NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
40
this outbreak is clearly shown, and in this relation the table from Schaumann's
monograph given on page 46 showing the phosphorus content of fresh and
preserved meat should be studied as it affords an explanation of the ameliora
-tion of the symptoms as noted by the P. M. O.
The following interesting report regarding an outbreak of Beriberi
which occurred on the S. S. "Clan Urquhart" was submitted by Dr. N. N.
Chowdhury, Port Health Officer, Chittagong, and forwarded to me.
He reports, "that the S. S. 'Clan Urquhart' arrived at this port from
the United Kingdom on 17th September 1910; there had been an outbreak
amongst the Indian crew during the voyage. This particular voyage con
-sisted of nearly 4½ months in all and commenced from Colombo on the 30th
April 1910, from where the crew were recruited and terminated at Chittagong.
on the 17th September 1910.
In all she had 68 Indian crew:—
Deck crew
.
.
.
.
.
.
.
.
. 26
Saloon crew..
•
.
.
•
.
.
.
8
Engine room crew
.
.
.
.
.
.
.
.
34
During her voyage from Colombo she touched the following ports noted
below till it reached Glasgow on 21st June 1910:—
From Colombo to
—
1. Suez.
2. Port Said.
3. Algiers.
4. Havre.
5. Glasgow.
Arrival 21st June 1910.
Departure 2nd July 1910.
The first manifestation of the outbreak was noticed by the master of the
ship at Glasgow where two cases occurred, just 52 days after her voyage from
Colombo. The chief complaints were swelling of the legs, inability to stand
on legs, and their tenderness, difficulty of breathing and palpitation, and in
one case the initial symptom was vomiting.
This number increased up to 24 on her way to Durban. She touched the
following places noted below till she reached Chittagong:—
From Glasgow t
o—
1. Birkenhead.
2. Durban.
3. Lorenzo Marques.
4. Biera.
5. Chittagong.
41
During the period 6 died and three were left at Durban Hospital and the
rest improved their health on their way to this port."
Dr. Chowdhury also gives a table, given below, which shows the distribu
- t i o n o f t h e d i s e a s e a m o n g s t t h e c r e w a n d h e d i r e c t s a t t e n t i o n t o t h e f a c t t h a t
the engine room crew were most affected:—
Total number of
crew.
Affected with
Beriberi.
Death.
Engine room crew
.
.
.
.
34
17
5
Deck crew
.
.
.
.
.
26
7
1
Saloon
.
.
.
.
,
,
8
0
0
Dr. Chowdhury forwarded to me at Calcutta a sample of the rice used by
the crew. It was Burma rice, ordinarily known as Rangoon rice, and was
very highly polished. There was not sufficient rice for an animal experiment,
but the chemical and histological examination of the rice showed that the
pericarp had been very completely removed and that the phosphorus content
was low.
The following table shows the result of the chemical analysis of the rice
used by the crew of the "Clan Urquhart"
Weight of 100 grains in grammes.
Water.
Ash.
P2
O
5
Per cent.
Per cent.
Per cent.
2.04
13.13
53
0.26
The following particulars regarding the diet of the crew during the
voyage were supplied to me by the Health Officer, Chittagong
:—
Daily scale of provisions for lascars and other native seamen.
(a) For foreign going ships.
Lb.
Oz. Dram
Rice
.
.
.
.
.
,
.
,
.
1
6
0
Flour .
.
.
.
.
.
.
.
.
0
10
0
Dal
.
.
.
.
.
.
.
.
0
6
0
Ghee .
.
. . . . . ,
0
2
0
Salt
.
.
.
.
.
.
.
.
.
0
0
8
Curry stuff .
.
.
.
.
.
.
.
0
1
0
At sea. On five days of the week dry fish .
.
.
0
4
0
At sea. On two days of the week meat
.
.
.
0
4
0
In harbour fresh meat every day
.
.
.
.
0
4
0
42
Lb.
Oz. Dram.
Vegetables—
Dry at sea .
.
.
.
.
.
.
.
0
6
0
Fresh in harbour
0
6
0
Tamarind
.
.
.
.
. .
.
.
.
0
1
0
Tea
0
0
4
Sugar .
.
.
.
.
.
.
.
.
0
1
8
Lime juice
.
.
.
,
.
.
.
0
1
0
Oil
.
•
.
•
.
.
,
.
.
0
0
12
In bad weather when unable to cook 6½ ozs. biscuits and 2 ozs. sugar in addi
-tion to the quantity provided in the above scale may be substituted in the
place of dal and rice.
When a lascar is ill and off duty, biscuits, tea and sugar should be given
to him with arrowroot or sago as needed.
The daily allowance of lime juice shall be served out to the crew as soon
as they have been at sea for ten days and during the remainder of the voyage,
except during such time as they are in harbour and are supplied with fresh
provisions.
Change of diet made on the 25th July 1910.
8 A.M. Lime juice one tumbler three parts full to each man.
9 A.M. Curry and rice one plateful to each man. The "rice" consists of
7 parts of rice, 3 parts barley. The curry consists of fresh mutton, potatoes,
onions and green peas.
11 A.M. 20 drops tincture of steel in a wine-glassful of water to each
man.
1 P.M. Tea with sugar and milk, bread and butter to each man.
5-30 P.M. Curry and rice one plateful to each man. The "rice" consists
of 7 parts rice and 3 parts barley. The curry consists of tinned fish, beans,
potatoes and onions.
8 P.M. Milk with port wine or brandy.
These observations are of very considerable importance; as was pointed
out in my first report1 the features of Epidemic Dropsy as met with in Cal
-cutta closely resemble those of " Ship Beriberi." In the above outbreak, the
history of which is very clearly given in the report of the Health Officer,
Chittagong, we have an example of " Ship Beriberi." The " Clan Urquhart "
had an Indian crew of 68, whose staple food was highly polished Rangoon
rice with a low phosphorus content, and the vessel made a prolonged voyage
starting from Colombo on 30th April, 1910, she arrived at Glasgow on 21st
1 First Report on Epidemic Dropsy in Calcutta by Major E. D. W. Greig, M.D., D.Sc, I.M.S., MScientific Memoi
No. 45.
43
June 1910 and it was at the latter port that the master observed the first
manifestations of the disease. It is interesting to note, therefore, that the
early cases did not occur in a tropical port. Further, the period elapsing
between the commencement of the Rangoon or polished rice dietary and the
development of the first case was about two months, and this interval corre
-sponds closely to that required for the experimental production of neuritis in
pigeons and fowls fed on polished rices. As will be seen from the report a
change of diet was made on July 25th, 1910, additional articles were given and
the dietary became much less " One-sided ;" after the change no further cases
of the disease occurred.
Schaumann' in his important monograph on the etiology of Beriberi
states that in his opinion, "Ship Beriberi" is the pathological expression of
a rapidly brought about deficit through a great want of organic phosphorus
components, whilst tropical Beriberi is a gradually produced deficit occasion
-ed by a slight, and indeed, sometimes, without a failure of these substances."
And he concludes further, " 'Ship Beriberi' is a disease of metabolism, which
is produced by a poverty of organic phosphorus compounds in the dietary."
A consideration of these facts shows that this disease presents an im
-portant problem in connection with shipping. In the case of the " Clan
Urquhart " the outbreak was brought about by the consumption of very high
-ly polished rice which had been deprived of constituents essential for nutrition,
especially of the peripheral nerves. Consequently ships undertaking pro
-longed voyages should be careful to avoid the use of polished rice and increase
the supply of Mung dal. The question of adding rice bran to the diet should
be carefully considered.
Archi v. Schi ffs u. Tropenhygi ene, Bd. XIV, Bei heft, Dec. 8, 1910.
G . 2
44
CHAPTER IV.
Epidemic Dropsy and Scurvy.
In my former Report I discussed at some length the relationship of Scurvy
-to Epidemic Dropsy, and quoted the opinions of the old Indian observers on
the subject, namely, Chevers, Morehead, Waddell, etc. Since the report was
written Couvy, a French investigator, has recorded some interesting observa
-tions on this problem. Couvy 1 observed an epidemic of Scurvy and Beriberi
amongst the garrison of Akjoucht. The Garrison consisted of 11 Europeans
and 150 Natives.
PROGRESS OF EPIDEMIC.
Natives.
On 23rd May
4 cases amongst the 150
„ 4th June
20 „
„
, ,
„ 5th
„
44 „
„
, ,
„ 17th „
124 „
„
, ,
„ 20th July
142 „
„
,,
„ 15th August 144 „
„
the 149 (1 died).
The first 40 cases presented no difficulties in diagnosis as they had all the
symptoms of typical Beriberi. From 5th June onwards the question of the
occurrence of Scurvy presented itself, indeed towards the 20th June the
pathognomonic lesions of Scurvy were observed. From this date we saw the
evolution of the two diseases side by side, but more frequently superposed,
and, as a rule, the symptoms of Beriberi start suddenly threatening the life
of the patients already presenting the clinical signs of Scurvy.
Europeans.
8th June
4 cases.
15th July
6 ,,
21st „
9 ,,
15th August
11 ,,
The Europeans were attacked by Scurvy but have never presented signs
of Beriberi. This is an interesting point : amongst the better class European
population of Calcutta cases of Epidemic Dropsy were not observed. When
the diagnosis was established on 23rd May the patients were given biscuits in
place of rice. Without other treatment the symptoms improved and dis-
appeared in a few days. On the 20th June the biscuits being exhausted the
124 patients under treatment were placed again on rice; from the 22nd a re-
lapse occurred amongst 30 of the cases, one case of fainting for 12 hours with
1Bull , de la Soc. de Path. Exot. T. 111 No. 10, Seance, Dec. 14, 1910.
45
paralytic symptoms occurred. On the 23rd aggravation of symptoms showed
itself in 88 cases. This relapse occurred in men already quite convalescent.
On June 23rd millet intended for the horses of the post was distributed to the
worst cases. Improvement was noted on the 29th and 30th June. From 1st
July, after the millet was exhausted, it was necessary to give rice; since the
3rd 17 cases of aggravation of the condition with cardio-respiratory trouble
occurred. On the 6th the number of relapses reached 66, some days later 83.
Before these occurrences a ration of 350 grammes of meal flour was sub
-stituted for rice in the case of the more severely affected patients. The poor
state of the provisions never permitted of continuing the appropriate diet
until the cure was complete; when a patient improved and was no longer in
danger it was necessary to put him on a rice diet which was followed by a
fatal relapse. Finally on 23rd August a convoy arrived with millet and bis
-cuits; since then all the beriberi cases have been able to consume without inter
-ruption their ration of biscuit in place of rice. This absolute suppression of
rice has corresponded with a rapid amelioration without relapse, and on 15th
September all the symptoms of severe beriberi had disappeared in all the
cases.
They had 5 deaths on 9th, 17th, 22nd August, that is during the period
they failed to have suitable provisions. Two deaths occurred on 1st Septem-
ber from cardiac disorder, the symptoms commenced on 20th August.
Suppression of rice and substitution of biscuit had always a beneficial
and rapid effect on the cardiac disorders. This influence was so distinct that
it was possible to obtain an improvement even in the most severe cases by
stopping rice for 2 to 6 days. On the contrary the absorption of 1 to 2 kilo
- g r a m m e s o f r i c e i n 2 t o 4 d a y s s u f f i c e d i n t h e m a j o r i t y o f c a s e s t o p r o d u c e a
severe relapse.
This interesting paper brings out the point that there is a relationship
between Scurvy and Beriberi, and further, it demonstrates how the symptoms
may be modified by change of diet.
Monteith,1 whilst in North-West Australia during 1890-91 and 1892, as
Medical Officer to Messrs. Streeters, Pearling Fleet, observed an epidemic of
Beriberi with symptoms which pointed very strongly to a Scorbutic origin.
The disease affected chiefly the lugger boys shipped from Koepang, F. M. S.
The cooks, Chinamen generally, the West Australian aboriginals, and the
white men who lived aft in the schooners, seemed exempt from the disease
The disease manifested itself when the men had been many months at sea.
The prominent symptoms were:—The ankles and legs were greatly swollen
and œdematous, and pitted on pressure, especially over the tibiæ, and were
1
Lancet, Oct. 3, 1908.
46
painful, especially at night. A bronzing or pigmentation was visible in the
buccal mucous membrane and the gums were redish and spongy and in some
cases overgrown. In a case of fatal termination the symptoms would be
obstinate constipation and vomiting and dyspnœa. Then anasarca developed
and the abdomen became prominent. The face and eyes were puffy and in
this stage the pupils were contracted. Later, when the patient could scarcely
stand, the dyspnœa increased to such an extent as to cause almost continuous
moaning and groaning. Post mortem examination, showed the heart to be
dilated and fatty degeneration to a marked degree was present.
The provisions, which were taken aboard when the ship put into port for
unloading the pearl, consisted chiefly of rice and tinned meat. When the
dietary of the sick was altered and included fresh meat, bullocks or kangaroo
flesh, and fresh raw lime juice the majority soon showed signs of improvement
and were able to return to sea again. Dr. Monteith observed that those who
did not improve complained of a pain or subjective suffocative sensation re-
ferable to the epigastric or midsternal regions to which regions they pointed
with their finger. Dr. Monteith came to regard this as the finger of death for
it foreboded with absolute certainty death in a few days.
This outbreak is an example of "Ship Beriberi" and its well marked as
-sociation with scurvy is interesting.
Macrae1 i n a n a c c o u n t o f S c u r v y i n S o u t h A f r i c a s t a t e s , " S c u r v y i s
still met with in South Africa, notably in Johannesburg and its environments,
and different opinions have prevailed as to its real nature. Some have spoken
of it as associated with a form of Beriberi."
In relation to " Ship Beriberi " and Scurvy it is of interest to note the
Distribution of Phosphorus in fresh and salted meat.
The following table is from Schaumann's monograph2:—
FoodImaterial
dried at 100 C. (In the
dried substance).
__100 GRAM. OF FOOD MATERIAL CONTAIN
TOTAL P203.
Phos-
phatid
P2 O 5
Water
soluble
Ester
P2O5.
N u c l e i n
and
Proteid
P2O5.
- . - ---
WATER SOLUBLE
PHOSPHATES P205.
E Estimated
direct. Calculated.
In
gram. of
substance.
In
per cent.
of total
P2O5.
Gram.
Gram.
Gram. Gram. Gram.
1. Fresh fat free horse flesh .
1'995
2031
0.246
0.499
0.330
0.956
47.92
2. Fresh fat free beef ,
.
1'937
1946
0193
0168
0215
1.370
70.73
1
L a n c e t , J u n e 2 7 , 1 9 0 8 .
2 Archiv. Schiffs u. Tropenhygiene, Bd. XIV, Beiheft, Dec. 8, 1910.
47
F Food material
(dried at 100 C. (In the
dried substance).
100 GRAM. OF FOOD MATERIAL CONTAIN
TOTAL P2O5 .
Phos- ,,
Phatid
P2O5.
Water
soluble
Ester
P2O5.
Nuclein
and P r o t e i d
P2 O 5.
WATER SOLUBLE
PHOSPHATES P2O5.
Estimated
direct.
Calculated.
In
gram. of
substance.
In
p e r c e n t . o f t o t a l .
P 2 O 5 .
2v5.
Gram.
Gram.
Gram. Gram. Gram.
3. Salt meat (beef) fat free
from ship M. K.
.
.
0.241
0.219
0.053
0.048
0.094
0.024
9.96
4. Salt meat (beef) fat free
from ship L. P.
.
.
0.139
0.161
0.040
0.. 0 5 5
0..0 4 8
0.018
12.96
5. Salt meat (beef) fat free
from ship H. .
.
.
0.386
0.378
0.066
0 .079
0.160
0..073
22.12
6. Preserved meat (boiled beef)
fat free from ship C. H. .
1.179
1.063
0.214
0..1 9 8
0.124
0. 527
44.70
7. Dried fish from ship H. fat
free.
1.823
1.625
0.144
0.125
0.148
1.208
66.26
8. Fat free preparation of
Testicles.
3.550
3.477
0.382
1.. 0 5 0
0.. 9 7 7
1.068
30.08
Phosphorus in fresh vegetables.
Vageler,1 states that, " The fresh vegetables, which in spring and summer
are always available, and whose advantages are generally recognised, are es
-pecially rich in Phosphatides. One will not go far wrong if one ascribes in
great part the excellent physiological action of these substances to the alcohol
soluble phosphatideS." Schaumann agrees with this and adds, " The salad
is frequently considered to be a specially active vegetable, this is explained
not only by the high Phosphatide content, but also by the fact that it is eaten
raw, hence all loss and alteration of phosphorus containing substances by
cooking is avoided."
The above facts afford an explanation of the improvement of the symp
-toms in the cases of Epidemic Dropsy amongst the Europeans of the ships of
the Squadron in the Persian Gulf, page 40 of this Report. As noted by Staff
Surgeon Munday as soon as fresh fruit and meat were added to the dietary
cases of peripheral neuritis diminished and finally ceased.
These questions, therefore, should be carefully noted by authorities re
-sponsible for the maintenance of health on board ship.
1Biochem. Zeitschr. 1909 Bd. XVII, p. 189 (quoted by Schaumann).
48
Effect of Pickling on Phosphorus Content of Meat.
The observations of Nothwang' on the effects of pickling beef are of in
-terest.
The following table shows the loss of Proteid and Phosphoric acid which
results from pickling:—
Duration of Pickling.
PICKLED FLESH IN THE LAKE. PICKLED FLESH IN DRY BRINE.
Loss of
Proteid.
Loss of
P2O5
Loss of
Proteid.
Loss of
P2O5.
Per cent.
Per cent.
Per cent.
Per cent.
One week .
.
.
.
.
.
1.53
35.5
0.99
31.7
Two weeks .
.
.
.
.
.
1.86
4 4 . 9
1.43
27.0
Three.
.
.
.
.
2.08
48.5
1.32
31.2
Four
.
. .
.
.
2.14
50.1
1.23
32.8
Nothwang' compares also the loss from fresh meat by cooking with that
of pickling.
Loss by pickling.
Loss by cooking
and steaming
pickled flesh.
Total Loss.
Per cent.
Per cent.
Per cent.
Extractive (meat bases)
.
.
,
.
42.2 —47.3
20.6—23.4
65.6—67.9
P20„
.
.
.
.
.
.
.
20.2—25.4
19.1—19.3
39.5—44.8
1Archiv. f. Hygiene, 1892, B1 XVI, p. 269 (quoted by Schaumann).
49
CHAPTER V.
Experimental Investigations.
In my first Report a number of experiments with fowls and pigeons are
recorded. It was shown that progressive loss of weight and neuritis resulted
from feeding pigeons on polished Bengal and Rangoon rice, whereas when
fed on a mixture of wheat and pulses no neuritis developed and the animals
remained in perfect health. The observations were carried on over several
Months.
In the present Report the results of further experimental researches are
given.
In December 1810 Fraser and Stanton' published the results of their re
-cent investigations on the etiology of Beriberi in the F. M. S. Schaumann 2 in.
the same month published an important monograph on the etiology of Beriberi
including " Ship Beriberi " in which he gives the results of his chemical and
experimental investigations on this subject. As these results are very inter
esting and important a full summary of the two works is given here before
proceeding to describe the details of my further experimental investigations.
Fraser and Stanton during the past year have directed their attention to
-wards the determination of the nature of the substances present in the sub
-pericarpal layers of the original rice grain which are removed in the milling
process and which it would appear are of such high physiological importance
in maintaining the normal nutrition when a diet largely composed of white,
polished rice is consumed.
As in the previous experiments Fraser and Stanton employed fowls for
testing the value of the various materials. In the present investigation all the
products employed, unpolished rice, polished rice, polishings, etc., were de
-rived from the same lot of paddy.
The following table shows the results of their analyses:—
Protein.
Fats.
Carbohydrates.
Ash.
Per cent.
Moisture.
P2O5.
Per cent. Per cent.
Per cent.
Per cent. Per cent.
Polishings (sifted) .
.
•
13.7
14.16
52.77
7.54
11.83
4.1
Unpolished rice . . .
9.0
1.65
75.52
1.08
12.75
0.56
Polished rice •
•
•
.
8.6
0.22
76.23
0.6
14.35
0.26
1
L a n c e t , D e c . 1 7 , 1 9 1 0 .
2 Archly. Schiffs. u. Tropenhygiene, Bd. XIV, Beiheft, Dec. 8, 1910.
f t
50
They also give the following table which shows the composition of these
articles calculated on dried materials which renders differences more striking
and accurate, and also the composition of a diet composed of 60 gram. of
polished rice and 5 gram. of polishings calculated in the same manner and
shows how closely this diet approximates to one of polished rice:—
Calculated on Dried materials.
Protein.
Fats.
Carbohydrates.
Ash.
P2 O 5
Polishings (sifted)
,
.
.
Per cent.
15.5
Per cent.
16.0
Per cent.
59.8
Per cent.
8.5
Per cent.
4. 65
Unpolished rice .
.
.
,
10.3
1.89
86.5
1.23
0.64
Polished rice
.
.
.
.
10.0
0.25
89.0
0.7
0.3
Ration 60 grammes rice plus 5
grammes polishings contains per
cent.
10.4
1.5
86.6
1.31
0.64
The polishings have been stored for months without impairing their
, efficiency, nor is the value affected by the ordinary cooking process.
1 Fat .—The polishings contain a high percentage of fat. In my first
Report,1 Mr. Hooper's analyses show that in the samples of polishings from
Bengal rice mills examined, a high percentage of fat was present. Fraser and
Stanton fed 12 fowls on polished rice and 4.5 gram. fat free polishings. The
fowls maintained their weight and remained in good health. From these ex
-periments the non-importance of fat was established.
2. Phytin .—Estimations of the phosphorus pentoxide in rices had con
-sistently shown their value as indicators of their liability or otherwise to pro-
duce polyneuritis. This question is discussed also in my first Report.' This sug-
gested the probability that the essential substance was one containing phos-
phorus and Dr. Hans Aron stated that the substance was phytin, the Calcium
magnesium salt of an organic acid containing phosphorus. Fraser and Stan
-ton determined that unpolished rice contained F07 per cent. phytin, the sifted
polishings contain 8.8 per cent., washed and dried rice contained none.
Fraser and Stanton prepared phytin from sifted polishings. A fowl consum-
ing 60 gram. of unpolished rice daily would be receiving 0.66 gram. of phytin
so that this amount of phytin would require to be added to a diet of washed
1
First Report on Epirlemie Dropsy in Calcutta by Major E. D. W. Greig, M.D., D.Sc., I.M.S., Scientific Memoir
No. 45.
51
polished rice alone. Fraser and Stanton disproved the importance of phytin
by their experiments.
3. Substance soluble in 0.3 per cent. hydrochloric acid.—Experiments
were carried out to ascertain if the essential substance or substances passed
into solution when macerated in 0.3 per cent. HCL.. This solvent was chosen
because it was employed in the extraction of phytin. By experiments on
fowls it was shown that the essential material was removed uninjured by the
process of extraction and subsequent treatment. It is also shown that 85 per
cent. phosphorus pentoxide is unimportant.
100 grammes sifted polishings yield 4.1 grammes P2
O
5
Dissolved out by 0.3 per cent. HCL.
3.6 gram. or 88 per cent.
Remains in polishings
0.5 gram. or 12 per cent.
On addition of alcohol.
Precipitate (phytin)
3 gram. or 73 per cent.
Filtrate
0.6 gram. or 15 per cent.
1.
4. Alcohol (proof spirit) soluble fraction of the substances originally
soluble in 0.3 per cent. HCL.
100 grammes sifted polishings extracted with 0.3 per cent. HCL.
Pass into solution
26 gram.
Insoluble
74 gram.
On addition of alcohol.
Precipitate (phytin)
8.8 gram.
Filtrate
17.2 gram.
It was found that fowls fed on polished rice plus the alcoholic filtrate
did not develop neuritis and remained healthy.
This experiment proves that of the 5 gram. of sifted polishings required
daily for the maintenance of weight and health in a fowl on a polished rice
diet, no less than 4.2 gram. are unimportant and of the 0.8 gram. probably
only a part is essential.
Fraser and Stanton reach the following conclusions
:—
1. White polished rice when forming the staple of the diet in man has
been shown to cause Beriberi.
2. Such white polished rice when fed to fowls produces in them a disease
closely analogous to Beriberi in man. This reaction has been taken in this
H 2