section of therapeutics anll pharmacology

Section of Therapeutics anll Pharmacology 7

We may conclude that a deficiency of biological protein is anessential factor in the causation'of pellagra. Other factors such asdigestive disturbances, and flagellate and helminthic infections are butcontributory in that they increase the protein losses and are addedcauses of malnutrition. The association of pellagra with the con-sumption of maize is not due to the maize, nor to any toxin contained init, but to the low biological value of maize protein.

(Professor Boyd showed charts and diagrams in illustration of hisaddress.)

Dr. W. H. WILLCOX, C.B., C.M.G.

In this paper I propose to deal with the treatment and managementof scurvy and beri-beri as they affect an army in the field. Amongthe many fascinating and interesting medical problems which presentedthemselves during the campaign in Mesopotamia those connected withscurvy and beri-beri occupied the foremost place. The deficiencydiseases of scurvy and beri-beri occurred to a greater extent inMesopotamia than in any other theatre of the War. The enormouswastage caused by scurvy in that campaign can be realized from thestatistics available: thus 11,445 cases occurred in the last six monthsof 1916. These cases were almost all evacuated to India, since theywere quite unfit to undergo the hardships of active service in the field.

The careful investigations made in connexion with these diseases inMesopotamia and the results of the management-that is, the scientificrationing of the troops-have 'most conclusively established that bothscurvy and beri-beri are essentially deficiency diseases and are due toa deficiency in the respective vitamines in the dietary associated withtheir causation.

From the beginning of May, 1916, until the end of January, 1919,as Senior Consulting Physician to the Mesopotamian ExpeditionaryForce, I made a special study of scurvy and beri-beri from theirclinical aspects and from the point of view of prevention and treatment.I would like to take this opportunity of expressing my thanks to theDirectors of the Medical Service, Major-General Sir Francis Treherne,K.C.M.G., and Major-General A. P. Blenkinsop, C.B., C.M.G., for thehelp and encouragement always given me in this work.

In order to understand clearly the problems which presentedthemselves in the Mesopotamian campaign in connexion with themanagement of scurvy and beri-beri it is necessary to review thoroughly

Willcox: Diseases due to Dietetic Deficiencies

the circumstances which effected the rationing of the troops in so far asthey related to the occurrence of scurvy and beri-beri.

The Mesopotamian campaign commenced on November 6, 1914,when troops under General Delamain landed at Fao, and onNovember 22, 1914, Basrah was occupied, General Sir Arthur Barrettbeing in command. The Force pushed its way up the Tigris andafter a series of brilliant military successes Kut was captured onSeptember 28, 1915. From the beginning of the operations until 1916the Mesopotamian Force was under the control of the IndianGovernment and the system of rationing troops was based on theField Service Scale of Rations laid down in "War Establishments,India," pages 10 and 11: Table I, British rations; Table II, Indianrations.

TABLE I.

(A) British Troops. Field Ration.

(1) Bread ... ... 1 lb. (6) Sugar ... ... 2.1 oz.(2) Fresh meat ... ... 1 lb. (7) Salt ... . oz.(3) Bacon ... ... 3 oz. (8) Pepper ... . oz.(4) Potatoes ... ... 1 lb. (9) Fuel ... ... 3 lb.(5) Tea ... ... 1 oz.

TABLE II.

(B) Indian Troops and Followers. Field Ration.(1) Atta ... ... 1j lb. (8) Ginger ... ... oz.(2) Fresh meat ... ... 4 oz. (9) Chillies ... ... oz.(3) Dhall ... ... 4 oz. (10) Turmeric ... ... oz.(4) Ghi ... ... 2 oz. (11) Garlic *.. ... oz.(5) Gur ... ... 1 oz. (12) Salt OZ. .2z(6) Potatoes ... ... 2 oz. (13) Fuel ... ... 1* lb.(7) Tea ... ... oz.

It may be stated now that scurvy in Mesopotamia was practicallylimited to Indian troops, only a few isolated cases occurring amongstBritish troops, the causation of which could be traced to inadequatedietary owing to some other diseases occurring in the individual patient.Beri-beri, on the other hand, was limited to British troops, practicallyno cases occurring amongst Indians. Some cases occurred amongst theChinese Labour Corps at Basrah in 1918. and also in the crews onboard ships arriving at Basrah. Both of these epidemics were traceableto polished rice as the aetiological factor.

A review of the ration scales shows that as regards deficiency diseasethe ration for British troops was fairly satisfactory. Attention will becalled later to the deficiency as regards beri-beri under the conditionsof -service at the Front. For Indian troops the field service raition wasvery deficient as regards antiscorbutic vitamines, the only antiscorbutics

8

Sectiont of Therapeutics and Pharmacology

being 2 oz. potatoes and 4 oz. fresh meat. This deficiency becamemuch accentuated owing to the conditions of service at the Front. Thegreat cause of the wastage in the Indian troops of the MesopotamianForce up to the end of 1916 was scurvy. To understand this thoroughlyit is necessary to call attention to the system of rationing of Indiantroops in India prior to 1917. An allowance was made to each soldierequivalent to the cost of the items in the field service ration. Hebought his ration from the bunniah or food contractor of his unit.The Indian has the instinct of saving money for his famnily very firmlyimplanted in his mind and under the old system of rationing Indiantroops in India there was no guarantee that the Indian soldier boughtand consumed even the field service ration. He no doubt often starvedhimself to save a few annas. As a consequence of this system theIndian troops arriving from India in Mesopotamia were found in manycases to contain a considerable percentage of men anmmic and debilitatedand suffering from pyorrhoea and a ready prey to scurvy if put underhardships as regards the restrictions in diet necessitated by service inthe field. They had little " balance in the bank" against the onsetof the deficiency disease scurvy and their latent period would be shortwere dietetic hardships imposed on them.

My colleague, the late Colonel H. G. Melville, I.M.S., paid specialattention to the examination of Indian troops arriving from Indiaduring the latter half of 1916, and he found at this time a considerablepercentage of men on arrival to be anaemic, lebilitated and sufferingfrom pyorrhcea. These men were not actually suffering from scurvybut they were in a condition to be strongly predisposed to it.

The British soldier, on the other hand, came out to Mesopotamiawell nourished and with a good "balance in his bank" against deficiencydisease, and if he developed this his latent period would be a long one.

A glance at the map of Mesopotamia shows the military situationup to February 23, 1917, when the Tigris was crossed at Shumram andthe Turks retreated towards Baghdad. From December 11, 1915, upto this date the operations of the Mesopotamian Force were directedtowards the relief of Kut and the advance onwards to Baghdad.Basrah and Amara were centres of local production of fresh fruitand vegetables and the incidence of scurvy was very slight amongst thetroops stationed there. Beyond Amnara there were no centres of localproduction of fruit or vegetables and troops had to rely entirely on theriver transport of supplies for these articles.

Attempts were made by the Army to grow vegetables for the

9

10 Willcox: Diseases due to Dietetic Deficiencies

troops, but it was impossible to do this in sufficient quantity since inMesopotamia irrigation is essential for cultivation and a scheme forgrowing vegetables for the Army on a large scale would have takena very long time to carry out. Also the art of growing fruit andvegetables successfully in Mesopotamia demanded a long and intimateexperience of local conditions, and it was found that this could be muchmore economically and satisfactorily carried out by the native Arabsunder our supervision, the produce being purchased from them bythe Army.

During 1915 and 1916 the river transport was taxed to its utmostin conveying troops and supplies and in carrying sick and woundeddownstream, and no special provision for the transport of fresh fruit orvegetables or fresh meat was available until towards the end of1916. The climatic conditions of Mesopotamia were such thatvegetables and fruit sent by river from Basrah arrived generally in adamaged condition unsuitable for issue as rations. It is thus obvious thatthe troops in the front area from December, 1915, to February, 1917,obtained few supplies of fresh vegetables or fruit; this explains the,fact that up to February, 1917, there was an enormous incidence ofscurvy amongst Indian troops in the front area in Mesopotamia.

ALTERATIONS OF RATIONS.

The incidence and causation of deficiency diseases in Mesopotamiawas thoroughly appreciated and steps were taken to put the rationscales on a scientific basis as regards deficiency disease. The ArmyCommander, Sir Percy Lake, in 1916, with this object sanctioned theration scales of July 4, 1916, which were a great improvement asregards the protection from deficiency diseases.

TABLE III.-RATION, JULY 4, 1916.

(A) British Troops. Field Ration.(1) Bread .. ... 1 lb. (10) Condensed milk ... 2 oz.(2) Fresh meat ... ... i lb. (11) Salt ... . oz.(3) Bacon ... ... 3 oz. (12) Pepper ... .... s16 oZ.(4) Potatoes ... ... 1 lb. (13) Wood ... ... 3 lb.(5) Tea ... ... 1 oz. (14) Oatmeal ... ... 4 oz.(6) Sugar ... , 2i oz. and Condensed milk 2 oz.(7) Cheese ... ... 3 oz. (15) Tobacco, weekly ... 2 oz.(8) Rice ... ... 3 oz. (16) Matches, weekly ... 2 boxes(9) Jam ... ... 3 oz.

Extras.(1) Chocolate ... ... 1 oz. (4) Dates .. ... 4 oz.

and Bread ... 4 oz. (5) Fresh fruit ... ... 4 oz.(2) Lime juice ... ... i fl. oz. (6) Dry lentirs... ... 2 oz.

and Sugar... ... i oz. Curry powder ... . oz.(3) Rum ... ... 4 fl.. oz. (7) Limes ... 3 per man

Section of Therapeutics and Pharmacology

TABLE III-(continued).

(B) Indian Troops. Field Ration.

(1) Atta ........ ... 1j lb.(2) Fresh meat ... ... 4 oz.(3) Dhall ... ... 4 oz.(4) Ghi ... ... 2 oz.(5) Gur ... ... 2 oz.(6) Potatoes ... ... 2 oz.(7) Fresh fruit ... ... 2 oz.(8) Tobacco, weekly ... 2 oz.

(Substitutes same as per British troops)

(9) Matches, weekly(9a) Condensed milk(10) Tea ...

(11) Ginger ...(12) Ohillies ...

(13) Turmeric ...

(14) Garlic(15) Salt(16) Fuel ...

Extras.

(1) Atta(2) Ghi... ...

or Gur(3) Fresh meat ...

3 lb.1 oz.2 oz.2 oz.

(4) Fresh vegetables(5) Fresh fruit ... ...

(6) Tamarind ... ...

(7) Rum (25 percent. underproof) ... ...

Later the rations were farther improved and the Army Commander,General Sir Stanley Maude, who took a very great interest in theprevention of scurvy and beriwberi, sanctioned the ration scales ofOctober 31, 1916.

TABLS IV.-RATIONS, OCTOBER 31, 1916.

British Troops.

Daily.

(1) Bread (or Biscuit, 12 oz. when bread not available) ...

(2) Fresh meat (or preserved, 12 oz., when fresh not available)(2A) Pickles, when preserved meat is issued ... ...

(3) Bacon ... ... ... ...(4) Potatoes or fresh vegetables (or dried vegetables, 3 oz.,

fresh not available) ... ... ... ...

(5) Tea ... ... ...

(6) Cheese (not in summer) ... ... .. ...

(7) Sugar ... ... ... ... ... ...

(8) Jam or golden syrup ... ... ... ...

(9) Tinned milk ... ... ... ...

(10) Salt ...

(11) Fresh fruit (or tinned fruit, t oz., or dried fruit, 1 oz.,

fresh fruit not available) ... ...

(12) Soup or Oxo (not in summer) ... ...(13) Fuel (coal 1 lb., wood 1 lb.) ...

Weekly.

(14) Pepper ... ... ... ... ...

(15) Mustard ... ... ......

(16) Tobacco (or cigarettes, No. 40, or sweets, 4 oz.)(17) Matches ... ... ...

lb. oz..,, 1 0,. 1 0

...I

11

3hen

12

... 3

... 3

... 32

lien... 2... 2

2 0

wb

wb

I

22

... .......

... (boxes)

Twice weekly.

(18) Marmite, Monday and Thursday (not in sununer) ...

11

2 boxes2 oz.,A oz.i oz.w oz.* oz.wA oz.

I oz.1I lb.

4 oz.4 oIz.2 oz.

2 fl. oz.


TABLE IV-(continued).

Thrice weekly.lb. OZ.

(19) Oatmeal (Monday, Wednesday and Friday) ... ... ... 3(20) Tinned milk (Monday, Wednesday and Friday) ... ... 1(21) Rice (Tuesday, Thursday and Saturday) ... ... ... 2(22) Curry powder (Tuesday, Thursday and Saturday) ... ...(23) Butter (Monday, Wednesday and Friday), not in summer ... 2(24) Lime juice (Tuesday, Thursday and Saturday), not in winter ...

Indian Troops.

Daily.

(1) Atta or rice ..... .....*..... ... 1 8(2) Fresh meat (or gur, 2 oz,, when fresh meat not available) ... 6(3) Dhall ....... ..... ... ... ... ...4(4) Gur ......... ... ... ... ... ... -2(5) Ghi .. ... ... 2(6) Potatoes or fresh vegetables (dried vegetables, 2 oz., when fresh

not available) ... ... ... ... ... 6(7) Fresh fruit (tinned fruit, 2 oz., or dried fruit, 1 oz., when fresh

fruit not available) ... ... ... ... 2(8) Tea ....... ... ... ....(9) Milk, tinned ... ... ... ... ... ...2

(10) Condiments (ginger, chillies, garlic, turmeric) ... ...(11) Bait .. .. .. .. ... ... ...i(12) Tamarind or coccum ... ... ... . .. 2(13) Fuel (wood) ... ... ... ... ... ... 2 0

Thrice weekly.

(14) Ghi (Monday, Wednesday, Friday) ... ... ... ... 2(15) Lime juice (Tuesday, Thursday, Saturday), not in winter ... fl. oz.

Weekly.

(16) Tobacco (Sundays) or cigarettes, No. 40, or sweets, 4 oz. .. 2(17) Matches ... ... ... ... boxes 2

REVIEWING THE RATION SCALES OF OCTOBER 31, 1916.

As regards protection against scurvy the Indian ration contained:Potatoes or fresh vegetables, e.g., onions, 6 oz. ; fresh fruit (limes, &c.),2 oz.; fresh meat, 6 oz.; tamarind or coccum, 2 oz.; lime juice, i oz.three times a week. The only difficulty was the conveyance of thisration to the troops. The fierce heat of Mesopotamia rendered thecarriage of perishable articles such as vegetables, fruit and fresh meatup the 300-mile journey on the Tigris an impossibility without specialprovision as regards transport. Up to the latter part of 1916 there wasan inadequacy of transport both on river and land to cope with thisgreat problem. Towards the end of 1916 the transport became muchimproved and refrigerator barges with cold storage chambers for freshmeat arrived, which were of great value. Major-General Sir G.MacMunn, K C.B., Inspector-General of Communications, took a great


interest in the problem of conveying antiscorbutics to the troops on thefront and devised crates for carrying fresh vegetables and fruit, whichwere of great value in protecting them from damage during transport.

Fresh Meat.

The evidence from the Mesopotamian campaign proved that this isof important antiscorbutic value. During 1916 when the troops at theFront, both British and Indian, were unable to get fresh vegetables orfruit for long periods the only protection that the British had abovethat of the Indians was the fresh meat allowance-I lb. daily. Theywere unable to get this, but usually two or three issues were obtainedfrom local supplies of Arab sheep, and on other days tinned beef wouldbe issued. The Indian troops did not care for meat and usually hadonly one or two rations of 6 oz. per week. On other days owing totheir caste prejudices tinned meat could not be issued.

Further evidence of the value of fresh meat was obtained byinvestigations carried out in 1916 by Nos. 9 and 10 Indian GeneralHospitals by Major Marjoribanks, I.M.S., on Indian patients sufferingfrom scurvy. Two parallel groups of scurvy cases were treated onidentical lines as regards diet: one group of patients was given a dailyration of fresh meat juice, and these improved much more rapidly thanthe other patients. I saw these patients several times in consultationand can testify to the striking antiscorbutic value of raw meat juice.The climatic condition of Mesopotamia and the risk of parasiticinfection prohibited the use of raw meat juice in the treatment andprophylaxis of scurvy. In the treatment of cases of scurvy in hospitalthe beneficial effect of a liberal allowance of fresh meat was verystriking.

Tamarind in all probability has antiscorbutic properties. It wastaken by the Indian troops either as a chutney with stewed meat, or asan infusion with sugar, which formed a palatable acid drink. Coccumis a sort of dried plum, which appeared to have no antiscorbutic value.It has had a reputation in India as an antiscorbutic, but it was not likedby the Indian troops and was little used in Mesopotamia.

Lime Juice.The ration lime juice up to the end of 1916 had no antiscorbutic

value and had no beneficial effect on patients suffering from scurvy.It usually arrived in Mesopotamia after a long journey overseas, andwas probably six months or more old before issued. At my suggestion

13

14 - Willcox: Diseases due to Dietetic Deficiencies

in August, 1916, fresh lime juice was prepared in India from fresh limes,a small quantity of alcohol (5 per cent.) and salicylic acid (2 gr. to thepint), being added as a preservative. This was sent to Mesopotamiain special casks with the date of preparation marked on it. This gavebetter results as regards antiscorbutic properties and was used in thetreatment of patients suffering from scurvy as well as for issue totroops.

Lime-juice as a prophylactic against scurvy is of uncertain value,since it is difficult to ensure its delivery to an army in the field withinthree months of its preparation, after which time much of its anti-scorbutic value is lost. Undoubtedly when fresh it has importantantiscorbutic properties, which I saw demonstrated on many occasionsin patients suffering from scurvy. After the occupation of Baghdadlime juice was prepared from limes and bitter oranges obtainedlocally and preservative was added as above described. This wasissued to troops with as little delay as possible, and had an undoubtedvalue as an antiscorbutic.

The recent work of Miss Chick and Miss Hume, showing thesuperior value of lemon juice to lime juice is of great value andinterest.

During the deficiency of fresh vegetables and fruit in 1916, inconsequence of the great incidence of scurvy in Indian troops, anorder was issued that Indian troops should have the first call onthe fresh vegetables and fruit available.

BERI-BERI IN RELATION TO THE RATION SCALES.

Indian.-This ration is highly protective as regards antiscorbuticvitamines. Atta was the usual issue to Indian troops, although ricewas an alternative. Atta is a wheat flour containing the germ andsome of the aleurone layer of the grain, so that it is rich in anti-beri-beri vitamines. Dhall contains the coat and germ of the lentiland is rich in antiscorbutic vitamines.

British.-In 1915 over 300 cases of beri-beri occurred amongstBritish troops. The Indian Field Service British ration wasprotective against beri-beri but owing to the inadequacy of transportand the long distances from the base of the troops at the front, freshmeat and vegetables were not available so that the basis of the rationwas tinned beef, bread or biscuits, jam and tea. The British bread andbiscuits were made of white flour from which the germ and aleurone


layer had been removed, thus depriving them entirely of anti-beri-berivitamines. Hence the British soldier as regards his vitamine rationbecame liable to beri-beri and in many cases fell a victim to thisdisease. In the July, 1916, ration, oatmeal, 4 oz., and dhall, 2 oz., wereadded to the British ration to supplement the British vitamine deficiency.In October, 1916, marmite, 4 oz., three times weekly was added to theration.

Marmite.

Beri-beri cases occurred in the Dardanelles. I saw practicallyall ofthese cases, and, at the suggestion of Colonel C. J. Martin, advised thetreatment with yeast, which gave satisfactory results. In February,1916 (vide Lancet, Mtarch 11, 1916), I suggested to the SanitaryCommittee of the War Office the advisability of an extract of yeastbeing issued to the troops as a prophylactic against beri-beri. Experi-ments were instituted at the direction of General Sir William Horrocks,K.C.M.G., and carried out by Professor Starling, F.R.S., Dr. S. M.Copeman, and their co-workers. These showed that extract of yeastwas a prophylactic against beri-beri, and a preparation known as marmitewas issued to British troops in Mesopotamia in October, 1916. Marmitecan be mixed with warm water and taken like bovril or be added to astew after cooking. Marmite was undoubtedly of great value as aprophylactic against beri-beri in Mesopotamia, and it was a valuableremedy in the treatment of cases that occurred. It kept well inMesopota.mia, and no difficulty was experienced in its issue as a rationto the troops.

In February, 1917, at my request, experiments were carried out atAmara to determine the practicability of issuing bread to Britishtroops made with a certain proportion of atta in the flour. Loaves weremade with flour containing 100 per cent., 75 per cent., 50 per cent.and 25 per cent. respectively of atta. In all cases the bread wasvery palatable but the addition of atta caused some difficulty in therising of the dough so that the bread was somewhat heavier. Breadmade with 25 per cent. of atta was quite as palatable, and differedlittle from ordinary bread except in the slightly brownish colour. Fora trial the bread was issued to several units at Amara with satisfactoryresults, and later on a general issue of this bread on three days a weekto the Army was sanctioned by the G.O.C. in C.

The issue of bread to British troops rich in anti-beri-beri vitamineswas undoubtedly an important factor in the reduction of beri-beri inBritish troops.

15


Rice.This article of diet as a causal factor of beri-beri amongst the

troops did not attract much attention because, as already mentioned,in its place, atta was almost entirely issued to Indian troops. How-ever, in 1918, a Chinese labour corps arrived at Basrah, and the menof this unit refused to eat any rice except the polished variety, and inconsequence a number of beri-beri cases occurred amongst them. Thedifficulty was overcome by the issue of atta in place of a portion of therice ration and afterwards the outbreak of beri-beri subsided.

After the occupation of Basrah, on March 11, 1917, local suppliesof fresh vegetables and fruit and fresh meat became available in amplequantity. The purchase of supplies was undertaken by the Departmentof Local Resources, the director of which (General Dickson, C.M.G.,C.B.E.) took the greatest pains in ensuring the issue of these articlesto the troops throughout the advanced area.

It was owing to the adequate supply of fresh vegetables, fruit andfresh meat that deficiency diseases were stamped out from theMesopotamian Expeditionary Force after March, 1917;

STATISTICS.Scurvy in Indian troops and beri-beri in British troops were very

prevalent up to July 1, 1916, but no correct statistics were available upto this date. From July 1, 1916, scurvy and beri-beri were madenotifiable diseases in the Army. From July 1 to December. 31, 1916,11,445 cases of scurvy occurred in Indian troops. In 1917 2,199 casesoccurred, and in 1918 only 825 cases although the force had largelyincreased in 1917 and 1918.

TABLE V. -SCURVY AND BERI-BERI.

Total figures, July 1 to December 31.191619 18Last six months 1917 1918

Scurvy-Indians ... 11,445 ... 2,199 ... 825

Beri-beri-British ... ... 104 ... 84 ... 51

Previous to the end of February, 1916, 335 cases of beri-beri were recorded asoccurring in the Mesopotamian Expeditionary Force.

As regards beri-beri, records are available showing that 335 casesoccurred. up to the end of February, 1916. In the last six mnonths of1916, 104 cames occurred in British troops. In 1917 only eighty-four

Section of Therapeutics and Pharmacology 17

cases occurred, and in 1918 only fifty-one cases occurred amongst

British troops.The attached curve shows for 1917 and 1918 the incidence of

scurvy, the maximum being in May and June. The incidental rates

are the admissions to hospital per mille of Indian strength.

Oat.e Jan. Feb. Mar: Api. May June Ju!y Aug. Sept. Oct. Nov. Dec.

Unoutelyth prm assocryJuner-ei r itmn

5 12152 2 316-2 25316233 6IJ2027 4I1i825 1 815222 6132027 310172431,7142128 5121926 2316233 714.2128

-0*60__ __

0*55-8O*50

0-4S~~ ~ ~ ~ __=1917

0-40 A_0:'35

0-30__ _ __ _ _

0.20--015 - ...L -

0d10 o7fg _____

0-05 -- ~ --~__-~-

0-00 -F '~

TABLEC VI.

AETIOLOGY.

Undoubtedly the prime causes of scurvy and beri-beri are vitaminedeficiencies; other factors, however, play a part as predisposing causes.

Climatic influences produced- the maximum incidence of scurvyin the hot 'months of May, June and July, while beri-beri attainedits maximum in November and December. Mental depression ismentioned by Osler as a predisposing cause in scurvy. In Mesopotamiathe depressing influences associated with the campaign in 1916 wereundoubtedly factors in the causation of the high incidence.

Intercurrent Diseases.

Patients suffering from diseases such as dysentery, the entericgroup, and epidemic jaundice, which required careful dieting, wouldrapidly develop scurvy unless care were taken that antiscorbuticsformed a part of the dietary. It was remarkable how quickly scorbuticsymptoms would develop in Mesopotamia in patients on a dietary devoidof antiscorbutics. I have seen several cases develop typicai scorbuticgums within six weeks of admission to hospital. It became a rule,

JA-5


therefore, to add to the diet of all patients in hospital a sufficiency ofantiscorbutics-e.g., lemons, limes, oranges, &c., in order to prevent thedevelopment of scurvy.

In the Dardanelles campaign I called attention to the occurrenceof beri-beri in patients recovering from an attack of epidemic jaundice.The cause of the beri-beri was undoubtedly the absence of anti-beri-berivitamines in the dietary for the jaundice. A few cases of scurvyoccurred in British troops in men with very carious teeth who avoidedeating any fresh fruit or vegetables on account of the difficulty ofmastication. I saw one case in a man who had an intense disliketo fruit or vegetables of any kind.

" Starvation" per se does -not cause scurvy or beri-beri. In May,1916, I examined a large number of sick who had been in Kut fromDecember 11, 1915, to April 29, 1916, during the period of its siege.Many of these showed signs of acute starvation, but the signs of beri-beri and scurvy were not usually manifest in them.

TREATMENT OF SCURVY AND BERI-BERI.

In order to obtain effective control of these diseases, in June, 1917,special hospitals were established in the centres Baghdad, Amara, andBasrah for scurvy and beri-beri-an Indian hospital for scurvy and aBritish hospital for beri-beri. A special medical officer was attachedfor duty in each of these hospitals, and special registers were kept inwhich all the scurvy and beri-beri cases were fully recorded. In thisway the occurrence of scurvy or beri-beri in any unit 'was at oncerecognized, and also uniformity of diagnosis and treatment was ensured.It was ordered that all the cases were to be seen by the consultingphysician of the respective areas, who would advise as regardsmanagement, treatment, and disposal.

Scurvy.The symptoms of scurvy exhibited by the individual cases called

for special lines of treatment, thus anemia and debility were the earlysymptoms.

Gum Changes.-The hyperplastic condition of the gums, withcharacteristic red buds between the teeth often shown best on the buccalaspect, was the most common symptom. In some cases the gums wereso swollen as to have an appearance resembling a new growth. Pyor-rhcea, which is quite a distinct disease from scurvy, often accompanied


it, and no doubt by its presence tended to accentuate the symptomsof scurvy.

Palate Changes. Petechis, or patches of hoemorrhage, occurred inthe soft and hard palate, and if old had a pigmented appearance, alsoa characteristic dark crimson or purplish area of discoloration com-monly extended from the inner aspect of the molar teeth upwardstowards the palate. This sign was very common, and a very valuableearly indication of scurvy. The palate itself was very pale owing tothe marked anaemia present.

Mluscle Haemorrhages.-These were very common (about 30 percent.), and usually occurred in the calf or thigh muscles or around thepopliteal spaces or anterior tibial region, forming a hard brawnyswelling, hot to the touch and tender on pressure.

(Edema.-Scorbutic cedema of a firm brawny type occurred in thelegs and feet and around the tendo Achillis; this oedema was of quitea different type? from cardiac or renal dropsy, and often showedtenderness on pressure. It was too firm to pit readily. Subperiostealswellings, e.g., along the ulna or tibia, were fairly common. Effusioninto the joints of a hemorrhagic type sometimes occurred.

Skin.-In Indians skin manifestations were very difficult to deter-mine owing to the natural pigmentation of the skin. In white racespurpuric patches are very common, and a general earthy or bluishappearance of the skin is frequently present.

Subjunctival hwmorrhages occurred in a few cases. Hwmorrhagicpleural efJusion was seen by me in six cases. Some cases showedhoemorrhage from the bowel, which required careful differentiationfrom dysentery.

Dilatation of the heart was usually present in severe cases, andwas an important indication of the period of rest in bed. Haemicmurmurs usually accompanied the dilatation.

Captain A. J. Stevenson, M.C., R.A.M.C., was appointed M.O. incharge of the scurvy wards in the special scurvy hospital in Baghdad,and he did valuable work. The following scheme of treatment forscurvy cases in Indians was drawn up by us:

(1) Rest in bed was essential as long as the anamia or cardiac dila-tation persisted, also the presence of muscle hoemorrhage, cedema,periosteal or joint hoomorrhages, or other severe hmorrhagic symptomsdemanded comiplete rest in bed.

(2) Local Treatmentt of the Mouth and Gumns.-A solution of 1 percent. salicylic acid in alcohol was applied to the gums twice daily,

JA-5a

19


and also a mouth-wash of alum and carbolic acid was used frequently.Dental treatment, such as scraping of the teeth to remove tartar, andremoval of carious teeth was carried out.

(3) Anwneia.-A mixture of iron and arsenic was given for this inaddition to the other measures.

(4) Diet.-6 a.m., tea and biscuits, and 2 oz. fruit; 8 a.m., 2 OZ.fresh lime juice; 10.30 a.m., chapatie or rice with 8 oz. vegetablesand two pints fresh milk; 12 noon, i oz. fresh lime juice; 2 p.m., 10 oz.fresh fruit; 7 p.m., 14 oz. meat, 8 oz. vegetables. Tomatoes, cucumbersand onions were given raw. Other vegetables were boiled for twentyminutes.

The accompanying tables show the selection of fruit and vegetablesobtainable in the Baghdad area:-

TABLE VII.-VEGETABLES OBTAINABLE IN THE BAGHDAD AREA.

A. B.Summer planting commencing from the month Winter planting commencing from the month

of February. of Septenmber.Onions. Tomatoes. Cabbage. Turnips.French beans. Cucumber. Beans. Radish.Haricot beans. Pumpkin. Spinach. Cauliflower.Brinjals. Melons. Beetroot. Lettuce.Lady's finger. Water melons. Carrots. Purslain.

TABLE VIII.-FRESH FRUITS OBTAINABLE IN THE BAGHDAD AREA.

C. D.Fruit produced during the summer looally. Fruit produced during the wvinter locally.Apricots. Figs. Oranges. Limes.Apples. Dates. Tangerine oranges. Quince.Peaches. Pears. Sour oranges. Pomegranates.Plums. Mulberrv. Lemons. Citron.Grapes.

One of the most effectual remedies for scurvy is raw potato salad.It is made by cutting raw potatoes into very fine slices and addingslices of onion and a little vinegar. Captain A. L. Shepherd, I.M.S.,at my suggestion tested this in 1916 on cases in the scurvy camp at thefront area. He found that it gave the best results of any of the anti-scorbutics he was then using.

(5) Physical exercises were given for twenty minutes twice a day tothose patients sufficiently well to undergo them. In a few isolated casesthe muscle hiemorrhages suppurated. These cases required surgicaltreatment-incision, &c. The cases of scorbutic htmothorax requiredtreatment by aspiration in addition to the other treatment of scurvy.


(6) Germinated Dhall.-The discovery in 1917 by Miss Chick andMiss Hume of the value of this as an antiscorbutic has resulted insupplying a very valuable antiscorbutic prophylactic to forces in thefield where no fresh vegetables or fruits are available. It was un-fortunate that this discovery was not made during the trying periods of1915 and 1916 in Mesopotamia, when antiscorbutics were unavailablefor the troops at the front. After May, 1917, germinated dhall was usedin outlying districts in Mesopotamia as a ration when fresh vegetables orfruit could not be supplied. The remedy was also employed in hospitalsfor the treatment of scurvy cases, but it had no advantage over the useof fresh fruit and vegetables, and was less palatable. The great valueof germinated dhall is that it can be used as a good substitute for freshfruit iand vegetables when these are not available. It is not meant totake the place of these.

Beri-beri.

In a country like Mesopotamia, where toxic influences causingmultiple neuritis were prevalent, the most careful examination wasnecessary to exclude such cases of multiple neuritis as: (a) dysentery,(b) enteric or paratyphoid fever, (c) effects of heat, (d) malaria, (e) sand-fly fever, (t) diphtheria, since these not uncommonly caused symptomsof multiple neuritis like beri-beri. The early signs of beri-beri werethose of cardiac weakness accompanied by symptoms of multipleneuritis, the disease being associated with vitamine deficiency as regardsdiet.

A valuable early diagnostic test for troops consisted in the squattingtest which I described in the Lancet, March 11, 1916. In this paperthe treatment for beri-beri cases was carefully dealt with. In Mesopo-tamia the cases were treated on similar lines to those described, theonly difference being that marmite was used in place of yeast, it beinggiven three times a day.

CONCLUSION.

The experiences of the War, especially in distant countries such asMesopotamia, called for special attention to the scientific rationing oftroops. The old idea of sufficiency of calories, or of proteins, fat andcarbohydrates is quite inadequate to meet the needs.

A dietary to be satisfactory must contain proteins, fat and carbo-hydrates in the proper amount and also must satisfy the calorierequirements. In addition it is essential that it should be adequate as

21

22 Wallis: Diseases due to Dietetic Deficienzcies

regards vitamine content, e.g., it must be protective against scurvy, beri-beri and other deficiency diseases.

Too often financial considerations predominate, and I cannot let thisopportunity pass without calling attention to the action of the IndianGovernment in the matter of the rationing of the Indian soldiersserving in India. On February 17, 1917, a ration was sanctioned bythe Indian Government for Indian troops in India. This ration repeatsthe field service ration which had been responsible for the enormousoutbreak of scurvy in the Indian troops in Mesopotamia, and indeed itis inferior as regards antiscorbutic value for it entirely lacks any freshmeat allowance. Under a ration of this kind scurvy is likely to beprevalent amongst Indian troops in India, and if at any time they arecalled upon for active service there is bound to be a great wastage owingto the incidence of scurvy. This method of rationing may appeareconomical to those without special knowledge, but to those who havestudied the subject it is a false economy. It seems incomprehensiblethat after the tragic experiences of Mesopotamia the saine mistakesshould be repeated.

Since the rationing of troops or of a civil population is carried outusually by the laity not possessing special medical knowledge, theeducation of the lay mind in the scientific principles which form thebasis of a sound dietary is of the utmost imnportance. For this purposein Mesopotamia the " Official Memoranda " on scurvy and beri-beriwhich had been carefully drawn up were circulated not only to all themedical units but to the O.C.s of all combatant units in the Force. Theeducation of the fighting forces in the principles of rationing as regardsprotection from the deficiency diseases scurvy and beri-beri was ofgreat value, for the Commanding Officers took the greatest care to set.that their troops received those articles of their dietary which wereessential for their protection.

Dr. MACKENZIE WALLIS.

My reinarks this evening refer more particularly to beri-beri.Experiments carried out in India upon the food value of the ground-nut, known also as the monkey nut, pea nut or Arachis nut, led to thefact that it was remarkably rich in anti-beri-beri vitamine. In view ofthis both bread and biscuits were made from the nut in the followingway: The thin red skin was first removed from the nut, and the arachis

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