Oct., 1945] EDITORIALS 515

Indian Medical Gazette

OCTOBER

&ERI-BERI : ADULT AND INFANTILE ? i

' found to be Beri-beri is a disease which is

forms the

^ODomon most when pohshet . -n Japan, bulk of the diet. It..?.ewle,Sam and tl>e South China, the Philippics- d .g ft very

^alay Peninsula and other <? > , mortality,

important cause of morb1(" ^ ^ of infant

^ is reported as a commmi <?-

war was re-

^ortality in Japan, and befo s0urces of Ported as one of the commonest

^ edit Slckness in the Japanese aim}-

^ cases 0f

^members seeing large num _ g ag0 and heri-beri in North Siam about li> y of tlie

Ss? hi the Chinese in however, the East. In most parts of I"cll^'.nheral neuritis .u% developed syndrome o P

^ attributed, frequently with cardiac affection a stated, 0 vitamin deficiency is rare. it n

is very however, that vitamm-B, detici <^uth India ?ommon in pregnant women. ?.

are n0t although typical cases of_ India as a ??ttimon either in India or in g0uth whole. There is, however, .^ V viz the Wia where beri-beri is not unpresidency- ^Jorthern Circars area of the M* +vr)ical beri-beri ?

reason for the rareness of t> P' nderstood. X, ̂ any parts of India is n? M^ng in many

use of rice parboiled befo p-v0<vVa) is said feas (but not in the Northern

Cnca to be the main factor. miinlo?'V ^c^!~ , The whole question of the

-

,i:scussion. On

^ei'i has been a subject, of ^ state as

^is subject Bicknell and Pie-(

0WS : iberi is a

j'A ,)een generally s?pp?se^l{ ^tamin Bi. ^ficiencv disease due to lack o

,? ^ed to lack loncy diseases, however. are neve1 is a vita^m"^n *, |mgle factor, and although tlielC. 'undoubtedly an

'Hciency in beri-beri, the disease q{ the 33 group.

iVltaminosis due to lack of the w sympt?nl? ?, ?ecause the oedema and cardiova:s vitamin l^ri-beri respond dramatically to P -Qre a diseas

las been argued that beri-beri is ^ this vitamin.

Specifically associated with a deficiency gignS and } is possible that in beri-beri the ?

are neurol- -yinptonis of vitamin-Bi deficiency, eltiselves before ?v>1Cal and cardiovascular, manifes When PU1P,

of other B complex deficiency .

^ foUnd ^nthetic vitamin Bi became ^ manifestation9 of

Produce a rapid cure of celta grew worse.. \

j ?ri-beri, but some persisted or e\?, f beri-beri is * now recognized that the treatm f00ds or con"

l0re satisfactory with vitamin Bi -

,, n with Pur,

grates rich in the B complex tna ^ induced

itamin B, alone. "Recent obseiv that lfc

yitamin-B, deficiency have also h ?

'

tallv in man lmPossible to produce beri-beri expeii a-

jjOCal c"S

^e?ple by diets poor in vitamin l

.j an ende ^ and food habits determine whet

^ ben-ben, ^ itamin-B deficiency manifests ltsei combina"?? 1 PeHagra or ariboflavinosis. No sel

of foods is entirely lacking in one vitamin. Clinically, few patients present all the classical signs attributed to any avitaminosis; actually any one case if carefully examined shows those of several. Certain manifesta- tions are common to beri-beri and pellagra, e.g. weak- ness, nervous irritability, vague malaise, lassitude, mental confusion, depression and inability to concen-

trate. Beri-beri patients often show the skin lesions or the glossitis of nicotinic acid deficiency ani the cheilosis of ariboflavinosis.'

Bicknell and Prescott go on to quote various workers who have questioned the view that vitamin Bt is the specific anti-neuritic vitamin. Adult beri-beri has been known for many

centuries in Japan and has been the subject of special study by numerous workers, Japanese and others during the last 50 years. It was a Japanese worker who 50 years ago first des- cribed infantile beri-beri differing in many im- portant points from the adult type of beri-beri. It appears in the first three months of life in children who are breast fed, and it is charac- terized by rapid onset, rigidity of the body, fretfulness, constipation, cedema of the extrem- ities, low urine output, enlargement of the

heart, tachycardia, and cyanosis and some-

times sudden death. Early symptoms are des- cribed as vomiting, anorexia, diarrhcea with

green stools. The infant is often attacked with sudden paroxysms of pain causing tenderness and rigidity but not true convulsions. Aphonia is common and is said to be characteristic, and

I the beri-beri cry is said to be diagnostic. I Laryngoscopy may show cord paralysis. The

| pulse is feeble and rapid, the neck veins are

I prominent and the face cyanosed. Death can occur within a day or two unless vitamin Bx is given. Many years ago the acuteness and severity

of infantile beri-beri was recognized, and it was considered that although the disease appeared in breast-fed children of mothers showing signs of beri-beri, the aetiology of infantile beri-beri was possibly or probably different from that of adult beri-beri. According to Fehily the term ' breast milk intoxication ' was suggested by Ito in 1911, and Fehily states that recent investi- gations of infantile beri-beri have simply con- firmed the idea that it is an intoxication and not the direct result of an avitaminosis. Fehily has surveyed the matter in a number of papers published in recent years, on the basis of a

special study of the disease in maternal and

child welfare centres in Hong Kong. Numerous

workers have shown that in the absence of vita-

min Bn the oxidation of carbohydrates to their end products is incomplete, and they accumu- late as intermediate metabolites which have

been shown to be toxic. One toxic substance,

methyl glyoxal, has been shown to be present in considerable amount in human be.'ngs^ with avitaminosis, and in the milk of avitaminotic

mothers, and it is suggested that it is the pres-

ence of this ^roup of toxic substsncGS in the

human milk that causes infantile ben-ben.

These facts are quoted to explain how infantile

mi

516 THE INDIAN MEDICAL GAZETTE [Oct., 1945

beri-beri can appear so very quickly even after a few breast feeds. It is true that the children of avitaminotic mothers have a very low vita- min-B intake, but they rarely show signs of beri-beri as seen in the adult. It is postulated that they suddenly develop

' milk poisoning' when any vitamin B they have in the body is exhausted and with the increase in the toxic

property of the mother's milk. It is stated however that the post-mortem findings in in- fantile beri-beri are similar to, but less marked and less constant than, those seen in adult beri- beri.

Fehily, in a recent article, discusses at length the diagnosis of infantile beri-beri and the diffi- culty of detecting the condition in a child who is often over-weight and shows no physical sign of disease, the symptoms being mainly vomiting after meals. She stresses the importance of this vomiting after meals of the fat, pale, flabby child with enlargement of the heart and some sign of cyanosis and dyspnoea. Loss of voice and the bringing up of mucus in the throat in a peevish, restless child who cries a lot some- times arouses the suspicion of infantile beri- beri. Some bronchitis and slight fever may be present. The hoarseness may be wrongly attri- buted to laryngitis. Fehily stresses the charac- teristic aphonia and the visible but inaudible

cry of the child. She attributes this to oedema of the mucous membrane and mucus collection in the throat, and oedema of the respiratory tract. Fehily discusses the differential diag- nosis of the condition in children from dyspep- sia, with flatulence (which is a common sign in infantile beri-beri), meningitis, nephritis, peritonitis, helminth infection, tetany, etc., and from broncho-pneumonia, bronchitis, laryngis- mus stridulus and other similar conditions. She also describes chronic infantile beri-beri and deals with its differentiation from other forms of malnutrition, and since all these may be co-

existent, differentiation is often difficult. It is

noteworthy that acute oedema is not character- istic of infantile beri-beri either in its acute or chronic forms, and if oedema is present, it is often localized.

Since in the Northern Circars, at any rate, adult beri-beri is by no means rare, it was pre- sumed that infantile beri-beri would also occur, although its occurrence in India has, as far as we know, only recently been recorded. In our present issue we publish an article on in- fantile beri-beri by Krishnan, Ramachandran and Kamala Sadhu, although the authors do not like the use of this term and avoid it in the paper. Nevertheless, it is obviously this con- dition which they are describing. We think it more than possible that this condition would be found in other areas of India, even in areas where adult beri-beri in its typical forms are

not seen. In other countries it is frequently found that the mother, although showing signs of vitamin-B deficiency, need not show the classical picture of beri-beri for actual infantile

beri-beri to be seen in the baby she is breas

feeding. We therefore think that this discus- sion of infantile beri-beri contained in this i?sVf may be of some general interest, and niig^ enable the condition to be more widely

recognized in India. J. L.