of the ova is almost impossible in a thick layer. A 
 better plan is to place a small quantity (a mass about the size 
 of a pea) of the material in the bottom of a test tube which has 
 been provided with a good cork, about a couple of inches of 
 1-20 solution of carbolic acid is then added, and a single 
 drop of some analine dye, such as magenta. The cork is then 
 inserted, and the contents well shaken and allowed to stand 
 for a few minutes. A pipette is then passed down to the sedi- 
 ment, but not quite to the bottom, and a small quantity of the 
 sediment allowed to run in and transferred thence to a slide. 
 The use of the carbolic acid does away the small disagreeables 
 of the examination, and the dye is useful in distinguishing the 
 ova from the other bodies. They themselves are little if at all 
 stained, except by a much more prolonged action of the dye, 
 but nearly everything else found in dejecta takes it up greedi- 
 ly, so that the ova are the more readily made out by the 
 contrast of remaining unstained. 
 
 The points of distinction between the ova of Dochmius 
 duodenalis and those of other human nematodes have already 
 been described, and the only other ova likely to be met with 
 are those of tape- worms and flukes. All of these, however, 
 want the clear belt which surrounds the yelk. Moreover, the 
 ova of all human flukes are much more segmented, as also is 
 that of Bothriocephalus latiis, while those of Tcenia saginata and 
 T. solium are smaller and quite spherical, instead of ovate. A 
 much more frequent source of difficulty, however, are coccidia, 
 a species sporozoon, which is very commonly found in immense 
 numbers in the dejecta of patients afiected with anchylosto- 
 miasis. Their occurrence is not constant, but is so common 
 that they are to be found in the larger proportion of cases. 
 In healthy subjects, I have not, as yet, met with them, and the 
 instances where they have been present in the largest numbers 
 have usually been advanced cases. What .their coimection 
 with the disease, if any, may be, is difficult to say, but they 
 certainly form no essential part of it, as they may be quite 
 absent in even the worst cases. 
 
 The number in which they may be present is astonishing, 
 and, estimated in the same way as was done in the case of ova, 
 many millions may be passed in the day, so that, even in the 
 diluted material, half-a-dozen may be found in each microsco- 
 pic field. They vary a great deal in size, but are generally 
 very much larger tlmn the ova of Dochmius, averaging about 
 
( 110 ) 
 
 y^Q- incli in diameter, so tliat it is only in the case of small 
 specimens that any doubt could arise. Besides varying much 
 in size, they are by no means uniform in shape, which, while 
 occasionally regular, is more often unsymmetrical, differing in 
 fact from ova much in the same way that potatoes do from 
 eggs. Each coccidium contains from 4 to 12 or more psoro- 
 sperms, and, in small specimens, where the outline chances 
 to be oval, the resemblance to Dochmius ova is very close. 
 As, however, they rapidly become intensely stained in even 
 very dilute solutions of analine dyes, no difficulty will be 
 experienced in distinguishing them if the second plan of exam- 
 ination be employed. 
 
 The occurrence of organisms of this class in human alvine 
 discharges has been previously observed byKjellberg andEimer,* 
 and it is doubtful whether they should be considered iden- 
 tical with C. oviforme^ found in the liver and intestinal canal of 
 rabbits, or not. These organisms sometimes cause fatal illness 
 in rabbits, and Leuckartf gives a fatal case in man, reported 
 by Gubler in Paris. The account of the case, however, reads 
 suspiciously like one of anchylostomiasis, and it is possible that 
 the psorosperm nodules found in the liver in this case may have 
 been but an accidental complication, especially as the occurrence 
 of such nodules in the tissues of animals is not inconsistent with 
 health. The date of the report (1858) is prior to the St. Gothard 
 tunnel outbreak of anchylostomiasis, which first brought an- 
 chylostomiasis, as an European disease into prominent notice, so 
 that the presence of anchylostomes would have been unlikely 
 to attract notice, even if present. The curious point is that, 
 though specially sought for, no psorosperm nodules could be 
 found in either the hver or bile ducts in the cases I have exa- 
 mined, but it must be remembered, however, that a considerable 
 number might be present, and yet escape notice. Another curious 
 circumstance is that these organisms maybe associated with other 
 epidemic diseases, for example Cobbold found that they were 
 almost universally present, in enormous numbers, in the flesh of 
 animals which had died of rinderpest, J and Leuckart found them 
 in the intestine of trichnized dogs, but neither author attributes 
 any pathological importance to their presence in either of these 
 cases, and, in the present instance, I hesitate to consider their 
 
 * Vercbow's Arcbiv, Pathol. Auat, Bel. XVIII., page 527,1860; vide 
 also E. Hoyle's translation of Leuckart's " Parasites of Man." Young 
 J. Pentland. Edinburgh, i^age 221. 
 
 \ Loc. cit., page 322. 
 
 X Cobbold: '' Parasites." J. A. Churchill, Ldfedon, 1879, page 278. 
 
( in ) 
 
 appearance as more than a coincidence, though, when present, 
 their attacks on the epitheha of the intestine can hardly fail 
 to aggravate the existing dyspepsia. However, whatever their 
 significance, they are extremely common in cases of anchylos- 
 tomiasis, whether under the name of Mla-azdr in villages, or of 
 heri-heri in tea-gardens, so much so, that, at one stage of the 
 investigation, before I had satisfied myself of the wide diffusion 
 of anchylostomiasis, and its adequacy to account for all the facts 
 of the case, I was inclined to suspect that they might have some 
 casual connection with Mla-azdr. The coincidence, however, is 
 too common to be purely, accidental, and it is possible, though I 
 have no facts to support the surmise, that the germs may be in- 
 troduced into man through the agency of the embryonic anchy- 
 lostomes, and that their frequency in man may depend on a 
 corresponding prevalence of psorosperm parasitic disease in the 
 free stage, anchylostomes, in which case, one stage of the life 
 of the psorospermia would be passed in the Ehabdites and 
 another in the intestine of man. If this be the case, they 
 must be a distict species from liver coccidia, and their non- 
 occurrence in that organ is explained. It will be seen, there- 
 fore, that, though their presence forms a possible source of 
 fallacy in the microscopical examination of dejecta for ova, their 
 frequent association with anchylostomiasis renders it highly 
 probable that when they are present, ova will be found also. 
 
 In any case where, in spite of suspicious symptoms, ova 
 cannot be ^discovered, the test of cultivation described on 
 page 72 should be resorted to, and I do not consider that 
 the absence of the parasites can be considered as proved until 
 resort to this method has been adopted. 
 
 The utterly insufficient grounds on which the absence 
 of the parasites has been assumed by various observers has 
 already been adverted to, and the commonest of these is the 
 non-discovery of the ' worms after the exhibition of thymol. 
 In most cases the examination has been nothing more than 
 a casual glance at the dejecta en masse. 1 can only say that, 
 however many may be present, it is in the last degree impro- 
 bable that any will be discovered by so casual a method of 
 examination, as their colour and small size makes detection 
 in this manner almost impossible. The only safe plan is to 
 place the mass on a loose surface of muslin, and to let water 
 run on it for a considerable time (about an hour). At the 
 end of tliis, a small quantity of quite inoffensive material, 
 consisting of the worms, and larger particles of undigested 
 matter will be left, but, even now, owing to the large propor- 
 
. • . ( 112 ) 
 
 tion of the food that passes through the bowel unaltered, 
 considerable numbers may be present, and yet not be visible 
 except under special circumstances, and to ensure their detec- 
 tion, the mass should be transferred to a shallow glass vessel 
 placed on a dark ground, and then carefully searched over, by 
 slowly stirring it, so as to successively pass the whole mass in 
 a thin layer over a portion of the dark ground. Such a 
 proceeding necessarily involves an expenditure of time and 
 trouble rarely at the disposal of medical men engaged in their 
 usual work, and what I deprecate is, not that the trouble has not 
 been taken to examine thoroughly, but that the most casual 
 examination is made the basis of most positive assertions aS to 
 the absence of the parasite. It is just because its discovery 
 is no easy matter that its presence has so long been over- 
 looked. Only once have I succeeded in discovering tjie 
 worm by mere casual examination, and that in a case where 
 they were exceptionally numerous. , / 
 
 From what has been said, the immense importancp of 
 making a diagnosis early in the case will be at once appre- 
 ciated. When circumstances will permit of such a course of 
 action, we should never wait for the patient to seek medical 
 aid, but should examine and make our diagnosis beforfe he 
 confesses himself to be ill. In ordinary practice such a 3lan 
 is unfortunately impracticable, but on tea-gardens it should be 
 quite easy to carry out. I feel convinced that the only 
 thorough way of eradicating the disease from these establish- 
 ments is by adopting the plan that has proved so successful in 
 dealing with scurvy in military and prison practice. Just as 
 is the case with anchylostomiasis, scorbutic mischief n^ay go 
 very far indeed before the patient is so iU as to be compelled to 
 seek medical aid, and it has long been recognized that the only 
 safe method of dealing with the disease is the early detecpion of 
 cases by periodical systematic medical inspections. Liickily, 
 just again, as is the case with scurvy, a diagnosis, good eaough 
 for all practical purposes, can be made at a glance, so that, if 
 the medical attendant time his visit at the usual weekly muster, 
 it need not prolong that process, as he will be able to make 
 his examination of the men in much less time than it will 
 take the manager to pay them. 
 
 • As the disease is essentially a chronic one, there would be 
 no need for making such an examination every veek, and 
 once a month would probably be sufficient. All cases detected 
 should at once be sent to hospital, and where the diagnosis is 
 doubtful, it might be supplemented by microscopical examina- 
 
( 113 ) 
 
 tion, thougli this will rarely be required, and in all cases, 
 where the diagnosis appears sure, the men should at once be 
 treated with thymol. Taken at this stage, before the patient's 
 digestive powers have, become thoroughly undermined, the 
 treatment need only involve two or three days' absence from 
 work, whereas, if the disease have once gained a fair hold, a 
 prolonged convalescence is inevitable, and may require months 
 to complete, during which the labourer is useless to his 
 employer, and necessarily becomes too poor to supply himself 
 with the liberal allowance of nourishing food indispensable 
 to his recovery. Hence, I repeat, every effort should be made 
 to expel the worms while the patient is still capable of 
 digesting his ordinary food. Another advantage is, 'that the 
 administration of tliymol to a man whose strength is but little, 
 if at all, diminished, is a trifling matter, while, if given to 
 advanced cases it may even accelerate the fatal termination 
 of the malady. By acting in this way, too, we put a great 
 check upon the spread of the disease, for it is just these 
 early cases, who are still able to move about freely, that 
 spread the ova of the parasites far and wide over the country, 
 and every worm killed means the destruction, or rather the 
 prevention of the birth, of thousands of the infective embryos. 
 Moreover, from all I have seen and all I can gather from gentle- 
 men engaged in tea-garden practice, who have had immense 
 experience in the treatment of the disease, there can be no doubt 
 that the treatment of advanced cases is entirely unsatisfactory, 
 and that we can rarely hope for a cure when once the fatal 
 destruction of the digestive powers has been allowed to progress 
 to any great extent, and hence every effort should be concen- 
 trated on the detection of cases while still in their earhest stage. 
 
 There is one symptom which has everywhere attracted 
 considerable notice in anchylostomiasis, v\^hicli requires some 
 notice here. I refer to geophagy, or earth-eating. It must 
 not be supposed that this symptom is pathognomonic of the 
 particular parasite with which we are at present concerned. 
 It is a common symptom of helminthiasis of all kinds, and 
 is not even peculiar to man. The same habit has been noticed 
 in elephants affected with flukes {rnasuri) as well as in horses 
 affected with strongyles and other parasites. 
 
 It is difficult to see why such a perverted appetite should 
 be caused by the presence of entozoa, especially as it is by no 
 means always traceable to- short-commons, combined with 
 increased appetite ; as the victims of the habit will eat earth, 
 even when plenty of proper food is easily obtainable, and even 
 
( IH ) 
 
 when the appetite for natural articles of diet is but small. As 
 is well known, a similar habit is common in pregnant women, 
 and her^ can only be owing to a sort of moral reflex to the 
 stimulation of the uterine afferent nerves, though why the 
 hnpulse should pass on to the higher centres, instead of 
 manifesting itself in the usual way in a current propagated 
 along the corresponding efferent fibre is a matter on which 
 we can form no guess. Probably, the phenomenon is here 
 owing to a reflex of a similar kind, initiated bv stimulation 
 of the intestinal afferent nerves. However that may be, the 
 habit is very common among tea-garden coohes, and also 
 in kdla-azdr-^ixiGken villages, the inhabitants of which recog- 
 nize it as one of the most characteristic symptoms of kdla- 
 azdr. The coolies do not seem at all particular as to the 
 kind of earth used, and a specimen, recently received from 
 Chiknagool, contained a quantity of gravel, as well as some 
 remarkably rough pebbles of coarse sandstone, and advanced 
 cases, who are too weak to walk easily, will devour the 
 mud from the floors and walls of the hut. The Assamese 
 villagers seem to be more particular, and prefer a smooth 
 clayey soil, which they regularly bake into a sort of biscuit, 
 having a pecuHar and extremely disagreeable smell, which 
 they call chikur. The cooking seems to be rather of the 
 nature of drying than baking, and I should doubt if the 
 whole mass is constant^- raised to 140°F. This peculiar habit 
 was first brought to my notice by my Assamese Hospital- 
 Assistant in one of my visits to Paru, where he got me some 
 of these earthen biscuits from a house where MZa-a^ar was 
 very bad. I gather from him that certain medicinal powers 
 were attributed to them, but he seemed to think this was 
 rather an excuse for eating them than otherwise, and that, as 
 he expressed it, they look upon them as "a sort of luxur3^" 
 It is perfectly obvious that the existence of such a habit 
 offers great facilities for re-infection by the ingestion of 
 quantities of earth which may contain infective embryos, and 
 such an occurrence is especially likely to occur in cases that 
 are too far gone to move far from their beds in search of this 
 extraordinary provender. As is well known, this habit is to 
 be met with, in isolated instances, all over India, and I can- 
 not help suspecting that microscopical examination of the 
 dejecta in such cases would lead to unexpected results. 
 When present, the desire seems almost uncontrollable. In a 
 case which came under my care at Hoshangabad, the patient, 
 an inmate of the Society of Friends' Orphanage there, and par- 
 
( 115 ) 
 
 ticularly well fed and cared for, was bedridden from liip- 
 joint disease. In spite of all entreaties and remonstrance, she 
 insisted on picking out and eating plaster from tlie floor of 
 the ward. Ultimately, the lady in charge of the case took to 
 tying her hands to the bed, and then, in spite of this and a 
 long splint and weight, she would contrive to wriggle the 
 upper part of her body off the bed and to grub up the plaster 
 with her lips and teeth, whenever she was left alone for a 
 few moments. My attention had not then been drawn to the 
 connection between earth-eating and helminthiasis ; but, look- 
 ing back upon the case, I now feel little doubt that the presence 
 of some parasite was the cause of this extraordinary longing*. 
 The only way of dealing with it is obviously by the 
 expulsion of the parasites. Its existence is an added danger 
 to those already caused by parasites, as death has been 
 known to be caused by exceptionally large meals of this 
 unnatural kind, and I can recall a case where this actually 
 took place, in my own practice, in the case of a grass- 
 cutter, while I was employed on regimental duty in the Punjab. 
 This man had swallowed several pounds of earth, but even 
 when the habit exists to but a small extent, it must greatly 
 aggravate the dyspepsia which forms so important a feature in 
 cases of anchylostomiasis. The difficulty of dealing with it, in 
 actual practice, may be judged from the case already described. 
 In the matter of treatment, I have little to add to what 
 has already been made public by previous writers on the 
 subject. There can be no doubt as to the efficiency of thymol 
 in expelling the parasites, but I am anxious to emphasize 
 the necessity of adhering to the dosage* recommended in the 
 Sanitary Commissioner's circular on the subject. I have 
 found a great deal of variation in the practice of different 
 people in this matter, with, as a rule, only the most vague 
 general opinions assigned as the reason for so .doing. 
 For example, I found that the Assistant-Surgeon at Dibru- 
 garh was employing doses of only a few grains, and, on 
 closely questioning him, the only justification he could urge 
 for the practice was, that he thought the patients were 
 improved, but that he had never attempted to ascertain 
 whether the worms were expeiled or not, by even the most 
 casual inspection of the dejecta. Probably, his real reason 
 was the tendency to hoard up "Europe medicines," which 
 
 * Subparagraph 49, Annual Sanitary Keport of Assam for 1888. See 
 also paragraph 48, lines 8-13, Assam Annual Sanitary Eeport for 1889, 
 which recommends thymol first, and then purgatives. 
 
.( 116 ) 
 
 amounts almost to a mania in many medical subordinates. 
 As lias already been remarked, my clinical opportunities 
 have been but scanty, but I have tried these small doses in 
 several cases, and have never found them expel a single 
 worm, and, moreover, I treated some of the cases that had 
 already been treated with these small doses in the Dibrugarh 
 Charitable Dispensary, with the ordinary doses, and expelled 
 the worms in such considerable numbers that it was perfectly 
 clear that, whatever effect the small dose may have liad, it 
 was entirely inadequate, and for practical purposes it may 
 be taken as certain that the employment of the drug in such 
 Small doses as 3 to 4 grains for adults is nothing better than 
 a purposeless waste of an expensive drug. 
 
 The smallest dose with which I ever succeeded in getting 
 any effect whatever in an adult was ten grains thrice repeated, 
 but the dose was clearly inadequate, as many worms were left 
 behind. The usual routine dose of 30 grains thrice repeated 
 very commonly expels every single worm, as has been ascer- 
 tained in several cases where the subsequent death of the 
 patient enabled the matter to be established beyond doubt. On 
 the other hand, even with this dose, I have often found consider- 
 able numbers of the parasites left behind, as evidenced by the 
 uninterrupted continuance of ova in the dejecta. However, 
 by employing a different plan of exhibiting the drug, I have 
 several times obtained excellent results with thrice repeated 
 twenty-grain doses, and am inclined to think that a great 
 deal depends on the manner in wliich it is administered. 
 Thymol is a body very little soluble in water, and its action on 
 the parasites appears to be, by contact with the solid material, 
 little or none of it appears to be absorbed into the circulation, 
 under ordinary circumstances, so that by far the greater part 
 of the drug passes unaltered with the dejecta. Owing to this, it 
 is quite evident that a dose of 20 grains, carefully triturated, 
 may be far more effectual than one of 30, which has been 
 but coarsely powdered. Unfortunately, thymol is anything 
 but easy to powder, and to do so thoroughly involves a great 
 deal of personal discomfort, in the way of sneezing and lachry- 
 mation, to the compounder, so that, with the very inferior 
 agency we are able to employ in such work in India, it is by 
 no means surprising that the job is often very badly done, 
 and, as a matter of fact, I have often, in searching for the 
 worms, recovered a large portion of the dose from the dejecta 
 in comparatively large crystals, often reaching the size of 
 a No. 8 shot. . Putting aside- then such absurd doses as 3 or 
 
• ( 117 ) 
 
 4 grains, the effect of a close will depend much more on the 
 fineness of the particles of the drug than on the actual weight 
 employed, and so, as at present administered, comes to depend 
 mainly on the endurance of the compounder, and the vigour 
 of his arm. There is, however, not the least reason why this 
 should be the case, as. there are other means than mechanical 
 trituration available, by means of which thymol can be reduced 
 to a much finer state of division than can ever be obtained by 
 the agency of pestle and mortar. Though so little soluble 
 in water, thymol is almost indefinitely soluble in rectified 
 spirit, and can be conveniently kept in spirituous solution for 
 dispensing purposes. If some of this alcoholic solution be 
 poured into a relatively large bulk of water (say, a drachm of spi- 
 rituous solution into an ounce of water), a milky emulsion at once 
 results, which consists of minute oily globules, not much larger 
 than those present in milk, and it is in this form that I would 
 strongly recommend the drug to be administered, if we would 
 wish to secure uniform results from uniform doses. If, however, 
 such an emulsion be allowed to stand for a while, the circular, 
 oily globules run together with larger ones, and, after attain- 
 ing a certain size, resume the crystalline form, and then, though 
 the crystals are usually but small, the advantage of over tritu- 
 ration is only one of degree. The addition to the water of muci- 
 lage or rice conji will retard this change for some time, but not 
 sufficiently long to admit of the drug being sent out to patients 
 in this form. Hence, the alcoholic solution should, wherever 
 practicable, be only added to the emulsif^^ing vehicle imme- 
 diately before administration, and where the necessity of sending 
 out of doses to patients renders this impracticable, it should be 
 made with hot coiiji of such strength as to gelatinize when cold. 
 I believe that 20 grains of thymol administered in this 
 way will be at least as effectual as 30 given in the usual 
 fashion. To go into practical details I would recommend the 
 following formulas : — 
 
 (a) S-tock solution of thymol — 
 
 Thymol grains 480 
 
 Sp. rect ounces ii. 
 
 Dissolve the thymol in the spirit, and add a sufficiency of 
 rectified spirit to make up to ounces iii. Twenty grains of 
 thymol are contained in each drachm of this solution. 
 
 (b) Vehicle for administration — 
 
 Strong mucilage of acacia or dextrine ounces ii. 
 
 Glycerine drachm one-half. 
 
 Water add ounces ii. 
 
I 118 ) 
 
 At the time of administration add one draclim of the stock 
 solution of thymola to ounces ii. of {b), shake well, and adminis- 
 ter at once. 
 
 Another point in connection with the use of thymol 
 which requires some notice is the concurrent administration 
 of purgatives. It is usually recommended to commence by 
 the administration of a purgative, and also to follow up the 
 doses of thymol with a second. Thus, treatment of a very 
 active character, consisting in all of five doses of very active 
 drugs, is extended over several hours, and the whole proceed- 
 ing becomes so heroic that it becomes quite beyond the endur- 
 ance of advanced cases, and, in some cases th§,t have come 
 under my observation, I am convinced has accelerated the 
 fatal termination, though doubtless these were cases which must 
 inevitably have died sooner or later whatever treatment had been 
 adopted. I must confess that I am unable to understand the 
 rationale of the first purgative dose. The intention is, I suppose^ 
 to obtain a- free field for the thymol in the shape of an empty 
 bowel, and, in the case of parasites whose habitat is the 
 lower bowel, its administration would be rationa^enough. But 
 the duodenum and jejunum, as the name of the latter indicates, 
 never contain sufficient food to interfere with the action of the 
 drug, and where we have to deal with Dochnius duodenalis 
 its administration can only be needless, and will probably be 
 prejudicial, for the irritating effect of the purgative will great- 
 ly increase the amount of mucus in the parts of the bowel 
 over which it has passed, and this mucus will be a much more 
 effectual bar to the action of the thymol than the presence of 
 a considerable quantity of food. Besides, as far as these parts 
 of the intestine are concerned, the withholding for a few hours 
 of all solid food will be more effectual than all the purgatives 
 in the pharmacopaea. 
 
 A previous abstinence-from solid food forms part of the 
 ordinary treatment, and I have been unable to trace the least 
 additional advantage in the additional administration of a 
 preparatory purgative in cases treated for comparison on the 
 two plans. In the case of subjects in the initial stages of the 
 disease, picked out by inspection, it is probably a matter of 
 little moment which course is pursued, though I believe the 
 preparatory purge to be in any cases needless, but, in the cases 
 we are more commonly called upon to treat, especially in 
 dispensary practice, every additional strain on the i3atient's 
 strength, and especially on his digestive powers, becomes a 
 matter of serious import, and, when diarrhoea is a prominent 
 
( 119 ) 
 
 symptom of the fatal dyspepsia of the disease, it becomes a 
 question whether the second purgative should not also be 
 dispensed with, which, where the patient's forces are at all a 
 low ebb, must be answered in the affirmative. As, however, 
 has been already remarked, the action of the drug seems 
 often to stupefy rather than kill the parasites, a subsequent 
 purge is clearly indicated wherever the patient's strength 
 will admit of it, lest the parasites should recover their 
 vitality before they have been expelled from the intestinal 
 canal. The danger of this is, however, perhaps more 
 apparent than real, as, provided the narcotized parasites had 
 been passed beyond the jejunum, the new habitat would be so 
 unsuitable to them, that it is highly improbable that they would 
 be able to establish themselves in these lower parts of the 
 intestinal canal. Hence, wherever there is any doubt of the 
 patient's ability to bear vigorous treatment, I should 
 personally incline to the exliibition of thymol alone, except in 
 cases where actual constipation is present, where the long 
 retention of the drug in the system might lead to a larger 
 absorption than is desirable. On the whole, as the mildest 
 of all purgative agents, good castor-oil is probably the 
 best drug for our purpose, and has only one disadvantage, 
 in the fact that the presence of the oil in the dejecta renders 
 the detection of the worms a matter of considerably greater 
 difficulty than when saline purgatives have been employed. 
 The way, indeed, in which it clings to the worms strongly leads 
 one to suspect that its use as a preparatory purgative, so far 
 from being advantageous, may defeat our object by giving 
 the worms a protective coating, and so preventing contact with 
 the thymol. 
 
 While deprecating the purposeless waste of thymol by the 
 exhibition of absurdly small doses, it is to be noted that there 
 are many indications that a dose of 30 grains is about as large 
 as can be safely given, and that in advanced cases the practice 
 of repeating this dose three times is not unattended with 
 danger. In particular, I recall a case observed by Dr. Mullane 
 andmyself inGauhati jail. The patient, who, while exhibiting 
 unmistakable symptoms of anchylostomiasis, seemed by no means 
 in the very last stages of the disease, was given thymol in the usual 
 way. The worms were expelled in fair numbers, but the man 
 died within 48 hours of the treatment. Onpost mortem examina- 
 nation, it was found that not a single worm had escaped the action 
 of the drug, but that the whole length of the intestinal canal was 
 in a state of active congestion, and there can be no practical 
 
( 120 ) 
 
 doubt that the man's death was accelerated by the treatment 
 adopted. Another reason for thinking that, in the customary 
 dose of 90 grs. we are closely approaching the limits of tolera- 
 tion of the drug, is to be found in the fact that I certainly 
 succeeded in poisoning a horse with a dose of 2^ oz. This 
 quantity was, it is true, given in a special manner, and in a single 
 dose, but it is not much in excess of the customary dose for' 
 a man, proportionally to the weights of the subjects, especially 
 when we remember that the whole 90 grains is usually in the 
 intestine at once, no motion of the bowel commonly taking 
 place until some time after the administration of the last 30 
 grains. I had some time previously given the animal 1| oz. in 
 three ^ oz. doses without producing any particular symptoms 
 beyond the expulsion of a number of parasites, but it died 
 within 6 hours of the administration of the larger dose. For 
 about an hour after receiving it, the animal fed naturally, and 
 seemed under no inconvenience, and I then went away, but, 
 shortly after this, he became restless and weak, and laid down in 
 his loose box and soon became unable to rise. He broke out into 
 a " cold perspiration," and died apparently in a faint, having 
 at no time exliibited much sign of pain. For the later symp- 
 toms I have to depend upon the description of Mr. Brown, the 
 Transport Conductor here, who is, however, a very acute ob- 
 server of animals. The animal seems to have died from cardiac 
 failure, and the symptoms bear some resemblance to those of 
 carbolic acid poisoning, as, indeed, might be anticipated would 
 be the case from the chemical constitution of the drug. It 
 should be added that the animal, a 13-2 Bhutia pony, though 
 excessively weak and ancemic from the effects of Sderostomum 
 tetracantham, a parasite which extracts blood from the mucous 
 membrane of the lower bowel of equine animals, in exactly 
 the same way as is done for the human small intestine by 
 Dochmius duodenalis^ was by no means in a dying state, and 
 had walked 1^ miles just before without showing much distress. 
 Any attempt, therefore, to increase the customary dosage should 
 be made with the greatest caution. 
 
 The scantiness of. my clinical opportunities prevented 
 my making many experiments with other drugs than thymol. 
 As to the efficiency of this drug there cannot be the least 
 doubt. It expels round worms more surely than santonine, 
 and, as I am told by Dr. Hancock of Dibrugarh, is far more 
 efficacious than male fern in the treatment of tape-worm. I 
 have myself seen it expel flukes, and there can be no doubt 
 that it is an almost universal vermifuge. Hence the most im- 
 
( 121 ) 
 
 portant point was to, if possible, ascertain the best way of 
 administering it, and the examination of other drugs was a 
 secondary matter. With salol, some success was obtained, but 
 it appears inferior to thymol, and, as it is somewhat dearer, no 
 advantage would be gained by its substitution. Picric acid 
 had no effect whatever, neither, as far as concerned anchylos- 
 tomes, had santonine. I meant next to have tried some of the 
 less soluble analine compounds, but it would hardly be justifi- 
 able to try an experiment of this sort on any but an early case, 
 and such cases I have not been able to obtain for treatment. 
 Moreover, in the entire absence of information as to the safe 
 dose of these substances, one would have to proceed very cau- 
 tiously, so that a large number of tentative administrations 
 would be necessary before one could be sure of one's ground. 
 The idea that they might be useful is based on their known 
 antiseptic powers ; but, after all, the difficulty lies not in the 
 expulsion of the parasites, but in the restoration of the digestive 
 powers, and as no drugs can ever be expected to efiect this, 
 the whole art of treatment resolves itself into the early detec- 
 tion of cases. 
 
 Complications of Anchylostomiasis. — Other parasites. — 
 probably to the peculiarly favourable nature of the climate 
 for the development of the free stages of nematodes and 
 other parasites, Assam is a perfect hotbed for parasites, 
 man and animals being alike affected, with an universality 
 that can hardly be surpassed elsewhere. 
 
 It is excessively rare to find an Assamese entirely free 
 from parasites, and, so far as my observations have gone, it 
 seems almost equally rare to find it the case in an Assamese 
 animal, whether free or domesticated. 
 
 In man, besides Dochmius duodenalis, the following parasites 
 were met with : — 
 
 Trichocephalus dispar. — It is exceptional to meet with an 
 Assamese who does not harbour this parasite. So far as my 
 own observations go, it appears to be almost confined to the 
 coecum, and as many as a hundred may be present. It 
 buries the long filiform aenterior, part of its body in the 
 mucous membrane, never penetrating deeply, but burrowing 
 along, barely beneath the 'epithefium, and subsists probably 
 on the intercellular plasma of the tissues surrounding the tunnel 
 it makes. Sometimes it does not seem to cause much irritation, 
 but at others an angry blush marks out the tunnelled line ; 
 and I have so often found it coiled up within ulcers of a dysen- 
 teric character that a causal connection between parasite and 
 
 K 
 
( 122 ) 
 
 ulcer may be strongly suspected. It, or a species anatomically 
 identical, was present in all five of the specimens of Macacus 
 rhesus that I have examined, so that the eggs must be very 
 widely diffused over the country. Its presence does not 
 appear to be incompatible with apparent health ; but if, as 
 appears probable, it be capable of causing ulcerations of the 
 gut, it is evident that, under certain circumstances, it may by 
 itself cause dangerous symptoms, and at best it cannot fail to 
 do something to help the destruction of" the digestive powers 
 initiated by anch3dostomiasis. 
 
 The life history of this parasite is involved in doubt, but 
 the general opinion seems to'be that infection is direct, i.e., by 
 ingestion of eggs. The structure of the envelopes of the ova 
 are somewhat in favour of this view, the shell* being hard, and 
 remarkably resistent to ordinary chemical agencies, a fact 
 which 1-eads one to suppose that they are designed to persist ; 
 a considerable time as ova, and that some special agency, such 
 as that of the gastric juice, is required to set them free. 
 Leuckart* states that they require a temperature of not less 
 than 72° F. for their development, and that the process is rarely 
 completed under a year. When deposited, the ova, which are 
 of deep red brown colour, of elongaed oval form, and possess- 
 ing a peculiar sort of knot at each pole, show no signs 
 of segmentation. In a cultivation started five months ago, 
 on the same plan as those of Dochmius ova, segmentation of 
 the ova commenced only five days after the commencement 
 of the experiment. The yelk divides into two very unequal 
 parts, and then the larger segment divides into two, and after 
 20 days, the morala stage was reached ; but at present many 
 of the eggs are still very backward, only a few contain em- 
 bryos, and I cannot be certain that any have hatched out. 
 The temperature has rarely exceeded Leuckart's minimum to 
 any great extent, and has often fallen below it during the rains. 
 A similar cultivation was kept for about a fortnight at a tem- 
 perature ranging from 80° — 104° F., but no particular hastening 
 of the process took place during this period, and the temperature 
 regulator worked so ill that a continuation of the experiment 
 had to be abandoned. A practical difficulty in this investi- 
 gation is that of getting specimens of dejecta containing Trich- 
 ocephalus ova alone. On the other hand, certain cultivation, 
 conducted in the open air and containing, inter alia, Tricho- 
 ^.ephalus ova, have been found, after a week or so, to contain 
 
 * Hoyle's Leuckart's " Parasites of Man," I., page 56. 
 
( 123 ) 
 
 a peculiar rhabditis, which is certainly referable to no stage 
 of Dochmius, and in which the oesophagus runs through a 
 peculiar cord of cells, the structure of which strongly recalls 
 that of a similar structure found in the entozoic Trichocephalus, 
 but, at the same time, other cultivations designed specially with 
 the object of obtaining such rhabdites entirely failed to show 
 any, so that the conditions, even supposing them to have been 
 in these instances accidentally complied with, involve some- 
 thing not plainly apparent, possibly an invertebrate interme- 
 diate host. It is clear, however, that more time than as yet 
 has elapsed is necessary for the thorough investigation of the 
 life history of a parasite about which there is good authority 
 for expecting a development extending over an entire year 
 within the egg alone. 
 
 Trichocephali offer more resistance to thymol than any 
 other parasite except Oxyuris vermicular is ^ but this is probably 
 due only to the habitat of these parasites being so low down in 
 the bowel. The drug is, however, far from being inoperative, 
 so that it is common to find a dozen or more on the dejecta 
 after the customary dosing, but, as a rule, as many or more 
 will be left behind. 
 
 The prevention of infection, as indeed in the case of all 
 intestinal parasites, is necessarily entirely a matter of conser- 
 vancy. Moreover, certain observations I have made tend to 
 show that the life of this entozoon is but short, and hence such 
 measures alone will rapidly effect a cure by mere prevention of 
 re-infection. Three little monkeys that I obtained for experi- 
 mental purposes, five months ago, positively swarmed with 
 Trichocephali, but now, simply by beings cleanly kept, scarce- 
 ly harbour any of them, and this can only be owing to the 
 death and expulsion of the majority of the parasites, combined 
 with the prevention of re-infection. 
 
 Ascuris lumhricoides is almost as common among the 
 Assamese as Trichocephalus, and not unfrequently exists in 
 such large numbers as by itself to constitute a distinct danger 
 to life. I have removed 45 large worms from the body of a 
 child a few years old, the whole mass weighing about 
 ^Ib, or nearly one-fiftieth of the weight of the host. 
 Although perhaps the commonest of all human para- 
 sites, we are in almost complete darkness as to its life 
 history, though direct infection by. ova is surmised. The 
 large slightly elliptical ova have a very thick, nodulated 
 envelope of a bright yellow colour, the density of which 
 makes observation of the interior a difficult matter. When 
 
 k2 
 
( 124 ) 
 
 deposited, there is no sign of segmentation, and I have never 
 seen any change in such ova as I have kept under observa- 
 tion, but some accidental observations place me in exactly the 
 same position as I stand with regard to Trichocephalus, as 
 lately, in some old cultivations, some peculiarly large rhabdites 
 have appeared entirely distinct from any stage oi Dochmius 
 and from the possibly Trichocephalus rhabdites. 
 
 This parasite, as is well known, often causes serious symp- 
 toms, and its extreme prevalence in Assam is no doubt one 
 of the causes of the low average of physical health of the 
 inhabitants. 
 
 In the treatment of patients for Ascaindes, thymol has 
 proved itself infinitely more sure and effectual than santonine, 
 having often caused the expulsion of large numbers after santo- 
 nine had been tried and had failed to expel more than two 
 or three, so that, personally, I am unlikely ever to use santonine 
 again. 
 
 Oxyuris vermicularis is not uncommon in Assam, but 
 is proportionately much less so than the two preceding. The 
 ova are thin-shelled, unsymmetrically oval, and always contain 
 an advanced, hvely embryo, which hatches out rapidly even 
 in water. Direct infection by ova seems to be considered as 
 proved, alike by Leuckart and Cobbold, but a species, anatomic- 
 ally indistinguishable, which infest Macacus rhesus^ certainly 
 goes through a distinct rhabditis free stage, and, though 
 prevention of direct self-infection was clearly impossible, 
 however cleanly the animals may be kept, they have, like the 
 TricJiocepfiali become distinctly less numerous during the period 
 the animals have been in captivity. Of course, however alike, 
 the human and simian parasites may be specifically distinct, but 
 possibly both methods of infection are possible, and indeed the 
 circumstance that oxyurids are common enough in European 
 towns, where conservancy arrangements qua the propagation of 
 intestinal worms, may be considered as almost perfect, may be 
 alone considered sufficient to prove the possibility of self-infec- 
 tion. They are clinically unimportant in connection with 
 anchylostomiasis, and are less afiected by thymol, adminis- 
 tered by the mouth, than *any other parasite. A copious 
 enema of weak emulsion is, however, far more effectual in 
 expelhng them than infusion of quassia, or any of the more 
 commonly used remedies. 
 
 Amphistoma hominis^ Lewis. — This curious little fluke 
 which, curiously enough, was first found at Gauhdti by Dr. J. 
 O'Brien in 1857, and was described by the late Dr. T. K. Lewis 
 
( 125 ) 
 
 in 1876* has been repeatedly met with during the present 
 investigation, though not in numbers sufficient to constitute 
 a danger to the patient. Its habitat is tlie coecum and colon, 
 and thymol appears to expel them with tolerable certainty. 
 A tailless cercaria, possibly of this species, was, on one 
 occasion, found in some mud used for plastering the walls near 
 a hut inhabited by a subject of this parasite. Lewis and 
 McConnell found them by hundreds, in which case they 
 would necessarily develop a clinical significance, but personally 
 I have never observed more than a dozen or so. I have 
 never met with the ova in the dejecta even in cases which 
 afterwards proved to harbour it, so that possibly these only 
 reach the exterior on the death and expulsion of the parent. 
 Distoma Crassum^ Busk. — A single specimen of this 
 large fluke was expelled by thymol from a little girl at 
 Chaygaon. Like many of her compatriots, this child har- 
 boured quite a museum of parasites in her own person, every 
 one of the species hitherto mentioned being represented. So 
 far as the scanty literature at my disposal enables me to 
 judge, this is the first occasion in which the occurrence of 
 this parasite in India has been recorded. In the case of a 
 missionary and his wife who had worked at Ningpo in China, 
 treated by Cobbold,f the most prominent symptoms were a 
 distressing diarrhoea, hepatic derangement, and wasting, but 
 very little is known about the species, and its habitat is only 
 surmised to be the hepatic ducts, and the only instance in 
 which it came under my observation being unexpected, and 
 complicated by the presence of so many other parasites, I am 
 unable to do more than to direct attention to its occasional 
 occurrence in Assam, and the possibility of its becoming the 
 cause of symptoms not altogether unlike those of anchy- 
 lostomiasis. 
 
 Cestode parasites. — Owing to the circumstance that the 
 people amongst whom most of my observations have been made, 
 never eat beef, and rarely consume pork, I have personally never 
 met with a case of tape-worm complicating anchylostomiasis, 
 but I am told by Dr. Hancock of Dibrugarh that he has 
 often met with, such cases among tea-garden coolies, and 
 I understand that these worms are very common amongst 
 the wild hill races on the south-eastern frontier of the Pro- 
 vince. The species would almost certainly be Tcenia 
 
 Lewis McConnell. Proc. Asiat. Soc. Bengal, Angust, 1870. 
 i Op. cit., page 22, ■ 
 
( 126 ) 
 
 ii^Uum, and, from what I can gather from others, thymol 
 would appear to be a far more efficient vermifuge in deal- 
 ing with them than male fern or any of the other drugs 
 more commonly employed for the purpose. 
 
 PedicuU. — In tlie course of examinations of the dejecta 
 of patients affected with anchylostomiasis, I liave repeat- 
 edly met with large numbers of immature pediculi crawling 
 about among the faeces. For a long time I believed their 
 occurrence to be purely accidental, and that they had 
 gained access to the stools after deposition ; aUhough in 
 some instances the rapidity of their appearance made this, 
 in tlie case of a wingless insect, extremely difficult of expla- 
 nation. Quite lately, while examining an unopened duodenum 
 preserved in spirit, I found six or eight of these insects 
 actually in the bowel, and there can now be no doubt 
 that the specimens met with in dejecta were deposited with 
 them, or, in other words, that the pediculi^ for some short 
 period of their lives, had actually been entozoa. Now, this is 
 somewhat remarkable, as there is no previously known 
 instance of any non-larval insect acting in this way. 
 
 I sent down one of the most advanced specimens I could 
 find to Mr. J. Wood Mason, the Superintendent of the Indian 
 Museum ; but, owing to its immaturity, he tells me that he 
 is unable to identify it with any known species. 
 
 I do not for a moment suppose that these insects pass any 
 length of time in the bowel, but, at the same time, believe that 
 they were born there. Any one who has watched the un- 
 sophisticated Assamese peasant when at his ease must have 
 noticed the habit they have of searching each other's heads for 
 vermin, and I have more than once seen the searcher deliberately 
 swallow the prey he had captured. Doubtless, the adult insect 
 gets, crushed by the fingers and teeth ; but the ova would 
 be unharmed, and, stimulated by the warmth of the 
 intestine, would hatcli out rapidly. In no other way indeed 
 can the presence of these insects living, and in considerable 
 numbers, in fresh dejecta be accounted for, especially as all 
 are still immature when met with. Since making this dis- 
 covery, I have had no opportunity of investigating what 
 species of Pedicuhis infest the persons of Assamese villagers, so 
 that I am still in doubt as to what species these temporarily 
 entozoic insects should be referred. 
 
 They probably have no clinical significance, and I 
 merely liere note their occiftrence, because it is desirable ta 
 put on record a fact which is, I beheve, new to medicine. 
 
( 127 
 
 Intestinal Coccidia. — The frequency of the occurrence of 
 these organisms has already been noted on a previous page, 
 and needs no further notice here. 
 
 It must be confessed that the above is a formidable list, 
 and when the great frequency of many of them is remem- 
 bered, it cannot be doubted that amongst them they form most 
 efficient aids to the action of the aifch-offender Dochmius 
 duodenalis. 
 
 Malarial Complications. — Complications of this character 
 are inevitable in any and every disease met with in such a 
 clii^ate as Assam ; but at the same time I believe that its 
 importance as a factor in the present increased mortality 
 has been enormously overrated. 
 
 A very good idea of the part it plays in an outbreak 
 of kdla azdr may be gathered from the tables given of the 
 relative prevalence of this compHcation in the case of Chunsali 
 tea-garden {vide page 143), but so much has already been said 
 on this subject in different parts of this report that its further 
 discussion here is unnecessarry. 
 
 Ihe Mode of Death in Anchylostomiasis. — Broadly speak- 
 ing, death in this disease always occurs from asthenia, but 
 the actual termination is usually brought about by the 
 supervention of some more or less acute complication. 
 
 Of these, perhaps the commonest of all is dysentery, 
 which seems occasionally determined by the action of 
 Jrichocepliali. 
 
 The frequency of phthisis has already been noted by Leitz, 
 and several cases of the kind have come under my own 
 observation. More frequent than this, however, are subacute 
 broncho-pneumonia and bronchitis, which, acting on organs 
 already almost incapacitated by oedema, are rarely entirely 
 absent, and rival bowel complaints in the frequency with 
 which they determine the fatal result. 
 
 The occurrence of other complications has b^en noted, but 
 they may be considered as rather accidental than as forming 
 a distinct feature of the clinical picture ; the above compli- 
 cations being present either together or alone in by far the 
 larger proportion of cases, while death from the disease itself, 
 without determining complication, is certainly the rarest 
 incident of all. One such case, however, occurred in the 
 Gauhdti dispensary, brief notes of which have already been 
 given, and here the patient died in the most typically 
 asthenic way it has been my lot to witness, the temperature 
 falhng, and the lungs and heart hampered by dropsical 
 
( 128 ) 
 
 effusions, acting more and more weakly, until tlie functions of 
 life came to a stop, much in the same way that a machine is 
 brought to a standstill by the dying out of the fire used to 
 originate its energy. 
 
( 129 ) 
 
 X. — Preventive and Eemedial Measures. 
 
 While this is undoubtedly the most important section 
 of this report, the conclusions to be drawn from the facts 
 recorded in previous sections, are so obvious that it appears 
 almost superfluous to record them. It has been shown that, 
 under different names, alike in native villages and among tea- 
 garden labourers, anchylostomiasis has for a long period 
 been causing a terrible mortality, and that nothing that has 
 as yet been done has had any effect in checking it. It has 
 further been shown that the disease is spread entirely by the 
 agency of the dejecta of the patients : that, apart from the 
 improvement of the condition of a few individuals, nothing can 
 be hoped for from medical treatment ; and that the improve- 
 ment of even these few is unlikely to be permanent, as long as 
 the material of infection is allowed to lie broadcast over the 
 land. From these facts it follows absolutely that there is only 
 one possible way of dealing with the disease, and that is to no 
 longer allow the general fouling of inhabited sites, in other 
 words, to adopt ordinary measures of conservancy.* 
 
 It is perfectly clear that even under the horrible old 
 English cesspit system, the spread of this disease would be 
 a physical impossibility, and that even the most rudimentary 
 application of conservancy will go further to diminish the 
 disease than all other measures, sanitary and curative, put 
 together. 
 
 In the case of tea-gardens I can see no possible difficulty 
 in the matter, but in Assamese villages I am well aware that 
 the introduction of sanitation is beset with difficulties quite 
 apart from the question of expense, and hence I could wish 
 it were my lot to have to recommend measures easier of reali- 
 zation. This is, however, clearly impossible. To introduce 
 a good water-supply and drain village sites are no doubt 
 desirable, and would necessarily go far to improve general 
 health, but they can do nothing to check the spread of anchy- 
 lostomias, nor have they done so where attempted. Even sup- 
 posing drinking-water to be the common vehicle of infection, 
 and strong grounds have been given for believing it to be the 
 rarest of all, to attempt to keep it pure by masonry wells, 
 service tanks, and so on, while pollution of the soil around is 
 allowed to any extent, is obviously a circuitous and inefficient 
 plan of going to work, and leaves us much in the position of 
 
 * See paragraph 2 of Circular No, 14S., dated the 10th May 1889, and 
 also paragraph 3, Sanitary Commissioner's Circular No. IS., of 25th 
 March 1890. 
 
( 130 ) 
 
 one wlio, wishing to prevent accidental poisoning, kept liis water 
 in carefully corked bottles, while allowing arsenic to be strewed 
 about anywhere. 
 
 We are thus unfortunately placed under the dilemma of 
 either introducing conservancy, or of leaving the disease to 
 settle the question by depopulation. The introduction of 
 conservancy must necessarily be very incomplete at first, but 
 this should not prevent our at least attempting it, for, even 
 if imperfect, it cannot fail to do something to improve 
 existing conditions, for the burial of every single infected mass 
 is a distinct blow at the spread of the disease. 
 
 Such measures have iDeen successfully introduced in other 
 parts of India, and though it is tlie fashion to speak of Assam 
 as an exceptionally backward province, it must be acknow- 
 ledged that many other parts of the country are not one 
 whit more advanced, and though the Assamese are perhaps 
 a shade more dirty in their habits than.the average Indian, 
 the difference is too small to involve any great increase in the 
 difficulties of the problem, while, in general civilization, I fail 
 to see that they are at all behind their neighbours, outside the 
 larger towns. 
 
 The question of village sanitation is cropping up all over 
 India ; but, owing to the presence of this terrible disease, it is 
 nowhere so urgent as in Assam, and, save by its introduction, 
 I fail to see any hope for the amelioration of the disease. The 
 exact plan of operations and the methods of securing their 
 adoption are outside the province of the sanitarian, and 
 all that need be done here is to indicate what appear to be 
 the simplest and least expensive methods of conservancy, 
 assuming their adoption to be enforced. 
 
 There is one fact which has been discovered in the 
 course of the present investigation, which is of immense 
 practical importance in this connection, and that is that the 
 infective embryos can only live on the surface of the soil. 
 Bury them, and they are rapidly killed, and hence any simple 
 system of trench latrines will be quite sufficient for our 
 purpose. The great practical difficulty in the matter is the 
 scattered character of the Assamese villages, owing to which a 
 considerable number of small latrines will be required to meet 
 the convenience of the people ; indeed, it is to be regretted 
 that, we cannot adopt the system enforced by the Jewish 
 legislator (Deuteronomy, Chapter XXIII., verses 12-13), but, 
 this being impracticable, the number will have to be large in 
 proportion to the population, as, unless they be made a con- 
 
( 131 ) 
 
 venience instead of a burden to the people, they are unHkely 
 to be used. In most places the expense of standing latrines 
 would be prohibitory, but simple trenches might be adopted, 
 into which a httle earth should be daily thrown until they 
 are nearly filled, when they should be closed and a fresh 
 trench dug. Standing latrines furnished with tarred gumlahs 
 and regular washing platforms would of course be better, 
 and might be adopted with advantage on tea-gardens and in 
 towns, but they would be too expensive for villages, and the 
 want of a sufficient population of the sweeper caste would 
 be aii almost insuperable bar to their use, as regular removal 
 of the sewage to a trenching-ground is absolutely necessary. 
 There is nothing, however, in either digging a trench, or hoe- 
 ing a little earth into it, which need hurt any man's caste, and 
 the whole expense of such a system would be very small. 
 
 No doubt, in the rainy season, the trenches would get full 
 of water, but this would be a matter of little moment, as the 
 ova and embryos would sink to the bottom, and they would 
 get buried just as surely, when the trench was filled in, as if it 
 were dry. 
 
 A proper dry-earth system would undoubtedly be far 
 superior, but, as the attainment of this is probably beyond 
 village finances, we must be content with such simple measures 
 as are within their means, remembering that, in dealmg with 
 anchylostomiasis, our one object should be to bury human 
 filth out of sight, and that any measure which will even confine 
 defilement to certain selected areas is better than nothing. In 
 large places, such as Barpeta, such a plan would be out of the 
 question. For such populations the adoption of proper dry- 
 earth latrines, with a proper conservancy staff, is the only 
 possible way of deahng with the matter ; but, in such places, the 
 expense would not be prohibitory, for the material prosperity 
 of the inhabitants of Assam is certainly greater than those, for 
 example, of the Central Provinces, and there, I know from 
 experience, that a very fairly efficient conservancy is carried 
 out by even small municipalities of only a few thousand 
 inhabitants. During my stay there, a return of inhabit- 
 ants capable of paying for medical attendance at the dis- 
 pensaries was called for, and the extremely small numbers 
 returned showed that the inhabitants were far from rich, so that 
 the expense cannot be prohibitory in places, for example, of 
 the size of Barpeta. In these towns in the Central Provinces 
 the latrines formed a circle round the town, but were placed 
 quite close to the houses. Each consisted of three buildings. 
 
( 132 ) 
 
 One designed for tlie use of males, and divided up into separate 
 compartments, and another, of equal size, but not sub-divided, 
 for females. Each was provided with a well-tarred platform 
 for ablution, the drainings from vrhich ran into a tarred recep- 
 tacle, and water was obtainable close by. The third building 
 was a shed for dry-earth. The buildings were constructed 
 either of galvanized iron or of ordinary country materials, and 
 the seats consisted of a couple of bricks, between which were 
 placed two small tarred earthen gumlahs. In the male latrine 
 the partitions were of ordinary bamboo matting. Some of the 
 larger towns had proper conservancy carts, but, in the smaller 
 places, the filth was removed in small receptacles by hand. 
 
 Tlie conservancy staff was extremely small, so small, 
 indeed, that it was surprising that the latrines were as well 
 looked after as they were ; it certainly did not exceed two men 
 for every thousand inhabitants, and the fact that the sweepers 
 somehow managed to do the work made me suspect that the 
 latrines could be but little used. That this was not the case, 
 however, I satisfied myself by personal observation. Some 
 of the larger towns badly required additional latrines in more 
 central situations ; and I have no doubt that much defilement 
 remained untouched, but the state of things was at least an 
 immense improvement on the conditions that must have existed 
 before their introduction, and nothing could show this better 
 than the comparative rareness of parasitic disease, on the 
 prevalence of which special returns were called for, the returns 
 from the various dispensaries showing that very few such cases 
 came under treatment. 
 
 An objection that is always raised to the adoption of 
 the dry-earth system in Assamese towns is the difficulty of 
 providing dry-earth. It is, however, purely imaginary. Assam, 
 if one of the dampest, is not the only rainy country in India ; 
 and the difficulty is got over elsewhere by the simple method 
 of storing a sufficiency of earth during the dry weather to 
 last over the rains. In the part of the country I have just 
 alluded to, during three months, the rainfall is quite Assamese 
 in heaviness, but, though the sheds were very small, not 20 
 feet square, I should say, they contained a sufficiency of earth 
 to tide matters over the rainy period, and, in this country, 
 it can only be a question of increased accommodation, nor 
 need be of an expensive character. Eegular sheds are quite 
 needless, beyond a small service shed, which may be located 
 in a corner of the latrine, capable of holding a supply for a 
 few days. For the main supply, all that need be done is to 
 
( 133 ) 
 
 throw lip a lieap or heaps of earth during the dry weather,, 
 arranging it, so as to form it into the shape of a roof. The 
 earth is then simply roughly thatched over with grass, and 
 from time to time a sufficiency to fill up the service-shed is 
 dug out from under the leeward end of the thatch. In this 
 way, at the cost of a few rupees only, it would be perfectly 
 easy to store an ample s'^pply of earth to meet the exegencies 
 of even an Assamese rainy season. 
 
 It is the duty of the sweepers to keep a little of the dry 
 earth dusted into each gumla, and, on emptying these into the 
 receptacles, to add a sufficiency to deodorize the mass. Once 
 a day, the receptacles are removed, either in a cart or by hand, 
 to the trenching ground, which should preferably be situated at 
 a little distance from the town, but not at a sufficiently great 
 one, to form a temptation to the conservancy men to shirk their 
 work by emptying them into any hidden corner. In the 
 absence of constant European supervision, this is a matter 
 which is often not sufficiently taken into consideration. In view 
 of the special dangers of anchylostomiasis, I should be inclined 
 to recommend the use of deeper trenches than are usually consi- 
 dered desirable, say, 2^ feet, and giving a full eighteen inches of 
 clean earth on top of the soil, so as to bury all infective material 
 thoroughly and deeply. Waste land should never be chosen for 
 this purpose, as, after being used for trenching during one season^ 
 it is essential that the ground should be cropped ; otherwise, in 
 the course of time, it will lose its deodorizing powers. I have 
 heard that an enormous yield of sugarcane can be got from land 
 that has been so treated, but my own experience has been 
 limited to corn lands, and, in one instance, to lucerne-grass,, 
 the yield of which was something astonishing. The drier the 
 piece of ground chosen for the purpose, the better, but I do not 
 look upon the trenches getting filled with water as an insuper- 
 able objection. The result will of course be not as good as 
 in more favourable climates, but the essential point is to bury 
 the infective matter, where it cannot be carried back into the 
 houses ; and, where the best is unobtainable, we must be 
 content with the nearest approach to it we can get. 
 
 Disinfection of Sites already injected. — Having thus indi- 
 cated the way in which the future spread of the disease may 
 be surely prevented, it remains to be considered how sites, 
 already infected, should be dealt with. 
 
 Provided only that all further supplies of nutritive "matter 
 be cut off by efficient measures of conservancy, it may be con- 
 sidered certain that, sooner or later, the infective embryos 
 
( 1?J ) 
 
 must die out, but unfortunately, we know that the time required 
 for this may be very considerable. 
 
 It certainly exceeds six months, even in the absence of 
 fresh nutritive supplies, and may be much longer. Given the 
 continual supply of fresh nutriment, inevitable, where no 
 attempt is made at conservancy, the infection of a site may 
 last for an indefinite time, and indeed, is more likely to increase 
 than decrease. 
 
 Two principal plans suggest themselves, the first of 
 which has been found to be tolerably efficacious by the people 
 themselveSj viz.^ desertion of the infected locality. Now, pro- 
 vided that the elimination of all infected persons could be 
 secured by efficient medical inspection, this plan would be 
 absolutely effectual even in the absence of all conservancy at 
 the new site. Unfortunately, however, such a course is quite 
 out of the question in actual practice, and hence migration only 
 checks, and cannot stop, the spread of the disease, unless the 
 inevitable infection of the soil of the new site be prevented 
 by a proper conservancy. Without this, unless the people 
 were to becon\p absolute nomads, moving every week or so, 
 migration can only be a palliative measure. 
 
 Given, however, the avoidance of fouling the soil of the 
 new site, migration from infected localities may be strongly 
 recommended wherever practicable. 
 
 The natural habits of the Gdros lend tliemselves easily 
 to this plan of action, and, as the introduction of sanitary 
 measures will be peculiarly difficult among such a wild race, 
 they should be encouraged in this custom as far as possible. In 
 the case of tea-gardens, the alteration of the site of the lines can 
 often be carried out, and should be effected wherever practicable, 
 of course coincidently with the introduction of proper measures 
 of conservancy on the new site. 
 
 The disinfection of already-infected sites is doubtless a 
 much more difficult matter, but cannot be regarded as hope- 
 less. On account of the broadcast way in which the infective 
 embryos are spread about such localities, and the impossi- 
 bility often of recognizing the places where they are to be 
 found, either by sight or smell, the use of all chemical disin- 
 fectants is clearly out of the question, but there are three 
 facts (which appear in Section YIII.) of which advantage may 
 be taken ; and these are — 
 
 1st. — Prolonged exposure to the direct rays of the sun 
 kills the embryos. 
 
( 135 ) 
 
 2nd. — Tlie same result may be effected by exposing 
 
 them to a temperature exceeding 140°F. 
 3rd. — Burying the embryos kills them. 
 
 In order to take advantage of the first fact, all that is 
 required is to clear the ground of vegetation as thoroughly 
 as possible, at the commencement of the dry weather. The 
 second property may be taken advantage of by firing the dry 
 vegetation at the end of that season. For, as the embryos 
 are confined absolutely to the extreme surface layer or the 
 soil, the passage of a grass fire would certainly kill any that 
 might have survived the dessication of the dry season. Lastly, 
 by ploughing the ground at the commencement of the wet 
 season, and so turning the surface layer under and burying 
 the contained embryos, we may complete the disinfection, 
 more especially of such parts of the sites as, for any reason, could 
 not be treated either by clearing or by fire. This last expedient 
 is, of course, available at any time of the year when the soil 
 is soft enough for the process. 
 
 I feel assured that, by attention to these points, the disin- 
 fection of sites may be secured, though I necessarily have not 
 been able to test them in actual practice. 
 
 Purification of water-supply. — It is a fortunate circum- 
 stance that the physical properties of the embryos are such as 
 to render infection by drinking-water an unhkely contingency. 
 They sink so rapidly in water, that, a short time after the in- 
 troduction of even a large number into a well, all of them 
 would become entangled on the mud at the bottom, and 
 infection could only occur by the scooping up a portion of the 
 sediment. 
 
 At the same time, more especially for the protection of 
 officers travelling in affected districts, it may be well to point 
 out that filtration affords an absolute security against infection 
 by this agency. Any of the ordinary filters in common use are 
 amply adequate for the purpose, as, owing to the, microscopi- 
 cally speaking, large size of the infective embryos, even the 
 coarsest filters will exclude all chance of infection. In illus- 
 tration of this may be instanced an experiment which I made, 
 to ascertain how far an ordinary handkerchief would serve as 
 a filter. 
 
 A piece of nainsook was placed over a glass funnel, and in 
 the bag so formed was placed a quantity of earth which literally 
 swarmed with embryoes. Water was then allowed to run 
 through for a considerable time, and the filtrate collected. It 
 
( 136 ) 
 
 was of course extremely turbid and obviously unfit for drink- 
 ing purposes, but the most careful examination revealed only 
 two embryos in the filtrate, while the residue on the nainsook 
 was proportionately richer in them than ever. 
 
 With respect to attempts directed to the rehef of the 
 sufierers from the disease in Assamese villages by medical 
 treatment, I have already plainly expressed my opinion. The 
 attitude of the peasantry towards European medical treatment 
 is such that it is perfectly certain that none but advanced 
 cases will be persuaded to submit themselves to treatment. 
 Such cases are practically incurable, and hence it is perfectly 
 certain that the good effected by itinerant medical subordi- 
 nates, extra dispensaries, and medical agencies in general, will 
 be so minute that, for all practical purposes, any money so 
 expended will be no better than wasted. 
 
 As an adjunct to proper sanitation, such measures can do 
 no harm, and may even effect some small good ; but, unless 
 proper measures of conservancy be adopted, the re-infection 
 of the few cases cured will be so inevitable that nothing but 
 discredit to the cause of European medicine can result. 
 
 In the case of the tea-gardens the case is quite different. 
 The labourers, to begin with, come, for the most part from 
 districts where the people have been long accustomed to the 
 benefits of European medical treatment, and generally 
 thoroughly appreciate it. Further, they are a great deal more 
 under control, and can be dealt with, as far as sickness is 
 concerned, almost in the same way as the men of a regiment,, 
 and, indeed the reception of all sick in regular hospitals is 
 a well established custom. 
 
 With very few exceptions, however, treatment is carried 
 out under the very mistaken policy of waiting till the man reports 
 himself as sick, before attempting treatment. In the case of 
 nine diseases out of ten, this is undoubtedly the best plan 
 to adopt, but in that of anchylostomiasis ii too often leads 
 to the postponement of treatment until the man is beyond cure, 
 and, at best, necessitates prolonged treatment and disability for 
 work in place of two or three days' stay in hospital only. On 
 this account,* I cannot too strongly urge the adoption of 
 systematic periodical medical inspections of all labourers em- 
 ployed upon tea-estates, combined with the prompt treatment of 
 all cases that may be detected, in addition to which, it is need- 
 less to say that all newly-arrived hands should be inspected. 
 
 * See paragraph 49, Annual Sanitary Report for Assam, 1888. 
 
( 137 ) 
 
 and, if necessary, treated before being allowed to mix with the 
 others. At the same time, here also I must repeat that such 
 measures can only be considered as adjuncts to the adoption of 
 
 E roper sanitary precautions, and, apart from these, can never 
 e expected to really stamp out the disease, as such measures 
 infallibly must do, if only carried out with sufficient efficiency. 
 The measures I have to recommend may therefore be 
 stated as follows — 
 
 A. — With respect to " kdla-azdr " in villages : — 
 
 1st. — ^The adoption and enforcement of some simple 
 
 * system of conservancy. 
 
 2nd. — Migration from infected sites when practicable ; 
 
 the disinfection of infected sites, by the measures 
 
 above described, when migration is impossible. 
 3rd. — The improvement of water-supply where this is at 
 
 present unsatisfactory. 
 Jt.th. — The clearing and drainage of ground included in 
 
 village sites wherever practicable. 
 
 B. — With respect to " heri heri " in tea-gardens : — 
 
 1st. — ^The enforcement of proper conservancy, preferably 
 
 on the dry-earth system. 
 2nd. — The removal of lines to a new site wherever the 
 
 disease has been very prevalent. 
 3rd. — Where this is impracticable or undesirable, the 
 disinfection of the site by the means above 
 indicated. 
 Mh. — ^The adoption of raised " chang " huts, such as are 
 customary in Burmese villages, whenever new 
 huts are constructed. 
 5th. — The entire prohibition of small enclosures round 
 
 or near huts. 
 6th. — ^The prohibition of the keeping of cattle within the 
 inhabited limits of coolie-lines, and the provision 
 of suitable separate enclosures for the purpose. 
 7th. — ^The provision of a proper water-supply in cases 
 when this is at present unsatisfactory ; the points 
 to be ainied at being — 
 {a) That the well or other source of supply should 
 be some little distance from all habitations. 
 (6) That if a well, it should be completely protected 
 by a locked cover, so that water can only 
 be got by pumping. 
 
 L 
 
( 238 ) 
 
 {c) That it should be carried by means of pipes to 
 tanks above level of soil placed convenient- 
 ly among the dwelHngs. 
 
 (d) In certain cases, e.g., when river-water is the 
 source of supply, it will be .necessary, and 
 ill all cases it is desirable, to filter it by 
 some apparatus on the ascension principle. 
 
 8th. — ^The provision of a proper supply of green vege- 
 tables, either by cultivation and sale to the 
 coolies at cost prices, or by the provision of 
 patches of ground somewhat on the English 
 village " allotment ground " system. 
 
( 139 ; 
 
 XI. — Anchylostomiasis in Tea-Gardens. 
 
 That the sickliness among labourers imported from India 
 into Assam, has, almost from the first, been a matter of 
 serious concern to the Local Government is a matter which may- 
 be gathered from successive emigration reports. It is of 
 course only of late years that the dependence of the up-to-then 
 inexplicable mortality has been traced to anchylostomiasis, 
 but the connection is now so firmly established that it would be 
 quite superfluous for me to enter upon any attempt to prove 
 what is already admitted. 
 
 Practically speaking, where any garden remains for any 
 length of time on the " black list," it may be taken as certain 
 that the cases that make up the excess over the normal 
 mortahty will be cases of anchylostomiasis. Of course, an 
 outbreak of cholera may put a garden on the list for any given 
 year, but an establishment will be singularly unlucky if such 
 an accident should occur on two or more successive years, and 
 putting aside cholera, the cause of relegation to the " black 
 list " will be found to be anchylostomiasis in more than nine 
 cases out of ten. Practically speaking, there are no statistics 
 available that can give even an approximation to the amoun.t 
 of mortality that should be credited to the cause. Of late 
 years, an attempt has been made to arrive at it by introducing 
 separate headings for anaemia and dropsy* in the mortality 
 returns of unhealthy gardens, but the results, so far, are quite 
 valueless, as often not a single case will be recorded in a whole 
 year from all the unhealthy gardens of an entire district, 
 and that in parts of the country w^here all European medi- 
 cal officers are perfectly agreed that the disease is extremely 
 rife. The fact is that, with but few exceptions, the persons 
 responsible for the diagnoses of the cases from which the 
 statistics are compiled are the native doctors of the tea- 
 estates. I may have been unfortunate in those I met, but, speak- 
 ing only of those I have seen, I can only say that I have never 
 met with a body of men more grossly ignorant of their work.f 
 In spite of the fact that anchylostomiasis has now for several 
 years been known to be the main cause of mortality among tea- 
 garden labourers, very few seemed to have the least power of 
 recognizing cases, and their entire diagnostic powers seemed to 
 
 * Sanitary Commissioner's Circular No. 14B., dated the 10th May 
 1889, directed the term '* anchylostomiasis " only to be used in all garden 
 returns. 
 
 + See Rule 122 under the Inland Emigration Act, I. of 1882. 
 
 l2 
 
( 140 ) 
 
 consist in the ability to make a lame translation into English 
 ^nedical terms of what th.e patient thought was the matter with 
 him.. To instance one c^se, met with among many, I may 
 mention a black-listed tea-garden that I visited in company with 
 Dr. Bannerji in the Sibsdgar district. On visiting the hospital, 
 we asked the native doctor whether he had any cases of ansemia, 
 and he replied that they never had had any. In spite of this, there 
 were sitting in the hospital verandah some half-a-dozen 
 advanced cases of anchylostomiasis, which had been entered iii 
 the register as fever, dysentery, bronchitis, spleen, and so on, 
 according to the coolie's notion of what was the matter with 
 bim, I then asked them to assemble all they could of the 
 working. hands, and some 60 were got together. Of these, a 
 full third were found to be suffering from the earlier stages of 
 the disease. Dr. Bannerji was at great pains to try and explain 
 to the man the symptoms and treatment of such cases, but, 
 from the expression of his face, I am strongly inchned to doubt 
 if he was left a penny the wiser, tjie fact being that the idea 
 of finding out a patient's disease for oneself was "something 
 entirely outside his notions of medical practice. 
 
 However, while these special statistics are so collected as 
 to be quite worthless, those of the general mortality upon tea- 
 gardens are probably more accurate than anything else of the 
 kind in India. Whatever may be the proportion of the total 
 that is due to anchylostomiasis, it is certainly so large that any 
 increase or diminution in t4ie disease would exert a marked 
 influence on the total mortality ; and, judging from the re- 
 turns of the last eight years, there can have been but little 
 change in the yearly number of victims, but what change 
 there has been is for the worse ; the past jea.Y showing a 
 higher total mortality than any of the eight except 1884 ; and, 
 when it is remembered that this increase has taken place in spite 
 of much general sanitary improvement, but little doubt can 
 arise as to the steady increase of this disease, which, as we have 
 seen, is untouched by any sanitary measures save one, which 
 has been left neglected. The actual total mortality ranges from 
 36-2 in 1889 to 43-2 in 1884, and last year stood at 41*8. Con- 
 sidering that this mortality includes not only that of anchy- 
 lostomiasis, but also of heavy annual outbreaks of cholera, the 
 general conditions of coolie life on the gardens cannot be 
 considered at all unfavourable, and if we could but stamp out 
 anchylostomiasis, would undoubtedly compare well with those 
 of any part of India. It is curious in looking over byegone 
 reports to see that opinion has passed through exactly the same 
 
( 141 ) 
 
 phases in the base of coohe ancemia as it is now doing in that 
 of Mla-azdr. Previously to the recognition of the parasitic 
 causation of the disease, we find exactly the same arguments 
 produced as to its malarial origin, and the same wearisome 
 invocation of " climate " as the cause of everything connected 
 with health, not easily explicable. Naturally, too, there was at 
 first some opposition to the renunciation of these time-honoured 
 notions, such as, I have no doubt, will meet the recognition of 
 the same fact in Mla-azdr, but now, in the case of coolie 
 anaemia, very few traces of the opposition are to be found, as 
 European tea-garden practitioners, with very few exceptions, 
 have fully recognized the nature of the disease. Another 
 statistical fact, that points even more strongly to a steady 
 increase in the disease, is the rapid rise in the number of 
 gardens relegated to the "black list," or, in other words, 
 with a mortality of over 70 per annum pter mille. In 1885, there 
 were in the Assam Valley but 23 gardens in which the mortal- 
 ity reached so alarming a height ; in 1886, it had risen to 
 41 ; in 1887, the number fell a little; to 37, only to rise again, 
 in 1888 to 54 ; and in 1889 to 88. No doubt the number of 
 tea establishments has increased during the period in question, 
 though I am unable to discover to what extent ; but it is per- 
 fectly certain tlmt the increase, whatever it may be, is insigni- 
 ficant in comparison with that of the number of black-listed 
 gardens, which has nearly quadrupled during the short period 
 in question, and at present 68,010 coolies, out of the 386*166 
 employed during the second half of last year, were working 
 on black-listed gardens, or very nearly a sixth of the whole 
 number. 
 
 In individual gardens the mortality is sometimes appalling, 
 vying with that of the worst Mla-azdr villages, close on a 
 third of the entire strength of a garden in one instances 
 having died off in a single year, and instances of mortalities 
 of, over 150 per annum per mille are by no means uncommon, 
 as may be seen from the subjoined table, which is compiled 
 from the statistics published in the immigration reports. 
 
( 142 ) 
 
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( 143 ) 
 
 Serious as it is, the mortality gives but a faint idea of the 
 prevalence of the disease, the number actually affected being 
 always largely in excess of the sick list. As an example, I may 
 instance a special examination of Chunsali garden, near Gauhdti, 
 which was made on August 31st, 1890, with the following 
 results : — 
 
 The estate finds employment, as a rule, for over four 
 hundred hands, out of which, at the time of my visit, only 121 
 (53 men and 68 women) were contract labourers, the remain- 
 der being obtained in the local labour market. The whole of 
 the contract labourers alike, working or on the sick list, were 
 carefully examined for the symptoms of anchylostomiasis, en- 
 largement of the spleen, and malarial cachexia, with the follow- 
 ing results. Out of the total number, 65 presented more or 
 less marked symptoms of anchylostomiasis, or 53*7 per cent. 
 These cases may be classified as below : — 
 
 Table ahcnving 'prevalence of Anchylostomiasis among Contract 
 Coolies at Chunsali tea-garden. 
 
 Sex. 
 
 
 Unmis take- 
 able symp- 
 toms. 
 
 Advanced 
 symptoms. 
 
 1 
 
 Males 
 Females 
 
 3 
 3 
 
 14 
 
 12 
 
 17 
 16 
 
 34 
 31 
 
 Total of both sexes 
 
 6 
 
 26 
 
 33 
 
 65 
 
 Those entered under the heading " Unmistakeable symp- 
 toms " include cases where there could be no reasonable doubt 
 as to the diagnosis, but which would still be, in all probability, 
 amenable to treatment with thymol. . On the other hand, those 
 included under that of " Advanced symptoms " are cases where 
 the prognosis would be bad, whatever treatment might be 
 adopted. 
 
 With respect to the prevalence of enlargement of the 
 spleen, a greater or less degree of it was present in 45 
 out of the total number, ^.^., 37*2 per cent. 
 
( 144 ) 
 
 These instances of splenic enlargement were classified as 
 follows : — 
 
 Table showing number of cases of splenic enlargement among Contract 
 Labourers on Chunsali Tea-garden. 
 
 
 1 
 
 h^ 
 
 ^ h 
 
 
 
 0) rt 
 
 1% 
 
 1 ? 
 
 
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 11 
 
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 Males 
 
 10 
 
 7 
 
 5 
 
 22 
 
 Females 
 
 10 
 
 3 
 
 10 
 
 23 
 
 Total of both sexes 
 
 20 
 
 10 
 
 15 
 
 45 
 
 No relationship whatever could be made out between the 
 prevalence of the two conditions. Some of the worst instances 
 of anchylostomiasis had no splenic enlargement whatever, 
 while, on the other hand, the case presenting perhaps the 
 largest spleen of any showed no signs of anchylostomiasis, and 
 laughed heartily at me when I asked him how long he had 
 been ill, saying that he did not know that he was ill. 
 
 There were five case^ of malarial cachexia either present- 
 ing no signs- of anchylostomiasis, or but slightly so compli- 
 cated, and some of the cases included under this head had but 
 slight splenic enlargement. The degree of splenic enlargement 
 was estimated by the native doctor while I was examining for 
 anchylostomiasis, and the figures can therefore be in no way 
 influenced by my own preconceived notions as to its absolute 
 unimportance in the causation of kdla-azdr. It is, however, 
 at least certain that he has not underestimated the prevalence 
 of splenic enlargement, as the list includes many cases of 
 abdominal enlargements from ascites consequent on advanced 
 anchylostomiasis, where, personally, I could find no physical 
 evidence of enlargement of the spleen. 
 
 The coohe-lines at Chunsali are placed on an excellent site, 
 the natural drainage of .which is perfect. The well-water is 
 bad, but the manager states they have- been disused for a long 
 time, and that nothing is used but Brahmaputra water, and 
 I have little doubt this is broadly the case, as the river is 
 nearer the greater part of the coohe-lines than the wells are, 
 and probably only the few coolies who live nearer the wells 
 than the river use the former. No systematic examination of 
 
( 145 ) 
 
 the non-contract labourers was practicable, but I saw enough to 
 convince me that they are at least as seriously affected as the 
 contract hands, and in exactly the same way. 
 
 The instance of this garden is interesting, as it shows how 
 entirely what is called Mla-azdr depends on anchylostomiasis, 
 the Civil Surgeon remarking that he could see no difference* 
 between this outbreak and those of Mla-azdr in villages. Now, 
 in this connection, the above facts speak too strongly for 
 themselves to need any comment ; but it is worthy of note that 
 the proportion of cases afiected with enlargement of the spleen 
 corresponds closely with Dr. Dobson's observations on its 
 prevalence among reputedly healthy children. 
 
 The irregular and apparently capricious distribution of the 
 centres of epidemic intensity in any given neighbourhood also 
 exactly recall what was found to be the case on the distribution 
 of kdla-azdr, and is an additional proof of the identity of the 
 maladies known under the two names. It will be observed too, 
 that, in both instances, while the severity of the disease is 
 rapidly increasing in severity in localized centres, and while 
 the number of the centres is steadily increasing, the increased 
 mortality, when absorbed into the data of a whole district, is 
 not sufficient to make any very distinct mark on its vital statis- 
 tics, and this is exactly what might be expected in the case of 
 anchylostomiasis, which, from the nature of the mechanism of 
 its spread, must essentially be always a disease characterized 
 by very localized centres of great intensity. It is also clear 
 that, in spite of thymol, and of such attempts at sanitary 
 improvement as have been made up to the present, the number 
 of such centres is steadily increasing, and that their severity 
 shows no sign of diminishing. I will now desv^ribe what I 
 observed of the physical surroundings of the garden labourers 
 as far as sanitary conditions are concerned. 
 
 {a) Housing. — There is no condition that varies more 
 widely than this does in different gardens. In some cases, espe- 
 cially on the larger concerns, a great deal of money has been 
 spent in providing comfortable habitations, while in others 
 the " lines " consist of the most wretched hovels imaginable. 
 On the. whole, however, in this, as indeed in other sanitary 
 matters, there is a praiseworthy eagerness on the part of the 
 planting community to do everything in their power for the 
 welfare of their coolies ; but great mistakes are often made, 
 and money spent to no purpose, simply through an ignorance 
 
 * Vide page 17. 
 
( 146 ) 
 
 of sanitary matters, in which, be it said, they are by no means 
 peculiar. As a rule, the " lines " consist of thatched huts with 
 wattle-and-daub walls ; but in some cases corrugated-iron has, 
 with great advantage, been substituted as a roofing material, 
 and more permanent materials have been employed as a por- 
 tion of the walls. 
 
 About the best pattern of huts I met with consisted of two 
 rooms, the gables and two pillars placed midway along the sidfes, 
 consisting of rubble in mortar masonr}^ while the sides were 
 filled in with wattle and daub work {eJcra). The roof was of 
 corrugated iron, and was prolonged beyond the gable containing 
 the door, so as to form a sort of verandah. One drawback 
 of its construction was an absence of ventilation. The lateral 
 walls were necessarily too low to make ventilation openings 
 in them tolerable to the inmates, while the solid nature of 
 the gables prevented the upper part of these being utilized 
 for the purpose. Again the advantage of the superior weather- 
 tightness of the door gable was neutralized by its protection 
 by the verandah. On this account it would be better, and 
 probably in the end cheaper, to make the lateral walls of 
 masonry and the gables of ekrcr, in which case the peak of the 
 gables can be left unplastered as to afford sufficient ventilation 
 without annoyance to the inmates, a plan which I have seen 
 in use in many gardens where the huts are walled entirely 
 with ekra. If then, the roof were prolonged at both ends, the 
 whole of the mud-plastered portion of the building would be 
 protected from the weather, and a very durable hut would 
 result. Another fault was that the back room had no exterior 
 door, and so was intolerably dark and stuffy. Whatever plan 
 be adopted, it is perfectly certain that no room should ever be 
 constructed without a door communicating with the open air. 
 The best point about the hut was the provision of a verandah, 
 which is a matter of great importance in a climate like Assam. 
 Coohes should, however, be never permitted to wall these in, as 
 they are very fond of doing, as, if this be allowed, they are 
 nothing better than a hindrance to ventilation. In many cases 
 I found small garden compounds, rudely fenced in, attached to 
 the huts. They rarely, however, showed any signs of cultiva- 
 tion, and the untidy hedges were nothing better than conve- 
 nient hiding-places for rubbish and filth of all sorts. The 
 encouragement of the cultivation of fresh vegetables is, no 
 doubt, a most important matter ; but I strongly doubt if it 
 really is encouraged in this way, as scarcely any of these little 
 patches showed signs of cultivation. Another most pernicious 
 
( 147 ) 
 
 •custom, which is permitted even on some of the best-managed 
 gardens, is the close association of cattle and human 
 beings. The large number of coolies who own cows is of 
 course an excellent sign of their well-being, but this is no 
 reasofi for permitting cattle and human beings to share one 
 dwelling. 
 
 In the better cases the coolie builds a small lean-to shed 
 against his hut, but everyone knows the filthy state in which 
 natives keep their cattle-sheds, and, in a damp climate like 
 Assam, the foul drainage from the cattle-shed cannot fail to soak 
 through into the sub-soil beneath the hut. It is to be doubted if 
 this arrangement be not actually worse than the actual associa- 
 tion of cattle and men, as it is probable that, in the latter case, a 
 certain amount of daily cleaning would be attempted. Provi- 
 sion should be, of course, made for the housing of the cattle, 
 but it. should be in a quite distinct enclosure, near to, but not 
 in, the lines, all the cattle being kept together very much in 
 the fashion of ' the cattle " kraals " in use among the Zulus. 
 Care should be also taken that this enclosure should be placed 
 lower in the drainage line of the land, and, if possible, to 
 leeward of the coolie-lines witR the prevailing wind. The 
 ground so. occupied soon becomes richly manured, and the 
 Zulus utilize this circumstance by periodically moving their 
 kraals, and sowing the ground with maize and vegetables, of 
 which they thus obtain immense crops. This practice has, too 
 the additional advantage of thoroughly purifying the ground, 
 though it is needless to remark that this is a consideration 
 which in no way influences the Zulus, for though their habits 
 are, in point of fact, far less unsanitary than those of Indians, 
 this is due rather to the accident of circumstances than to 
 any particular desire or liking for cleanliness. Perhaps the 
 greatest fault in the huts of all the coolie-lines I have met with, 
 and I cannot recall a single exception, is that they are never 
 provided with any plinth worthy of the name, an omission of 
 a most fatal character in a country like Assam, where the 
 raising of dwellings above the damp soil is a matter of the 
 first importance. Of course, the provision of raised pfinths 
 would be a matter of considerable expense, especially as, in 
 such a climate as this, nothing short of three or four feet can 
 be considered adequate. Another disadvantage is that the 
 necessary excavations would leave the ground honey-combed 
 with depressions, which would certainly become receptacles for 
 rubbish, and in the ra^ns would be always full of filthy stag- 
 nant water. The whole plan then, of any of the huts I have 
 
( 148 ) 
 
 seen appears to me radically wrong and entirely unsuited to 
 the climate. What surprises me is that no one has thought 
 of building their lines on the plan of Burmese villages, in 
 which the huts are universally raised upon piles, the floor, 
 which is made of split bamboo, being thus elevated some 'three 
 to five feet above the level of the ground ; a rude form, in fact, 
 of the " chang " bungalow in common use among Europeans 
 in Assam. The plan cannot be an expensive one, as it is to be 
 seen in the poorest houses in the most wretched fishing villages 
 on the coast. Moreover, the materials are at least as 
 cheap and abundant in Assam as they are in Burma. That 
 they are in universal use among so notoriously lazy a race 
 as the Burmans, shows that but little additional trouble or 
 expense can be involved in their construction. 
 
 No walls or obstructions of any kind should l)e allowed 
 to interfere with the free passage of air beneath the floor^ and, 
 if the ground beneath the huts be kept clean, no better form 
 of hut could possibly be contrived. In climate, density of 
 jungle, soil, and all essential conditions, Burma and Assam 
 closely resemble each other, except that, owing probably to the 
 inferiority of the cold weather of the former Province, it is, if 
 anything, rather the more malarious of the two, a fact shown by 
 the much better health enjoyed by Europeans in Assam over 
 their fellow-countrymen resident in Burma, and I am inclined to 
 impute much of the undoubted physical superiority of the 
 Burmese over the Assamese to the sanitary advantages of the 
 national style of village architecture. The people here, too, are 
 adepts in the craft of working with the bamboo. The walls of 
 their houses being often constructed on exactly the same plan 
 as the floors of Burmese raised huts, so that there could be no 
 difficulty whatever in obtaining the necessary skill of labour. 
 
 There cannot be the least doubt that, with the exception of 
 the special measures for the prevention of anchylostomiasis, no 
 sanitary measure can be expected to do more for the improve- 
 ment of the health of tea-garden coolies than the adoption of a 
 style of housing suited to the climate in place of the system at 
 present in vogue, which is modelled on the plan of village con- 
 struction in use in India Proper, and which is entirely unsuited 
 to the very difierent climatic conditions of the Indo-Chinese 
 Peninsula. 
 
 There is, of course, no necessity for any slavish adherence 
 to anything but the principle of the Burmese plan, and the 
 adoption of improved roofing material, ^s well as of masonry 
 supports, would be undoubted improvements, and would pro- 
 
( 149 ) 
 
 bably result in a saving of expense in tlie long run ; at least 
 that is one of llie reasons advanced for the adoption of galva- 
 nized iron by some of the garden managers I have met. 
 
 Provided that, as appears to be the case, expense need not 
 stand in the way, the adoption of an impervious roofing material 
 in place of thatch would be an immense advantage, for the 
 mass of continually wet, rotting thatcli is, I am convinced, a fre- 
 quent source of ill-health not only in native, but also in Euro- 
 pean dwellings. 
 
 {b) Clothing. — In this matter the coolies do not seem ill 
 off, at any rate, they seem to have as much as they care to 
 wear, though it is probable that the adoption of woollen jackets 
 during tlie chilly fogs of the cold weather would be an im- 
 provement. Eecommendations to this effect occur frequently 
 in the inspection reports of many medical officers, but the diffi- 
 culty in providing the clothing would be but a small one in com- 
 parison with that of inducing the coolies to wear it. While, 
 however, I doubt if adults suffer in this way, there can be no 
 doubt that the children are universally wretchedly underclad, 
 ^nd there cannot be the least doubt that neglect of this kind 
 is an important factor in the heavy infant mortality. It can' 
 not, however, be said that tea-garden labourers are any more 
 careless in this matter than natives of India generally, though 
 its consequences are probably more serious in Assam than 
 they are in other, and drier parts of the country. It is, 
 however, to little purpose discussing the subject, as, pernicious 
 as the custom undoubtedly is, it is too deeply rooted in native 
 habits for any improvement to be hoped for. 
 
 (c) Food consists mainly of rice, pulse of various 
 kinds, fish, milk, and vegetables. Its adequacy depends mainly 
 on the state of the labourer's finances, and, in the case of new 
 comers, is often none too liberal. Old hands, however, are gene- 
 rally fairly well off, as may be seen by the large numbers of 
 cattle and poultry often possessed by them. From what I 
 saw I am inclined to think that the coofies, when free from 
 disease, are mostly well nourished. 
 
 In the case of immigrants coming from parts of India 
 where corn forms the staple food, a really serious matter 
 is the enforced change to the insipid and comparatively unnu- 
 tritious rice. So much larger a bulk of rice is required to meet 
 the demands of the organization, that a wheat-eater must needs 
 contract a certain amount of chronic dilatation of the stomach 
 before he can accommodate a sufficiently full meal. Unfortu- 
 nately, wheat is an exotic luxury in Assam, but facilities for its 
 
( i-'-o ) 
 
 purchase should certainly be afforded in the case of men coming 
 from the corn districts of India, at any rate, for a sufficient 
 time to enable them to accustom themselves gradually to the 
 new diet ; and, as rice is considered a great luxury in their native 
 homes, they would not probably be long in doing this. This is 
 a matter, however, which has been repeatedly adverted to in 
 reports from various officers, and I tliink its importance should 
 not be underrated. 
 
 In the matter of vegetables, the coolies are often but ill 
 supplied. Their own efforts do not go much beyond the 
 cultivation of a few pumpkins, a vegetable which, however 
 valuable, is by no means the best of antiscorbutics, while 
 many of the gardens are placed in portions of the country, 
 so destitute of indic^enous inhabitants, that nothinGf of the kind 
 can be bought. Outside the medical profession, peoj)le are 
 too apt to underrate the importance of a due supply of food 
 of this sort. This is, no doubt, owing to the small proportion 
 of nutriment they contain, the meagreness of which is so 
 obvious that it needs no acquaintances with analytical tables 
 to inform any one on the point. Green vegetables, however, 
 contain a large amount of certain organic salts which are 
 absolutely essential to the preservation of health, and which 
 are not contained in grain, flesh, or the other solidly nutri- 
 tious articles of diet. 
 
 Owing to this want, scurvy is by no means rare amongst 
 the immigrant labourers, and, as a man in this condition 
 will never be fit to do a good day's work, I am certain it 
 would often pay well to systematically cultivate sag, onions, 
 cabbages, turnips, radishes, plantains, and other suitable vege- 
 tables, even if it involved the diversion of a certain amount 
 of labour from the regular work of the garden. For want 
 of a proper appreciation of the importance of green vegetables, 
 scurvy is common all over India, as indeed it was in England 
 when in a similar stage of civilization, so that it is useless 
 to trust to the coohes' own instincts to overcome any notable 
 difficulties in this direction, though he will doubtless avail 
 himself of a cheap and plentiful supply when obtainable. 
 
 The question of food-supply cannot be passed by without 
 some allusion to the "hotel system," of which I have heard 
 much, though I regret to say I had but few opportunities of 
 seeing the system in full working order, the time of the year 
 being unfavourable for this. Sufficient, however, was seen to 
 convince me of its immense value, which mainly lies in 
 tiding the new arrival over the time during which the strange- 
 
( 151 ) 
 
 Tiess of his surroundings prevents his being able to look pro- 
 perly after himself. The only criticism I have to make on 
 the subject is that, if it is desired to get the full nutritive 
 value out of the food supplied, more attention should be paid 
 to its cooking. If properly cooked, so that the grains are 
 plump but remain separate, rice is one of the most digestible 
 of foods ; but if, as is often the case, it be allowed to get into 
 a stodgy mass, closely resembling bookbinder's paste, it 
 becomes heavy and hard of digestion. In the same way, 
 dal, when properly cooked, is one of the most nutritious and 
 easily assimilable forms of nitrogenous food, so much so, that, 
 under the name of " Eevalenta Arabica," it has gained a great 
 reputation in Europe in the treatment of dyspepsia. Yet this 
 very same article of food, if imperfectly cooked, as it general- 
 ly is amongst natives, becomes extremely irritating, and much 
 of it passes through the intestinal canal unaltered, and so is 
 lost, or worse than lost, for not only has it in no way contri- 
 buted to the nutrition of the body, but it has caused positive 
 harm by producing irritation. When properly cooked, dal 
 should form a perfectly smooth uniform pulp, no sign of 
 the component grains being left, and, when so prepared, it is 
 unrivalled as a source of nitrogenous pabulum. 
 
 Attention to little points of this kind in cooking, may 
 make all the difference between recovery and death in the 
 case of patients after treatment with thymol for anchylosto- 
 miasis, who form a large proportion of the inmates of an 
 " hotel." The digestive powers of these poor creatures are 
 always reduced to the lowest ebb, and the mere expulsion of 
 the parasites is absolutely useless, a mere waste of an expensive 
 drug in fact, unless it be followed up by a supply of food, not 
 merely plentiful, but also so prepared that it can be made use 
 of by their utterly enfeebled digestive organs. Now rice and 
 dal can both be made, with very Httle trouble, into food highly 
 suitable for invalids, but, cooked as they commonly are by 
 natives, especially when the operation is conducted upon at 
 all a large scale, they are little better than the loading of the 
 intestines with indigestible, and, at the best, inert matter. 
 
 If, however, we can once check the spread of anchylos- 
 tomiasis, there will be little further need for " hotels," for, as 
 long as he is in health, the coolie may be trusted to take care of 
 himself in the matter of feeding. It is commonly enough 
 asserted that coolies will half starve themselves from motives of 
 economy, but I entirely disbelieve in the commonness of such 
 cases. In nine cases out of ten, miserliness has nothing to do 
 
( 152 ) 
 
 with the matter ; and the reason of the man's not buying a suffi- 
 ciency of food is that he is too ill to care for it, and, naturally 
 enougli, will not waste his dwindling resources on the purchase 
 of food for which he has no appetite. 
 
 In quite the earlier stages of the disease, it is true patients 
 often exhibit an increased appetite, but this is only for a short 
 period, and, as the digestive powers become more and more 
 undermined, and the patient a confirmed dyspeptic, the appetite 
 becomes small and capricious. Arrangements should, however, 
 be made on all gardens for a cheap and plentiful supply of 
 green vegetables just as they are in the case of the other ne- 
 cessaries of life, as it is impossible for the coolie to supply 
 himself with what is unobtainable. 
 
 (d) Water-supi^ly . — More attention has been devoted to 
 this matter than to any other sanitary point, and there are 
 large numbers of gardens where large sums have been spent 
 in the provision of wells, receiving tanks, and even filters, and 
 the supply is often excellent. This is often especially the case 
 on "unhealthy gardens" which will be more frequently found 
 to possess a good water-supply than such as have never been 
 relegated to the black list. The reason of this is, of course, 
 that a heavy sick list has directed attention to the necessity of 
 sanitary improvements, and, as might be expected, a marked 
 improvement in general health has resulted. The improve- 
 ment, however, fails to take the garden off' the black list, as it 
 fails to touch the most important factor of the mortality, for I 
 could not find any instance in which the improvement of -water- 
 supply could be shown to have done much, if anything, 
 to diminish anchylostomiasis. 
 
 In those instances where improvement had resulted from 
 the carrying out of sanitary recommendations, removal of the 
 site of lines would generally be found to be one, and as I 
 believe the, effective agent in the improvement. No one can 
 be less disposed than the writer to underrate the advantages 
 of a pure water-supply; but, as has already been said, I do not 
 think its provision can do much for the prevention of the parti- 
 cular disease we have under consideration. Let it not, however, 
 be supposed that the water-supply of tea-gardens in general 
 is everywhere as it should be ; indeed, so far from this being 
 the case, a supply of good quality is almost restricted to those 
 gardens where the spur of a heavy mortality has led to strenu- 
 ous efforts at better sanitation. A glance at the table given on 
 page 32 et seq., will show that the drinking-water of many 
 gardens is horribly foul, and the introduction of a pure sup- 
 
( 153 ) 
 
 ply in such cases must be a crying necessity. Even where 
 money has been freely spent, mistakes due to want of knowledge 
 of a very special subject have not unfrequently resulted in a 
 doubtful, in place of a thoroughly reliable, supply. For 
 example, in one of the most progressive establishments in the 
 Lakhimpur district, at the time of my visit, they were busily 
 engaged in digging a well. It was being sunk through an ex- 
 tremely porous, sandy soil, and, owing to its shifting character, 
 the amount of labour that was required was enormous. 
 In nearly any other situation but where it was placed, it 
 might be expected, when completed, to yield excellent water ; 
 but, instead of putting it well away in the midst of the cul- 
 tivation, they had been at great pains to find it a place in the 
 very heart of the coolie village, which accommodated many 
 hundred souls, having actually gone to the additional expense 
 of demolishing some buildings to find space for the enormous 
 conical excavation necessitated by the unstable character of 
 the soil. Placed as it is, and in such a soil, defilement with 
 the foul surface washings of the lines will be almost in- 
 evitable, as no masonry tube, however well made, can be 
 trusted to entirely exclude percolation for any great length 
 of time. It was intended that the well should be covered, and 
 provided with a cemented supply tank, and the additional 
 cost of an iron pipe to convey the water from a weU, situated 
 well away from the habitations, to a tank or tanks in the lines 
 would have involved an additional outlay so trifling as to be 
 hardly worth considering, as a part of the large expense that 
 had already been incurred. 
 
 [e) Conservancy. — In this matter the arrangements in 
 use upon tea-gardens may be very briefly described. There are 
 none. The entire neglect of this most essential of all sanitary 
 necessities is the greatest blot to be found in the condition 
 of the tea-gardens, and is the essential cause of the spread 
 and persistence of anchylostomiasis, to say nothing of the evil 
 effect it must have on the general health. The existing state 
 of things cannot be described in too strong terms. Crowded 
 together, as the huts necessarily are, and, indeed, should be, 
 for I do not use the term in the sense of overcrowding, the 
 filthy state of these settlements, in even the best-managed 
 gardens, is revolting. If you ask what conservancy measures 
 are adopted, you will be told that the people "go to the 
 jungle," or " amongst the tea-bushes," but a visit to the locali- 
 ties pointed out will seldom result in the discovery of 
 anything particularly offensive to either the nose, or eye. 
 
 M 
 
( 154 ) 
 
 It is between and beliind the huts, and in the little enclo- 
 sures already alluded to, that nine-tenths of the offence 
 will be found to be concentrated, and, for all practical purposes, 
 the ground immediately round a man's hut forms his only 
 latrine. When this is pointed out, you will be told that " it 
 has been done by the women and children," bu^ the scantiness 
 of deposits elsewhere makes this improbable ; and, even if it 
 were true, its source in no way diminishes the harmfulness of 
 the practice. Besides, even supposing the men do resort to 
 the tea-bushes, &c., as described, it is difficult to see how we 
 are more than a degree better off*. It is perfectly certain that 
 they will not go far afield, and that they will habitually resort 
 to nearly the same piece of ground, and wherever cases of 
 anchylostomiasis are to be found am'ongst the coolies, the 
 result will be the production of a nursery for rearing the 
 infective embryos of this most fatal of parasites, under the 
 most favourable conditions imaginable ; for the trampling 
 about of a considerable number of persons on the small 
 area so used will result in the broadcast diffusion of the 
 embryos over its whole surface, and the ready supply of 
 fresh nutriment will ensure their indefinite multiplication. 
 
 In addition to human pollution, the droppings of cattle, 
 stable refuse, and rubbish of every kind commonly litter 
 the ground, and are seldom cleared away ; and when this 
 is done, the refuse is seldom removed to a sufficient dis- 
 tance, or burnt. In one large garden, I found, flanking 
 the lines, a mass of accumulated sweepings some three to five 
 feet high extending along the whole of one face of the settle- 
 ment. It was not more than twenty feet distant from the 
 nearest huts, and was placed rather above them, on the gentle 
 slope on which the lines were built. The surface of this 
 mass, which must have represented the accumulation of 
 several years, was evidently the "jungle" and "tea-bushes" I 
 had heard so much about, so that the nature of its drainage, 
 which necessarily flowed into the lines, may be better 
 imagined than described ; and yet in this garden the expen- 
 diture on good huts, and the provision of a good water- 
 supply could only be described as liberal in the extreme. 
 
 Tea-garden sanitation has, in fact, been commenced at 
 the wrong end, for water-supply might, with comparative 
 impunity, have been left to take care of itself, provided 
 measures had been taken to put a stop to its pollution by 
 means of adequate measures of conservancy.* 
 
 * See Circular from Sanitaiy Commissioner, No. IS., paras. 3, 7, 25th 
 March 1890. 
 
( 155 ) 
 
 It would be wrong, however, to impute much blame to 
 the planter for the existence of this state of things, for the 
 cause lies in the naturally dirty habits of the coolie, and, 
 unless he resort to illegal means, the planter has no power to 
 enforce the observance of more decent habits. All that can 
 be laid to the planter's door is that, by omitting to provide 
 proper latrines, he has neglected to give his labourers the 
 chance of becoming cleanly. The c^use of this neglect 
 is mainly a rooted belief that, even if provided, they would 
 not be used. This belief is, however, based on purely 
 theoretical considerations of the innate dirtiness of the coolie 
 character, for I found no garden where they had tested the 
 theory by actual experiment. The argument is a stock one, 
 which has been made use of by the opponents of sanitary 
 measures, wherever proper conservancy has been proposed 
 in India, and has almost universally proved fallacious when 
 put to the actual test. Where the introduction of latrines 
 has proved a failure, it has almost always been owing to 
 mistakes in the choice of site. If they be placed at a 
 long distance from the habitations of those who are to use 
 them, they are naturally enough never resorted to ; but if 
 so placed and arranged as to be an actual convenience, 
 they will soon come into use, for a man soon learns to 
 prefer to go to a well-kept latrine, on a dry site, with water, 
 and a platform for ablution at hand, to wading a longer 
 distance, through a sea of mud. Once the matter is fairly 
 faced, the difficulties will, I believe, be found to be mainly 
 imaginary. During my recent tour I made at least one 
 convert to these views, and I am told that the success which 
 has attended the introduction of a simple form of latrine I 
 recommended to him, has greatly- surprised the experimenter, 
 as the coolies very soon took to availing themselves of the 
 greater convenience of the arrangement placed at their 
 disposal. 
 
 The disposal of other offensive matter, and rubbish, 
 which also forms an essential of proper conservancy, is a 
 less simple matter, as it is hard to make a convenience 
 of the labour involved in keeping the lines in a cleanly 
 state. If health is to be improved, however, it is certain 
 some organization must be instituted for the purpose. The 
 nature of such an organization ' is somewhat outside the 
 province of the sanitary officer ; but personally I would 
 make the coolie himself responsible for the cleanliness of his 
 surroundings, and would limit the function of the European 
 
( 156 ) 
 
 manager to directing tlie attention of tlie authorities to cases 
 of neglect of proper sanitary precautions. There is this much 
 to be said for the labourer, that he has not the least idea 
 that there is anything in his mode of life dangerous either 
 to himself or his neighbours, and that the law as yet puts no 
 veto on these habits, although they are far more destructive 
 to life and comfort, than many matters about which it minutely 
 concerns itself. There is, of course, not the least chance of 
 being able to convince the coolie that his habits are a stand- 
 ing danger to himself and every one around him, but what- 
 ever their faults, Indians are at least a most law-abiding 
 race, and if they were once made to see that breaches of the 
 common decencies of sanitation are illegal, they would slowly 
 come to acquiesce in the inevitable, and adopt more cleanly 
 customs ; but without some amount of legal coercion it is difficult 
 to see how any great improvement can be expected. Such being, 
 then, the conditions under which the coolie lives, it is in no way 
 surprising that anchylostomiasis should be rife amongst them. 
 Given the introduction of a single case into a community so 
 situated, the spread of the disease becomes almost inevitable, 
 and the result is that very few gardens can now be said to 
 be absolutely free from it; and, unless strenuous preventive 
 measures be instituted, the number of gardens on the " black 
 list " must necessarily go on increasing, even more rapidly than 
 it already has, until nearly the whole of the establishments of 
 the province come under this melancholy category. 
 
 With this section, this report comes to a close. The inves- 
 tigation into the method of spread of the disease leads to but 
 one conclusion, for it follows from the facts I have endeavoured 
 to set forth, that the only -commonsense method of prevention 
 is to adopt the absolutely sure plan of destroying all chance 
 of infection, by proper measures of conservancy. From no 
 other plan can any appreciable improvement be hoped for. 
 A thoroughly efficient conservancy cannot fail to ultimately 
 entirely stamp out the disease, and, whatever success may be 
 achieved in practice will be exactly proportional to the 
 efficiency of the measures of conservancy adopted. 
 
 Geo. M. GILES, m.b., f.r.c.s., san. sci. cert. uotv. Lond., 
 Surgeon I.M.S., on Special Duty, Assam. 
 
 Shillong, 1st October 1890. 
 
ADDENDUM 
 
 On pages 7-8 of the present report, reference is made 
 to a note in Dr. Kynsey's pamphlet on the beri-beri of Ceylon, 
 on a paper by Leichtenstern on anchylostomiasis, and to the 
 inexplicable character of the abstract given. During a 
 recent visit to Simla, I found that the office of the Surgeon- 
 General with the Government of India is provided with a file 
 of the " Deutsche Medicinische Wochenschrift," and I accord- 
 ingly proceeded to search for the paper in question. 
 
 It is not surprising that I was unable in the first instance 
 to obtain it, as the authority appears to be incorrectly given. 
 The paper referred to is, I presume, one entitled " Einiges 
 iiber Anchylostoma duodenale " Yon Otto Leichtenstern, 
 Deutsch. Med. Wochen., Vol. XIII., 1887, pages 565, 594, 
 620, 645, 669, 691, and 712. 
 
 Though modestly entitled " a few words " on the subject in 
 question, the article, it will be seen, is a very long one, 
 running through no less than seven issues of the periodical. 
 The main bulk of the paper is taken up with a criticism 
 on the work of Dr. Schultess, a translation of which, it may 
 be remembered, appears in Dr. Kynsey's pamphlet; but I 
 could find no such statement as that quoted thence in ^'" 
 text of this report, no mention being made of p -^ ^^ 
 extraordinary a method of multiphcation as by *^^ separa- 
 tion of the " segments " of a rhabditic nematod'^*, .^, 
 
 I am glad to find that Leichtenstern p:"^^^^^ ^^J'f^ ^}^? 
 my own views as to the significance - ^H ^^"^^^^^^ ^^^^,'" 
 fication of the embryos, looking ur-^^ ^^^ ^^/^g^ ^^ ^^^^^^ 
 an indication of death, and Any pag^s of the paper are 
 occupied in controvertinjr »^ne views of Schultess on the 
 point. We are also J- accord as to the explanation of this 
 non-development o^ ova within the human intestine being 
 diie to the «Dsence of oxygen, Leichtenstern having 
 established t2iis matter beyond doubt by rigid experimental 
 tests, showing that cultivations immersed in other gases fail 
 to develop. 
 
 It is, however, quite obvious that, like his predecessors, 
 he quite failed to follow the rhabdites to maturity, and so 
 missed the true significance of the free stage. 
 
 This failure I believe may be traced to his view (page 
 669) that water is the natural habitat of the rhabdites, 
 whereas, as has been demonstrated in the text, no complete 
 development of these organisms can take place in that 
 medium, their true habitat being not water, but fcecal matter. 
 
( 2 ) 
 
 Hence he has no suspicion that a regular sexual multi- 
 plication of the free stage is possible and normal. Hence, too, 
 his laborious description of the so-called encapsuling and 
 re-incapsuling of the embryos, which are, of course, nothing 
 more than ordinary ecdyses, greatly delayed by the unsuit- 
 ability of the conditions to which his embryos were exposed. 
 
 He speaks, too, of successful feeding experiments ; but, as 
 they are not given in detail, their true significance cannot be 
 judged. 
 
 A further point on which our experiences are in entire 
 agreement is the non-discovery of any worms encysted in 
 the submucosa, and indeed the remarks I have made on pages 
 85-86 of this report might almost pass as a free translation 
 of what he has written at page 692 of the "Deutsche 
 Medicinische Wochenschrift." He does not, however, dispute 
 the accuracy of the older observations of Bilhartz, Greisiger, 
 and Grassi (1852-1854); but looks upon the worms they 
 found encysted as having "wandered" from their proper 
 habitat. 
 
 This explanation, however, fails to satisfy me, as it runs 
 
 counter to the general phenomena of helminthiases, and I 
 
 should still prefer to believe that our failure is rather to 
 
 be traced to neither of us having met with suitable cases. 
 
 ^ Of great interest, too, are the cases he gives (page 693, 
 
 . "t^O illustrative of the longevity of the parasite. In one 
 
 livpd V ^^ considers he has good evidence of their having 
 
 not ^^ ^ years within the human intestine, but it does 
 
 , • 1 1 ^ clear that the possibility of re-infection is 
 
 entirely excludect, u- ^ f • x i ^i 
 
 .• ./ ^ ' 7US ari^ument bemf]f based on the assump- 
 
 tion that opportumtie. 1^^ infection are afforded only by 
 brick-fields. In another, ^^_^^ ^f ^^^ ^ duration 
 
 of two years appears to be di^u^ctly proved, as the patient 
 passed that period m jail, subseqjjy to infection, and it 
 may be fairly considered an impossibilK, that infection should 
 take p ace withm the walls of an Euro^.an prison. Cfeie 
 would like, however, to know the nature of the labour on 
 which the prisoners were employed. I have met with 
 Biniilar cases in Assamese jails ; but here the possibility of 
 re-infection cannot be entirely excluded, as the prisoners are 
 much employed on extramural labour, in the pursuance of 
 which frequent opportunities of infection may occur. 
 
 Sanawar : ^ 
 
 December 20th, 1890. ] G. M. GILES. 
 
 A. S. Press (General) No. 79a— 520— 14 1-91. • 
 
EEEATA. 
 
 Page 54, line 27 frbm top, /or " ilum " read " ileum. " 
 
 „ 60, „ 18 „ „ " jejunam " read "jejunum. " 
 
 „ 76, „ 7 from bottom, fm* " rhabdites " read " rhabditis. " 
 
 „ 91, „ 26 from top, /or " caleoptera " reo^ " coleoptera. " 
 
 „ 98, „ 3 „ „ "rhabdites" „ "rhabditis." 
 
 „ 98, „ 14 from bottom, for "there " read " their. " 
 
 „ 117, „ 20 from top, for " with " read " into. " 
 
 „ 117, last line, for " add " read « up to. " 
 
 „ 121, line 22 from top, before "probably" insert "owing. " 
 
 „ 122, „ 22 „ /or " elongaed " reacZ " elongate^ 
 
 •, 139, „ 9 „ „ "or"reaci"of." 
 
 ,c6 " measure. 
 „ 140, „ 10 from bottom, f<yr " measures " 
 
 „ 141, top line, for " base " read " ca?^ 
 
 Explanation of ^ * 
 
 jcual " rtad " pre-sexual. " 
 Plate II., figure 2, /or" pr-'''^^^^ , ^ ^ „ 
 .V / ilium" read "ileum." 
 
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