(Metal paper.

REPORT OX THE OUTBREAK OF BERI-BERI IN

THE CRIMINAL PRISON, SINGAPORE. 1/ Ckiminal Prison Hospital,

Singapore, 14th June, 1880. Sir.?I have the honour to forward, for the information of

Government, the following Report on the outbreak of Beri- beri in the Criminal Prison, from its outset to the present time.

2. According to some authors, the name of this disease is derived from the Singalese word "beri" or "weakness," "beri-beri" meaning "great weakness." It is also termed the " bad sickness of Ceylon."

3. According to others, it takes its name from the Hindus- tani word " behri" signifying a sheep,^ on account of the strag- gling gait of those affected with it, resembling the walk of these animals.

4. Its appearance was first recognised as a distinct affec- tion in this Prison in the early part of May, 1875, though, from the information afforded by previous records, it may fairly be gathered that it had occurred, from time to time, in a sporadic form, but classified under the heads of oedema, general dropsy, rheumatism, and paralysis.

5. It at first confined itself to long-sentenced Malays, but as time passed and the disease spread, prisoners, both long and short term, were attacked?Chinese, Malays, and Indians alike. This will be readily illustrated by a glance at Table 2?, which gives a tabular statement of the number of those attacked, and their nationalities, &c. With the exception of the year 1877, which was an unusually dry one, and was one, moreover, in which all the prisoners were employed in labour outside the Prison, it will be observed that the disease has made steady progress, till at last, owing to the rapid increase in the numbers of prisoners attacked, and the certainty of more, it was found necessary, in the beginning of April of this year, to recommend to Government that the whole native portion of the Gaol be at once con- demned as unfit for occupation.

6. It is worthy of remark, that not only the European, but the native female prisoners as well, have enjoyed perfect immunity. The reason of this will appear later on.

Pathology. 7. The nature of this malady is acknowledged to be ob-

scure. It is supposed to be endemic in the tropics, to be limited to certain latitudes, and not to extend further in- land than from forty to sixty miles.

8. The former supposition, however, would appear to be incorrect, as it is well known, and has been described as

existing in an endemic form in certain low lying parts of Ja* pan, where it shows itself only during the hot months of the year. It has no existence in the colder climates. In Java, Sumatra, Ceylon, and the northern parts of the Madras Presidency it has been long known, and great fatality attends it; in many cases the onset and termination are equally rapid and unexpected.

9. The ratio of mortality in our Gaol from this cause alone during 1878-was-16*20 per cent., and in 1879, 2063 per, cent'. The increase during the latter year was owing- to many of the

92 THE INDIAN MEDICAL GAZETTE. [March 1, 1881.

admissions being cases of relapse, and to the disease having become more virulent in type.

10. This ratio of deaths to admissions, though high, con- trasts most favourably with that of similar outbreaks in India, Ceylon, and elsewhere, whether among the Europeans or Natives, and in a disease of this virulence and nature is

habitually high. 11. Table A will show the mortality occurring in our

Prison in the different years, from the commencement of the disease till the end of the first quarter of this year.

12. It has been, as a rule prevalent during the decline of one monsoon, and the setting in of another, when the vicissitudes of temperature are at their greatest, as well as during certain loaded states of the atmosphere, and when- ever the rainfall has been excessive. During the whole of the rainy N.E. monsoon, the number of admissions has

always been augmented. Reference to Table B will show this. A certain length of residence in the Gaol has been found to be essential for its production, but this period has become more and more curtailed with the increased

development and intensification of the disease. Damp and moisture have had their unquestioned influence in adding to the numbers of those attacked.

13. It has been characterised, in most cases, by its insi- dious commencement and progress, and by the difficulty of its detection in the early stages ; it develops a tendency to a watery condition of the blood, as shown by debility, small pulse, short breath, throbbing in the vessels of the neck, with a bruit de iliable souffle in the cervical veins, and palpitation on any slight exertion.

Morbid Anatomy. 14. In the many post mortem dissections held in the

Prison, the appearances presented have been very uniform. They may be thus briefly enumerated :?

a. In the generality of cases a most striking and unusual deposition of fat throughout the body. This was one of the appearances which was earliest noted.

b. Effusions of serous fluid into the areolar tissue through- out the body. This is, however, absent in many of the cases, especially such as have had a short dura- tion, and been suddenly fatal.

c. Effusions of varying amount into the chest and pericar- dium. The quantity effused into the latter space has averaged from three to six ounces.

d. There is generally more or less serous effusion into the abdomen, but rarely amounting to ascites.

e. In all cases effusion has been found, not only in the ventricles of the brain, but on the surface of the cerebrum itself. The quantity of this, however, is very variable. There is also effusion into the

spinal canal, which accounts for the paralytic symptoms.

15. The heart is, as a rule, pale, enlarged and flabby, sur- rounded by deposits of fat. The structure of the valves has been found to be often affected, whether accidentally or not, it is impossible to say. In the heart cavities, large masses of coagulated lymph have been of frequent occurrence. The musculi pectinati are often hypertrophied, as also the whole muscular substance of the heart. There is no doubt that death in this disease often takes place from embolism on account of clots passing into the circulation.

16. The lungs are cedematous, their fine connective tissue being filled with fluid.

17. The kidneys have been found to be pale, enlarged, and fatty ; the spleen pale, and more than ordinarily friable.

18. The brain sometimes, and always the spinal cord, have been found congested. There is no doubt that it is the cord which is primarily affected in the disease.

Symptoms. 19. The symptoms may be gradual in their appearance,

or be at once sudden and severe, spreading over a period of from a few hours to as many months. As they have been noted in this Hospital, they are as follows :?

20. A feeling of weakness, lassitude, and languor, inapti- tude for exertion, stiffness and formication of the legs and thighs followed by numbness ; later on by oedema and some- times paraplegia. This numbness, in course of time, extends to the upper extremities and abdominal walls. The body then generally commences to swell, there is a distressing

sense of fulness at the pit of the stomach, increased after meals, tension and weight at the praecordia, difficult breath-

ing, especially on motion, and the usual train of symptoms attending thoracic effusion. With the progress of the disease the dyspnoea becomes extreme, sleep becomes uneasy, there is difficulty in lying down, vomiting is often present, and muscular spasms of different parts of the body occur. The

pulse increases in frequeney and feebleness, there is flutter- ing about the heart, the lips and countenance become livid, there is a scared aspect, the extremities become cold, and the patient soon dies nearly suffocated.

21. In the more sudden cases, these symptoms have follow- ed one another with the utmost rapidity, and a few hours have sufficed to close the scene.

22. The bowels are, as a rule, torpid, requiring for their evacuation the occasional use of the so-called drastic purga- tives. Diarrhoea and nmous dysentery have been exceptional occurrences. The urine is scanty, high-coloured, albuminous ; and fatal cases are preceded by almost complete suppression of this secretion. The intellect remains, as a rule, uncloud-

ed, and consciousness is retained to the last, much resem-

bling, in this peculiarity, death from cholera morbus. Scorbutic symptoms have shown themselves in some cases by the presence of spongy gums alone. A white line at the com- missures of the mouth is an almost universal premonitory sign.

23 Relapses have been very frequent, each fresh attack adding to the danger.

24. Burning of the hands and feet have not been observed as a symptom.

25. In many instances little else has been complained of beyond rheumatic pains in the limbs, and no oedema has existed throughout. The most quickly fatal cases have been such as were accompanied by the least visible outward signs, i. e., in men of apparent health.

2G Before entering upon what must be admitted to be the essential agent in the production of this outbreak in the

Prison, it would be well to mention some of the causes which have been assigned for the disease by writers on the subject.

27. These will be found materially to vary, and are :?(1) Impure water ; (2) Deficient and poor diet; (3) Damp and moisture ; and (4) Marsh miasm.

Water.

28. Water as a cause may be at once dismissed, for there can be no question that the water supply to the Gaol is good, and is what is supplied to the whole town, being brought by pipes from a reservoir in the country some five milea distant. Since its introduction into Singapore town, not a

single case of cholera, so far as I am aware, has appeared.

Diet.

29. The scale of food supplied to the prisoners will be found by reference to Table C.

30. I feel assured that the dietary per sc cannot be credited with having been a factor in the causation of the disease. It is a prison diet, but it is one which is liberal, suffieiently nutritious, and varied.

31. It lias been an increasing and not a decreasing diet. The nitrogenous element is certainly deficient in it, and this I purpose recommend having rectified.

32. It is the same diet which is in use in the Gaols of the sister Settlements of Penang and Malacca, and is that which the native female prisoners have had and who fatten on

it. It is the same as the prisoners have had who have been sent to the Civil Prison for treatment, and is a diet unques- tionably better than the mass of prisoners, previous to their entering the Gaol, enjoy outside, and, in liberality, will vie with that of almost any of the Gaols in India. It is, moreover, a dietary on which two-thirds of the prisoners gain weight, and some largely so.

33. That this disease is not caused by any particular diet is clearly proved by the fact that all classes of individuals are liable to contract it?natives or Europeans, whether under favourable or unfavourable circumstances as regards food. It has occurred in persons, when exposed to its influence, who have had the same diet all their lives, in free men who have a choice of diet, in European Officers as well as men, and in natives working on their own account, having quarters of their own selection, but who unfortunately have been in situations where they have been exposed to its influence.

March 1,1881.] OFFICIAL PAPER. 93

34. The history and progress of the outbreak too have

shown conclusively that the diet has been a cipher in its

production. In wet weather and certain atmospheric con- ditions, the numbers increased ; in dry weather, the opposite condition prevailed.

35. In the year 1877. which has been mentioned as an

exceptionally dry year, only two cases were admitted for treatment. The rainfall this year was about one-half of that

of either 187S or 1879.

36. In addition the symptoms have latterly shown them- selves far too soon among new prisoners to admit of its being ?a question of diet at all.

Damp and Moisture.

37. With regard to damp and moisture, there can be no question that, without this exciting element, Beri-beri would not live. Damp alone, however, will not cause it. Proof is

simple to substantiate this.

Malaria,.

38. Malaria or marsh miasm is the fourth cause of this

disease, which has been adduced by authorities, and it is

without doubt this influence which has been in operation in our Gaol. This opinion, I may add, is confirmed by Dr. Anderson, Resident Surgeon of this place, who has had large experience of this disease in Java and elsewhere. To this

also its occurrence in Japan is attributed by those medical

men who have observed it.

39 The Prison is built on an old mangrove swamp, at an

average level of only two-and-a-half feet above high water

mark, is surrounded by high walls, and along one side of it runs a tidal stream much contaminated with organic im-

purities. 40. The drains connected with the Prison are surface

drains carrying off the water from the roofs of the different

buildings. There is no deep subsoil drainage of any kind. 41 Opposite to the European and more elevated portion

of the building, a stone embankment exists which effectually prevents the percolation of the canal water into the soil in this locality. Here too the bank is higher, and no overflow ever has taken place.

42. In this portion of the Gaol, which is some two feet higher than the native part, is placed the Hospital and the

Dormitory for the female native prisoners in separate enclosures.

43. Opposite to the part of the Prison occupied by the natives, the bank of the stream is very low, the result being that, at high tide and after heavy rains, the water rises to a level with that of the surface of the Prison enclosure and overflows into it through the outlet drains. This evil has been very much aggravated by the erection of sluice-gates close to Raffles' Institution Bridge, in March, 1878. These

gates were on occasions naturally closed, and as the water could not pass through them, it found its way back to the Gaol compound through the outlet drains. On representation to the Municipality, these gates are now kept permanently open. The foul water, too, from the canal finds its way by percolation into the Gaol soil, there being no stone embank- ment to prevent it.

44. There can be no doubt, that these gates materially affected the increase in the sickness, which, it will be seen, corresponds with the date of their erection. A reference to Table A will show how this is borne out.

45. The surface soil is a made one, averaging two feet in depth, consisting of about six inches of white sand on the top, then twelve inches of red earth, and lastlv six inches of black sand resting on mangrove mud. It is loose and permeable, readily absorbing and retaining moisture, and capable of the easy transmission through its substance of the gases resulting from the oxidation of the organic matter beneath it.

46. On digging down into it water may be reached at a depth varying from between one-and-a-half to three, or at the most four, feet m different parts of the compound, a ground water

^ar ^igh ke compatible with health. The depth <>t this ground water would vary with the amount of rainfall and would also be under tidal influence.

47. In one spot mangrove roots were found at a depth of about one-and-a-half feet from the surface.

48. The chemical constitution of the water was analysed, and was found to contain under the microscope, organic vegetable cells in a more or less disintegrated state. The vessel containing it, when closed for 48 hours and then

opened, emitted a bad smell. Nesslers test for ammonia was also used, with a positive result. It was only found, however, in small traces.

49. To produce malaria, three principal compounds are required, viz :?the presence of decomposing organic matter in the soil, humidity, and solar heat, which are all therefore in existence in the Prison.

50 Overflowings, whether from sea or river, or an admix- ture of both, as has been the case here, are from the action of the sun's rays, and the resulting high temperature pene- trating to the lower alluvial strata of the soil, well known to be fruitful sources of endemic disease.

51. The high walls around the Prison stagnate the air within it and prevent its escape, thus favouring the conden- sation of malarial poisons circumscribing its limits, and

increasing and intensifying its influence on the human

economy. 52. This accounts, in a great measure, for those resident

in the vicinity of the Gaol not being attacked by it. There are no high walls, and the air, therefore, surrounding their dwellings is quickly renewed and carried off, and to this must be added, of course, the absence of the many evils, such as confinement, the massing of men together in asso-

ciation, Sac., which are incidental to Gaol life. From the

above, it has been fairly proved that Beri-beri is a malarial

poison arising from the decomposition of organic matter in the soil, favoured and strengthened by damp and moisture, and is inhaled into the system through the lungs, acting pri- marily upon the spinal cord. This poison is a great depressor of the vital powers, its first operations being in the quality and distribution of the blood.

53. The recent increase of the disease is almost entirely owing to the heavy rainfall, and the increased dampness thrown on the ground by the inundations from the canal, and caused by the erection of the sluice gates noticed above.

54. Besides the above-mentioned causes, there are other circumstances which have had a certain amount of influence in keeping up the unhealthiness of the Prison, but which, had the Gaol been built on a healthy site, would have been negative in their action in this endemic. I allude to the

high walls, the intersection of the Prison quadrangle by cross walls, the sheds and dormitories being too much crowd- ed together, the system of association among the prisoners, the dormitories being built on the ground iu plaee of on open basemeut arches to admit of a free current of air under

them, and, perhaps., the too sedentary labour of the mass of the prisoners

Treatment.

55. General.?This has consisted in increased vigilance in all points relating to the sanitary condition of the Gaol, such as improving the ventilation of the work-sheds, the latrines, &c., and using all endeavours to keep the dormitories as dry as possible by lengthening the intervals between the washing of the floors, &c. Tar and sulphur were burned every day in them for the purposes of fumigation. The prisoners were recom- mended throughout extra-mural labour. There was a work of importance to be done in 1877, aud*as it was within easy access of the Gaol, all the prisoners were employed at it. That year there were almost no cases of Beri-beri, and, though I attribute this chiefly to the small rainfall recorded, yet, doubtless, this mode of employing the prisoners had its effect in maintaining their health. This work was completed in the end of that year, and there being none other found near enough for safety, or suitable, outside labour had to be abandoned for the long term prisoners.

5G. When the disease first broke out in 1875, and the sick prisoners were not found to rally from its effects, a change to Penang Prison was recommended by the Medical Officer then in charge. This was attended by the best results, the

sea-trip, though of short duration, quite recruiting their health. This recommendation was repeated on occasions

throughout the outbreak, but difficulties attended its execu-

tion, and it was not carried out. Instead of this, the Ci.vil Prison has, on occasions referred to, been made use of, and on the whole, has been found to answer well, the patient,

94 THE INDIAN MEDICAL GAZETTE. [March 1 1881.

soon becoming convalescent from the change to the drier site.

57. When at last the disease spread with such marked rapidity in the beginning of the year, and there was appa- rently no chance of its decreasing, and a panic seemed to seize the whole of the prisoners, there was no other course left than to recommend that the whole of the native portion of the Gaol should be, for a time at least, vacated. This re- commendation was made by a Committee, consisting of three medical men.

58. All long-sentenced prisoners were sent to the Penang and Malacca Prisons, and the sick accommodated in the old armoury building and the native ward at the Sepoy Lines. The short-sentenced prisoners are, in the meantime, sleeping in some of the unoccupied European quarters, an arrange- ment which has been attended with satisfactory results. Since then, only two cases have been admitted for treatment, and these were clearly cases which had contracted the dis- ease before the change to the drier part of the Prison took

place. 59. I do not see, nor do I recommend, that this native

portion of the Gaol can be reoccupied. The air over the ground and around the dormitories has become so saturated now with the poison, that it would certainly not be safe.

60. To rid the Gaol of this malaria, and make it healthy, thorough drainage would have to be carried out, sufficiently deep, and so effective as to ensure the withdrawal of all moisture from the stratum of the ground containing the de- composing organic matter. The native dormitories at present in use would have to be removed, and new ones re-built at an elevation of at least five feet from the ground, with open basement arches to admit of the free circulation of air under- neath them.

61 The stone embankment above alluded to would have to be continued the whole length of the Prison wall to pro- vide against percolation of the water from the canal into the Gaol soil. In addition, other minor alterations, needless to mention, would have to be made.

62. All this, with the new prison in process of execution, would entail an unjustifiable expenditure.

63. In the course of the outbreak many of the prisoners were treated out of the hospital as out-patients, receiving medicines and being seen daily. These were convalescents as such as were in the incipient and premonitory stage with no defined symptoms, and who were not requiring direct medical treatment.

64. It was better to treat them this way and apportion them light labour suited to their state than to take tliem into hospital without positive occasion, and perhaps with harm. This procedure was a wise one, and attended with the best

results. The purely medical treatment was simple enough? the cases being treated generally in accordance with their

symptoms. When constipation, which was common, existed, a ten to twenty-grain dose of Calomel was found to answer

very well, as also a half-grain to one-grain dose of Elaterium in combination with four or five grains of Pil. Rhei. Co., or half-a-drachm dose of Pulv. Jala pre Co. After the bowels

were well evacuated the symptoms of oedema and tightness about the body were found much lessened, and a mixture called " Steel Diuretic" of a tonic and derivative nature was

frequently administered. This was a combination of tincture of Steel, Acetate and'Nitrate of Potash, Spirits of Nitre, and has answered very well throughout.

65. Drastic purges were only used when there was obsti- nate constipation, and the dropsical symptoms marked.

66. Oleum Nigrum, an oil procured from India, and of great supposed efficacy, was tried, but disappointment was

the result.

67. Lime Juice was ordered to all the long-sentenced prisoners outside the hospital, and, though continued for

some time, had little or no effect.

68. Cream of Tartar drink was freely given to the sick. A mixture of gin and Acetate of Potash and Nitrate of Potash was tried, and answered fairly well.

69. Hot baths and Jaborandi were tried, to act on the disease through diaphoresis, but were attended with doubtful success.

70. The combination which has succeeded best and yielded

most uniform good results is one of twenty drops Tinctura Ferri Perchloridi with ten to fifteen of Tinctura Digitalis in a vegetable tonic infusion given three times a day.

71. When dyspnoea set in, diffusible stimulants?ammo-

nia, tether, and camphor?in large and repeated doses were

given with alcholic stimulants. A dose of gin at bed time was given to almost all cases.

72. In the more chronic and rheumatic cases, Iodide of Potassium and Tincture of Aconite in suitable doses were

given, and when paralytic symptoms were present, Ergot and Nux Vomica combined were the most reliable drugs.

73. The diet consisted of food easily assimilable, milk and sago, bread and milk, beef tea, chicken soup, and stimulants as required, and gin to almost all cases.

Locally. 74. The local treatment is of much importance. Daily

frictions of the extremities with some stimulating liniment and flannel bandaging. When dyspnoea sets suddenly in, the application of a large blister to the chest is the best

remedy, aided by mustard poultices to calves of legs, &c. 75. Mustard cataplasms over epigastrium, blistering the

spine, counter irritation over the kidneys, the button cautery to the spine, have all been found useful in suitable cases.

70. In conclusion it is only to be regretted, that a more

successful treatment for this disease has not yet been dis-

covered. 77. The milder and more chronic cases are simply enough

treated, but in these sudden and severe cases the physician feels himself as helpless, as if he were in the presence of a

case of cholera of the worst type.

1 am &c.,

T. IRVINE ROWELL, H. D.,

Prinojjal Civil Medl. Officer, Straits Settlements.

The Hon''hie

The Colonial Secretary,

Straits Settlements.

(To he continued.)