Clinical researches on disease in India

Front matter

I

CLINICAL

RESEARCHES

Preface

The desire which I have long entertained of contributing to the resources of practical medicine in India, has been realised at the present time, in obedience to the wishes of the Honourable Court of Directors of the East India Company, originating in the following minute, which was submitted on the 15th May, 1854, by Dr. Mc- Lennan, Physician-General of the Bombay Army, to his colleagues in the Board of Education, approved by them and by the Government of Bombay : —

MINUTE.

" 1 now beg to submit to my colleagues the proposition to which I lately adverted, when treating of the approaching departure of Dr. Morehead on sick leave. My own impression was, that in all probability eighteen months would be necessary for the purpose of recruiting his health ; but in consideration of the special nature of the leave applied for, the Medical Board restricted their recommendation to a period about which there could be no doubt, and, therefore, mentioned twelve months only as the time deemed requisite for his restoration to health and efficiency.

" I would now submit, that the Board of Education make a suggestion to Government, in view to its transmission to the Honourable Court of Directors, that at the end of that period Dr. Morehead be requested to occupy himself in advancing

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the cause of Indian Medical Education, by the preparation of a work on the Diseases of India, calculated, not only for the Students educated in Indian Medical Colleges and for Indian Graduates, but also for Medical Commissioned Officers of the Honourable Company's Service on first arrival in India, and till such time as they have acquired that experience which years of service alone supply. The period necessary to bring out such a work, with the materials already accumulated by Dr. Morehead, would probably not exceed another year, and thus the whole term of absence, both on account of health and duty, would not exceed that for which leave within the limits on the old Furlough Rules has hitherto been given.

"It may be well that I should say something of the grounds on which I venture to make this recommendation, and here I would say that Dr. Morehead's experience has been varied and extensive. On first arrival in India he served for two years with European, and for as many years with native troops, at different stations. He was then for two years in charge of the sanatory station of Mahableshwur thereafter, for more than six years, resident Assistant Surgeon of the European General Hospital, Bombay — an institution in which the inmates are of very varied circumstances as to habits, position in life, nature of duties, and length of residence in India, &c. In that hospital are accommodated the newly arrived European and the old servant of many years' Indian residence — the seamen of the Royal, Indian, and Mercantile navies — the soldiers of all arms and both services, Queen's and Company's — the townsman — mechanic

_ clerk male and female — adult and child — from most

classes of life, and many stations in the interior. The opportunity for seeing variety of disease, therefore, under great diversity of circumstance, is considerable.

« Dr. Morehead was likewise for six years Surgeon of the Byculla Schools. In parts of 1843 and 1844 he was in Sinde, and had an opportunity of observing the state of health of Europens and Natives after the sickly season of 1843.

« He has been for nearly nine years Surgeon of the Jamsetjee Jejeebhoy Hospital, and for six years has been engaged in teaching Medicine and Clinical Medicine in the Grant Medical vii

College : and the records of the Clinical Wards have been carefully preserved during the whole of this period.

" He has been twelve years Secretary to the Medical and Physical Society, during which time there has been afforded him by the Medical Board the opportunity of becoming acquainted with the tenor of the medical reports and cases from all parts of the Presidency.

" In 1833, and again in 1853, Dr. Morehead had the opportunity of observing some of the hospitals and medical institutions in Madras, Calcutta, Colombo, &c. &c.

" Very numerous papers on Dysentery — Dracunculus — Diseases of the Abdominal Viscera — Intermittent and Remittent Fevers — Delirium Tremens — Diseases of the Brain — Hepatitis and Cholera — Measles in the Byculla Schools, &c. &c, have been inserted by him in the Edinburgh Medical and Surgical Journal, Transactions of the Medical and Physical Society of Calcutta, and Transactions of the Medical and Physical Society of Bombay.

" In the last work, too, at a comparatively recent date, five papers, based on observations chiefly made in the Clinical Wards of the Jamsetjee Jejeebhoy Hospital, on the important subjects of Smallpox — Bright's Disease of the Kidney — Diseases of the Heart — Pneumonia — and Beriberi — have been contributed, and there are records from which to make the same kind of observations in respect to other important diseases treated in the same wards, such as Hepatic Abscess — Dysentery — Fevers — Phthisis Pulmonalis — Paralytic Affections, &c. &c.

« Having thus detailed the sources from which Dr. Morehead's experience and fitness for the task which I have ventured to suggest have been derived, I may now add a few words as to the nature of that want which I propose he should supply ; and here I honestly give it as my opinion, that till some work of the kind I suggest be brought forth, the efforts of Indian Govern-

DO O '

ments and their servants in medical education will be incomplete. At present, Graduates and Students of Indian Medical Colleges are without any book on practice in Indian Disease, as

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Yin

PREFACE.

now generally followed, or as requiring modifications to meet peculiarities of native habit and constitution.

" The duties of the Clinical Wards in the Grant Medical College have been so carried on, and so recorded, as to constitute an important collection of facts and practice, which may be brought to bear on this want. The labour of collecting, digesting, and condensing for such a work will be considerable, and, as it is valuable for Indian purposes, it should (it seems to me) receive support and encouragement from the Indian Government, which Dr. Morehead has so zealously and usefully served.

(S I, therefore, trust my colleagues will support my proposition, and recommend, that after the expiration of the leave lately granted, Dr. Morehead may have, for the above purpose, another year in England on Indian allowances, and to count as service, with the right of returning to that place in the Grant Medical College, over which he has so beneficially presided." *

In performing this duty I have endeavoured to embody my experience in a connected form, and to illustrate my opinions by cases which have passed under my immediate observation f and care j while, at the same time, I have not been inattentive to the views of other inquirers.

My clinical researches have been directed to disease, as occurring both in Europeans and in the Natives of India. I have aimed not merely to increase practical knowledge of the diseases usually termed tropical, as malarious fever, hepatitis, dysentery ; but, also to show that affections — pneumonia, phthisis pulmonalis, pericarditis, Bright's disease — familiar to European

* Report of the Board of Education, Bombay, from May 1. 1854, to April 30. 1855, p. 144.

•j- The few cases not observed by myself which have been inserted, are indicated by an asterisk.

PREFACE.

observers, are sufficiently common in India, more particularly in some classes of the native community.

Cases have been introduced chiefly with the object of elucidating the Symptomatology and Pathology of disease. They have been used freely in the form of summaries, which have in every instance been carefully prepared by myself. The graduates of the Indian Medical Colleges, . for whose benefit I have chiefly written, may often, for many years yet to come, be placed in positions remote from their professional brethren, and in circumstances ill adapted for the prosecution of pathological research. The recollection of this fact has removed any hesitation which I might otherwise have felt relative to the expediency of inserting so many illustrative details. But, at the same time, I have been careful so to arrange the text of the work, that it may be readily perused independent of the cases ; and so to classify and indicate the cases, that they may be referred to without difficulty by those who may be engaged in the close investigation of the diseases to which they relate.

In my remarks on the treatment of disease I have invariably endeavoured to explain fully the principles, and to state the means by which they may be best applied. Cases illustrative of treatment have been sparingly used by me, because practical conclusions arrived at, after a lengthened course of experience, are grounded partly on cases successfully treated, partly on those which have proved fatal, and partly oil

X PREFACE.

the observations of different method in the hands of others. Therefore the physician, on looking back to the records of his practice through a long series of years, is not likely to meet with many cases calculated to illustrate at all points his matured therapeutic opinions.

Making exception, then, of the few cases which have been detailed in explanation of treatment, I would request the reader to refer exclusively to the text for my views on this important part of my subject. Doubtless the principles inculcated by me will be found applied in the management of many of the cases which have been narrated with a different object ; but, on the other hand, I am very sensible that some of them may be fairly open to criticism.

It was my desire to have concluded this work with a a chapter on the Diseases of Females and of Children, but the time at my command has come to a close. In respect to some of the diseases of which I have treated, reference has been made to their occurrence in females, and in the early periods of life; and a little reflection will readily suggest the modifications of the pathological and therapeutic principles which I have endeavoured to enforce to the circumstances of difference of sex and of age. Still, the subject is of much interest and importance, and I would indulge the hope that I may be permitted, at some future time, to supply the omission which at present I have been unable to avoid.

London, May, 185G.

Section II. — Simple Intermittent Fever. — Symptoms, Pathology, and Treatment - - - - 26

Section HI. — Intermittent Fever complicated with Enlarge - mentofthe Spleen. — Symptoms. — Pathology. — Treatment - 51

Section IV. — Intermittent Fever with Hepatic Complication. — Symptoms Pathology. — Treatment - - - 72

Section V. — Intermittent Fever complicated with Jaundice, or Affections of the Stomach or Bowels - - - 78

Section VI. — Intermittent Fever complicated with Cerebral Affection - - - - - - 82

Section VII — Intermittent Fever complicated with Bronchitis, Pneumonia, Rheumatism, Scorbutus, Pericarditis, Asthma -------87 xii

CONTENTS OF

Chapter II. On Remittent Fever

Page

Section I.— The Diagnosis of Remittent Fever, from Intermittent Fever and Ardent Continued Fever. — Division into Simple and Complicated 7 - - - - 93

Section II.— Symptoms of Remittent Fever.— Ordinary, Inflammatory, Adynamic, Congestive, Badly Developed, with unexpected Collapse, with peculiar Features. — Also complicated with Cerebral Affection, Irritability of Stomach, Jaundice, Bronchitis, Pneumonia. — Diagnosis from Hectic and Symptomatic Fever - - - - - 97

Section III. — Pathology. — Mortality from Remittent Fever. —Relation of Type to Diathesis and previously existing Structural Lesions. — Complication with Cerebral Affection and Consideration of the Pathological Import of Cranial Serous Effusion. — Complication with Gastric Irritability, Affection of the Bowels. — Hepatitis, Jaundice, Parotitis, and Pneumonia - - - - " -122

Section IV. — Treatment. — Contrast of the Principles of Treatment of Malarious Remittent Fever, and the Zymotic Continued Fevers of Cold Climates.— Treatment of Ordinary, Inflammatory, Congestive, Adynamic, and Irregular Types of Remittent Fever.— Then of those complicated with Cerebral Affection, Gastric Irritability, Jaundice, Hepatitis - 172

Section V. — Treatment further considered in Remarks on Blood-Letting, and the Mercurial Treatment, which is fully discussed.— On Cold Affusion and Wet Sheet Packing.— On Purgatives, Emetics, Blisters, Opiates, Quinine, Diet, and Change of Air -

Section VI. On certain obscurer phenomena probably

related to Malaria. — And on Adynamic Remittent Fever Infectious in Character observed at Pali and elsewhere - 203

THE FIRST VOLUME.

Xlll

CHAPTER HI.

ON COMMON AND ARDENT CONTINUED FEVER. — THE FEVERS OF CHILDREN IN INDIA. STATISTICS OF FEVER IN THE EURO- PEAN GENERAL HOSPITAL AND JAMSETJEE JEJEEBHOY HOS- PITAL AT BOMBAY.

Page

Section I. — Febricula and Ardent Continued Fever. — Causes. — Symptoms. — Treatment- - - -261

Section II The Febrile Affections of Children in India. —

Febricula. — Intermittent and Remittent Fever - - 266

Section HI. — Statistics of Fever in the European General Hospital, and in the Jamsetjee Jejeebhoy Hospital at Bombay - - - - - - - 268

Chapter IV

A SHORT SKETCH OF THE PLAGUE OF THE LEVANT ; OF YELLOW FEVER ; AND OF TYPHUS, TYPHOID AND RELAPSING FEVERS OF COLDER CLIMATES.

Section I. — Plague ------ 290

Section II. — Yellow Fever ----- 298

Section in. — Fevers of the Colder Climates — Typhus, Typhoid, Relapsing Fever, and Febricula - 304

Chapter V. On Eruptive Fevers. — Small-pox

Section I. — Small-Pox — Notes on, as observed in the

Jamsetjee Jejeebhoy Hospital — Prevalence Prevention

by Vaccination. — Table - - - -' ,'jOS

MEASLES.

Section II.— The Clinical History of Measles as occurring in the Byculla Schools in Bombay - 329

Section III. — Scarlatina. — Erysipelas — Varicella Hooping Cough. — Cynanche Parotidea - 360 xiv

CONTENTS OF

Chapter VI. On Epidemic Cholera

Section I— Remarks on the Seasons of Prevalence and on the Causes of Cholera

Section II. -Symptoms considered in reference to their Decrees of Severity. - Diagnosis from Bilious Cholera, Irritant Poisoning, and Collapse of Remittent Fever

Section IH.-Pathology.-The General Rate of Mortality- Its Relation to Age, Period of Epidemic, and Duration before Admission considered. - General Pathology shortly noticed. — Morbid Anatomy described and illustrated with Cases -

Skction IV. — Treatment in relation to the different Degrees and Stages of the Disease.— Illustrative Cases

Section V.-Statistical Tables relative to Epidemic Cholera in the European General Hospital, and the Jamsetjee Jejeebhoy Hospital at Bombay

Page 363

378 402

Chapter VII. On Dysentery

Section I.-The Importance of Dysentery in India—Order in

which the Subject will be treated - Section n.-Pathology.-Detailed Statement of the Morbid

Anatomy -

Section HI— Etiology of Dysentery—Importance of distinguishing Exciting and Predisposing Causes. - Exciting Causes. - Cold, Food- Predisposing Causes. - Cachectic States— Action of Malaria discussed

Section IV— Symptoms of Dysentery

Section V.- Treatment— General Principles and Indications. -Detailed Remarks on Blood-letting General and Local, Calomel, Mercurial Influence, Ipecacuanha, Purgatives,

438 440

522 533

THE FIRST VOLUME.

XV

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Diaphoretics, Opium, Astringents, Tonics, Fomentations, Blisters, Enemata, Diet, and Change of Climate in Dysentery - - - - - - - 544

European General Hospital and the Jamsetjee Jejeebhoy Hospital, at Bombay ..... 589

Chapter VIII. On Hepatitis

Section L — Preliminary Remarks on the Nature of the Symptoms of Hepatic Disease, and a Reference to the Anatomical Relations of the Liver. — Arrangement of the Subject - 594

Section IL — Pathology. — Preliminary Remarks on the General Pathology of Hepatitis. — Morbid Anatomy of Stage of Vascular Turgescence, Lymph Exudation, and Formation of Abscess, explained. — The several Courses and Situations of Rupture of Hepatic Abscess. — Abscess Absorption. — Secondary Peritonitis, and Formation of Circumscribed Purulent Sacs. — Secondary Pleuritis, Circumscribed and General Empyema.— Secondary Pericarditis. — General Secondary Peritonitis. — Colour of Pus in Hepatic Abscess - - 598

ON THE

DISEASES OF INDIA.

Introduction

Clinical research implies the investigation of those doctrines of Pathology and Therapeutics which may be reasonably deduced from the careful observation and comparison of numerous individual instances of disease.

As the study of the doctrines and of the instances is most advantageously conducted in connexion with each other, it is unnecessary in the introduction to a clinical work to do more than to take advantage of the opportunity which it presents of alluding in general terms to some of those facts which more or less apply to all forms of disease.

One of the earliest important truths which becomes impressed upon the mind of the practical inquirer is, that the diseases described in systematic treatises are favoured in their access and modified as respects their course and treatment by pre-existing states of the constitution of the affected. On inquiry, it further appears, that these states are in general either original or acquired in one or other of the three following ways :

1st. By neglect of a right condition of those agencies termed vital stimuli, which are as essential to the physiological performance of function as organic integrity.

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DISEASES OF INDIA.

They are food, atmospheric air, exercise, and repose of

body and mind.

2nd. By undue discharges from the blood or retention of excreta.

3rd. By reception into the blood of external injurious agencies — poisons.

Under one or other of these heads may be classed cachexia from struma, scurvy, vitiated atmosphere, mental states, prolonged lactation, hemorrhages, albuminuria, rheumatism, malaria, syphilis, carcinoma, mercury, arsenic, lead, alcohol, &c.

Though in the cachexias arising in these various ways there maybe peculiarities special to each, still there are features common to all. The actions of the system are defectively carried on in all. The nutrition of the blood and of the solids is impaired, secretion is diminished and deranged, nervous influence and muscular irritability are imperfect, and the generation of animal heat is lowered in degree. In the course of my clinical remarks on different forms of disease I shall have to make frequent reference to these states under the designations "Asthenic" and " Cachectic." By the first term I wish to express merely a lowered degree of function ; and by the second, defect in quality as well as in degree.

It is very probable that an essential condition of cachectic states is an altered quality of the blood; and we may hope that future pathological research will ultimately determine the speciality of each. The term dyscrasia is used by Rokitansky in a similar sense ; but I have preferred retaining the word cachexia, as more familiar to English readers, and as quite adequate for the expression of our present positive knowledge^

In conducting the treatment of disease the clinical

INTRODUCTION.

physician is constantly reminded of the obstacles which these asthenic and cachectic states interpose to the success of his remedies, and of the necessity which is thereby entailed upon him of making the removal of these states a leading indication in the management of the special disease which has been grafted on them. Thus, among others, two important practical lessons are enforced : —

1st. Though the statement and inculcation of the details of sanitary measures are not within the province of clinical medicine, yet the paramount importance to the public health of a well organized system of medical police is a prominent inference from clinical research.

2nd. The advantage derived in practice by the removal of the sick from the influence of the causes of cachexia? impresses upon the mind of the physician this truth, — That a rational system of medicine is one that includes a just arrangement of the vital stimuli and the removal of Itedentia, as well as the use of medicines ; and that, when the cachectic states are very marked, then the two first therapeutic principles are the most important.

The principles hinted at in these few remarks will be frequently illustrated in these pages with reference to particular forms of disease.

The importance of regarding asthenic and cachectic conditions of constitution in the treatment of all forms of disease is true of every country. But, when investigation has reference to a particular country, it then becomes a preliminary question with the inquirer to determine whether, as regards the field of his observation, there is any special cause of these states generally operative or not.

In applying this rule to India I would remark that,

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DISEASES OF INDIA.

in comparing the tropical with the temperate climates of the globe, we find that in the former there are two additional causes of asthenia and cachexia more or less prevailing, viz., the influence of long continued elevation of temperature and of malaria.

The effect of elevated temperature on the European constitution in increasing the biliary secretion has been a constant theme with a succession of able and estimable writers on the diseases of Europeans in tropical climates. The observations on which these opinions rest are undoubtedly correct ; but they have reference only to a particular class, and there has consequently been error in deducing from them a general inference.

One effect of elevated temperature on the animal system is less necessity for animal heat; hence less demand for food, diminished metamorphosis of tissue, and decreased excretion. That this is true becomes manifest in the asthenic condition of the residents in warm climates compared with those in cold.

The European soldier or sailor lately arrived in India does not readily appreciate or adapt himself to the alterations in habits of life necessary to the maintenance of health under these circumstances of a warmer climate. The excesses therefore which in the cold climate might be unattended with disorder, are, under the increased predisposition consequent on the influence of elevated temperature, followed by derangement.

Bilious diarrhoea or cholera is in these circumstances very apt to occur, and the theory usually conceived of this event is in all probability correct, viz., that defective elimination of hydrocarbon by the lungs, under diminished heat-generation, is liable to throw on the liver the burden of the elimination of these elements, when they are present in excess in the system. But it

INTRODUCTION.

by no means follows from this that, when there is the just relation, between food-supply and excretion, which is implied in the habits of every prudent resident in a warm climate, there obtains more of action of the liver vicarious of the lung, in the one climate than in the other.

Questions which refer to the relative proportion of ingesta to excreta, and of the various excreta to each other, under varying circumstances of the animal system, can only be satisfactorily determined by careful observation and experiment. Researches of this kind on an extensive scale are still amongst the desiderata of physiological science. In the absence of just data, all that I can venture to advance on this subject, in reference to India, is the expression of my belief that, in the normal state of the system, all the solid* excreta are considerably less in amount than in the colder climates of European countries. The evidence that the biliary excretion is not increased, rests on the fact, that in the natives of India, and in Europeans whose habits of living have become adapted to the climate, derangement of this kind is very rarely observed.

From these observations on elevated temperature, as inducing asthenic and cachectic states, I pass to the consideration of the other influence, which was named, — Malaria.

Malaria is the exciting cause of intermittent and remittent fever, and will be frequently referred to in connexion with these diseases. It causes cachexia also, either by means of frequent febrile recurrences, or by the exercise of a slower and a gradual influence on the s}7stem.

This subject is well and fully discussed by our best

* I use the term solid, to exclude that water which has been received and eliminated without resolution into its elements.

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DISEASES OF INDIA.

systematic writers on disease, and it will therefore be sufficient for me to state very shortly the leading facts relative to the generation and action of this morbific cause.

1. We judge of the presence of the invisible agency termed malaria by certain derangements of the animal system which we attribute to its influence ; for as yet all other means of investigation have failed in detecting its presence and determining its nature.

2. A certain elevation of temperature acting on the earth's surface previously moistened is essential to the production of malaria. It is generated more certainly while this process of drying is going on, and in degree bears proportion to the rapidity with which the process is effected. Therefore malaria is most abundant in marshy grounds after the quantity of water has been reduced by evaporation and brought to that condition when the drying of the surface of the^ ground begins and the atmospheric temperature is still high. It is then, after the heats of summer have passed and the autumnal season has set in,— the months September and October,— that in marshy countries malarious fevers prevail.

3. In those tropical regions in which there are periodical rains, generally associated with elevated temperature, the generation of malaria coexists with the periods when the heavy falls have ceased and the drying of the earth's surface is rapidly going on. During the periodical rains of the western side of India, which commence about May and terminate in September, malarious fevers are prevalent sometimes in July, but generally most extensively in October. But there may be variations in respect to the particular months. The necessary conditions are such relation between the rainfall and the temperature as shall bring about the rapid drying of a surface previously soaked with moisture.

INTRODUCTION.

4. There are districts of countries, chiefly in the warmer climates, subject to the periodical inundation of large rivers ; and, should the subsidence of the waters coexist with elevated temperature, then the generation of malaria, as evidenced by the prevalence of intermittent and remittent fever, takes place. The Ganges, the Indus, the Euphrates, and the Nile are rivers of this kind.

Consequent on the melting of the snows in the mountain regions in which these rivers take their rise the supply of water is increased. They begin to rise about the month of March ; attain their greatest elevation, overflowing their banks and covering extensive tracts of country, in the month of September. Then they begin to fall and to expose the surface of the inundated tracts to the rapid drying of the elevated temperature of this season of the year. It is then that malarious fevers in these districts appear in their most aggravated form. It would seem that, whether in tracts habitually swampy, or regions wetted by periodical rains or the overflow of large rivers, still the autumnal season is one of prevalence of malarious fevers.

5. Malaria shows a preference for low levels compared with elevated sites. It often coexists with decaying vegetation, but" not unfrequently occurs altogether independent of it in situations where the surface is sandy, dry, bare of vegetation, and where the moisture, that essential condition of malaria generation, must be present in the subsoil.

6. Its influence on the animal system is more surely experienced at night and near to the surface of the ground. Malaria may be carried by currents of wind from the spot where it has been generated, and thus infect adjacent localities ; or by the same power it

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DISEASES OF INDIA.

may be rolled up the slope of a mountain just as clouds of vapour are.

7. Malaria is believed to lose its noxious properties by passing over a surface of water even of small extent. It is, however, attracted by and clings to the foliage of trees, thus rendering them a focus of the poison, but at the same time a protection to tracts of country beyond.

8. Malaria is lessened by cultivation and adequate population, but becomes rapidly increased when lands have been deserted and allowed to run waste.

Such general statements as these, relative to the generation and action of malaria, rest upon evidence which may be found in the Medical Statistical Reports of the British Army, and in the medical histories of military or naval expeditions to the coasts of Africa and Arracan, to Burmah, Java, the peninsula of Spain, and to other countries. They are, moreover, amply confirmed by observations made in my own field of research, or in districts adjacent to it. The fevers which occur in the months of September and October in the provinces of Guzerat, Candeish, and Scinde, illustrate the relation of malaria to elevated temperature and rapid drying of the earth's surface. In the Deccan and at Hursole in Guzerat there is evidence of malaria generation without vegetable decay; while at Deesa they have occurred in association together. The history* of a fever which prevailed among the marines of her Majesty's frigate " Endymion," in the dockyard at Bombay, affords a striking proof of the greater influence of malaria by night than by day. At Tatta and at Hyderabad in Scinde the malaria generated in the

* To be more particularly alluded to in the Chapter on Remittent Fever.

INTRODUCTION.

adjacent lowlands was carried by the prevailing wind to the hill slopes upon which the troops were stationed. That malaria is attracted by and clings to the foliage of trees has been in too many instances painfully proved by the record of detachments of troops injudiciously marched at unseasonable periods through the extensive jungle tracts which intervene between the provinces of Candeish and Guzerat. In the fallen condition of the city of Almedabad, and in the state of health of the troops at Hyderabad immediately after the battle of Meanee and the capture of Scinde, we have illustrations of the statement that malaria generation is favoured when districts are deserted, and previously cultivated lands are left waste.*

Exciting Causes of Disease. — Keference has been made to those asthenic and cachectic states which predispose to disease of all kinds, and the importance of a right appreciation of their influence in the etiology of disease in India will be frequently explained in various parts of this work. Malaria has also been named as a predisposing and exciting cause, and it now remains for me shortly to allude to the other ordinary exciting causes of disease in India. Of these, external cold is the most common. In judging of the facility of the reduction of the temperature of the surface of the body in India we must bear in mind the diminished power