Beriberi

BERIBERI (beri-beri, in Japanese and Chinese-"kakke"), synonyms: polyneuritis endemica (Balz), neuritis multiplex endemica (Scheube), hydrops asthmaticus, multiple chronic alimentare Nervendegeneration (Nocht). A. Castellani and Chalmers derived the word "beri-beri" from the Sinhalese "I cannot," "I am unable." Beriberi is an acute, subacute, or chronic endemic or epidemic disease, characterized by multiple degeneration of peripheral nerves of the extremities, disturbance of mobility and sensitivity, circulatory system disorders, decline of cardiac activity, and edema. Beriberi occurs in many tropical and subtropical countries, but under certain conditions (one-sided nutrition) it can appear in any climate. -Etiology. At present it has been established that beriberi results from one-sided insufficient nutrition. If previously there existed the view that beriberi is an infectious disease, held by major epidemiologists such as Scheube, Balz, Miura (miastic theory of beriberi-Patrick Manson), now the number of adherents to this view is becoming fewer and fewer. Prolonged exclusive feeding of polished rice, deprived of vitamin B (see Vitamins and Avitaminoses), in both animals and humans serves as the cause of the appearance of beriberi. -Pathological anatomy. Macroscopically, depending on the stage of the disease, emaciation, atrophy of muscles, and generalized or partial edema are observed; frequent signs are hydropericardium (Nocht) and pulmonary edema; the heart is almost always dilated, the liver often enlarged and congested; frequently ascites; the adrenal glands are enlarged, their medulla hypertrophied, the brain is edematous (edema of the membranes and accumulation of fluid in the ventricles). Microscopically the most important changes are noted in the peripheral nerves and muscles (Balz and Scheube, 1882/83). In nerves the picture of parenchymatous neuritis is observed, in muscles-phenomena of atrophy, with the muscles corresponding to the altered nerves being mainly affected. On the legs the calf, thigh are affected, on the hands-the hand and forearm. -Pathogenesis. In 1882 Tanaka changed the almost exclusively rice diet of Japanese sailors, who were then severely affected by beriberi (see statistics below). Although this led to a decrease in the caloric value of the ration, meat, vegetables, bread, fruits were introduced into the diet, and as a result, beriberi almost completely disappeared from the fleet. The most important research on this question belongs to Dutch researchers, who showed the dependence between beriberi and "white" nutrition, i.e., polished rice deprived of the "silvery film" (pericarp), covering the grain and containing vitamin B [as Funk (C. Funk) later clarified]. Eijkman experimentally obtained beriberi in chickens by feeding them only polished rice. Vorderman found that among the 281,878 persons confined on the islands of Java and Madura in 1895/96, 96,530 were fed so-called red rice, i.e., with preserved pericarp, and of these 9 persons (1:10,000) contracted beriberi, while among 150,266 people fed white polished rice (without pericarp) 4,201 (280:10,000) contracted beriberi. The clinical picture of beriberi is quite diverse; following Balz and Scheube, it is customary to divide it into the following four forms, often passing into one another: 1) incomplete, rudimentary, 2) atrophic, dry, 3) wet, or hydremic and 4) acute pernicious, or cardiac. Rudimentary forms are most common. After slight prodromal phenomena (weakness, feeling of fullness in the epigastrium, constipation, etc.) a previously healthy person, from slight causes, e.g., after a long walk or even just after getting out of bed, suddenly feels uncertainty and weakness in the legs. The calf muscles are painful on pressure, which is less frequently noted in the thigh and forearm muscles. To this are added heart palpitations during movement and slight edema on the tibia. The knee reflex is initially elevated in 50%, then disappears. Temperature is normal, pulse is variable, heart tones are slightly impure; internal organs are normal. This can last quite a long time, and with the onset of cold weather, all the above-mentioned symptoms may even disappear, but more often the disease passes into the second stage - the dry, atrophic form, in which paralysis are followed by atrophy of the calf muscles (always in front). The same can be on the hands and even on the trunk, and therefore in cases of muscle atrophy, patients really represent a skeleton covered with skin (the bladder and large intestine are not affected). In favorable cases, even with such severe conditions, recovery can occur after several months, with sensitivity returning first, then mobility, and finally normal muscle volume. The third form - wet, edematous-atrophic - occurs less frequently than the previous one and is nothing other than both previous forms + edema. Heart palpitations, accelerated pulse, tightness in the chest, shortness of breath, pain in the calf muscles, with not sharply expressed motor and sensory disorders-are characteristic clinical symptoms. In mild cases there is edema only of the ankles or tibia, and in severe cases-of the legs, arms, trunk, face and accumulation of fluid in the pericardial, pleural, abdominal cavities. The amount of urine is reduced (200-300 cubic cm), its specific gravity is high, little protein, and with increased diuresis there is none at all, occasionally hyaline cylinders and a few white balls are found, and albumin is always present. During recovery diuresis increases, edema disappears, and emaciation and atrophias appear, as in the second form. An unfavorable outcome occurs partly from dropsy, partly from paralysis of the respiratory muscles or due to transition to the fourth form-cardiac, which usually develops acutely or from the previously described forms with overexertion, or in connection with febrile diseases, sometimes without any apparent cause. Rapidly, sometimes in a few hours or days, symptoms of cardiac failure develop in all their variety. Death occurs in this form after a few hours or weeks from the onset of the disease. Diagnosis in pronounced cases is not difficult, based on the presence of sensory disturbances with weakness in the legs, arms, loss of knee reflex, pain on pressure on the m. gastrocnemius, edema on the tibia, in the absence of albuminuria and fever. Differentially, beriberi must be distinguished from alcoholic polyneuritis, arsenic poisoning, lead poisoning (intestinal spasms, blue line on the gums, spotted erythrocytes); the edematous form-from heart diseases (rheumatism and other infectious diseases in the anamnesis), from kidney diseases, from myelitis (lesion of the rectum and bladder), from tabes dorsalis, from pellagra (by the presence of skin phenomena), from leprosy [thickening of nerve trunks, true anesthesia (in beriberi only hypesthesia), nodules on the skin, bacilli in nasal mucus]. -Prognosis is good with early prescription of appropriate treatment, but only not in far advanced cases with heart and circulatory organ involvement and if there are no complications. In potators, morphinists, opium smokers, luetics the prognosis is poor. -Treatment, besides bed rest, consists in prescribing a diet rich in vitamin B, with white polished rice being completely excluded at first, after which patients recover very quickly: cardiac insufficiency and circulatory organ disorders disappear very quickly, the amount of urine increases, edema disappears, the pulse becomes normal. Pareses, paralyses and sensory disturbances last longer (weeks and months), but then they also completely disappear. In severe neglected cases vitamins must be given in concentrated form, in the form of special beans Phaseolus radiatus L., boiled for 20 min., or extract from rice bran, or extract from yeast, and also beer extract (see Yeast, Vitamins).-As for the prevention of beriberi, it consists of social measures that eliminate exclusive feeding of polished rice in those categories that are fed a predetermined ration (sailors, soldiers, prisoners, construction workers), as well as in the prohibition of exporting rice containing P₂O₅ less than 0.4% (P₂O₅ is contained mainly in the rice grain shell). Geographical distribution. The main endemic focus of beriberi-Eastern Asia (Malay Peninsula, Java, Borneo, Philippine Islands, Japan, China along the sea coast), South America (Brazil), Africa (Congo ports), Madagascar, Union Islands. In Europe beriberi was noted in France (in a hospital for the mentally ill) and in Ireland (in Dublin).-Statistics. Exact figures are not available, but a few examples will give a clear idea of the geographical distribution of the disease. During the Russo-Japanese War the Japanese army in Manchuria had 70 to 80 thousand patients with beriberi (and according to some data-up to 200 thousand), while in the Russian army there was no beriberi, but there was scurvy.

In the Indian army from 1900 to 1914, out of 130,000 natives, 565 people contracted beriberi. In the Japanese fleet before 1884, 33% suffered from beriberi. Pelts and Miura believe that in Japan, 50,000 people annually contract beriberi. In 1886, in the Dutch East Indies, in the troops, 3,584 Europeans and 5,850 natives were being treated for beriberi. On the Philippine Islands, out of 5,200 natives in the army in 1908, 618 contracted beriberi, and in 1909, 558 people; in 1910, when substances containing vitamin B were added to the food, only 6 people contracted beriberi. On the Malay Peninsula (Straits Settlements in Malaya), out of 1,250,000 people who passed through hospitals in the last 20 years, there were at least 150,000 cases of beriberi with 30,000 fatal outcomes; it should be noted that only 1/3 of Chinese coolies enter hospitals, so the overall mortality from beriberi on the Malay Peninsula would have to be calculated at 100,000 people (Castellani, Chalmers).-Epidemiology. The disease occurs in all races, in both sexes, more often in adults from 15 to 30 years, but it has also been observed in infants and the elderly. Men get sick more often than women. Generally, beriberi is a disease of wet lowlands along river valleys, near the sea, in rice-eating areas, but cases of beriberi have also been observed in people not eating rice. As for personal predisposition, fatigue, exhausting diseases such as pleurisy, dysentery, tuberculosis, and childbirth more often lead to beriberi; local inhabitants in endemic foci get sick less often than newcomers.

L., 1919; Manson P., Tropical diseases, L., 1919; Bahr Ph., Manson's Tropical diseases, L., 1921; Nocht B., Beri-beri (Mense C, Handbuch d. Tropenkrankheiten, B. II, Lpz., 1924; all the latest literature is cited); Scheube B., Die Krankheiten d. warm en Lander, Jena, 1910; Balz E. u. Miura K., Beri-beri Oder Kakke (Mense C, Handbuch d. Tropenkrankheiten, B. III, Lpz., 1924). P. Popov* BERING ,Emil(1854-1917), outstanding German bacteriologist. He received his medical education in Berlin, was a military

physician, assistant at the Institute for the Study of Infectious Diseases. In 1894 he was invited as a professor of hygiene to Halle, and to F^^ЧИШ''

^burg- ^{where he worked} fli ** ViieAw ^B created by him 4г Щ#£лИКаЧ Institute for experimental- \ШШШш %Itt therapy. In 1900 he was elected a member of the Paris Academy, and in 1901 he was awarded the Nobel Prize jointly with Roux. The first scientific work of B. was the study of the action of iodoform on bacteria. The main merit of B. is the discovery of the therapeutic properties of antitoxic sera, which he obtained by injecting animals with bacterial cultures and toxins (1890). The application of the antitoxin serum he discovered for the treatment of diphtheria sharply reduced mortality from this disease. The antitetanus serum, which proved to be little effective in the developed picture of the disease, has great importance as a preventive means in case of injuries, as confirmed by the experience of the imperialist war. Of other scientific works of Behring should be mentioned the experience of vaccinating calves by intravenous administration of live weakened cultures of human tuberculosis (Bovovac-cina Behring's). Adhering to the intestinal theory of infection in the etiology of tuberculosis, B. recommended consuming the milk of immunized cows as the best preventive measure against childhood tuberculosis. This vaccine gave fairly good results; among immunized calves, cases of tuberculosis were observed less frequently; however, the vaccine was subsequently abandoned as not entirely safe. In the last years of his life, B. developed a method of active immunization against diphtheria by injecting a mixture of toxin with antitoxin. This method is now widely used as a preventive measure and gives good results. The main works of Behring: "Die Blutserum-therapie", 1892; "Die Geschichte der Diphtherie", 1893, "Die Bekampfung der Infektionskrankheiten", 1894; "Allgemeine Therapie der Infektionskrankheiten", 1898; "Die Serumtherapie in der Heilkunde u. Heilkunst", 1901; "Die Lungenschwindsuchtentstehung u. Tuberkulosebekampfung", 1903; "Uber alimentare Tuberkuloseinfektion im Sauglingsalter", 1904; "Einfiihrung in die Lehre von der Bekampfung der Infektionskrankheiten", 1912.