CO885-(6-7) — Page 681

112

PUBLIC RECORD OFFICE

Reference :-

C.O.885

7

PUBLIC RECORD OFFICE, LONDON

ALLY WITHOUT PERMISSION OF THE BE REPRODUCED PHOTOGRAPHIC-

COPYRIGHT PHOTOGRAPH-NOT TO

8

after remaining ten hours insensible, the patient had recovered consciousness; but what surprised me most was that there was no paralysis. The patient's chief com- plaint, in fact, was the blister. In the afternoon of the same day the patient was seized with shivering, fever, and sweating. There could now be no difficulty either as to diagnosis or treatment. The patient probably owed his life to the fact that the apoplectic seizure did not recur and prove fatal, as it often does when treated on the lines I had followed. What I conclude from this is that grave mistakes would often be K Ex- obviated by special instruction in tropical medicine." Dr. Davidson remarks: perience, no doubt, is a good teacher, only the fees are very heavy." The microscope would probably have diagnosed this case correctly, but then one must be taught how to apply it.

I could relate from my own experience many similar stories illustrative of the danger to life with which a working experience in malaria has been bought. As with malaria, so with many less important, though nevertheless very important, tropical diseases. What, I would ask, does the student learn of practical value about beri-beri, a disease which, if he is to practise in the tropics, he is almost sure to encounter often enough, although he may not recognise it when he does come across it! Beri-beri is a very important malady. Occurring both endemically and epidemically it annually kills its thousands and tens of thousands. It makes the settlement of many fertile lands almost impossible. It kills off the planters' coolies like flies and makes his plan- tations unprofitable. It fills the hospitals and is a downright scourge in some of the fairest lands of the earth. But it is a disease which can to a great extent be prevented; and it is a disease which can by proper management be robbed of much of its danger. Its recognition, therefore, is of the first importance. Many times, in beri-beri perhaps more than in most diseases, early and correct diagnosis means the saving of life. When This I had sometimes I first went to the east all I knew about beri-beri was its name. seen in books. I had wondered at its quaintness; perhaps, medical student-like, I had waxed facetious about it and had punned upon it. So little did I know about beri- beri that I believed some medical writers who said that it was a kind of anæmia. Ex- aminers, I was told, were not likely to ask any troublesome questions about the symp- toms, pathology, or treatment, so I skipped the chapter on beri-beri in "Aitken's Practice of Medicine" as being for my immediate purpose useless. Students then, as I suppose students now, worked to pass their examinations as their primary object; Little wonder, therefore, to learn their profession was altogether a secondary affair.

I failed to recognise the disease when I first came across it. I well recollect my first I was case, and the horror and the shame with which it filled me, and still fills me. then in practice in Formosa. One day I was called to see a Chinese clerk employed in a European firm. I had known him well as an active, obliging young fellow. I found the patient sitting propped up in a chair, short of breath, dropsical from head to foot, with a cardiac bruit, irregular, tumbling action of the heart, and complaining As there was no albumin in the urine, and as there of a feeling of distress in his chest.

was a loud bruit with manifest disturbance of the heart, I felt convinced it was a case of heart disease, and from other circumstances in the case one which treatment would benefit. I prescribed and gave directions, and went away feeling, and probably ex- pressing by my manner, that we Europeans knew a great deal more about disease than the old Chinese doctor who hitherto, with the assistance of the village idol, had been treating the patient. Next day I went to see the lad expecting to find an improvement. I thought as I passed the door that there was a strange hush about the house. I en- On the bed, covered with a blanket, there was tered what was my patient's room. something long and rounded and still, which explained the hush I had noticed; and so I left the house sadder, wiser, and, I trust, humbler than I did the day before. Some years later, being then in general practice at Amoy and in charge of a large,native hospital, I used to see a number of Chinese soldiers who came to hospital suffering Some could from what appeared to me, in my ignorance, to be locomotor ataxia. hardly walk, others could just stagger into the out-patient room, and some had to be carried in. The significance of the knee-jerk symptom in spinal disease was then a new discovery, and in those days was regarded as a sure sign of locomotor ataxia. In all of these soldiers the knee-jerk was absent, and all of them exhibited what I took to be ataxic symptoms. If you would criticise my diagnostic acumen please bear in mind that in those days peripheral neuritis had not been invented. However that may be, I diagnosed these cases as locomotor ataxia, prognosticated that they would never re- Cover, declared that there was no immediate danger to life, put them to bed, and

ม

prescribed strychnine in various forms. But by-and-by, in utter disregard of my prognosis and of my reputation, in the course of a month or two some of those soldiers whom I had regarded and pronounced as hopeless cripples were walking about; some had even returned to their military duties. This is the pleasant, not to say the funny, side of my mistake. There is another side, however-oue not quite so funny. A good many of these patients died-died suddenly, just as my dropsical Formosa patient had done. I was mortified as well as puzzled. What was the nature of these cases? My books did not help me. I noticed that whereas some of these paretic patients were wasted to shadows, others were swollen and edematous. I also noticed that in most of them the muscles, especially the calf muscles, were tender. Occurring, as this disease did, as an epidenne, and confined to a very limited area (for most of the cases came from a damp, ill-constructed fort, the casemates of which served as a barrack); and knowing that the Chinese are very fond of pork, I thought that the muscle tender. ness and the dema might be symptomatic of trichinosis. I thought I might be dealing with an epidemic of trichinosis. Indeed, went the length of searching the muscle for trichina. If they can help it, the Chinese will not allow their dead to be dissected. I always entertained a great respect for what we in our civilised pride call "native prejudices," but in this instance, in view of the importance of correct diagnosis, I thought I would run the risk of offending these for once. So with the aid of an old and seasoned native porter I smuggled one of the dead bodies into a piece of waste ground near the hospital, and there behind the well excised a piece of muscle. Need- less to say, I found no triching. In this way I groped about for a long time in search of a diagnosis. It was not till months had elapsed and not a few deaths had occurred that I recognised that I had to deal with an epidemic of heri-beri, and it was only then that it began to dawn upon me that the poor dropsical fellow who had died in Formosa some years before had really died from beri-beri and not from heart disease after all.

For exactly the sime reason-lack of proper teaching the history of

up

my education in the matter of heri-beri is that of most of the medical men of my generation who, in lonely places in the tropics, essayed to practise their profession. And I am grieved to say that in this matter even at the present day it is just as it was thirty years ago. My education in beri beri was got by experience: "the young medical man of the present day has to learn in exactly the same costly way as I did and in the same stern school of experience. As Dr. Andrew Davidson says in his letter to me, "The fees are heavy." Only the other day I got to know that there had been no improvement on the teaching of heri-beri in all these thirty years. This is how I came to realise the ugly fact. Beri- beri is very common, you may be astonished to hear, in the port of London, especially among the seats and Seedy boys who in many instances for the bulk of the crews of the large steamers trading to the east. The cases are often brought to the Seamen's Hospital. They come on written medical recommendation and are sent as cases of heart disease, kidney disease, almost anything but beri-beri. They are very rarely correctly diagnosed. Now the ship-surgeons who make out the certificates are usually men fresh from the schools and from their examinations, and therefore, presumably, well

Here is a verbatim enumeration of some of in all that is newest in medicine. their diagnoses: anasarva, rheumatism, pericarditis and fits, dyspnea, cardiac disease, debility, asthma and anasarca, Bright's disease, locomotor ataxia, myelitis, tachycardia, apoplexy, paraplegia, progressive muscular atrophy, and, of course, hysteria. I tran- scribe these diagnoses from the admission registers. Not once in a dozen instances is the diagnosis correct. Now it does not matter so much whether the cases are correctly diagnosed or not provided they are sent to hospital. But there is every reason to believe that many of the cases of ship beri-beri are not sent to hospital, but are treated on board their ships, and that many die in consequence.

When we admit a case of beri-beri from a ship we ask if there are any more cases of the disease on board and if there have been any deaths. We are generally told that there are no more cases on board, but that there have been deaths from heart disease, asthma, or some such name, which from experience we know, under the circumstances, stands for beri-beri. Sailors. we may be sure, are not shipped with active heart disease or with asthma, such as would be likely to have a speedily fatal issue. I heard of one instance of a lascar who had been shipped in India as an effective seaman. Within a few weeks he died on board ship, and the cause of his death was officially logged as locomotor ataxia; as if locomotor ataxia ever ran its course in four or five weeks. The man died from un- diagnosed beri-beri as many others have done. All this represents a very serious, not to say disgraceful, state of matters. Most of these deaths are avoidable. No beri- beric should be allowed to remain in the place, whether house or ship, in which his

1918

B