AL Se es « He yo Nk ee 2 Sh ROOM TE CP Mae TES Nae GWAR REMARKS ON KALA-AZAR 129 both having greatly enlarged spleens ; proof of their deaths in Khartoum I was not able to obtain. The marmiton (cook’s boy) also died of fever in the same year. All apparently occupied the same quarters.

(2) At Mafaza, between August, 1907, and April, 1909, amongst those occupying the police lines, eight died of this disease, while another policeman, the sub-mamour and his two servants almost certainly died from this cause-(3) At Abdin, two brothers were found, one with definite kala-azar, while the other had been ill for two years with fever and had a spleen reaching to the umbilicus.

There was practically no time to study the important question as to how the disease is transmitted, but the following facts were forcibly impressed upon one.

(a) Bed-bugs are extremely common; quite 75 per cent. of the native angareebs harbour them ; (b) Angareebs in places away from the river banks seem to harbour bugs just as frequently as those in places situated on the rivers.

The following facts, with reference to the presence or absence of bugs in angareebs, were ascertained in 20 cases of kala-azar :— (1) Live bed-bugs found in eight instances ; (2) Recently deposited eggs, but no live bed-bugs found in four instances ; (3) No signs of bugs or their eggs in four instances ; (4) In the case of those who did not use angareebs, or had not used them in the place where seen, bed-bugs were found in four instances.

All the bugs examined were believed to be Oimex lectularius, owing to their presenting distinctly flattened or concave edges on the dorsal aspect of the pro-thorax.

Cimex rotundatus has, I believe, at present never been identified in the Sudan.! The disease in the Sudan certainly seems to spread, in some cases, through the members of a household or community, and this suggests that it may be conveyed by the bed-bug.

Against this view, however, is the striking fact that in the Sudan, as in India, the disease appears to cling to river banks, and yet bed-bugs are equally common in places on and away from the river and infected persons must frequently be visiting these places off the river.

The popular belief, which I have often heard expressed, that angareebs strung with strips of hide do not harbour bugs is quite fallacious, as many such angareebs were seen teeming with these pests. In view of the possibility of the disease being carried from domestic animals to human beings, the animals kept in the twkls or hooshes of those suffering from kala-azar were noted, but in no instance were animals, evidently ill, discovered. The domestic animals seen were donkeys, sheep, goats, dogs and chickens.

Trade, habits, and food seemed in no way connected with the transmission of the disease, but it still has to be determined whether river water, or the eating of fish, may not be a means of conveying the disease in the Sudan, a possibility in view of the tendency of the disease to cling to river-side villages and the frequent initial intestinal disturbance.

The disease runs in many cases a very severe and rapid course, and of those diagnosed on this tour, eight were known to be already dead in June, 1909. The average duration of the illness, according to the statements of the various patients, who, however, are not by any means entirely to be relied upon, was twenty-one-and-a-half weeks, while five terminated fatally in thirteen weeks. Nine cases gave a history of illness of less than three months, while five more stated the disease had lasted five months or less. The most rapid case was that of a woman aged about 18, at Kassala; she and her husband were ‘ It has now been found in the Red Sea Province and the Lado district.—A.B.

Associated cases Bed-bugs Clinical type often severe and rapid