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CONTENTS.
PAGES.
CHAPTER I.
Introduction .
. .
.
.
.
.
. .
. .
.
. . 1
C H A P T E R I I .
Features of Epidemic Dropsy .
.
.
.
.
.
.
.
.
.
.
.
5
CHAPTER III.
Infectivity of Epidemic Dropsy
.
. .
.
.
.
.
.
.
.
. 12
CHAPTER IV.
Geographical Distribution of Epidemic Dropsy in Calcutta .
.
.
.
.
. . 17
CHAPTER V.
Polishing of Food Grains in relation to Epidemic Dropsy .
.
.
.
. .
. 19
C H A P T E R V I .
Examination (Chemical and Histological) of samples of Food Grains taken from Affected Families 24
CHAPTER VII.
Observations on the effect of Variations in Diet on the mortality from Epidemic Dropsy, (1)
Addition of Meat to Rice. (2) Supplementing and replacing Rice by Grain
.
.
. 30
CHAPTER VIII.
Experimental Researches to note the effects of Feeding Pigeons on different kinds of Rice and
Grain .
.
. .
.
. .
.
.
.
. .
.
.
. 34
CHAPTER IX.
Periodicity of Outbreaks of Epidemic Dropsy .
.
.
.
.
.
.
.
. 39
CHAPTER X.
The Prevention and Treatment of Epidemic Dropsy .
.
.
.
.
.
.
. 42
APPENDIX.
Forms used in Epidemic Dropsy Enquiry .
.
.
.
.
.
.
.
.
. 45
Illustrations at the end of the Report.
1. Map of Calcutta showing distribution of fatal cases of Epidemic Dropsy during 1909.
2. Chart No. 1 showing Mortality from Epidemic Dropsy in Wards inhabited mainly by Marwaris
and in two Wards inhabited by Bengalis, during 1909.
3. Sections of Rice Grains to show effect of Polishing.
4. Chart No. 2 showing effect on the mortality from Epidemic Dropsy of the addition of Meat to
staple Rice Diet. Bengali Hindus. (Adults) and (Children).
5. Chart No. 3 (1) showing"result of Feeding Pigeons on Bengal Rice, Khulna (polished).
(2) Showing result or Feeding Pigeons on Burmah Rice, unboiled (polished).
(3) Showing result of Feeding Pigeons on Burmah Rice, boiled (polished).
(4) Showing result of Feeding Pigeons on Wheat and Pulses (controls).
6. Drawing showing the degeneration changes seen in the nerve of a Pigeon fed on ' Polished ' Rice.
7. Chart No. IV showing variation in price of Rice in Bengal (1885—1909) and its relation to Epi-
demic Dropsy.
8. Chart No. V showing variation in price of Rice in Bengal from (1875—1883) and its relation to
Epidemic Dropsy.
9. Chart No. VI showing variation in price of Rice in Bengal (1878—1881) and its relation to Epi-
demic Dropsy.
First Report on Epidemic Dropsy in Calcutta.
CHAPTER I
.
Introduction.
I N accordance with instructions received from the Director, Central Research
Institute, Kasauli, I proceeded to Calcutta to enquire into the causation of
an outbreak of Epidemic Dropsy or beri-beri there. I arrived in Calcutta on
December 13th, 1909. Assistant Surgeon Taraknath Sur and Assistant Surgeon
Charu Chandra Bose were detailed for duty in connection with the enquiry and
joined on 14th and 15th January 1910, respectively.
The Government of India appointed Mr. D . Hooper, F.C.S., officiating Reporter
on Economic Products to the Government of India, on the 24th May 1910, to con-
duct the analytical portion of the enquiry. All the chemical analyses referred to
in this Report have been made by Mr. Hooper.
When I reached Calcutta the acute phase of the outbreak of Epidemic Dropsy
was over. However I took every opportunity of seeing cases of the disorder:im-
mediately after my arrival : in addition to the various Hospitals, I visited a large
number of private houses, schools, etc. In this way I was able to observe and in-
vestigate a fair number of cases. After the Assistants arrived and the organiza-
tion for the enquiry was complete, the investigations proceeded along the follow-
ing lines :—
(1) The complete investigation of each fresh case of Epidemic Dropsy as
it occurred, including examination of blood, excreta, etc.
(2) House to house enquiry.—A list of all houses in which cases of Epidemic
Dropsy had occurred was obtained from the Health Officer, Calcutta.
Two forms were drawn up (Appendix I), and on these all details con-
nected with the house and its inhabitants are recorded. This portion
of the enquiry is still in progress, but many records have already been
made.
(3) Experimental research—A large number of feeding experiments are being
carried on with various animals, especially pigeons and fowls.
(4) Chemical investigation of food grains.—This is being undertaken by
Mr. D. Hooper at his laboratory in the Indian Museum.
(5) In addition to the work on the Calcutta epidemic a number of outbreaks
have been reported to me by the Government of Eastern Bengal and
Assam in accordance with the orders of the Government of India.
B
2
I have received the Reports of the several outbreaks and have issued
instructions for the transmission of food grains from the affected
areas, which were investigated experimentally by me and chemically
by Mr. D. Hooper.
Through the kindness of Lieutenant-Colonel Drury, I.M.S., Principal, and Major
L. Rogers, I.M.S., Professor of Pathology, Medical College, Calcutta, accommoda-
tion for the enquiry was provided at the Medical College, which, from its proximity
to the large hospitals, was very convenient for the purpose.
The investigation is still in progress and some months more will be required
for its completion. In the meantime, however, certain important results have
been obtained, and in this Report it is proposed to deal with these, leaving the other
aspects of the investigation for a final Report.
It may be well to clear the way for the discussion which follows by explaining
one or two points which, if misunderstood, may lead to confusion and miscon-
ception of the problems which will be considered in this Report. In the first place
it is necessary to bear in mind that the prominent features of epidemic dropsy, viz .,
swelling of the feet and breathlessness, may be produced by other conditions,
which may be confused with it by the ordinary, and even by the skilled observer.
These features may be produced by, over-indulgence in alcohol, 1 by ankylosto
miasis, which for years Was placed under the heading '' Beri-beri of Ceylon " in Gov
ernment returns, and by other causes. Hence it is necessary to eliminate in the
first place these various conditions by a careful examination of each patient, and
opinion on cases, cited as "Epidemic Dropsy," must be suspended until the re-
quired evidence is forthcoming. In the second place as the narrative of this Re-
port proceeds certain questions regarding rice and wheat and their preparation in
steam and other mills will be discussed in detail : but it must be remembered that
this treatment of grains and the removal of portions containing physiologically
important constituents only forms part of a general problem, namely, that of
'one-sidedness' in dietary. In the present outbreak and probably in many others
'polishing ' of food grains plays an important part in bringing about such a 'one-
sidedness ' in the diet, but it can be brought about also, by the habitual consump-
tion of other articles, e.g., meat, which has been exposed to a high temperature,
sago, etc., or in other words, deficiency of diet in certain essential constituents
necessary for the physiological requirements, is the underlying principle, the
mechanism of the production of this ' one-sidedness' of dietary will vary in different
races an.d peoples with the staples of their food, in one case it may be 'polished '
rice, in another a starchy flour, and so on. Indeed if Bengalis replaced entirely the
' polished ' rice by the 'fine ata,' which many of them consume, the 'one-sided-
ness ' of their dietary would be more accentuated than at present. I have stressed
1 McGill, Bombay Medical Congress Trans., 1909.
3
these points here as I know From experience that their correct meaning is frequently
not clearly understood, and it is a common error to consider that the present
special case represents the general problem of defective dietary, whereas it is only
one aspect of it. The question is an extensive one, involving as it does the influence
of nourishment upon general health.
As the subjects discussed in this Report are complex arid highly technical it
may be well to pick out the main conclusions arrived at regarding the recent out
break of Epidemic Dropsy in Calcutta. The evidence available appears to warrant
the following :
—
(1) That no causa morbi is to be found in the blood, œdematous fluid, ex
creta, etc., of Epidemic Dropsy cases.
(2) That the features of Epidemic Dropsy very closely resemble those of
'Ship Beri-beri.'
(3) That the evidence points to Epidemic Dropsy being non-infectious.
(4) That there is evidence to show that Epidemic Dropsy is a nutritional
disease, and is brought about by a 'one-sided' dietary.
(5) That a community (Marwaris), living in the heart of the affected portion
of Calcutta, practically entirely escaped Epidemic Dropsy. A careful
chemical analysis of their dietary, which differs materially from that
of the Bengalis, shows that it is much richer in some important con-
stituents,—phosphorus, etc., than a rice dietary, and, therefore, the
quantity of these constituents taken by the Marwaris, amongst
whom no fatal cases of Epidemic Dropsy have been recorded, is
greater than that consumed by Bengalis, whose staple is rice, and who
were very severely affected by Epidemic Dropsy in the recent out
break. The better class European community in Calcutta, living on
a 'mixed dietary,' and not consuming large quantities of rice con-
tinuously, have escaped.
(6) That chemical analysis and histological examination show that by the
process of 'polishing,' as carried out in the steam and other mills
at Calcutta and elsewhere, constituents essential for nutrition are
removed from the rice, and that the ata (wheat) which many Ben-
galis consume habitually, had been so finely 'sifted ' that it is deprived
of these ingredients to an even greater extent than rice.
(7) That the chemical examination of samples of the kind of rice consumed
habitually by patients affected by Epidemic Dropsy shows that the
samples had undergone a process of ' polishing ' by steam milling
and that important constituents had been removed to a consider-
able extent ; that wheat consumed by patients affected by Epidemic
B 2
4
Dropsy had undergone a considerable loss of phosphates in the pre -
paration of ata.
(8) That pigeons show, when fed on 'polished' rices, both boiled and un-
boiled, a progressive loss of weight with characteristic polyneuritis.
Chemical analyses of these samples of rice show them to have a low
phosphorus content.
(9) That control pigeons when fed on a mixture of wheat and pulses show
no loss of weight, but rather a gain, and they have remained for
months in good. health. Chemical analysis of this food shows that
it contains double the quantity of phosphorus contained in the sample
of rice used for feeding the pigeons,
(10) That the two severe outbreaks of Epidemic Dropsy in Calcutta and
Bengal, namely in 1877-78-79 and 1907-08-09, have been correlated
with a sustained high price of food grains during the period and the
cessation of these epidemics has synchronised with the fall in price of
food.
5
CHAPTER
II.
Features of Epidemic Dropsy.
The various signs and symptoms of this disease will be discussed in full in
a later Report after the observations which are being recorded on the subject at
present are completed, but it may be well to refer at the present stage to certain
broad features of the disease which have a bearing on the problem of etiology.
The " symptom complex " of this disorder deviates fairly widely from that
observed in Chinese patients in Calcutta suffering from beri-beri. It approximates
much more closely to the condition described under the name " Ship Beri-beri."
The symptoms of the latter condition consist 1 " In the great majority of cases
in weakness and a prominent dropsy of the lower limbs, extending often to other
parts of the body. There, also, exists shortness of breath and other symptoms of
a weak heart, causing often sudden death from acute paralysis of the heart. But
as Nocht ² in Hamburg and the Norwegian Ship Beri-beri ' Committee ³ have
shown, symptoms of neuritis of the limbs are comparatively rare. For instance,
Nocht was only able to ascertain neuritis in cases from four of his thirty-four beri-
beri ships : and though the investigations of the Committee extended to fifty-seven
affected ships, the neuritis was only found in men from four of them." " The
great majority of patients suffering from the ordinary, i.e., dropsical ship disease,
recover as soon as they are able to change their food." These symptoms and signs
of " Ship Beri-beri " agree very closely with those of Epidemic Dropsy as seen in
Calcutta. Bradon 4 states, " There is not, according to the Report of the Nor-
wegian Commission and later of Hoist, who especially investigated both this dis-
order and true beri-beri, in pelagic dropsy (Ship Beri-beri), any constant or definite
implication of the nervous system any more than there is in Epidemic Dropsy,
which it indeed more closely resembles." Munro 5 who investigated Epidemic
Dropsy in the Darjeeling District in 1907 states, " There are certain facts in support
of a theory that the disease is due to under-feeding on certain of the constituents
of a physiological diet." As in " Ship Beri-beri " the records of the occurrence of
neuritis in Epidemic Dropsy are variable some authorities 6 consider that it is not
a feature in the latter disease ;others hold that it does occur : thus Megaw,7 in a
careful study of cases of Epidemic Dropsy in Eurasians and poor Europeans in the
European General Hospital, Calcutta, notes that neuritis is invariably a marked
1 Holst, Axel. Experimental studies relating to " Ship Beri-beri and Scurvy.'' Journal of Hygiene,
Vol. VII, Part II, 1907.
² Festschrift zum sechzigsten Geburtstage Von Robert Koch. Jena, 1903.
³ Indstilling fra Beri-beri Komiteen (Report of the Beri-beri Committee). Christiania, 1902.
4 Trans. Bombay Medical Congress, 1909.
5 Munro, Captain, I.M.S., on the prevalence in the Darjeeling District of a disease resembling Beri-beri
Report to Government of Bengal, February 1908.
6 Rogers. Fevers in the Tropics, 1910.
7 Megaw, J. W. D., Captain, I.M.S., Volume XLV, No. 4, April 1910. Indian Medical Gazette.
6
feature of the disease. He states, however, " That there is a marked difference in
type between Epidemic Dropsy and beri-beri as seen among Chinese patients in
Calcutta ;" but he inclines to the opinion that the two diseases are not essentially
different. Authorities, who have studied Epidemic Dropsy recently in India, record
the fact that alteration of the dietary plays an important part in the cure of this
disease ; thus Neil Campbell 1 in considering of treatment of Epidemic Dropsy
states, " The first thing is absolute rest, knock off every form of labour and permit
the patient to be in the recumbent posture as much as possible, the next is good
and nourishing diet." Megaw 2 also observes, in the treatment of his cases of
Epidemic Dropsy, " That tendency towards recovery within a short time after the
patient has been placed on a liberal diet free from rice is strongly in favour of the
dietetic theory." These observations are in agreement with those of Axel Holst,
Nocht, and others, in regard to the treatment of " Ship Beri-beri." Holst 3 states
" That ' Ship beri-beri ' is, in accordance with the opinion of Nocht, a food disease,
showing a marked congruence with scurvy." In this connection it is interesting
to record that a certain proportion of the patients during the recent Calcutta
outbreak of Epidemic Dropsy showed sponginess of the gums, which bled readily,
also a certain number had hæmorrhage from the bowel, etc. The following table
shows the number of cases of Epidemic Dropsy which presented on examina-
tion spongy gums :—
NO. OF CASES EXAMINED.
NO. OF CASES SHOWING BLEEDING FROM
GUMS AND HÆMORRHAGE FROM
BOWELS.
ADULTS.
CHILDREN.
ADULTS.
CHILDREN.
Male.
Female.
Male.
Female.
Male.
Female.
Male.
Female.
249
241
23
15
27
18
3
1
In his description of scurvy as seen amongst the troops after the occupation
1 Campbell, Neil, Lt.-Col., I.M.S., Report on outbreak of Epidemic Dropsy in the Lunatic Asylum, Dacca,.
in March 1908.
2 Ibid.
Journal of Hygiene, Vol. VII, Part II, 1907.