NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
8
ingredients sometimes die in this manner. In teaching I put aside the name
Diarrhœa Hectica1 , and called the malady 'Morbus Bengalensis.' Throughout
his daily work, the powerful influence of this condition of chronic semi-starvation
not merely in the poor Bengali himself but throughout his entire race and genera-
tion, is constantly obtruding itself upon the physician, who says ' This man's
constitutional malady is mal-nutrition, anæmia, asthenia, complicated with fever,
dysentery, or what not. ' ' Consequently the first indication of treatment is a
proper and nourishing diet.' " If we replace Chevers' 'what not,' with the
symptoms, swelling of the feet and breathlessness, a fairly complete description
of the features of Epidemic Dropsy results.
McLeod 2 in his account of Epidemic Dropsy as met with in Calcutta during
1877-78-79 states, " There can be no question that, in consequence of the Madras
famine, the price of food in Calcutta, throughout Bengal and Assam, was unpre-
cedently high in the years 1877-78-79. Rice sold at double its usual rate, and the
lower classes were undoubtedly underfed. There was also an influx into Calcutta
of half-starved folk from the famine district. This circumstance may perhaps
explain the amount of scurvy and general ill health observed in many of the Cal-
cutta cases." These are important observations, and it is evident that in former
outbreaks of Epidemic Dropsy symptoms of scurvy were noted also, and at the
same time famine-rates for food were being charged. McLeod, also, notes that
symptoms of Epidemic Dropsy occurred in persons showing no scorbutic symptoms,
which is in agreement with Hoist's observation in " Ship Beri-beri."
A disease very closely resembling Epidemic Dropsy has been observed in
the prisons of Europe and America during the early part of the 19th century.
Thus, " Besides typhoid fever and consumption, this Prison Dropsy ' (Wasser-
sucht der Geilingnisse) is stated, in 1847, to have been the most prevalent cause of
death in 41 prisons in England, France and North America. 3 I n 1 8 5 7 i t c a u s e d
one half of the deaths in a prison in Breslau, 4 and if it were not that nothing is
said about the occurrence of neuritis, some reports from those days recall the-des-
criptions of the Asiatic beri-beri prisons of our own time." 5
Schauman 6 has endeavoured to show that " Ship Beri-beri " is caused by a
lack of nucleophosphoric acid which is extracted or destroyed by certain sterili-
zation processes, and further he contends that a similar lack of organic phosphorus
(nucleoproteins) in the food, especially in white rice, may produce tropical beri-
1Tytlor J., Trans. Medical and Physical Society of Bengal, volume III, Page 1826.
2Indian Medical Gazette, January 1894.
3 Wald. Vierteljahrchr. für. gericht. Med. 1857, Vol. IX (quoted by Hoist).
4 Bær. Weyls Handbuch der Hygiene, Hygine des Gef " ängnisswesens," pp. 42-43 (quoted by Holst).
5 Kersandt, quoted, by Bær, Vierteljahrchr. f. offent. Gesundheitspffege, 1876.
6 Arch. f. Schiffs. Und. Trop. Hyg. Beiheft (1908, 12 and 37).
9
beri. Schauman 1 recently has published a second paper on the same subject
giving the results of animal nutritional experiments.
The examination of the blood in cases of Epidemic Dropsy in India by differ-
ent observers shows that the most marked feature is a reduction of the red cor-
puscles and hæmoglobin during the course of the disease, and as the case progresses
towards recovery there is a gradual return to normal of the condition of the blood.
This change in the blood picture is significant in relation to the nutritional origin
of the disease. Neil Campbell 2 gives the result of the enumeration of the
R. B. C. and W. B. C., at the onset, during the course, and in convalescence of
five well marked cases of Epidemic Dropsy.
The following table gives the average of his results :—
ONSET.
COURSE.
CONVALESCENCE.
R. B. C.
W. B. C. Proportion.
R. B. C.
W. B. C.
Propor-
t i o n .
R. B. C. W. B. C. Propor- t i o n .
4,030,000
9,800
1-481 3,442,200
10,500
1-328 14,087,500 6,925 1-530
Neil Campbell 3 states, "I am inclined to conclude from careful clinical
observation that progressive anæmia is a very interesting feature of the disease."
Rogers 4 gives the result of the examination of the blood in eight typical
cases of Epidemic Dropsy in natives. The following table shows the average of
his results :—
Hb.
Hb value.
R. B. C.
W. B. C. Proportion. P. N.
S. M.
L. M.
E.
37.5
.69
2,608,000
8,719
1-325
60.3
25.2
8.6
5.9
1 Arch. f. Schiffs Und. Trop. Hyg. Beiheft (1909, 82-90).
2 Campbell, Neil, Lt.-Col., I.M.S., Report on outbreak of Epidemic Dropsy in the Lunatic Asylum,
Dacca, in March 1908.
3 Ibid.
4 Fevers in the Tropics, 1910.
C
10
Megaw,1 as a result of his examination of the blood of six of his cases at the
European General Hospital, Calcutta, states, " That the red cells were from two and
a half to five millions, the hæmoglobin from 45 to 80 per cent., the rule being a
moderate reduction in the red cells and a more marked reduction in the hæmo-
globin. The leucocyte count showed an increase, both total and relative, in the
lymphocytes and an increase in the eosinophiles in most of the cases." The results
of the examination of the blood in Epidemic Dropsy, which I have obtained in my
investigations in Calcutta, are in general agreement with the above quoted observ-
ations.
The following table shows the results of the enumeration of the R. B. C.
and W. B. C., the percentage of Hb, the total, and the differential counts of the
leucocytes in cases of Epidemic Dropsy :—
No. Age. Sex. Race. Stage of disease. Date of examina-
tion.
R. B. C.
H b % W.B.C.
PERCENTAGES.
P.N. S.M. L.M. E.
1 15 F
I. Ch. Chronic (relapse) 1st February 1910 . 3,540,000 48 4,500 56 31 12 1
2 14
F
„
„
1st February 1910 . 3,580,000 48 4,000 41 50 8 1
3 15
F
„
„
2nd February 1910 . 4,590,000 5 6
5,000 50 32 18 0
4 15
F
„
„
3rd February 1910 . 4,020,000 57 5,000 50 44 5 0
5 14 F
„
„
2nd February 1910 . 4,670,000 6 0 5,000 63 29 8 0
6 15 F „
„
2nd February 1910 . 4,780,000 65 9,000 71 21 9 0
7 24
F
„
„
3rd February 1910 . 4,990,000 62 8,000 52 39 7 0
8 15 F
„
„
2nd February 1910 . 4,590,000 56 5,000 50 32 12 0
9 33
M
„
„
17th January 1910 . 3,200,000 55 8,000 65 21 14 0
10 35
M
B
„
20th January 1910 . 3,740,000 40 5,500 58 34 17 1
11 28 M
B
„
25th January 1910 . 3,650,000 55 9,000 52 36 12 0
12 24 F
I. Ch. Acute . . 18th December 1909 2,200,000 32 7,812 72 13 15 0
13 25 F
„
„ . . 4th January 1910 . 3,910,000 60 9,000 58 30 12 0
14 19 F
„ Chronic . . 10th February 1910 3,350,000 50 12,000 78
8 14 0
15 15 M
B. H.
„ . . 16th February 1910 4,000,000 42 5,000 65 26
8 1
16 55
M
„
„ . . 16th February 1910 3,940,000 35 12,000 62 25 12 1
17 29 M
„ Acute . . 20th September 1909 2,100,000 14 6,700 .. .. .. ..
18 22
M
M Chronic . . 23rd April 1910 . 3,800,000 60 5,600 60 34 6 0
19 45 F
I. Ch. Convalescent . 5th February 1910 . 5,020,000 8 0 7,000 65 27 8 0
20 16 F
„
„
5th February 1910 . 4,850,000 70 6,000 43 48 5 2
21 16 F Brahmo .
„
8th February 1910 . 5,110,000 78 7,000 57 38 5 0
22 22 F
„ .
„
8th February 1910 . 4,420,000 75 5,000 37 48 13 2
The coagulation time of the blood was determined in a number of cases of
Epidemic Dropsy. In none of them was it abnormally prolonged when controlled
by observations on the presumably healthy.
1 Megaw : Fevers in the Tropics, 1910.
11
The following table shows the records of the coagulation time of the blood in
cases of Epidemic Dropsy :—
Serial
No.
Age.
Sex.
Race.
Stage of dis-
ease.
Date of examination.
Coagulation
time.
1
15
F
I. Ch. B. .
Chronic
.
1st February 1910
.
4'—50"
2
14
F
,,
.
,,
.
1st February 1910
.
3'—45"
3
15
F
,,
.
,,
.
2nd February 1910
.
2'—25"
4
15
F
,,
.
,,
.
3rd February 1910
.
3'—40"
5
14
F
,,
.
,,
.
2nd February 1910
.
4'—20"
6
15
F
,,
.
,,
.
2nd February 1910
.
3'—0"
7
24
F
,,
.
,,
.
3rd February 1910
.
4'—30"
8
15
F
,,
.
,,
.
2nd February 1910
.
4'—47"
9
19
F
,,
.
,,
.
10th February 1910
.
3'—30"
10
15
M
H
.
,,
. 1 16th February 1910
.
3'—30"
11
55
M
H
.
,,
.
16th February 1910
.
2'—50"
12
22
M
M
.
,,
.
23rd April 1910
.
2'—45"
I. Ch. B. =Indian Christian (Bengali).
H. =Hindu.
B. =Bengali.
M.=Mahomedan.
c 2
12
CHAPTER III.
Infectivity of Epidemic Dropsy.
An important question to determine in the first place was, whether or not
an organism exists in the tissues of patients suffering from Epidemic Dropsy.
A careful examination of the blood of cases of Epidemic Dropsy, which came
under observation, was made, both by cultivation in various media and direct
microscopic examination.
The following table shows the presence or absence of bacteria in the blood of
patients suffering from Epidemic Dropsy :—
No.
of
case.
Date of examination. Age.
Sex.
Race.
Stage
of
disease.
Quantity
of
blood.
Nutrose
broth.
Nutrose
Agar.
Serum.
39
18th December
1909 .
. 24
F
I. Ch.
Early
5 c.c. . Sterile Sterile Sterile.
40
4th January
1910 .
. 25
F
„
„ 5 c.c. .
„
„
„
41
10th January
1910 .
. 35
M
Panjabi
„
5 c.c. .
„
„
„
42
8th January
1910 .
. 30
M
I. Ch.
„
5 c.c. .
„
„
„
44
16th February
1910 .
. 15
M
H
Chronic 5 c.c. .
„
„
„
45
16th February
1910 .
. 55
M
H
„
5 c.c. .
„
„
„
53
22nd February
1910 .
. 18
M
H
„
5 c.c. .
„
„
„
54
19th March
1910 .
. 22
M
H
„
5 c.c. .
„
„
„
62
23rd April 1910 22
M
M
„
5 c.c. .
„
„
„
63
4th May 1910 . 22
M
M
„
5 c.c. .
„
„
„
68
10th June 1910
15
M
Eura-
sign.
„
5 c.c. .
„
„
„
I. Ch.=Indian Christian.
H.=Hindu.
Remarks. —The blood, which was removed with the usual precautions from a vein at the bend of the
elbow, was placed at once in a considerable quantity of nutrose broth ; the blood was found invariably to be
sterile. The blood was planted, also, on nutrose agar and serum, but with like result. Therefore as far as
t h e b l o o d i s c o n c e r n e d t h e r e i s n o e v i d e n c eo
f
b a c t e r i a l i n v a s i o n i n
E p i d e m i c D r o p s y .
13
Careful microscopic examination of films of blood taken from the cases of Epi-
demic Dropsy and stained in various ways gave negative results as regards the
presence of parasites. Also 5 c.c. of blood were taken from a vein and mixed with
a little sodium citrate to prevent coagulation and then centrifuged the clear
plasma was pipetted off and again centrifuged : then the supernatant fluid was
poured off and the residue which remained was examined fresh for parasites.
The result was negative in each case.
In this connection it is interesting to note that Megaw1 drew 3 c.c. of blood
from an early typical acute case of Epidemic Dropsy and having allowed the blood
to clot he inoculated himself with the serum subcutaneously without ill effects.
I have inoculated subcutaneously several monkeys with blood taken from
typical cases of Epidemic Dropsy, an interval of a few minutes only elapsing be-
tween the time of taking blood from the patient and the injection into the monkey.
For the purpose 5 c.c. of blood were removed from the vein at the bend of the
elbow of early cases of Epidemic Dropsy, and mixed with a little Sodium Citrate
to prevent coagulation. No noteworthy sign or symptom was observed in the
monkeys, which remain free from disease after the injection.
In several instances the skin of the œdematous limb of early cases of Epidemic
Dropsy was disinfected carefully with carbolic 1-20, and afterwards washed with
alcohol and ether : a sterile hypodermic needle was then introduced under the
skin and some of the fluid was sucked up into the syringe. This fluid was planted
on various media. It was examined, also, microscopically, both before and after
centrifuging, but no parasite was detected in any case ; and the fluid remained
sterile the various culture media, viz., nutrose broth, nutrose agar, serum, etc.
The fæces and urine were examined microscopically and culturally in several
typical acute cases, but no specific organism was determined.
It will be seen that the results of the search for a causa morbi in the tissues
of cases of Epidemic Dropsy have been uniformly negative. Whilst these results
do not prove a non-microbic origin of the disease they increase considerably its
probability. Recent work on beri-beri in the Far East has given similar results.
De Haan states, 2 " My own very numerous attempts to find the causa morbi
in the blood, the organs, or the excreta of persons suffering from beri-beri, also.
have never succeeded."
Apart from the results of the examination of the blood, etc., of the patient,
there is other evidence in support of the non-microbic origin of the disease. Epi-
demiological investigations do not support the view that the disease is infectious
from person to person. Thus in Calcutta there is a large community of Marwaris
(Hindus) living in the heart of the affected portion of Calcutta, and the sanitary
1Megaw : Fevers in the Tropics, 1910.
2 De Ha a n . Phi l i ppi ne J our nal of Sci ence, Vol . V. , No. 1, Febr uar y 1910.
14
conditions under which many of them are living are not especially favourable.
In Wards 5 and 7, in which they chiefly live, comparatively few fatal cases of
Epidemic Dropsy occurred, and a careful investigation of those fatal cases
in Wards 5 and 7 showed that all of them were Bengalis, not Marwaris; none of
the fatal cases were traced to the latter. Hence we see that in these two Wards
in Calcutta two communities, Marwaris and Bengalis, the former largely predo-
minating, were living under the same environmental conditions, yet fatal
cases are recorded from the one, and not from the other. The reason for this
will be evident when the question of geographical distribution of the disease
in Calcutta is described; this example indicates the absence of infective power
of the disease. Further, no authentic case of Epidemic Dropsy has been
recorded amongst the better class European community in Calcutta. The latter
have no such immunity from ordinary infectious disease, e.g., cholera, small-pox,
etc., or from such diseases as malaria, seven-day fever, etc. The reason for
their immunity will be discussed later.
During the course of the enquiry I have directed special attention to the study
of the movements of persons and households affected by Epidemic Dropsy. Re-
cords of persons at all stages of the disease, who came into households in which no
disease existed previously, and the subsequent history of these households, have
been and are being obtained. In practically all these instances the imported
case has recovered or died, but no spread of the disease to healthy members has
occurred.
The following table shows the number of Epidemic Dropsy free houses into
which persons suffering from Epidemic Dropsy at various stages came, and the
occurrence or non-occurrence of Epidemic Dropsy in the houses thereafter.
No. of Epidemic Dropsy free households into which
cases were imported.
No. of these households which recorded cases of Epi-
demic Dropsy after the importation.
28
2
From this it will be seen that the movement of affected persons was not follow-
ed by a spread of the disease. The cases coming to the houses were in all stages
of the malady, from the early initial phase to convalescence. In only two examples
did the disease occur in households, apparently, after the entry of cases, but on
careful enquiry these instances were explainable on other grounds.
Evidence was obtained in many cases of one out of several families living
in the same house being affected with Epidemic Dropsy, the remaining unattached
families keeping free from the disease, although the sick and healthy mixed inti-
mately. In the majority of instances the only difference being that the food
15
was not the same, or procured from separate sources. Further, in some of the
schools in Calcutta (which I investigated), after cases of Epidemic Dropsy had
occurred no attempt was made to isolate the scholars. The children suffering
from the disease mixed freely with the healthy ones, and the disease did not spread.
The cases of Epidemic Dropsy treated in the Hospitals in Calcutta have
not been isolated and no dissemination of the disease has taken place. On this
point Neil Campbell1 i n d e a l i n g w i t h t h e D a c c a A s y l u m o u t b r e a k o f E p i d e m i c
Dropsy states that, '' Removal of the insanes from the asylum, or segregation of the
affected, was considered unnecessary." Megaw2 also observes, " Against the
disease (Epidemic Dropsy) being an infection is also the fact that all the cases
were treated in the open wards without any attempt at segregation being
considered necessary, and that no case of infection occurred among the other
patients." Assistant Surgeon Rammay Ray, 3 who saw many cases of Epi-
demic Dropsy in Madras and Calcutta, during the previous outbreak, 1877-78-79,
concludes as follows :—" From all the facts mentioned above, I believe that beri-
beri (Epidemic Dropsy) is not communicable from person to person." McLeod 4
states regarding the same outbreak of Epidemic Dropsy, " The general opinion
among natives was that the disease was not infectious." Lovell 5 w r i t e s r e g a r d i n g
the Epidemic Dropsy in Mauritius (1879) that the majority of medical men at
Mauritius were opposed to the view that the disease was contagious.
Dr. de Haan, Director of the Government Medical Laboratory at Waltevreden,
Java, who has made a prolonged study of beri-beri at Waltevreden, states, 6
regarding the infectivity of that disease : " No one hitherto has succeeded in
proving beri-beri to be caused by a specific microbe, or shown that it should
be classed among infectious diseases." He further gives this important warning
on the point : " Neither its epidemic nor endemic dissemination, nor the
few cases mentioned in literature indicating the possibility of infection from
one person to another, should be considered as proof of its microbic origin, since
the clinical symptoms of beri-beri—polyneuritis with all its sequels—may be
caused by many other factors."
Dr. Hans Aron of the Philippine Medical School, observes 7, " In spite of the
claims of various investigators who have described a number of so-called beri-beri
organisms which all, more or less have been proved not to be the specific cause
1 Campbell, Neil, Lt.-Col., I.M.S., Report on outbreak of Epidemic Dropsy in the Lunatic Asylum,
Dacca, in March 1805.
2 Megaw : Fevers in the Tropics, 1910.
3Indian Medical Gazette, May 1st, 1880.
4Indian Medical Gazette, March 1st, 1880.
5 Indian Medical Gazette, page 222, August 1880.
6 Philippine Journal of Science, Vol. V, No. 1, February 1910.
7 Philippine Journal of Science, Vol. V, No. 1, 1910.
16
of the disease, we can to-day regard it as proved that beri-beri is not an infectious
disease."
Further, Dr. Grijns1 i n h i s o b s e r v a t i o n s o n p o l y n e u r i t i s g a l l i n a r u m , a d i s e a s e
closely related to beri-beri of man, and which can be produced experimentally
by feeding birds on polished rice, records the following results to show that the
injection of the blood and nerves of fowls suffering from polyneuritis into healthy
fowls was not followed by the disease :—
"He injected into the peritoneal cavity of healthy fowls the blood of diseased
birds (a minimum of 57 c.c. in 12 injections and a maximum of 220 c.c. in 23),
but without result. The nerves of diseased fowls, either free or inclosed in col-
lodion sacks, and introduced into the peritoneal cavity of healthy birds, did not
give rise to polyneuritis. The feeding of healthy fowls on the flesh of diseased
birds had no effect, neither did the injection of the blood of the former into the
latter accelerate the appearance of polyneuritis in the case of fowls fed on cleaned
rice."
By Fraser and Stanton's carefully controlled observations, 2 on 300 Javanese
indentured labourers employed in the work of road construction in a remote part
of Jelebu District in the State of Negri Sombilan, it was clearly shown that beri-
beri was not infectious and was not conveyed from person to person. "Systematic
examinations were made of the blood and urine of patients suffering from beri-
beri. Various methods of examination were employed, but in no instance were
any organisms found except those well known as the causative agents of other
diseases." " The results of observations made on such occasions furnished evi-
dence that the disease is not a directly communicable one."
It will be seen that the results obtained on the question of the infectivity of
Epidemic Dropsy during the enquiry at Calcutta are in agreement with those of a
number of competent observers. The importance of this aspect of the investiga-
tion requires no comment.
1Over Polyneuritis gallinarum I on II, Genees Tyds. V. Ned. Ind., 1900, 41 and 1909, 49.
2Studies from the Institute for Medical Research, F. M. S., No. 10, 1909.
17
CHAPTER IV.
Geographical Distribution of Epidemic Dropsy in Calcutta.
In studying the epidemiology of disease valuable information may be obtained
from observing the geographical distribution of the cases. Accordingly the records
of all fatal cases of Epidemic Dropsy reported to the Health Officer, Calcutta,
during the outbreak of 1909 were obtained and investigated. In the first place a
map showing the geographical distribution of fatal cases of Epidemic Dropsy in
Calcutta was constructed in the following manner : If after enquiry into the case
the diagnosis of Epidemic Dropsy was confirmed, a dot was placed on a blank
map of Calcutta on the locality where the death occurred. This was done for
every fatal cases of Epidemic Dropsy in Calcutta and suburbs up to the end of
1909. in this way it was possible to study the distribution of the outbreak of
Epidemic Dropsy in Calcutta. The skeleton map made from the original shows
the geographical distribution of Epidemic Dropsy in Calcutta during 1909.
A glance at this map shows at once that certain populous Wards in Calcutta
have to a large extent escaped the disease. These wards are 5 and 7, and 15,
16, 17. Can the immunity of these wards from Epidemic Dropsy be accounted
for, or can it be correlated with any particular feature of these Wards or the
inhabitants of them ? On further enquiry into these points several interesting
and significant facts emerge. Wards 5 and 7 are very largely inhabited by
a community of Hindu merchants, Marwaris, whilst Wards 15, 16, 17 are popu-
lated almost entirely by the better class European community, and form the
European quarter of Calcutta. Proceeding further with the investigation of
this problem it is found that the dietary of the Marwaris is entirely different
from their Bengali neighbours in adjoining Wards, who have suffered so severely
from the disorder. As is well known the staple article of diet of the Bengali
is rice, which they consume in large quantities daily. The Marwaris on the
other hand consume much less rice and only a small proportion take it habitually.
They replace the rice by coarse ata (wheat), mung dal, and other pulses to a
large extent. The chemical analysis of the Marwari and Bengali diet will be
discussed shortly. In the map, Wards 5 and 7, the inhabitants of which
are chiefly Marwaris, with a sprinkling of Bengalis, have been enclosed in a
thick continuous line. When compared with adjoining Wards it will be seen the
number of fatal cases of Epidemic Dropsy recorded within this line is small. A
most careful and special enquiry was made into each case, and it was ascertained
in every instance that the person who had died of Epidemic Dropsy was a Bengali,
not a Marwari. This is a very significant fact, because from this it will be seen
that the foci of disease existed in these Wards and the sanitary conditions are
D