BERI-BERI IN THE NORTHERN CIRCARS.

To the Editor of "The Indian Medical Gazette."

Sib,?I liavo made it a rule not to discuss matters that have come to my notice during official work, either in professional or in lay papers. Hence, when in your issue for June 1899 (page 211) you criticized certain opinions that you declared had been expressed by me, I thought it both unnecessary and undesirable to enter into discussion in your paper on the subject referred to. That article was characterized by crediting me with opinions that I have never expressed, and with others that bore an erroneous interpretation. But I recognized that, although you had taken the unusual course of giving your decision on the ex-parte statement of the author of the pamphlet you reviewed, you had a right to form your own conclusions upon such evidence as was before you. In your review of Captain Fearnside's pamphlet, you had to deal solely with such interpretation of official records as he chose to make ; you had not those records?or, at least, in their complete form?before you. In your issue for November 1900, you aj;ain refer to this matter in an editorial paragraph, and remind your readers of your issue of the previous year.

It is not my intention to enter into the pros, and cons, of the

question, as represented by Captain Fearnside ; but to reply, as briefly as possible, to the various points which you selected from his statements to support your arguments in the two issues mentioned. I have, nevertheless, to apologize for the length of my communication, which I am afraid cannot be avoided in discussing so diffuse a subject.

In the first place, allow me to refer you to your article of June 1899 ; in the first sentence of the 2nd paragraph, you state as follows :?" Owing to the unhealthiness of this jail in 1896-97, the Surgeon-General of Madras and the Sanitary Commissioner visited it, and reported to Government that in their opinion the disease to which high mortality was and had been duo was beri- beri." This statement is absolutely incorrect. We did not ascribe the mortality in the Rajahmundry Jail to beri-beri, but pointed to the existence of beri-beri, during several years previously, as likely to unfavourably influence mortality, in that sanitary errors and the occurrence of other diseases would find here constitutions already shaken. The actual words (which were stated in italics in the Conjoint Report) were "What then wo would contend is that so long as the jail population is liable to beri-beri, any sanitary error committed is likely to be at once responded to more readily than might be expected in a population not suffering from such disadvantages" (April 1897). This summary of opinion was stated with the special object of demanding alteration of the structure of the jail and securing various sanitary reforms, considered essential in buildings where beri-beri had appeared from time to. time. The necessity for these alterations with reference to beri-beri, I had as early as 1894 (when the jail was fairly healthy) urged attention to, and continued to do so up to the period of the excessive mortality of 1898, when, at last, they were attended to, with the result that the jail is no longer unhealthy. In this, "history has repeated itself.

" In 1865-66, the Superintendent of the old District Jail, Rajahmundry, reported that 51 deaths hnd occurred in a strength of 118, and that " there were 36 cases of diarrhoea and 5 deaths. Anasarca?two remained from last year?44 admitted and 26 died, which usual It/ 'proved fatal by effusion into the chest and pericardium [Italics not in original]. Since the plaster has been removed from the walls both diarrhoea and anasarca have entirely disappeared.

"

In the following year, instead of 51 deaths, the old District Jail had only 10 and, excluding cholera and small-pox, for four years subsequently there w.is but one death each year ! To my mind, to the disease characterized by anasarca and causing death by effusion into the chest and pericardium, which was got rid of by a process of radical disinfection and removal of unfit structures in 1866 and transfer of affected men, there is n remarkable resemblance in epidemic behaviour to that milder form of beri- beri intoxication which has been apparently eradicated, for the time being, in tho existing Central Jail, by measures directed to the renewal of unfit floors and walls, disinfection, transfer of the infected, general attention to sanitary details, and prophylaxis against anchylostomiasis and malaria. In 1896, when, after a period of fairly good health, sickness became first marked in the Central Jail, I reported officially as follows:?"1 consider from enquiries made as to the nature of work of weakly men that more care is requisite in selecting the description of labour on which they are placed.

'

[A subsequent investigation by tho Inspector-General of Prisons proved that this want of discretion was a factor of much importance in regard to the general decline of health]

* * *

" .My opinion of the present position in this jail then is as

follows:?The jail is one notoriously unhealthy, and although there are hopeful fluctuations from time to time, on the whole, the tendency is to considerable mortality from all causes, plus the exhibition of a special disease, beri-beri; (2) that no effort has been made by modifying the structure of the buildings to place the inmates in a correct position to resist the influence of this special disease ; (3) that, granting this disease is endemic, and that persons placed under good hygienic condi- tions more especially as to suitability of food (as clearly proved of late in connection with the Japanese navy) can successfully resist beri-beri intoxication, it may well happen that a general lowering of the health, of those exposed to its influence may occur, although not proceeding so far as to declare itself in the form of typical beri-beri ; (4) that in addition to incorrect buildings under the special circumstances stated, errors have occurred in impor- tant matters in connection with the preparation of grain, and the issue of flour, and of vegetable diet, and control of water purity, which factors acting upon a population, the health of the more susceptible members of which has been lowered, have readi- ly combined to increase the general sick rate, and diseases referable to the intestinal tracts. My recommendations amount to revision of building, water-supply arrangements, and details as to food. In addition, the Medical Officer should be required to carefully separate those suffering from grades of anaemia, spongy gums and dyspepsia (as shown by great flatulence), and where work is possible?a certain amount being desirable?its nature should be defined by him." I further drew atteution to the fact that

"

although the cubic space is duly marked, it seems to me likely height has been too much trusted to, and that the fact that space should not be regarded as

" available" above 13 to 14 feet has been ignored." [After the excessive mortality of 1898, it was found that the jail destined for 1041 had really air space for 880?a factor of importance in reference to beri-beri.]

It ought to be evident from the above that neither in my ordinary reports nor in the conjoint report did I hold beri-beri was the sole, or even chief cause of the death-rate, but that I

regarded its existence as a special danger in the midst of insani- tary conditions, and that I held the correction of these conditions was the first step towards placing the population under normal conditions of resistance to ordinary diseases. My warnings on this point of 1894, 1896, 1897, 1898, were well justified by the fearful mortality and sickness which occurred in 1898, on the accession of a weakly famine population subjected to unfavourable conditions of exposure in a wet camp, overcrowding, and unusual

prevalence of malarial fever. You state it was suggested in the conjoint report that the

introduction of this infection [beri-beri] '' was owing to the trans- fer of a batch of Burman convicts to the Eajahmundry Jail in that

year." This is again incorrect. It was a particular point of my argument that beri-beri had existed in the jail before the arrival of these men (in 1887, not as suggested by you in 1896-97), and I ascribed to them the role only of concentration of the virus. The actual words used are,

" But the medical returns show that one case of beri-beri was admitted in 1887, previous to the arrival of the Burman convicts. Further, it would be observed that the statement given above shows admissions to the extent of 3*3 per mille in the year 1882 for this disease." I would add that from 1887 to 1896, beri-beri found an important place in the Jail Returns under successive Medical Officers. I am not alone in thinking concentration of beri-beri implies risk. Manson states " The lia- bility to introduction of the beri-beri germ is proportionate to the number of people coming into it, and to the number of different centres from which new comers are derived." Indeed, I may state that, in my opinion, the disaster which occurred to the Rajahmundry Jail population in 1898 was indirectly due to cessation of the custom, which had obtained up to the first quarter of 1896, of instantly transferring cases of beri-beri from the endemic area to Yellore ; subsequent to that date, this sensible precaution was not carried out at all, or was effected in the hesitating manner due to disbelief in their nature. In drawing attention to this subject, we stated in the conjoint report, "Thus the most striking beneficial results, subsequent to 1887, were obtained in 1893, when the Inspector-General of Prisons grasping the importance of the step directed he should be informed of such cases, and that arrangements for their removal should be made by telegram." I must ask it to be remembered that the Burman convicts were no mere passive bearers of the hypothetical germ of beri-beri ; of the batch of 21 men, 13 died of this disease.

Again, you inform your readers, "the symptoms upon which the Sanitary Commissioner appears to have based his opinion were the occurrence of anaemia and dropsy, complaints of numbness, and a few eases of heart symptoms." I think I have a special right to complain of this statement on your part. I have never based my diagnosis of beri-beri upon

" anaemia and dropsy," as I shall presently show you. The only way I can account for your ascribing this opinion to me is that Captain Fearnsicle in his pamphlet states, "the usual symptoms of beri-beri" described in this jail had been as follows:?"anaemia, puffi- ness of the face, and oedema of the feet, difficulty of breathing and of oppression of tho chest, numbness and burning sensation

Jan. 1901.] THE BERI-BERI QUESTION IN N. CIRCARS. 37

(Neuritis) of the extremities." Now, although this statement is made within inverted commas, Captain Fearnside has neglected to state what authority he is quoting. Indeed, upon this text devoid of authority he founds his whole discussion, and completes his pamphelet by quoting three typical cases. Two of these he declares " would have been considered in former years typical of beri-beri," and the other he states specifically " was considered one of beri-beri" during the epidemic of 1898?had it not been for the interposition of his "high power microscope." Now, I have to state that I have nowhere given the opinion that

" anajmia and dropsy" are symptoms that betoken beri-beri. On the opposite, I cling to the insufficiently supported opinion that in this disease so far as the conjunctiva is a gauge of this condition? there is, in the absence of secondary disease, nt only no anaemia but the conjunctiva in many acute cases is peculiarly brilliantly tinted?a condition that I think is possibly connected with the disturbance of the vasomotor system, which seems to me to accompany this disease. As to the three typical cases reported by Capt Fearnside, I have to state that a list of cases suspected of beri-beri by myself and the Surgeon-General was kept by me, and that the numbers of these men do not occur, and that I have 110

reason to believe that either of us was so ignorant of malarial cachexia as to have failed to recognize the nature (if these selected cases. A perusal of the following extract from one

of

my reports will show you that, on my inspection in 1898,1 carefully

differentiated, in the presence of the Inspector-General of Prisons and Capt. Fearnside, cases of oedema that the latter could account for by appealing to amemia and consequent nedema, and that

not

onljr did I not ignore the existence of malaria and its evil effects

on the population, which is his prime contention, but that I was

the first to impress upon Capt. Fearnside, in the midst of

his hesitation between what he claimed to be the result of a

malarial germ of infective qualities and relapsing fever for which

he strongly contended?the simple fact that he had to deal with

malarial fever acting upon a population already subjected to

beri-beri intoxication:? "'In the camp, a considerable portion of the men presented

puffy faces and oedematous extremeties to a more marked extent

than seen on any previous inspection. * * *

Tho first indication in this enquiry was to ascertain whether

the fever now complained of was causative of mortality in the

present time, or whether it had brought about the mortality in

the past months. So far as could be gathered, under the un-

favourable circumstances described above, the fever was not

otherwise than of mild and ephemeral type, and was not directly connected with the mortality ; it was also of recent occurrence, and was, therefore, not connected with the past mortality.

The

next question to decide was whether the fever had indirectly affected the gravity of prevailing diseases and mortality. Thus, it might well be that the fever had increased the number present- ing puffy faces and oedematous feet. Enquiries, however,

elicited

no defiue relation between the two events. A few declared the

oedema had occurred subsequent to the fever ; others that it had

appeared gradually without fever. It, therefore, seemed that,

whilst the oedema might follow an attack of fever, it was not

essential it should precede it. As to the exact nature of the

fever, whilst explicitly not committing himself to a definite

opinion, the Medical Superintendent [Capt. Fearnside] suggested thit "relapsing fever" was present, and, indeed,

had so far

convinced himself on this point as to state, in the hospital records, that in a case of pneumonia,

" the symptoms may be only due

to spirilla present in the lungs." It was, of course, desirablo to

determine whether malaria or relapsing fever was suffered from

that the blood should be examined microscopically, and for this

purpose, finding the Superintendent unwilling to place his private

instrument at my disposal, I asked him to forward specimens to

Madras ; this, however, he has neglected to do up to date. 1 he

clinical symptoms, however, are such as to negative relapsing fever definitely, and to demonstrate sufficiently obviously

fever

of a mild malarial type. Again, a very large number of examina-

tions of urine negative the connection between the presence of

oedema and kidney mischief ; indeed, tho persistent search for

albumin, with negative results, seems in some measure to accounf

for the absence of sufficient time on the part of medical_ subor- dinates for effecting detailed measures in respect to the

sick. A

further suggestion of the Superintendent was that a malarial

fever was dealt with that had been brought about by germs that

had undergone an increase of virulence sufficient to cause

infectiveness. Of this infectiveness, however, he was not in a,

position to produce evidence. This explanation is similar to^ that

advanced by Surgeon-Captain Rogers with reference to kala

azar." The infectiveness of this disease is still [189b] a under discussion by the medical profession, but to argue

at this

stage that the malarial germ (a protozoon) can acquire a direct

infectiveness is at least premature. That ankylostomiasis would

undoubtedly favour the existence of oedema was in a former

report conceded ; but such a result, if uncomplicated by any other disease, would oe looked for solely in cases presenting

a

high state of anaemia following the blood-sucking propensities of

tho parasite concerned. An examination of 59 cases failed to

establish a connection between aniemia and the oedema. Indeed, at

least two casos that wero selected as typical for discussion presented no anajmia whatever ; they were physically well deve- loped men, and did not suffer from any disease of the heart. In one of these oedema of the extremities was not bilateral, thus pointing decidedly to deranged nervous control and not^to a blood condition; slight oedema over the tibia was also evident in men not obviously anasmic. In one case the patellar reflex on both sides and, in another, on one side was found impaired ; in others, certain of the reflexes was exaggerated. Every

_

effort was made to prevent the prisoners understanding the subjective symptoms of beri-beri ; yet the feeling of precordial tightness, of burnings in the hands and feet, twitchings of the muscles, and palpitation of the heart were complained of in various instances. In this connection, it must be remembered that twenty-eight cases which were regarded as most resembling beri-beri had, previous to my inspection, been transferred to Vellore by the Superintendent. In reference to the admitted existence of ankylostomiasis, it

was found that the Superintendent had, as a matter of routine, exhibited both santonine and thymol for several months. Ho declared the latter had not been given as systematically as he could havo wished, as the bazaar supply did not equal his demand. Still, he admitted th it a very largo portion of the prisoners had been treated, as a routine measure, since he had taken charge in 1897. Ho was, however, not in a position to show that this measure had either diminished the number of cases suffering from puffiness of the face and oedema of the feet, or had produced an improvement in the general health of the population. On the other hand, the statistics given in paragraph 2 show that, whilst up to July some care as to beri-beri had been exercised, subsequently no special selection had been undertaken for this disease. Although not neces- sarily post hoc propter hoc mortality and sickness set in, a circum- stance that coincides generally with the history of this jail (vide paragraph 16 of the joint report alluded to in paragraph 2 of this letter). Under tho above circumstances, I sec no x*eason to modify the

opinions, and advice founded thereon given in the. report by the Surgeon-General and myself. This opinion was to tho effect that beri-beri was endemic in the jail, and that a condition of " intoxi- cation " from this disease coupled with weakening influence of ankylostomiasis predisposed the inmates to less effectual resistance to the inroads of other diseases [from which in the then present or past history of sickness, there was not the slightest wish to exclude tho important factor of malaria], and to results of un- satisfactory hygienic conditions than would be the case with the population under normal circumstances, and that it was essential that by hygienic measures calculated to decrease the chances of beri-beri maintaining a hold in the building he adopted, and that side by side with these means he enforced against the spread of ankylostomiasis. In this case, the predisposition of the jail popu- lation was doubtless favoured by tho admission of a large number from tho hills in a weakly condition, during tho prevalence of famine. In this condition prisoners would more readily be open to infection, and thus more foci of beri-beri would exist within an area favourable to the persistence of the still dubious microbe produc- ing it. There is, however, no evidence to show that the presence of those famine-stricken persons had infected the jail with dysen- tery. As to the fever itself, it seems to bo merely a superadded factor to tho ordinary circumstance's, affecting the health of tho jail population. This disease was, so far as could be judged by depending on the incomplete data at disposal, of a mild malarial type, and acted detrimentally in precipitating the puffiness of tho face and oedema of the legs to which " beri-beri intoxication " had predisposed the prisoners."* You then refer to the question of cardiac enlargement. Captain

Fearnside, in his tables, distributes these cases under the diseases from which they died other than beri-beri. This method to be of any value would presuppose that a patient having beri-beri was bound to die with that disease and no other. A tendency to this opinion is exhibited in his statement that a " convict suffering from phthisis during his life which is confirmed by post-mortem cannot possibly have died of beri-beri"?an opinion in marked contrast to that held by Manson who, after quoting cases to the point, puts the query,

" Does phthisis render the subject of it specially sensitive to the beri-beri poison" ? At the best, his tables can only be received as a rough statement of facts ; but he has really made his comparison of little value, by accepting too high a standard of weight for -the normal heart of South Indian natives. It is true Surgeon-General Sibthorpe has given the weight as7'8 ounces but, in the General Hospital, Madras, 7 ounces is accepted as the standard. In the large-framed Chinese, Bentley gives the range of beri-beri hearts (where the organs happened to be affected in his cases) as from 8 to 13 ounces. Taking then 8 ounces as the point at which departure from the normal may be accepted, Captain Fearnside's table IX would yield not 25 enlarged hearts, as exhibited by him, but 65. I would add that Captain Fearnside omitted to include in his table a case having a heart

* The clinical history of beri-beri shows that it is occasionally ushered in by mild fever, but it is no essential part of what is a non-febrile disease.

38 TEtE INDIAN MEDICAL GAZETTE. [Jan. 1901.

weighing 17 ounces. This case was transferred by bim in 1897 to Vellore because, as stated by him, " the case is suspected to bo beri-beri." By way of showing that the beri-beri of the Northern Gircars is quite capable of securing typical cardiac enlargement, T would inform you that not only does Malcoaison describe it, but that Surgeon Everzard in 1866 reported cases in the Masulipatam Jail?which was in this area with hearts of 12^, 15 ounces, 1*2 ounces, (a youth of thirteen years) and lii^ ounces ; but neither authority had the temerity to suggest that cardiac enlargement is a necessary occurrence in beri-beri.

In your article, you then proceed to state " moreover the total

absence of paraplegia, loss of reflexes, &c., in the recorded cases are more than strange, if the disease is beri-beri." I send you photographs of two cases of paraplegia which were transferred from the Ilajahmundry Jail to Vellore Unfortunately, Gantain Fearnside forgot to send

" transfer notes" with these cases. According to Bentley, the method of progression of one of these cases is characteristic. Moth cases developed their paraplegia after transfer. They had been three years in jail, where they could certainly not have poisoned themselves with alcohol. In the total period previous to transfer, one of the cases had admission for malarial fever for four days and anchylostomiasis twelve days ; the other suffered from bronchitis, and no malarial fever ; neither suffered from syphilis. There can be no reason for Captain Fearnside transferring these cases to Vellore, unless (whether he agreed with the diagnosis or not) such cases were likely for "official reasons" (!) to be classed as beri-beri. it is absolutely erroneous to affirm that there were no cases of disturbance of reflexes; there were instances both of their exaggeration and absence, which apparently paradox condition was received, during my inspection of the jail, with polite incredulity as to its value, by the then lay Inspector-General of Prisons. But, although Captain Fearnside had originally conceded that at least one case was " typical of beri-beri," and that a " truly neurotic gait" was present, since the exciting discovery by him that men in his Jail suffering from ague harbour the plasmo tium malarias, he has chosen to inform me that this "

truly neurotic gait" was due to malarial neuritis. Indeed, I may say that either as

" alcoholic neuritis" or " malarial neuritis," Captain Fearnside has, to his own satisfaction, explained away all disturbances of reflexes. I may add, lest I be reminded of the fact by him, that he managed during our examination of cases (for I made a point of placing nothing on record unless he agreed with my results) in one of the instances to elicit a diminished patellar reflex, in which I had failed to produce any after repeated examination. In connection with neurotic symp- toms generally, and the sudden access of dyspnoea which occur in such cases, I would quote the following replies given by Lieutenant-Colonel Lancaster in charge Vellore Jail (where most of the beri-beri cases were transferred), to queries given by Captain Fearnside as to behaviour of the cases subsequent to their arrival at Vellore :?

Captain Fearnside's Queries. 1. How many showed ataxic gait of beri-beri on arrival, and

when did it disappear ? 2. How many do you consider had oedema of the lower extre-

mities ? 3. In the extreme dropsical cases, how long did the albu-

minuria continue ? 4. Do you consider that the

" temer " some complained of

of might not be due to passive oedema. 5. Do you think that any stiffness in the gait might bo due

to the same cause and effusion in the ankle joint ? 6. How many have shown the state described by the Japanese

as " Shiyashin" which is a paroxysmal attack of violent

dyspnoea, palpitation and vomiting. 7. Did any of the fatal cases show this state before death ? 8 Under what headings were those sent returned in the

monthly returns, and were any of these diseases subsequently changed, and, if so, how many, and to what disease ?

9. In this jail I find that albuminuria is common in dysentery and is common in sequohc. Do you think any of the dropsy might be due to this cause ?

10. Do you think that syphilis, malaria, alcoholism, liver and kidney cirrhosis, dysentery, toxamia (ganja and opium), anchylostoma, singly or combined, explain to some extent the neuritis and dropsy and anaemic symptoms.

Lieutenant-Colonel Lancaster's Replies. 1. Two showed the ataxic gait. In one it continued till

death and in the other it disappeared under treatment for two months. [These two, with the ataxic gaits, do not include the cases of paraplegia mentioned above.]

2. Fifteen had oedema of the lower limbs. 8. Only two had general anasarca, and in these there teas a

trace of albumen until death. 4. Very few complained of "temer" [numbness] to any

appreciable extent, and in these it could not have been due to "the stretching of the skin or pressure on nerve endings, as there was little cedema to speak of.

5. The stiffness in the gait cannot be attributed to the same cause for the same reason, nor to effusion in the ankle joint as there was nono.

6. Two had paroxysmal attacks of dyspnoea and palpitation unaccompanied by vomiting, and in only one case was this pretty well marked.

7. '

No. 8. No change was made in diagnosis. [Lieutenant-Colonel

Lancaster was under the impression, owin?; to correspondence with Captain Fearnside, that his right to alter diagnosis of cases transferred to him was open to question.]

9. In no case of typical dysentery was albuminuria found, but in anchylostomiasis with intense anaemia there was albu- men in urine (cyclical albuminuria).

10. Yes, I consider that malaria, liver and kidney cirrhosis, dysentery and privation, ane'aylostomia, both singly or combined, explain to some extent the neuritis, dropsy and anaemic symptoms ! [To these extensive articles of faith the fact of Lieutenant-Colonel Lancaster politely subscribing in the faltering terms "to some extent," by no means implies that he did not consider that in the transfers from Rajahmundry he had not beri-beri cases to deal with. Doubtless, all were not beri-be i cases ; but in reply to a question from the Surgeon- General, he has definitely stated that he had no doubt the "majority of the cases" received from Rajahmundri were genuine beri-beri.]

In regard to your more recent editorial paragraph, you intro- duce the subject as follows:?"He [Capt. Fearnside] had shown to our satisfaction that the disease hitherto considered to be beri-beri* wa? no other than a cachectic condition due to malaria and the

ravages of the anchylostoma parasite." You then proceed to state that I held Captain Fearnside contended beri-beri was due to malaria. You are not justified in making such a statement. The statement made by me was that Captain Fearnside, i.m.s., "in a pamphlet which was communicated to a professional journal and the Government of India [had held] that the symptoms usually recognized in this Presidency as beri-beri f are due to a malignant infective form of the Plasmodium malaria."

" I feel absolutely convinced, after examining microscopically the blood of a large number of cases, that the disease known as beri-beri in the Madras

Presidency is not due to the presence of the plasmodinm malaria." The only way you could possibly arrive at the conclusion you have is from the following sentence ; after pointing out that lieri-beri and malarial cachexia may co-exist, and if so it was a bad look-out for the patient, I state,

" this is a very different matter to malaria being regarded as the fons et origo of the disease." It ought not to require me to point out after the distinct references to

" the disease known as beri-beri in the Madras

Presidency" and to "the symptoms usually recognized in this Presidency as beri-beri," that the word

" disease " with which the paragraph ends distinctly relates to those expressions. Your own opening statement, as italicized by me, actually corresponds with my definition. Although you had my report before you, showing that my microscopical investigation amongst the free population extended to Amalapuram, Rajahmundry, Masulipatam and Vizianagram, which are widely scattered areas, you elect to make it understood that these were confined to

" the neighbour- hood of Rajahmundry

" You then proceed to express doubt whether beri beri does exist in the Northern Circars, and you give a distinct statement of the facts which guide you to this conclusion ; firstly, that Captain Fearnside had shown that malaria existed in the Rajahmundry jail; and, secondly, that he had read a paper showing anchylostoma existed. How you could reconcile

yourself to come to such a conclusion on these facts, to use your own words, I am "at a loss to understand." You might just as well have informed your readers that Captain Fearnside had certified to the existence of typhoid fever in the jail, and had read a paper proving that measles existed amongst the population, and that, therefore, beri-beri did not exist in the Northern Circars. As to your warning to the members of the profession in this Presidency not to diagnose beri-beri by paying attention to cedenm or ancemia, but by studying; the condition of the heart and peripheral nerves, with all diffidence to your editorial chair, I would state that such elementary lessons in diagnosis are not required in a Presidency where, from experi- ence gained in the Circars, Malcomson in 1835 was the first to point to the nature of the disease in respect to the nervous

system, and held clear conceptions as to the condition of the heart. It is undesirable that you should think

" Cimmerian

darkness," so far as ankylostomiasis is concerned, shrouded the diseases of prisoners until Captain Fearnside gave us light. The existence of ankylostomiasis in the Rajahmundry Jail was reported by Assistant-Surgeon Hadden in 1887?three years before Captain Fearnside entered the service ; although, be it said to Captain Fearnside's credit, that its importance was specially insisted upon by him. In return for your hints on diagnosis, which, in my humble opinion, contain the very great and very common error of regarding beri-beri as following a rigid

* Italics not in original. | Italics not in original.

Jan. 1901.1 SERVICE NOTES.

typo, allow me to refer you to the following remarks of Dr. Manson. The italics are mine :? " Sometimes wo may see a case which is completely paralysed

so far as legs and arms are concerned, and perhaps wasted to a skeleton ; and yet this same patient may never have had a serious symptom referable to his heart, or in any way threatening his life.

*

* * * * He [the Medical Officer] will learn that this disease which is beri-beri, commences slowly or suddenly ; that it may be preceded by a period of intermitting languor, aching legs, slowly advancing oedema of legs or face ; or that the patient may wake up some morning and find that during the night he has become dropsical or paretic. Thus, the disease may develop slowly or rapidly. Equally uncertain is its progress and danger; within a day or a week, or at any time during its course, it may assume fulminating malignant characters. It may completely subside in a few days or it may drag on for months. It may get well apparently, and then relapse. It may, and generally does, clear up completely : or it may leave a dilated heart, or atrophied limb muscles with corresponding deformity. The variety in the severity, progress and duration of beri-beri is infinite ; hut in all cases the essential symptoms are the same?greater ?r less cedeina, especially over the shins ; muscular feebleness and hyperaathesia, especially of the legs ; liability to palpitation from cardiac dilation, and to sudden death from the same cause." **#**?

" In all cases death is, so to speak, rather a matter of accident than necessity ; it depends partly, of course, on the intensity of the poisoning, but more on the particular set of nerves picked out by the poison.

* * * The mortality is very difficult to estimate. If we include the minor forms of beri beri intoxi- ration?what we might designate beri-beri ambulans?such as slight degrees of leg paresis, pr(tibial anesthesia and (edema, in our estimate, then the mortality is proportionately smaller than if ice estimate it only on such cases as lay up, or exhibit serious signs of heart and other thoracic complications." Of recent instances in which in certain epidemics the virus

seems to " pick out" special parts of the system. I cannot do better than refer you to the details of an epidemic which occurred in 1899 amongst the sepoys of IX Regiment, M. I., which was investigated by Major Moore, Captain Giffard and myself. This was at Vizianagaram, within the Northern Circars. Whether you believe in the existence of the disease or not in that area, it may interest you to know that within 8 or 10 days after spend- ing many hours for three days in succession in the hospital where these men were, I was attacked with a low form of fever which was followed by painful contraction of muscles of the calf, numbness and oedema, of one leg, which condition corre- sponded precisely with that found in mild cases amongst the sepoys, and that the symptoms in this epidemic extended from this mild form to that of spastic paraplegia attended with most painful dyspnoea.

W. G. KING, Lieut.-Col., I. M. S.

Madras, 2?th November, 1900. j

[We gladly publish Lieutenant-Colonel King's paper, as it throws mucu hght upon an interesting and difficult question Considerations of space prevent us at present discussing this question in detail. Our main point was that the co-existence of malaria and ankylostomiasis strongly suggested that these cases might (as in Assam and Ceylon) have been wrongly regarded as beri beri. Much turns upon the exis- tence of neuritie symptoms, these Captain Fearnside's pamphlet showed were absent, or what was interpreted as such were present in other cases certainly not beri-beri (see resume in Report of San. Commsr., Government of India for 189S, p. 131 (foot of page). We shall return to the subject.?Ed., 1. M. G.]