THE PRACTITIONER.

JANUARY, 1877.

Original Communications.

BERIBERI.

BY SIR J. FAYRER, K.C.S.I., M.D.

Honorary Physician to H.M. the Queen, Physician to H. R.H. the Prince of Wales and H. R. H. the Duke of Edinburgh.

BERIBERI (the bad sickness of Ceylon); the sleeping sickness of the west coast (Horton); Progressive pernicious anæmia (Biermer); Beriberia, Barbier (Bontius); Timmery Waivoo (Teloogoo); Wawayah (Telingee); Soojh Báee (Hindee); Soondke Báee (Deccan); Soon-Bhayree (Bengal, NorthWest Provinces.)

DEFINITION. Anæmia, resulting in anasarca, and general dropsy of all the cavities and tissues; and degeneration of muscular tissue. Debility, oedematous swelling of limbs, trunk, and face, numbness, pain, and paralysis of extremities, especially the lower. Precordial anxiety, pain, and dyspnoea. Scanty and high-coloured urine. In some cases drowsiness or sleep. Occurs in a chronic and acute form, in the latter it often proves rapidly fatal from exhaustion, syncope, or cardiac or pulmonary coagula. GEOGRAPHICAL DISTRIBUTION.-It prevails endemically in Ceylon; in India, on the Malabar Coast, and in the Northern Circars, between 13° and 20° N. latitude, extending inland from forty to sixty miles. It is known in other parts of India, as in the Deccan, Central India, Bengal, and probably, occasionally, all

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over the peninsula. In Burmah and the Malayan peninsula. In the crews of ships trading to ports in the Persian Gulf, Red Sea, coast of Africa, Bay of Bengal, Singapore, Siam, and the islands of the Indian Archipelago (Carter, Morehead, and others). In the Australian seas (Morehead). On the west coast and other parts of Africa, where it is known as the sleeping sickness (Horton and others). In Europe, as pernicious anæmia (Biermer). And probably wherever the conditions of food, water, soil, climate, and mode of life that originate it in the above-named sites exist.

Etymology of beriberi is obscure. The name is unknown to natives of India as that of a disease. Herklotts says it is unaccountable how it has crept into such general use. He suggests the Hindi word, Bhéree-a sheep-from the fancied resemblance of the gait of persons affected to that of the sheep.

Soond-bhéree, from the words numbness and sheep; the latter reference as above.

Soond-ke-baiee, from numbness and rheumatism.

Bhér-bheri, a Hindi word, signifying a sore, swelling.

Dr. Mason Good says that Bontius introduced the word Beriberia, and tells us it is of oriental origin-thus: Birabirtillage, and its produce, sheep (hence brebis, French); from the resemblance of the patient's movements to those of an overdriven sheep.

Carter suggests Bhari, sailor, from Bahr, the sea; and Bhayr, shortness of breath. As it is seen among African and Arab sailors, this is probable.

Some writers think it is derived from a Cingalese word meaning weakness; the reiteration implying intense weakness; and that it was first applied to a variety of conditions, the result of scorbutic, malarious, rheumatic, and anæmic cachexiæ, on the Malabar Coast.

Dr. Paul, of Madras, believes it is from a Tamul word having reference to the gait of those affected.

ETIOLOGY.-According to Malcolmson and others the disease is very prevalent among the natives of the Northern Circars, especially in the jails of Masulipatam, Raja Mundry, Vizagapatam, Chicacole, Cuddapah, Bellary.

The death-rate from it in these jails reached to 36.5 per cent. ; among Sepoys, 13.9 per cent; among Europeans, 26.2 per cent.; thus indicating that the unfavourable conditions of prison life intensified the mortality. Mohammedans suffer more than Hindus. Mortality is higher in Europeans than in the ordinary native population.

In the same locality it prevails most towards the close of the rainy season. There were 291 admissions between July and October; 195 between November and February; and eighty-six between March and June. The above facts show the influence

of wet and cold in developing the disease.

All observation tends to show that the disease occurs where causes of debility have for some time operated, and especially in the climates and localities previously mentioned; certain conditions of soil, air, and water, exposure to great alternations of temperature, especially when accompanied by wet, fatigue, depression mental and physical, food deficient in quantity and quality or variety, previous exhausting diseases, malaria, and other undefined atmospheric and telluric influences, all, in fact, that tends to depress the vital energies, impoverish the blood, and starve the nerve centres. The symptoms, it is said, seldom begin to appear within ten months or a year after first exposure to the causes.

Its prevalence in certain districts points to causes intensified in those localities; its occurrence in other intertropical countries, at sea, and, as would seem from Biermer's observations, in more northern climates, all suggest that it is to be classed among general rather than specific diseases.

It has been ascribed by Ranking to disease of the kidney, but there is no evidence to prove that it is due to this cause, or indeed to structural changes of any of the viscera. Morehead refers it rather to a scorbutic origin, and in some respects it resembles scurvy; it may probably, also, be a result of the cachexia that so often results from long residence in a malarious climate, especially when that has been accompanied by exposure, privation, and excessive exhaustion of the vital powers. In such, the most complete anæmia, with debility, may occur, independently of the existence of organic visceral disease, though naturally they will be intensified where that is present.

It seems probable that further investigation will prove that beriberi is due rather to impaired nutrition than to specific disease.

PATHOLOGY.-The phenomena characterising this disease are those of anæmia and general dropsy.

Edema of the limbs and body generally, with numbness, pain, heaviness, and loss of power, amounting in some cases to paralysis.

Precordial anxiety, dyspnoea, irregularity, palpitation of heart, pain at ensiform cartilage, anæmic murmurs, debility, small quick pulse, which at the outset may be rather hard and full, accompanied by dryness and heat of skin. Appetite at first not impaired, later there is coldness of extremities and torpor of bowels; scanty high-coloured urine, sp. gr. 10-20 to 10:40. Albuminuria not, as a rule, present. According to Horton and others excessive drowsiness and stupor attend some stages of certain cases of the disease,-pale, flabby tongue and blanched mucous membrane, occasionally hæmorrhage from stomach and bowels, with petechial eruption, anxious look, puffy, swollen, and sometimes livid face, a peculiar tottering gait.

Death results rapidly in some of the acute cases, with symptoms of effusion into the thoracic and abdominal cavities, or into the brain; by exhaustion, syncope, or the formation of coagula, either in the systemic or pulmonic circulation. The disease seems to be rarely noticed in the sanitary reports from India of the last ten years.

The Army and Medical Blue Book of 1871 mentions fifteen cases having occurred among native troops in Ceylon, and seventy cases in the Ceylon Rifles in Labuan (Borneo). No European deaths, however, are recorded in the above period.

The inference is that the disease, when it has occurred, has been referred to other headings, such as anæmia, dropsy, &c.

The recent discovery by Mr. T. Lewis in India, of the embryo of a nematode worm in the blood of persons suffering from chyluria, lymphorrhoea, and elephantiasis, of which diseases it appears to be to some extent the cause, suggests inquiry whether it may not also be in some way concerned in inducing beriberi. Fonsagrives and Leroy de Mericourt, describe it as general dropsy with a rapid course, no albuminuria, weakness and loss

of sensibility in lower limbs. Dropsy commences as anasarca, and extends to the serous cavities.

Heyman says it is a combination of acute rheumatism and intermittent fever. There are irregular febrile paroxysms, great debility, paretic and hyperæsthetic phenomena; sometimes bilious diarrhoea and vomiting; swelling of the ankle, knee, and hand articulations; seldom oedema and ascites; occasionally delirium and continued fever; the only constant alteration seen in post-mortem examinations, being a thin fluid dark state of the blood.

Oudenhoven says it occurs in three forms, the three often being blended.

The marastic, which is chronic, but tends to a fatal termination, complete paralysis ensuing; sensorium remaining active, and functions of internal organs continuing to be performed: the patient at last becomes apathetic and dies comatose.

The hydropic has a speedier course, but gives more hope of recovery; dropsy of areolar tissue and cavities sometimes rapidly fatal from effusion into pleura and pericardium.

Anæsthesia and paralysis less marked.

The polysarcous-sometimes slow, sometimes rapid in its fatality. Heart often notably enlarged. Death often occurs suddenly and unexpectedly. No post-mortem appearances explain the disease. Nothing has been found in the nerve centres to explain the paralysis. Heart generally fatty. Liver, as a rule, enlarged and hyperæmic. Kidneys normal.

MORBID ANATOMY.-Serous fluid effused everywhere, in the areolar tissue, in the lungs, brain, heart, and abdominal viscera. The cavities are, like the tissues, soaked with watery effusion. Tissues soft and degenerate. Muscular fibre fatty and feeble, especially the heart, which is often enlarged and dilated.

The kidneys, enlarged, anæmic, and softened. But though hepatic, splenic or renal complications may exist and intensify the severity and hasten the progress of the general symptoms, they are not essential concomitants of the disease, but appear to originate in a spanæmic state of the blood, and to be kept up by its progressive imperfect elaboration. The resulting partial starvation of the cerebro-spinal nerve centres, and the nervous effusion into and amongst them, sufficiently