A CASE OF BERI-BERI IN THE CHINA EXPEDITIONARY FORCE. By T. H. DELANY. M.B., CAPT., I.M.S. The following case of beri-beri is, I think, sufficiently interesting to warrant its being published, and I desire to draw attention to the very early symptoms and signs of beri-beri which I had a unique opportunity of observing in this case. On the nights of the 6th, 7th and 8th January 1901, on returning to my tent after dinner, I heard the groan- ing noise usually made by a native in ; and as the noise on each occasion was sufficient to prevent my sleeping I sent for and examined the man on the 9th January. He was a bhisti of this B. (58 Native Field) Hospital of the China Expeditionary Force, and was about twenty years of age He stated that for the last nine nights he had suffered from in the legs and burning pains in the feet, and that for the last three nights the pains had been intolerable. The pains began about sunset, that is about the time when he sat down after his day's work, and they continued most of the night so as to prevent his sleeping. The pains were often accompanied by cramps in the backs of the legs and in the toes. On feeling the muscles of the calf of one leg I was struck by the expression of pain exhibited by his face. I found this tenderness was well shown in each calf by pressing the muscles forward on to the bones. I carefully examined the patellar reflexes, and found in the right leg that the first four taps on the ligamen- tary patella elicited no reflex, but that the fifth tap did cause a reflex which was small and delayed. Sub- sequently only every second tap elicited a reflex, which was slight, and delayed a few seconds. In the left leg every second tap caused a moderate reflex, the others resulting in none. His temperature was 99?, pulse 96. I carefully examined for anaesthesia of the hands and feet and fronts of the tibia?, but found sensation^almost normal. I noticed however on further examination that about the toes all sensations, viz., touch, pain and temperature were delayed frequently ; and referred to the wrong place () occasionally. This was especially marked on the skin in front of the free ends of the toe-nails. I could not make up my mind whether there was any swelling of the legs or feet; but thought that at the lower end of the tibia a slight pitting occurred on prolonged pressure by the thumb. There was no other symptom or sign whatever, yet I felt justified in giving it as my opinion that the case was one of peripheral certainly ; and beri-beri probably. ?330 THE INDIAN MEDICAL GAZETTE. [Sept. 1901.

I will briefly state the further progress of the case. be for where anaesthesia is anil On the 15th the reflexes were lost : sought expected January completely cannot be demonstrated. It would that tenderness of the muscles still severe. appear On the 24th January the fronts of the legs were slight- delayed sensations and allochiria are indicative ly yet distinctly swollen, the skin was glossy-looking, of the early, and anaesthesia of the later, stage and the hollows over the crests of the tibiae obliterated. of involvement of the sensory apparatus. Touch and sensations were pain temperature distinctly the reflexes could not be said delayed over the dorsal and plantar surfaces of the foot. Again, although " to have on the first examin- The prick of a pin elicited a sensation of "vibration entirely disappeared rather than pain, and allochiria was marked over the ation of the patient, they were sufficiently same area. His temperature up to date has varied diminished to enable one to foretell their prob- between was same 96-4 and 99F.,it 96'6F. the morning. able early disappearance. Pulse soft, small, and 110 to the minute. the combination of in the mus- On the 12th February complete anaesthesia was well Lastly, pains marked on the toes and inner sides of both feet. The cles of the legs and tenderness of same points to area of delayed sensations and allochiria had, on the the necessity of examining the reflexes and other further so as to the hand, shifted up extend around sensation, with a view to one over- ankles and lower third of the preventing legs. looking beri-beri. The pulse was exceedingly ataxic and irregular, and at times broke into a series of beats that could scarcely be counted. The average number of beats to the minute were 140. The second sound of the heart at the base was accentuated. The first sound at the apex was roughened, and at times might be considered to be replaced by a murmur. On the 1st March before I sent him to the Station Hospital, Kowloon, Hong-Kong, he presented the picture of a well-marked case of beri-beri of the dry form Anaesthesia of both legs extended to near the knee-joints, and anaesthesia of both h inds to just above the wrists. There was an elongated oval patch of anaesthesia on the abdomen extending from the pubes to above the umbili- cus, and mostly to the right side of the middle line. The reflexes were absolutely lost. The feet dropped, the gait was ataxic, and the muscles of the legs were wasted, flabby-looking and tender to the grasp still. The hands had a weak grasp, and lis had ataxia of the upper limbs. The fronts of the legs were rounded, and a puffiness was visible in front of the ankle joints. The temperature was 96?F.; pulse 130 and soft. The area of cardiac dulness was increased to the left, the apex heat diffused, there was epigastric pulsation, and the heart sounds were as noted above. The patient arrived in Hong-Kong on the 30th October 1900. There is no other case of beri-beri in this camp. He has always slept in a tent with three or more other followers. He often visited the Chinese bazar. There is much beri-beri in Hong-Kong. All the Chinese hos- pitals have many cases, in fact it is probably the commonest disease in the medical wards of those hospitals. I saw over one hundred cases in all stages and of all forms in the Tung Wall Hospital, Hong-Kong, last November. There were about nine other cases, all of which are of a mild type, among the fighting men and followers of the China Expeditionary Force, in the Station Hospital, Kowloon, Hong-Kong, where the ? Indian natives are treated. I think the early of this case are worthy of note, as it is just the sort of case that in the early stage is liable to he incorrectly diagnosed. I would point out the fallacy likely to arise by one making a hasty examination of such a case as this was on the 9th January, and concluding that there was no involvement of the sensory simply be- cause there was no anaesthesia. I think this case shews, on the other hand, that delayed sensations and allochiria should always