being employed so that the current may reach as much muscular tissue as possible; only such a strength should be employed as will produce visible contraction and cause no after-pain. Voluntary muscular action constitutes a more effective stimulus to nutrition; but if, although the muscle can be put in action by the will, there is loss or great diminution of faradic irritability, or an excess of voltaic irritability shows that some fibres are in an abnormal state in consequence of the degeneration of their nerves, voltaism may still be applied with advantage. There is no evidence that the application of electricity to the nerves has any influence on their regeneration. Slight sensory loss is sometimes lessened in the chronic stage by the application of faradism by the wire brush.

The tender limbs may be wrapped in cotton-wool, with or without a covering of oiled silk. Massage is of service in the later stages of the disorder, for its influence on the nutrition and circulation in the affected limbs. An upward movement of the pressing hand helps the circulation of fluid in the vessels and in the tissues. It cannot be borne during the acutely painful stage, and, indeed, as long as it gives. pain, it probably has more capacity for harm than for good. In the later stages it helps to overcome the contracture of the muscles, which should be gently extended at the same time as they are rubbed, -pressure, for instance, being made upon the ball of the foot at the same time as the calf muscles are rubbed.

The very long course of all severe cases makes a heavy demand on the patience of the sufferer and the perseverance of the medical practitioner; but the prolonged convalescence has the advantage, in alcoholic cases, of enabling a habit of abstinence to be formed. This, with the recollection of what has been endured, renders multiple neuritis more often a cure of intemperance than any other of the many maladies to which alcohol gives rise. During the slow recovery, the measures above indicated-tonics, electricity, and massage-should be continued. As already stated, the power of standing is interfered with for a time after the muscles have regained adequate strength, by the contraction of the gastrocnemii, causing a degree of talipes equinus. This is often so considerable as to suggest the desirability of dividing the tendo Achillis, but the operation is seldom if ever necessary. The attempt to stand and walk constitutes a powerful means of extension of the calf muscles, before which they soon yield sufficiently to permit the balance of the body to be maintained, and then progress becomes more rapid. The contraction at the knee and hip is more difficult to get rid of, but generally yields in time to persevering and gentle

efforts.

ENDEMIC NEURITIS.

The clear evidence that has accumulated, showing the dependence of multiple neuritis on toxic blood-states, some connected with an organismal virus, might prepare us to find that it sometimes results

from such poisons of endemic character. It is probable that many varieties of neuritis of this origin will yet be discovered; at present it is proved to be part of only three such diseases,-the malaria of remittent fever, leprosy, and the malady so widely prevalent in certain regions of the earth, the Kak-ké of Japan, Beri-beri of the Eastern Archipelago.

MALARIAL NEURITIS.-Several cases have come under my notice in which persons living in districts in which remittent fever is endemic have suffered from weakness in the legs, chiefly in the muscles of the foot, and far greater in the anterior tibial group of muscles--the flexors of the ankle and extensors of the toes--than in any others. In most cases the paralysis of these muscles was absolute, and they presented the reactions of degeneration. The hands were unaffected. Such palsy is typical of peripheral neuritis. In one case there was a suspicion of alcoholic excess, but in the others there was no history of this or of any other cause than the exposure to malaria. There was slight muscular tenderness in some, but the more acute symptoms had had an opportunity of passing away during the long sea voyage to England. In all the sphincters were unaffected. The symptoms steadily improved, quinine being given and the muscles stimulated by voltaism. Contraction of the calf muscles had, however, resulted from the foot-drop in all the cases, so that the foot could not be brought beyond or up to a right angle; but as soon as the patients were able to attempt to stand, this contracture, however great, gradually yielded, and all made a good recovery.

This outline embodies the chief symptoms of the disorder. It must be regarded as a peripheral neuritis, involving chiefly the motor nerves and confined to the legs, at least in cases of moderate severity. It is probably due to the malarial agent that causes the endemic fever of tropical countries-which is presumed to be of organismal nature -or to some virus left behind by this. Its occurrence may be aided by alcoholism or excited by exposure to cold, but no case came from a non-malarial district. How frequent it is we cannot at present say. Its nature had not been recognised in any of the cases that have come under my own notice, the symptoms having been ascribed to disease of the spinal cord. But most physicians who have practised in such districts as those in which it occurs (India, the East Indies, coast of Africa, &c.) have recollected such cases when the symptoms were described to them, and it may perhaps turn out to be far from rare, and to occur also in a more acute and general form, the nature of which has also been misunderstood. Its symptoms and pathology are of especial interest in connection with the variety next to be described.

BERI-BERI, the KAK-KÉ of Japan, is also known by other popular names in the various countries in which it is native.* Probably many

Beri-beri is probably a modification of the Cingalese name for the disease, bahr

names and localities remain to be discovered, or rather identified, for it is a mysteriously wide-spread disease, having apparently its chief homes in Japan, the Eastern Archipelago, India, New Zealand, Ceylon, the South Pacific Islands, and the coast of Brazil. It is especially prevalent in the Dutch East Indies, among the soldiers and in the prisons, and this has led to its systematic investigation under the direction of the Netherlands Government. Through this our knowledge of the malady has been much increased, especially by the investigations of Pekelharing and Winkler,* who had a large number of cases under their observation both during life and after death. Opinion as to its nature and cause has varied much, and still is far from uniform among those who have studied it; but there is a strong preponderance of evidence that it depends on a specific organism, and that symmetrical peripheral neuritis is the common effect of the virus, and the mechanism by which its chief symptoms are produced. The organisms found † are in the form of rods and cocci, but it is probable that these are only different stages in the development of the same species. They have been cultivated, and peripheral neuritis of nearly the same distribution as in beri-beri has been produced by their inoculation. Repeated inoculations are, however, necessary for this result to be produced; and hence, from this and the phenomena of the disease, it is assumed to be not a simple infectious malady, capable of being induced by a single exposure to its cause, but one in which repeated opportunities for infection are necessary. In harmony with this are the facts that sufferers acquire the disease from residence in certain infected houses, or places in which it is supposed that the soil is saturated with the organisms; that they may rapidly recover on removal to a district that is free, and relapse only on returning to an infected place; that it prevails where persons are gathered together, as in barracks and prisons; and that the air of these places is found to contain the organisms which, collected from it, will cause the disease in animals, from whom it is transmissible to bari extreme weakness. Kak-ké is the old Chinese name for it, by which it is mentioned by their medical works since 200 B.C.; it is derived from two words, meaning "legs" and "disease." The affection disappeared from China two cen turies ago, remaining in Japan, where it continues a most serious endemic malady.

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Pekelharing and Winkler, 'Onderzoek naar den aarden de oorzaak der Beriberi,' Utrecht (sep. publication), 1889, analysed in the Centralbl. f. Nervenkr.,' 1889; also 'Weekblad f. Nederl. Geneesk.,' 1888, and Deut. med. Wochenschr.,' 1888, No. 30. Other important contributions to the subject are by Bälz, Zeitschr. f. kl. Med.,' 1881; Scheube, ib., 1882; Weintraub, Wien. med. Wochenschr., 1888, Nos. 23-44; Van Eecke, Tijdschr. v. Nederl. Indre,' 1887, p. 71; Wernich, Virchow's Archiv,' Bd. lxxi; Minra, Virchow's Archiv.' Bd. cxi and cxiv, whose conclusions, however, differ from those of most investigators; Seguin, Phil. Med. and Surg. Rep.,' 1888; and Springthorpe, ‘Australian Med. Journal,' 1889. Balz, in 1881, expressed the opinion that the disease was specific "panneuritis."

✦ First described by Bälz and Scheube, and since by Pekelharing and Winkler, Eigkman, Weintraub, Springthorpe, and others.

others by further inoculation. The serious extent to which it may spread among those who live together under conditions favouring its extension, is shown by the instance of a ship arriving in Japan from New Zealand after a voyage of 272 days. The disease spread on board so rapidly that altogether 169 cases occurred, with twenty-five deaths. In 1878 no less than 38 per cent. of Japanese soldiers were affected. It is probable that the inhalation of dried organisms floating in the air as part of "dust," is the chief way in which the disease is propagated. By some it has been thought that a nitrogenous diet induces or predisposes to the disease, and facts apparently supporting the opinion have been adduced; an exclusive fish diet has been thought to cause it, and so also has a rice diet. A remarkable outbreak in Manila in 1880 followed a period of rice-eating during a cholera epidemic. These influences probably merely produce susceptibility.

It is a remarkable fact that Europeans seldom suffer. Males are more liable to the disease than females, and it is chiefly prevalent during the hot season.

Symptoms.-Peripheral symmetrical neuritis is a constant feature of the malady, which is usually chronic in course and gradual in onset, but prone to undergo acute exacerbations. These have been generally regarded as acute forms of the disease, but it is said by Pekelharing that the symptoms of neuritis may always be discovered before the onset of the definite symptoms, and this when the patient is ignorant of their existence and feels quite well. Most observers have failed to recognise this, and it is probably true only under certain conditions, and persons suddenly exposed to an intense infection may suffer acutely from the very commencement. Occasionally the malady develops with extreme rapidity and severity. On the other hand, many cases are chronic throughout, and last for months. The leading symptoms are those of multiple neuritis (chiefly affecting the legs and the cardiac branches of the vagus), dropsy, and symptoms of cardiac failure. The amount of urine is generally lessened, and its secretion may be almost suppressed in acute cases. A "critical" increase in the secretion may mark the commencement of improvement. It is unchanged in character, and does not contain albumen. The dropsy is a very variable symptom, and this has led to the distinction of two forms, the dry and the dropsical. Pekelharing and Winkler, however, found some effusion of fluid almost invariably after death, and it is probable that its conspicuous presence or absence depends chiefly on the state of the heart (conditioned by that of its nerves), and partly on the trophic and vaso-motor disturbances due to the local neuritis.

The earliest symptoms are a change in the electrical excitability of the peroneal nerves and the flexors of the ankles (which suffer most throughout)-a slight degree of the reaction of degeneration, quantitative and often qualitative. These are often to be found before there are any subjective symptoms, which begin as a sense of heaviness of the

legs, readiness of fatigue, dysæsthesia and diminution of tactile sensi bility in the lower legs, palpitation and undue excitability of the heart. The electrical changes may be met with in slight cases which proceed no further,* and have shown that some patients, supposed to be shamining, were real sufferers. To these subjective symptoms are added other objective signs,-cedema along the edge of the tibiæ, a peculiar pasty and stiff aspect in the face, an increase in the cardiac dulness to the right, roughness of the first and accentuation of the pulmonary second sound. These symptoms may increase slowly, or rapidly in the form of an acute stage. The degenerative reaction. becomes complete in the muscles first affected, and they become paralysed and undergo the characteristic atrophy, while other nerves and muscles progressively suffer in the same manner, the calf muscles, the extensors of the knee, the adductors of the thigh, and, lastly, the flexors of the thigh and the abductors of the hip. In the trunk the abdominal muscles and intercostals may be involved, and in severe cases the arms are paralysed, first the extensors of the wrist and fingers, later the flexors, and sometimes most of the muscles may be so atrophied as almost to disappear. The face often suffers: the diaphragm may become paralysed, and also the larynx (the inferior before the superior laryngeal nerve); while grave cardiac weakness and increas ing dilatation of the heart testify to the serious implication of the cardiac branches of the vagus. Simultaneously, sensory symptoms develop, corresponding in distribution to the more severe motor symptoms; sensibility to touch is lessened or lost (first on the inner side of the lower leg), while that to pain usually remains, and sometimes is augmented to the degree that constitutes what has been termed "anesthesia dolorosa." The temperature-sense may be diminished to either heat or cold or both in various parts, and there is often considerable loss of cutaneous sensitiveness to faradism. There may be tingling, formication, and other dysæsthesiæ, together with tenderness of the nerves and muscles, but far less in degree than in most forms of polyneuritis, and chiefly marked in the early stage of the disease.

The oedema that is so common begins in the legs, usually spreads widely, and involves not only the subcutaneous tissue but the cavities of the peritoneum, pleura, and pericardium: in the last it seriously impedes the action of the already dilated and feeble heart. It is to the cardiac failure that death is commonly due; the other chief cause is failure of the respiratory muscles, aided generally by effusion into the pleural cavities, and accompanied by the indications of cardiac weakness, and of dilatation of the right side of the heart. From this cause the cardiac dulness sometimes increases rapidly, even in a few hours. The cedema is usually attended by increasing anæmia, which doubtless facilitates its occurrence. These symptoms are always later in development than are those due directly to the neuritis. In the most acute cases the definite symptoms Pekelharing and Winkler, Eigkman (1889), &c.